Louisiana State University Health Sciences Research Articles

Association of ABO blood groups with risk factors of intracranial cerebral aneurysm formation

Introduction: The association between ABO blood groups and intracranial aneurysms is not well-understood. Many co-morbid factors are associated with intracranial aneurysms. The prevalence of different blood groups and associations with the risk factors in patients with intracranial aneurysms are reviewed. Methodology: A retrospective analysis was conducted on patients presenting with intracranial aneurysms and undergoing active neurosurgical intervention at the Louisiana State University Health Sciences Center between 1 st January 1993 and 31 st December 2012. A total of 1248 patients were identified for the analysis. Data pertaining to demographics and clinical characteristics of these patients were extracted from the electronic patient records by two authors independently. A univariate and multivariate analysis was performed to investigate the association of ABO blood groups with risk factors in patients with intracranial aneurysms. Results: The most common ABO blood group in our study population was O (543 cases, 43.5%), followed by group A (525 cases, 42%). Blood group A (46% vs. 35.5% patients; P = 0.01) and blood group B (18% vs. 7% patients; P = 0.000) were significantly associated with the development of intracranial aneurysms in Caucasians and African Americans, respectively. We found smoking (P = 0.01) and hypercholesterolemia (P = 0.006) to be an independent risk factor for the development of intracranial aneurysms in blood group O and blood group A, respectively . Conclusion: Racial disparity in the distribution of blood groups and risk factor association with blood groups in the development of intracranial aneurysm needs to be considered. The findings from our study may be useful in identifying patients at increased risk of developing intracranial aneurysms.

Serum Biomarkers in Head and Neck Squamous Cell Cancer

Serum biomarkers may be useful in the evaluation of suspected head and neck squamous cell cancer (HNSCC) and as indicators of treatment success or failure in adjuvant and chemopreventive clinical trials. To determine serum cytokine and chemokine concentrations altered in patients with HNSCC compared with healthy volunteers to identify potential biomarkers. A retrospective experimental laboratory study at Feist-Weiller Cancer Center, Louisiana State University Health Sciences Center, Shreveport. Serum samples from 50 patients with stages II, III, and IV HNSCC and 20 healthy volunteers were available for study. Primary tumor sites represented in the patient group included the nasal cavity, oral cavity, oropharynx, hypopharynx, and larynx. Following institutional review approval and written informed consent, blood samples were drawn from patients. No intervention, to include any kind of diagnostic workup or treatment, was provided to patients during the course of this study. The main outcome measures were the quantification of cytokine and chemokine concentrations in serum samples. Luminex multiplex panel technology was used for simultaneous measurement of 18 analytes, including fibroblast growth factor 2, granulocyte-macrophage colony-stimulating factor, growth-related oncogene, interferon (IFN)-γ, interleukin (IL)-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, inducible protein (IP)-10, soluble CD40 ligand, tumor necrosis factor, and vascular endothelial growth factor. The serum samples of patients with HNSCC contained lower levels of IFN-γ (mean patient serum level, 6.08 pg/mL, compared with the mean control level, 26.20 pg/mL; P = .004), IL-13 (mean patient serum level, 2.85 pg/mL, compared with the control mean level, 7.23 pg/mL; P = .02), and macrophage inflammatory protein-1β (MIP-1β) (mean patient serum level, 14.91 pg/mL, compared with the mean control level, 28.98 pg/mL; P = .004), and elevated levels of IP-10 (mean patient serum level, 359.24 pg/mL, compared with mean control level, 216.40 pg/mL; P = .04). All other markers tested were not significantly different between patients with cancer and controls. This pilot study demonstrated a significant decrease in serum IFN-γ, IL-13, and MIP-1β levels and a significant elevation of serum IP-10 concentration in patients with HNSCC, irrespective of primary tumor site. If validated in larger, independent studies, these serum biomarkers may be useful in the diagnosis and treatment of HNSCC. In the future, a defined, multianalyte screening panel could facilitate early diagnosis of HNSCC, allowing for earlier treatment and thereby reducing patient mortality.

Recent Advances in Otolaryngology Head and Neck Surgery, Vol. 2, Anil K Lalwani, Markus HF Pfister. New Delhi, India

Fellow, Otology, Neurotology and Skull Base Surgery, Louisiana State University Health Science Center, New Orleans and Our Lady of the Lake Hearing, and Balance Center, Baton Rouge, Louisiana, U.S.A. Otology, Neurotology and Skull Base Surgery, Louisiana State University Health Science Center, New Orleans and Our Lady of the Lake Hearing, and Balance Center, Baton Rouge, Louisiana, U.S.A. The authors disclose no conflicts of interest.

