Driving under the influence of cocaine or therapeutic administration of cocaine?

Introduction: In forensic toxicology, cocaine is better known for its powerful stimulating effects of nervous system and its high potential for recreational abuse, than for his therapeutic use. However, cocaine is still use as a topical anesthetic and peripheral vasoconstrictor in surgeries of eye, ear, nose and throat. Last decade, an increase of the presence of cocaine and metabolites in blood samples of drivers suspected to drive under the influence of drugs (DUID) was observed in Switzerland (Augsburger et al., Forensic Sci Int 153 (2005) 11-15; Senna et al., Forensic Sci Int 198 (2010) 11-16). Observed blood concentration ranges of cocaine and benzoylecgonine were 10-925 μg/L and 20-5200 μg/L, respectively. Since 2005, zero-tolerance approach was introduced in the Swiss legislation for different substances, especially cocaine (analytical cutoff: 15 μg/L). Thus, the interpretation often amounts to determine if the concentration is situated above or under the limit. However, it is important for the interpretation to take into account the context and to be critical with the obtained results, at the risk of ending in erroneous conclusions. Methods: Systematical toxicological analyses were performed on blood and urine, if available, for 5 DUID cases, as already published (Augsburger et al., Forensic Sci Int 153 (2005)). Positive results were confirmed and drugs were quantified in biological samples by GCMS, GC-MS/MS or LC-MS/MS. Results: Administration of cocaine after traffic accident was identified in five cases. All people were admitted to the emergency room because of severe trauma. Maxillofacial surgery was done shortly after admission to the emergency room, involving use of nasal application of cocaine (swab). For all cases, use of cocaine swab was not mentioned in the document filled by the police and by medical staff requested for blood and urine sampling. The information was obtained retrospectively after consultation of the medical records, without precise indication of the application time or dose. Case 1. A 83-year old man (pedestrian) was hit by a car. Blood (+11h after the accident): cocaine (16 μg/L), benzoylecgonine (370 μg/L). Urine: cocaine (1700 μg/L), benzoylecgonine (560 μg/L). Case 2. A 84-year old woman (pedestrian) was hit by a car. Blood (+1.5h after the accident): cocaine (230 μg/L), benzoylecgonine (370 μg/L). Urine was not available. Hair (+4 months after the accident): segment 1 (0-2 cm), cocaine not detected; segment 2 (2-4 cm), cocaine: <0.5 ng/mg. Case 3. A 66-year old man was involved in a car/car accident. He died 2 hours and 5 minutes after the crash. Blood (+1.5h after the accident): cocaine and metabolites not detected. Blood (+2h after the accident): cocaine (1750 μg/L), benzoylecgonine (460 μg/L). Blood (post-mortem): cocaine (370 μg/L), benzoylecgonine (200 μg/L). Urine (+1.5h after the accident): cocaine not detected. Case 4. A 57-year old woman on a motor scooter was hit by a car. She died 2 hours and 10 minutes after the crash. Blood (+0.5h after the accident): cocaine and metabolites not detected. Urine (post-mortem): cocaine (<20 μg/L), benzoylecgonine (120 μg/L). Case 5. A 30-year old man was involved in a car accident. Blood (+4h after the accident): cocaine (29 μg/L), benzoylecgonine (< 20 μg/L). Urine (+4h after the accident): cocaine and metabolites not detected. Ethanol (1,32 g/kg) and cannabinoids (THC (2,0 μg/L), THCCOOH (38 μg/L)) were also detected in blood. Conclusion: To our knowledge, this is the first description of DUID cases involving therapeutic use of cocaine after an accident. These results indicate that even if a per se law is effective for prosecution case of DUID, a critical interpretation of the results is always needed, especially if a medical intervention occurs after an accident.

Reduction des risques au cabinet du généraliste chez les consommateurs de cocaine: une perspective motivationnelle [Risk reduction among cocaine users: a motivational approach in the GP's office]

Today, cocaine use is a public health issue. Cocaine is a powerfully addictive stimulant drug which use is increasing among some part of the population. After a brief description of the physical and psychological effects of cocaine use, the article presents a motivational way for general practitioners to deal with risk-reduction issues. Based on the Transtheoretical Model of human behavior change and providing clinical examples, the article focuses particularly on the two earliest stages of change: "pre-contemplation" and "contemplation".

