David G. E. Caldicott

A systematic review of adverse events arising from the use of synthetic cannabinoids and their associated treatment

Abstract Context: Synthetic cannabinoids (SCs) such as “Spice”, “K2”, etc. are widely available via the internet despite increasing legal restrictions. Currently, the prevalence of use is typically low in the general community (<1%) although it is higher among students and some niche groups subject to drug testing. Early evidence suggests that adverse outcomes associated with the use of SCs may be more prevalent and severe than those arising from cannabis consumption. Objectives: To identify systematically the scientific reports of adverse events associated with the consumption of SCs in the medical literature and poison centre data. Method: We searched online databases (Medline, PsycInfo, Embase, Google Scholar and Pubmed) and manually searched reference lists up to December 2014. To be eligible for inclusion, data had to be from hospital, emergency department, drug rehabilitation services or poison centre records of adverse events involving SCs and included both self-reported and/or analytically confirmed consumption. Results: From 256 reports, we identified 106 eligible studies including 37 conference abstracts on about 4000 cases involving at least 26 deaths. Major complications include cardiovascular events (myocardial infarction, ischemic stroke and emboli), acute kidney injury (AKI), generalized tonic-clonic seizures, psychiatric presentations (including first episode psychosis, paranoia, self-harm/suicide ideation) and hyperemesis. However, most presentations were not serious, typically involved young males with tachycardia (≈37–77%), agitation (≈16–41%) and nausea (≈13–94%) requiring only symptomatic care with a length of stay of less than 8 hours. Conclusions: SCs most frequently result in tachycardia, agitation and nausea. These symptoms typically resolve with symptomatic care, including intravenous fluids, benzodiazepines and anti-emetics, and may not require inpatient care. Severe adverse events (stroke, seizure, myocardial infarction, rhabdomyolysis, AKI, psychosis and hyperemesis) and associated deaths manifest less commonly. Precise estimates of their incidence are difficult to calculate due to the lack of widely available, rapid laboratory confirmation, the variety of SC compounds and the unknown number of exposed individuals. Long-term consequences of SCs use are currently unknown.

Dancing with "Death": P-Methoxyamphetamine Overdose and Its Acute Management

Para-methoxyamphetamine (PMA) is a substituted synthetic amphetamine used in the recreational drug scene. It is unusual because of the high incidence of significant morbidity and mortality in overdose. We report a case of PMA overdose in South Australia, and review our experience with the drug. We review the literature on PMA overdose and offer suggestions on the management of overdose with this dangerous drug.

The anatomy of a shark attack : a case report and review of the literature

Shark attacks are rare but are associated with a high morbidity and significant mortality. We report the case of a patients survival from a shark attack and their subsequent emergency medical and surgical management. Using data from the International Shark Attack File, we review the worldwide distribution and incidence of shark attack. A review of the world literature examines the features which make shark attacks unique pathological processes. We offer suggestions for strategies of management of shark attack, and techniques for avoiding adverse outcomes in human encounters with these endangered creatures.

Persistence of specific IgM and low avidity specific IgG1 following primary rubella.

Persistence of specific IgM in sera following primary rubella infection was compared with the maturation of the specific IgG1 response. 206 sera, from 171 patients with primary rubella, taken 1 day to 2.5 years after onset of illness, were tested. Rubella-specific IgM was detected by M-antibody capture radioimmunoassay in 100% of sera taken 15-28 days after onset, but in only 9% taken 3-4 months after onset. However, using the diethylamine (DEA) shift value (DSV) method, low avidity specific IgG1 was detected in 91% sera taken at 3-4 months and at 5-7 months 21% of sera remained positive. Using an avidity index method, with urea in the wash buffer, none of the sera were positive for low avidity specific IgG1 beyond 3 months after onset. With DEA in the wash buffer, the number of sera positive rose to 38% at 3-4 months. Thus, the DSV method for detecting low avidity specific IgG1 is a useful additional test for confirming or refuting a diagnosis of primary rubella and is of particular value for assessing pregnant patients.

Keep off the grass: marijuana use and acute cardiovascular events.

Marijuana is one of the most widely used recreational substances in the world, considered by many consumers as a relatively safe drug with few significant side-effects. We report the case of a 21-year-old man who suffered an acute myocardial infarction following the use of marijuana, despite having no other identifiable risk factors for an acute cardiovascular event. We review the published medical literature regarding acute cardiovascular events following marijuana use and postulate a possible mechanism for this unusual pathological consequence of marijuana use.