Acute alcohol intoxication increases lymphatic permeability and promotes a perilymphatic adipose tissue inflammatory milieu

Acute alcohol intoxication increases lymphatic permeability and promotes a perilymphatic adipose tissue inflammatory milieu

Resveratrol Exacerbates Both Autoimmune and Viral Models of Multiple Sclerosis

The polyphenol compound resveratrol is reported to have multiple functions, including neuroprotection, and no major adverse effects have been reported. Although the neuroprotective effects have been associated with sirtuin 1 activation by resveratrol, the mechanisms by which resveratrol exerts such functions are a matter of controversy. We examined whether resveratrol can be neuroprotective in two models of multiple sclerosis: experimental autoimmune encephalomyelitis (EAE) and Theiler's murine encephalomyelitis virus-induced demyelinating disease (TMEV-IDD). EAE was induced in C57BL/6 mice, which were fed a control diet or a diet containing resveratrol during either the induction or effector phase or through the whole course of EAE. SJL/J mice were infected with TMEV and fed a control diet or a diet containing resveratrol during the chronic phase of TMEV-IDD. In EAE, all groups of mice treated with resveratrol had more severe clinical signs than the control group. In particular, resveratrol treatment during the induction phase resulted in the most severe EAE, both clinically and histologically. Similarly, in the viral model, the mice treated with resveratrol developed significantly more severe TMEV-IDD than the control group. Thus, surprisingly, the resveratrol treatment significantly exacerbated demyelination and inflammation without neuroprotection in the central nervous system in both models. Our findings indicate that caution should be exercised in potential therapeutic applications of resveratrol in human inflammatory demyelinating diseases, including multiple sclerosis.

Middle Ear and Mastoid Microsurgery, 2nd Edition,Mario Sanna, Hiroshi Sunose, Fernando Mancini, Alessandra Russo, Abdelkader Taibah, Maurizio Falcinoi. 2nd ed. New York, NY

Otology and Neurotology, Louisiana State University Health Science Center New Orleans and, Our Lady of the Lake Hearing and Balance Center, Baton Rouge, Louisiana, U.S.A. The author discloses no conflicts of interest.

The Impact of ICD-10 on Pain Management Practice

Dr. Gevirtz is Associate Professor of Anesthesiology, Louisiana State University Health Sciences Center, New Orleans, LA, and Medical Director, Somnia Pain Management, 627 West St, Harrison, New York, NY 10528; E-mail: [email protected]. All faculty and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This activity expires on July 31, 2014.