Involvement of the extracellular signal-regulated kinase cascade for cocaine-rewarding properties

A central feature of drugs of abuse is to induce gene expression in discrete brain structures that are critically involved in behavioral responses related to addictive processes. Although extracellular signal-regulated kinase (ERK) has been implicated in several neurobiological processes, including neuronal plasticity, its role in drug addiction remains poorly understood. This study was designed to analyze the activation of ERK by cocaine, its involvement in cocaine-induced early and long-term behavioral effects, as well as in gene expression. We show, by immunocytochemistry, that acute cocaine administration activates ERK throughout the striatum, rapidly but transiently. This activation was blocked when SCH 23390 [a specific dopamine (DA)-D1 antagonist] but not raclopride (a DA-D2 antagonist) was injected before cocaine. Glutamate receptors of NMDA subtypes also participated in ERK activation, as shown after injection of the NMDA receptor antagonist MK 801. The systemic injection of SL327, a selective inhibitor of the ERK kinase MEK, before cocaine, abolished the cocaine-induced ERK activation and decreased cocaine-induced hyperlocomotion, indicating a role of this pathway in events underlying early behavioral responses. Moreover, the rewarding effects of cocaine were abolished by SL327 in the place-conditioning paradigm. Because SL327 antagonized cocaine-induced c-fos expression and Elk-1 hyperphosphorylation, we suggest that the ERK intracellular signaling cascade is also involved in the prime burst of gene expression underlying long-term behavioral changes induced by cocaine. Altogether, these results reveal a new mechanism to explain behavioral responses of cocaine related to its addictive properties.

Sudden death and cocaine abuse

We read with great interest the results of the study by Lucena et al.(1) and present the following comments related to the paper. Lucena et al. presented a series of 21-cocaine-related sudden deaths (SD) showing two main structural abnormalities, cardiac hypertrophy and atherosclerotic coronary disease. Both abnormalities have been previously considered as a consequence of a chronic cocaine abuse, but could also be related to others cardiovascular risk factors, as admitted by Lucena et al.

Activin a inhibits antigen-induced allergy in murine epicutaneous sensitization.

Activin A, a member of the TGFβ superfamily, is involved in physiological processes such as cell differentiation, tissue homeostasis, wound healing, reproduction, and in pathological conditions, such as fibrosis, cancer, and asthma. Activin enhances mast cell maturation, as well as regulatory T-cell and Langerhans cell differentiation. In this study we investigated the potential role of activin in epicutaneous sensitization with ovalbumin (OVA), notably with respect to its effect on known Th2-polarization. For this purpose, transgenic mice overexpressing activin in keratinocytes and their wild-type (WT) controls were sensitized epicutaneously with OVA. Skin biopsies were analyzed with regard to histopathological features and mRNA expression of pro-inflammatory and Th1/Th2 cytokines, and Ig levels were measured in the serum. Unexpectedly, activin overexpressing animals were protected from Th2-cytokine expression and induction of OVA-specific IgE levels compared to WT animals. On the other hand, transgenic mice were more susceptible to inflammation compared to WT littermates after tape-stripping and saline (vehicle) or OVA application, as shown by increased pro-inflammatory cytokine mRNA levels and neutrophil accumulation at the site of the treatment. We conclude that activin protects from antigen-induced cutaneous Th2-polarization through modulation of the immune response. These findings highlight the role of activin in cutaneous sensitization, allergy, and in skin homeostasis.

Prevalence of beryllium sensitization in patients diagnosed with sarcoidosis

Occupational exposure to beryllium (Be) may lead to development of Be-specific CD4+ T-cell immune response and occurrence of a granulomatous disorder called chronic beryllium disease (CBD). Due to similar clinical pictures, CBD may be misdiagnosed as sarcoidosis if Be exposure (BeE) and Be sensitization (BeS) are not looked for. To determine whether some patients diagnosed as sarcoidosis may have undetected CBD, we screened a retrospective cohort of patients with sarcoidosis for BeE and BeS. BeE was assessed through a self-administered questionnaire and a standardized occupational health interview. BeS was assessed using CFSE flow cytometry developed as an alternative to the classical Be lymphocyte proliferation test (BeLPT). 159 patients recorded in a Swiss interstitial lung disease registry with a diagnosis of sarcoidosis were enrolled through their pulmonary physician and received a screening questionnaire. 68 filled questionnaires were returned. 28/68 patients had positive screening. 24/28 underwent an occupational health interview. BeE was considered probable in 6/24 and possible in 18/24. Using CFSE flow cytometry, BeS was detected in 7/24 of these patients (4/6 with probable BeE and 3/18 with possible BeE). BeS testing by CFSE flow cytometry was positive in 5/6 controls with proven CBD and positive BeLPT, and negative in 10 healthy subjects. Conclusions: the minimal rate of BeE and BeS in an unselected population of patients with sarcoidosis was 7/159 (4.4%), suggesting misdiagnosed CBD. A screening questionnaire could help to detect BeE in patients diagnosed with sarcoidosis, and prompt investigations in search of CBD. CFSE flow cytometry may be an alternative to BeLPT to document BeS.