Transhepatic insertion of a metallic stent for the relief of malignant afferent loop obstruction

A 65-year-old man with a polya gastrectomy presented with biliary obstruction. Percutaneous cholangiography indicated strictures of the distal common bile duct and afferent duodenal loop due to an inoperable carcinoma of the head of the pancreas. The patient was unlit for bypass surgery, and a previous gastrectomy precluded endoscopic intervention. Successful palliation of the biliary obstruction was achieved by placing metallic stents across the duodenal and biliary strictures via the transhepatic route. The use of stents for gastrointestinal stricture is reviewed.

NBOMe - a very different kettle of fish . . .

NBOMe — a very different kettle of fish . . . TO THE EDITOR: We are concerned that recent media reports about a 17-year-old Sydney boy who died after allegedly consuming 25Bor 25I-NBOMe might lead to an increase in the incidence of NBOMe toxicity among patients presenting to emergency departments. NBOMe was reported to be available online for as little as

Clandestine drug laboratories in Australia and the potential for harm

1.50 per tablet.1 The subsequent media interest is likely to have increased public awareness of the availability of the NBOMe series of drugs; and increased awareness of psychoactive substances through media reporting is associated with their increased initial uptake.2 It is possible that the increased awareness of this cheap LSD (lysergic acid diethylamide)-like drug will prompt some individuals to buy NBOMe tablets and sell them as LSD in order to make a significant profit. The NBOMe series are analogues of the 2C series of psychedelic phenethylamine drugs that include an N-methoxybenzyl (hence, “NBOMe”) substituent that has significant effects on their pharmacological activity. NBOMe drugs have been characterised in in-vitro receptor studies as remarkably potent agonists of the 5-HT2A and 5-HT2C receptors, 3

The identification and chemical characterization of a new arylcyclohexylamine, methoxetamine, using a novel Emergency Department toxicosurveillance tool

The emphasis in the literature regarding illicit drugs has been overwhelmingly on the subject of harm caused by their ingestion. Little has been reported on the potential and real harm associated with the illicit manufacture of drugs. This paper describes the increasing prevalence of clandestine drug laboratories in Australia, overwhelmingly devoted to the manufacture of methamphetamine. The nature of the illicit synthetic process is reviewed together with its inherent dangers for the ‘cook’, first responders and bystanders including children, and the environment. We have analysed the emerging trends in manufacture and seizure in Australia, and offer suggestions to remedy significant deficiencies in knowledge and policy in the management of clandestine drug laboratories, especially with reference to clinical management issues, data collection, environmental contaminants and remediation, legislation and research. In particular, we conclude that:

Tenecteplase for massive pulmonary embolus.

The Emergency Department is frequently the first port of call for patients suffering from recreational drug overdose, alongside pre-hospital and other emergency services. Many drugs are familiar to the seasoned practitioner, but the fluctuant and dynamic nature of both the licit and illicit recreational drugs market is such that there are always new products emerging. Manufacturers, eager to avoid prosecution where possible, have put some effort into developing the ‘legal high market’, using untried and untested compounds bearing labels such as ‘research chemicals’ to bypass the legal ramifications of selling drugs to consumers. One such recently described group of so-called legal highs are the substituted cathinones, of which mephedrone is the best known. We believe that drugs from the arylcyclohexylamine class are becoming the next class of legal highs to significantly spread through the drug-using community, and that both clinicians and analytical chemists should be aware of their existence and effects. A 35-year-old man presented to the Emergency Department at Nevill Hall, Abergavenny (South Wales) in early 2011, having collapsed at his home. He was initially unresponsive on ambulance arrival, and was noted to be bleeding from his left nostril, following insufflation of a white powder (although there was no evidence of further nasal irritation resulting from insufflation). A small empty package was found with the patient, which was labelled with the chemical structure of the compound and the word ‘methoxyphenyl-2-(ethylamine) cyclo-hexanone’. The patient was initially incoherent in his general manner and communication with Emergency Department staff, but returned to a GCS (Glasgow Coma Scale) of 14 over 20min, and a GCS of 15 over 90min. He was hypertensive (blood pressure = 167/ 110mmHg), but not tachycardic (with heart rate and temperature in the normal range), and he had bilateral pupillary mydriasis. Neurological examination was normal, with no focal neurological signs. He described being in contact with both heaven and hell and the spirit of his dead father. His behaviour was ecstatic, but otherwise good-natured. He appeared to be confused about the origins of sounds and colours in his proximity, but denied frank hallucinations. On further enquiry, he was identified as having had previous mental health issues, and was known to have been treated for bipolar disorder using lithium, but had been non-compliant. He