Gonorrhea Positivity in New Orleans Public High Schools, 1996 to 2005

To the Editors The US Preventive Services Task Force recommends screening all sexually active women for gonorrhea if they are young or have other individual or population risk factors for infection.1 Individual risk factors depend on the local epidemiology of gonorrhea, and population risk factors include residence in urban communities and communities with high rates of poverty.1,2 Gonorrhea rates are higher among adolescents. In 2011, the US rates of reported cases of gonorrhea per 100,000 populations were 98.7 in men and 108.9 in women; among individuals aged 15 to 19 years, these rates were 248.6 in men and 556.5 in women.3 The state of Louisiana reported 545.4 and 1242.0 gonorrhea cases per 100,000 populations in men and women aged 15 to 19 years.3 In 2010, 97% of adolescents aged 14 to 17 years were enrolled in US schools.4 Although the US Preventive Services Task Force does not recommend screening men for gonorrhea for insufficient evidence,1 available evidence clearly makes Louisiana adolescent boys and girls candidates for gonorrhea screening,2,3 and schools are an ideal place to find adolescents.4 From school years 1996 to 1997 to 2004 to 2005, between 1545 (1996–1997) and 6078 (1999–2000) 9th through 12th grade students in New Orleans public schools (age, 14–24 years; mean, 16.7 years; median, 17.0 years) provided urine specimens that were tested for both chlamydia and gonorrhea (LCx Chlamydia trachomatis Assay and LCx Neisseria gonorrhoeae Assay [Abbott Park, IL] until 1999–2000; BDProbeTec ET C. trachomatis and N. gonorrhoeae Amplified DNA Assays [Sparks, MD] thereafter) in a school-wide chlamydia screening program.5 The average 9-year gonorrhea positivity was 1.2% (184/14,988; 95% confidence interval [CI], 1.1%–1.4%) in men and 3.3% (478/14,343; 95% CI, 3.0%–3.6%) in women (P < 0.001). Positivity ranged between 0.8% (24/3084; 1999–2000) and 2.0% (23/1179; 2002–2003) in men and between 2.2% (42/1944; 1997–1998) and 4.8% (67/1399; 2000–2001) in women. In sex-specific multivariate logistic regression analyses with age, race, laboratory assay, school year, and chlamydia test results as covariates (Table 1), gonorrhea positivity in men was significantly associated with age (P = 0.01) and with chlamydia positivity (P < 0.001). In women, gonorrhea positivity was associated significantly only with chlamydia positivity (P < 0.001). The odds of gonorrhea positivity increased in aging women (adjusted odds ratio [AOR], 1.08; 95% CI, 1.00–1.16; P = 0.05) and in African American men (AOR, 2.55; 95% CI, 0.35–18.45; P = 0.36) and women (AOR, 5.59; 95% CI, 0.78–40.14; P = 0.09), although the increases did not achieve significance levels of P < 0.05, partly because of the relatively lower baseline gonorrhea positivity among students who were tested. Gonorrhea positivity did not vary significantly over time (P > 0.16).TABLE 1: Multivariate Logistic Regressions of Gonorrhea Positivity Between 1996 and 2005The lack of significant differences in gonorrhea positivity between 1996 and 2005 reflected endemic and stable prevalence of gonorrhea among New Orleans school-aged adolescents. The morbidity associated with N. gonorrhoeae,6 its role in facilitating sexual transmission of HIV,7 and emerging resistance to antibiotics used against it8 dictate that its public health impact and population distributions be continuously monitored. Diagnostic tests that simultaneously detect C. trachomatis and N. gonorrhoeae in the same specimen9 would allow chlamydia screening programs to detect N. gonorrhoeae in populations that otherwise would not be tested for gonorrhea for lack of clear gonorrhea screening guidelines. Musheni Nsa, MD Department of Pediatrics Our Lady of the Lake Regional Medical Center Baton Rouge, LA Ngozi C. Mezu-Patel, MD David H. Martin, MD Stephanie N. Taylor, MD M. Jacques Nsuami, MD, MPH Department of Medicine Louisiana State University Health Sciences Center New Orleans, LA [email protected]

The Brucella abortus General Stress Response System Regulates Chronic Mammalian Infection and Is Controlled by Phosphorylation and Proteolysis

Virulence of pathogenic bacteria is often determined by their ability to adapt to stress. The Brucella abortus general stress response (GSR) system is required for chronic mammalian infection and is regulated by phosphorylation and proteolysis. The B. abortus GSR signaling pathway has multiple layers of post-translational control and is a determinant of chronic infection. This study provides new, molecular level insight into chronic Brucella infection. Brucella spp. are adept at establishing a chronic infection in mammals. We demonstrate that core components of the α-proteobacterial general stress response (GSR) system, PhyR and σ(E1), are required for Brucella abortus stress survival in vitro and maintenance of chronic murine infection in vivo. ΔphyR and ΔrpoE1 null mutants exhibit decreased survival under acute oxidative and acid stress but are not defective in infection of primary murine macrophages or in initial colonization of BALB/c mouse spleens. However, ΔphyR and ΔrpoE1 mutants are attenuated in spleens beginning 1 month postinfection. Thus, the B. abortus GSR system is dispensable for colonization but is required to maintain chronic infection. A genome-scale analysis of the B. abortus GSR regulon identified stress response genes previously linked to virulence and genes that affect immunomodulatory components of the cell envelope. These data support a model in which the GSR system affects both stress survival and the interface between B. abortus and the host immune system. We further demonstrate that PhyR proteolysis is a unique feature of GSR control in B. abortus. Proteolysis of PhyR provides a mechanism to avoid spurious PhyR protein interactions that inappropriately activate GSR-dependent transcription. We conclude that the B. abortus GSR system regulates acute stress adaptation and long term survival within a mammalian host and that PhyR proteolysis is a novel regulatory feature in B. abortus that ensures proper control of GSR transcription.

Prophylactic neck dissection in papillary thyroid cancer: When is it necessary?