Acute coronary syndrome after levamisole-adultered cocaine abuse

Cocaine is a well known trigger of acute coronary syndromes. Over the last 10 years levamisole, a veterinary anthelminthic drug has been increasingly used as an adulterant of cocaine. Levamisole was used to treat pediatric nephritic syndrome and rheumatoid arthritis before being withdrawn from the market due to its significant toxicity, i.e. hematological complications and vasculitis. The major complications of levamisole-adultered cocaine reported up to now are hematological and dermatological. The case reported here is of a 25 year old man with a history of cocaine abuse who died at home after complaining of retrosternal pain. Postmortem CT-angiography, autopsy, and chemical and toxicological analyses were performed. An eroded coronary artery plaque was found at the proximal segment of the left anterior descending coronary artery. Two myocardial infarct scars were present in the left ventricle. Microscopic examination of the coronary artery revealed infiltration of eosinophils into the adventitia and intima. Toxicological examination confirmed the presence of cocaine and its metabolites in the peripheral blood, and of levamisole in the urine and pericardial fluid. Eosinophilic inflammatory coronary artery pathologies have been clinically linked to coronary dissection, hypersensitivity coronary syndrome and vasospastic allergic angina. The coronary pathology in the presented case could be a complication of levamisole-adultered cocaine use, in which an allergic or immune-mediated mechanism might play a role. The rise in cocaine addiction worldwide and the increase of levamisole adulterated cocaine highlights the importance of updating our knowledge of the effects of adultered cocaine abuse.

Dual-energy CT behavior of heroin, cocaine, and typical adulterants.

PURPOSE: To investigate the dual-energy CT behavior of cocaine and heroin and of typical adulterants, and to evaluate the elemental composition of pure cocaine and heroin compared with cocaine and heroin in bodypacks. METHODS: Pure heroin and pure synthetic cocaine samples, eight different adulterants, and in each case ten different bodypacks containing cocaine or heroin, were imaged at 80, 100, 120, and 140 kVp in a dual source CT system at two different degrees of compression. Two radiologists, blinded to the samples, measured the attenuation. The dual-energy index (DEI) was calculated. We performed atomic mass spectrometry for the elemental analysis of pure cocaine, pure heroin, and heroin and cocaine in bodypacks, and 140 kVp in a dual-source CT system. RESULTS: Inter- and intra-observer agreement for attenuation measurements was good (r = 0.61-0.72; p < 0.01). The cocaine bodypacks had a positive DEI of 0.029, while the pure drugs and the heroin bodypacks had a negative DEI (-0.051 to -0.027). Levamisole was the only substance which expressed a positive DEI of 0.011, while the remaining adulterants had negative DEIs ranging between -0.015 and -0.215. Atomic mass spectrometry revealed a concentration of tin in the cocaine bodypack that was 67 times higher than in the pure synthetic cocaine sample. CONCLUSIONS: The different DEIs of bodypacks containing cocaine and heroin allow them to be distinguished with dual-energy CT. Although the material properties of pure cocaine, pure heroin, or common drug extenders do not explain the differences in DEI, tin contamination during illicit natural cocaine production may be a possible explanation.