BACKGROUND The American Cancer Society estimates that there will be approximately 56,460 new diagnoses of thyroid cancer in the United States during 2012, and more than 90% will be papillary thyroid cancer (PTC). Despite the large, ever-increasing number of thyroid cancer cases, the ideal initial management of well-differentiated PTC remains controversial. The role of the prophylactic central neck dissection (pCND) has emerged as the most highly debated topic, with conflicting reports regarding indications, recurrence prevention, and reduction of cause-specific mortality. Currently, there is no argument that a formal, compartmental CND should be performed if preoperative or palpable nodal disease is encountered. However, the 2009 American Thyroid Association (ATA) guidelines state that, “Prophylactic central compartment neck dissection may be performed in patients with papillary thyroid carcinoma with clinically uninvolved central neck lymph nodes, especially for advanced primary tumors (T3 or T4; Grade C recommendation; expert opinion).” With the advent of personalized therapy based on molecular testing, the BRAF gene has shown the most promise in predicting lymph node metastases and may be used to direct clinicians on whether to perform a pCND. The focus of the review will seek to answer the question of best practice with regards to pCND in PTC. LITERATURE REVIEW Due to the excellent outcomes seen with PTC, the importance of lymph node metastases has been difficult to interpret. Recent, large, population-based studies have demonstrated a decrease in cause-specific survival in lymph-node positive PTC patients. Zaydfudim et al. used the Surveillance, Epidemiology, and End Results database to analyze outcomes of 30,054 patients with PTC. They concluded through multivariate analysis that metastatic LNs conveyed a 46% increased risk of death (HR, 1.46; P<.001) in patients 45 years, even with the majority of patients with excellent long-term survival. However, in patients< 45, lymph node status did not influence survival. While the presence of metastatic positive lymph nodes in PTC may dictate a decrease in cause-specific survival, does performing a prophylactic central neck dissection actually improve the patient’s outcome? A meta-analysis of five studies with a total of 1,264 patients demonstrated a decrease in lymph node recurrence (2% vs. 3.9%) in the thyroidectomy1pCND group, but this did not achieve statistical significance. The rate of transient recurrent laryngeal nerve paralysis (1.8%–5.4% thyroidectomy1pCND, 1%–1.3% thyroidectomy alone) and transient hypoparathyroidism (18%– 44% thyroidectomy1pCND, 8%–14% thyroidectomy alone (P< 0.02)) was higher in the group receiving pCND. Permanent recurrent nerve paralysis and hypocalcemia were not different between the two arms. The authors concluded that the balance between the risks and benefits favored thyroidectomy alone. However, they recognized several limitations to the study: inclusion of retrospective data, inconsistencies in the use of RAI and thyroid suppression postoperatively, limited data on timing of recurrence, and a lack of standardized reporting with regard to the extent of central neck dissection (ipsilateral vs. bilateral, etc.). The authors conclude with the call for a large, prospective trial to fully resolve the controversy. However, the feasibility of such a randomized trial was investigated by the ATA, which concluded that prohibitively large sample sizes (5,840 patients) and approximately $20 million would be required to demonstrate significant differences in outcomes. From the Louisiana State University Health Sciences Center– Shreveport, Department of Otolaryngology/Head and Neck Surgery, Shreveport, Louisiana, U.S.A.

Visual Diagnosis: A 3-month-old Male With Wheezing

1. Kamakshya P. Patra, MD 2. Suman Shekar, MD 3. Robert D. Jackson, MD 4. Ernest A. Kiel, MD 5. Jon D. Wilson, MD 1. Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA. A 3-month-old boy presents to the emergency department with difficulty breathing and wheezing for the past week. His medical history is notable for being born at term via normal vaginal delivery, followed by an uneventful neonatal period. There is a family history of asthma in both parents. The patient’s mother has recently recovered from a viral upper respiratory tract infection. On physical examination, the infant’s vital signs include a temperature of 99°F, heart rate of 192 beats per minute, respiratory rate of 77 breaths per minute, blood pressure of 50/36 mm Hg, and 95% oxygen saturation in room air. The extremities are cool to touch, the peripheral pulses are thready, and the capillary refill time is 5 seconds. A gallop rhythm and a grade 3/6 holosystolic murmur with radiation to the left axilla are present. There are bibasilar crackles and wheezes. The liver edge is palpable 5 cm below the right costal margin, with a total span of 8 cm. There is generalized hypotonia and head lag. There are no obvious facial abnormalities. The rest of his physical findings are normal. A chest radiograph shows an enlarged cardiac silhouette (Fig 1). Complete blood cell count and metabolic profile results are normal for age. The serum creatine kinase level is elevated at 438 U/L (normal: 22–198 U/L). Electrocardiography demonstrates a short PR interval with tall and broad QRS complexes (Fig 2). Figure 1. Chest radiograph demonstrates a large cardiac silhouette. Figure 2. Electrocardiogram demonstrates high-voltage QRS complexes and shortened PR intervals. Further tests confirm the suspected underlying diagnosis. Doppler echocardiography demonstrated severe mitral regurgitation and a concentric, hypertrophied left ventricle (Fig …