Sensitization of endothelial cells to TNFα-induced death

RESUME L'angiogénèse tumorale est un processus essentiel au développement des tumeurs. Les intégrines, molécules d'adhésions transmembranaires, sont d'importants effecteurs de l'angiogenèse. En permettant l'adhésion à la matrice extra-cellulaire, les intégrines transmettant des signaux de survie, de migration, et de prolifération. Le facteur de nécrose tumorale α (TNFα) est utilisé pour le traitement régional de cancers chez l'homme. II agit en détruisant sélectivement les vaisseaux angiogéniques. Cependant, son administration systémique chez l'homme est limitée par les réactions de vaso-dilatation sévères qu'il provoque. Le but de mon travail fut de rechercher des conditions permettant la sensibilisation des cellules endothéliales au TNFα et qui pourraient être applicables en clinique, ceci afin d'accroître l'efficacité de cette molécule. Nous avons testé la possibilité d'interférer avec les signaux de survie provenant des intégrines. Pour cela, des cellules endothéliales furent cultivées dans des conditions d'adhésion ou en suspension, ou alors exposées dans des conditions d'adhésion au zoledronate (biphosphonate contenant du nitrogène). Dans ces conditions, les effets du TNFα sur les cellules endothéliales furent étudiés, en particulier l'induction de la mort cellulaire. Dans ce travail, nous montrons que le zoledronate sensibilise les cellules endothéliales à la nécrose induite par TNFα. Cet effet s'accompagne de l'inhibition de la phosphorylation de FAK, PKB, et JNK, ainsi que de l'inhibition de la prénylation des protéines. En revanche, l'activation de NF-kB et p38 n'est pas perturbée. La restoration de la prénylation des protéines empêche la mort des HUVEC traitées par zoledronate et TNFα, et rétablit la phosphorylation de FAK, PKB, et JNK. Des essais d'angiogénèse in vivo montrent que le zoledronate inhibe l'angiogénèse induite par FGF-2. Le zoledronate encapsulé dans des liposomes permet de ralentir la croissance tumorale et synergise avec le TNFα en l'inhibant. L'inihibtion de la prénylation des protéines est un des mécanismes de sensibilisation du zoledronate au TNFα. In vivo, la synergie de leur association sur la croissance tumorale est efficace. Ces résultats encouragent la poursuite de l'étude des effets de ces deux drogues sur la croissance tumorale. SUMMARY The formation of tumor-associated vessels is essential for tumor progression. Cell adhesion molecules of the integrin family are important mediators of angiogenesis, by providing adhesive signals necessary for endothelial cell migration, proliferation and survival. Anti-angiogenic therapies are currently considered as highly promising in the treatment of human cancer. Tumor Necrosis Factor α (TNFα) is used for the regional treatment of human cancer, whose mechanisms of action involved selective disruption of angiogenic tumor vessels. Systemic administration of TNFα in humans, however, induces a severe inflammatory condition that prevents its use far the treatments of tumors localized outside of limbs. The aim of my work was to find strategies to sensitize angiogenic endothelial cells to TNFα-induced death, which could be potentially translated into clinical setting to improve the therapeutic efficacy of TNFα. We specifically tested the hypothesis whether interference with integrin-mediated adhesion and signaling may sensitize endothelial cells to TNFα-induced death. To test this hypothesis we cultured endothelial cells (EC) under conditions of cell-matrix or cell-cell adhesion or exposed matrix-adherent EC to the nitrogen-containing bisphosphonate zoledronate, and characterized the effect on TNFα-mediated signaling events and cell death. We show that zoledronate sensitizes HUVEC to TNFα-induced necrosis-like programmed cell death. This effect was associated with suppression of sustained phosphorylation of PKB and JNK and decreased protein prenylation, whereas TNFα-induced activation of NF-kB and p38 were not inhibited. Restoration of protein prenylation rescued HUVEC from zoledronate and TNFα-induced death, and restored FAK, PKB and JNK phosphorylation. By using in vivo angiogenesis assay we showed that zoledronate suppressed FGF-2-induced angiogenesis. Liposome-encapulated zoledronate partially inhibited tumor growth and synergized with TNFα to fully suppress tumor growth. Taken together, this work has identified protein prenylation as a mechanisms by which zoledronate sensitizes endothelial cells to TNFα-induced death in vitro and provides initial evidence that zoledronate synergizes with TNFα in vivo resulting in improved anti-tumor activity. These results warrant further study of the anti-tumor effects of zoledronate and TNFα and should be further studies in view of their clinical relevance.

Silicon nanocluster sensitization of erbium ions under low-energy optical excitation

The sensitizing action of amorphous silicon nanoclusters on erbium ions in thin silica films has been studied under low-energy (long wavelength) optical excitation. Profound differences in fast visible and infrared emission dynamics have been found with respect to the high-energy (shortwavelength) case. These findings point out to a strong dependence of the energy transfer process on the optical excitation energy. Total inhibition of energy transfer to erbium states higher than thefirst excited state (4I13/2) has been demonstrated for excitation energy below 1.82 eV (excitation wavelength longer than 680 nm). Direct excitation of erbium ions to the first excited state (4I13/2)has been confirmed to be the dominant energy transfer mechanism over the whole spectral range of optical excitation used (540 nm¿680 nm).