Gene Therapy to Restore Hearing

ene therapy restored hearing in a mouse model of human hereditary deafness, reports a team led by researchers at the Louisiana State University Health Sciences Center, in New Orleans, and the Rosalind Franklin University of Medicine and Science, in North Chicago, Ill

Curcumin Inhibits UV Radiation–Induced Skin Cancer in SKH‐1 Mice

As skin cancer incidence increases, research has focused on novel chemopreventive agents that inhibit tumor formation. In prior experimentation, curcumin, a naturally occurring food substance and anticarcinogenic agent, inhibited cutaneous squamous cell carcinoma xenograft growth. We hypothesize curcumin will inhibit UVB radiation-induced skin cancer growth in mice, approximating a human chemopreventive model. Randomized experimental animal and laboratory study. Louisiana State University Health Sciences Center-Shreveport, Louisiana. SKH-1 mice were pretreated with oral or topical curcumin or oral or topical control (n = 11/group) for 14 days. Mice received UVB radiation 3 times weekly for 24 weeks or were not radiated. Number of tumors formed and time to tumor onset for each mouse were recorded through tumor harvest after week 24. Tumor multiplicity and time to tumor onset were compared. Time to tumor onset was significantly shorter in control mice compared to mice receiving either oral (P = .025) or topical (P = .015) curcumin. A significant difference in the average number of tumors formed per mouse was seen, as fewer tumors were formed in the oral curcumin (P = .01) and topical curcumin (P = .01) groups, compared with respective controls. No significant difference in average number of tumors per mouse was seen between oral and topical curcumin (P = .56), suggesting that both routes were equally effective. Curcumin appears to inhibit skin cancer formation and prolong time to tumor onset when administered by either an oral or topical route. These data suggest that curcumin may have chemopreventive potential against skin cancer, necessitating future experimentation with human subjects.

Hearing Aids, Second Edition , Harvey Dillon; Thieme, New York, 2012

Louisiana State University Health Science Center New Orleans, Our Lady of the Lake Hearing and Balance Center, Baton Rouge and CNC Hearing and Balance Center, New Orleans, Louisiana, U.S.A. [email protected] The author discloses no conflict of interest.

Diabetic and non-diabetic human cornea and tear &amp;gamma;-glutamyl transpeptidase activity

BackgroundDiabetes-related eye disease is due in part to oxidative stress. Gamma-glutamyl transpeptidase (GGT) is a γ-glutamyl cycle enzyme that protects against oxidative stress via glutathione recapture. This study investigates corneal and Schirmer tears GGT activity in diabetic and non-diabetic adults aged 50 to 83 years old.MethodsGGT activity was determined by colorimetric assay on 50 corneas from 14 diabetic (without keratopathy) and 20 non-diabetic donors and on Schirmer type 1 test strips (no anesthesia) of 14 diabetic and 14 non-diabetic subjects.ResultsType 1 (T1) diabetic cornea GGT activity was 40% lower than Type 2 (T2) diabetic cornea GGT activity (P = 0.04), but GGT activity was similar for corneas (without keratopathy) from diabetic and non-diabetic donors (P ≥ 0.44 for all). The number of endothelial cells/unit of GGT activity in diabetic corneas was 22% higher (P = 0.1) than in non-diabetic corneas. GGT activity per Schirmer strip and GGT activity per mm of tears were 36% and 50% higher (P ≤ 0.008 for all) for non-diabetic (tear volume dependent) than diabetic donors (tear volume independent), respectively. GGT activity per mm was 50% lower in T1 than T2 diabetics (P = 0.02). Higher tear GGT activity in non-diabetic than diabetic females (P ≤ 0.05) was due to higher GGT activity in the African American females.ConclusionGGT activity was less in T1 than T2 diabetics, but comparable to non-diabetic corneas. Schirmer tear GGT activity in diabetic eyes was tear volume independent, less in T1 than T2, lower than in tear volume dependent, non-diabetic female eyes. Low cornea and tear GGT activity suggests loss of antioxidant potential and supports ocular antioxidant therapy for diabetic patients.

Cholesteatoma

Louisiana State University Health Science Center New Orleans and Hearing and Balance Center Our Lady of the Lake Regional Medical Center, Baton Rouge and Director CNC Hearing and Balance Center New Orleans, Louisiana, U.S.A. The author discloses no conflicts of interest.

Duus’ Topical Diagnosis in Neurology

Louisiana State University Health Sciences Center New Orleans New Orleans, U.S.A. The authors disclose no conflicts of interest.

Minocycline Blocks Asthma-associated Inflammation in Part by Interfering with the T Cell Receptor-Nuclear Factor κB-GATA-3-IL-4 Axis without a Prominent Effect on Poly(ADP-ribose) Polymerase

Minocycline protects against asthma independently of its antibiotic function and was recently reported as a potent poly(ADP-ribose) polymerase (PARP) inhibitor. In an animal model of asthma, a single administration of minocycline conferred excellent protection against ovalbumin-induced airway eosinophilia, mucus hypersecretion, and Th2 cytokine production (IL-4/IL-5/IL-12(p70)/IL-13/GM-CSF) and a partial protection against airway hyperresponsiveness. These effects correlated with pronounced reduction in lung and sera allergen-specific IgE. A reduction in poly(ADP-ribose) immunoreactivity in the lungs of minocycline-treated/ovalbumin-challenged mice correlated with decreased oxidative DNA damage. The effect of minocycline on PARP may be indirect, as the drug failed to efficiently block direct PARP activation in lungs of N-methyl-N'-nitro-N-nitroso-guanidine-treated mice or H(2)O(2)-treated cells. Minocycline blocked allergen-specific IgE production in B cells potentially by modulating T cell receptor (TCR)-linked IL-4 production at the mRNA level but not through a modulation of the IL-4-JAK-STAT-6 axis, IL-2 production, or NFAT1 activation. Restoration of IL-4, ex vivo, rescued IgE production by minocycline-treated/ovalbumin-stimulated B cells. IL-4 blockade correlated with a preferential inhibition of the NF-κB activation arm of TCR but not GSK3, Src, p38 MAPK, or ERK1/2. Interestingly, the drug promoted a slightly higher Src and ERK1/2 phosphorylation. Inhibition of NF-κB was linked to a complete blockade of TCR-stimulated GATA-3 expression, a pivotal transcription factor for IL-4 expression. Minocycline also reduced TNF-α-mediated NF-κB activation and expression of dependent genes. These results show a potentially broad effect of minocycline but that it may block IgE production in part by modulating TCR function, particularly by inhibiting the signaling pathway, leading to NF-κB activation, GATA-3 expression, and subsequent IL-4 production.

A Trip on “Bath Salts” Is Cheaper Than Meth or Cocaine But Much More Dangerous

BATH SALTS, THE PSYCHOACTIVE DEsigner street drugs that emerged in the United States in 2010, have left a trail of bizarre and alarming reports: the man who slashed himself to remove the “wires” in his body; the mother who left her “demon-ridden” 2-year-old in the middle of a highway; the 21-year-old son of a family physician who, after snorting bath salts once, shot himself following 3 days of acute paranoia and psychosis, including hallucinations of police squad cars and helicopters lined up outside his house to take him away. The fine powder in small packets doesn’t even resemble the large crystals intended for a soak in the tub. The drug merely borrows the name of an innocuous product so it can be sold openly. “Take all the bad attributes of ecstasy, PCP, LSD, cocaine, methamphetamine: lump them together, and that’s what you get with bath salts,” says Mark Ryan, PharmD, director of the Louisiana Poison Center and assistant professor of clinical emergency medicine at Louisiana State University Health Sciences Center in Shreveport. In late 2010, as Chinese suppliers began shipping the raw ingredients of illicit bath salts to the Port of New Orleans, Ryan found himself at the center of a widening outbreak of cases of intoxication from what he calls “the worst drug I’ve seen in 20 years.” By December 2010, the American Association of Poison Control Centers reported 304 cases of bath salts intoxication across the country. In 2011, poison centers fielded 6138 calls from hospital emergency departments for advice on how to treat bath salts abuse. SoldundernamessuchasWhiteLightning, Cloud 9, or Ivory Wave, bath salts represent a category of illicit drug that typically contains combinations of various synthetic cathinones, including3,4methylenedioxypyrovalerone (MDPV), mephedrone,andmethylone.Peoplewere abusing a synthetic cathinone in Russia and eastern Europe for several decades before the drug appeared in western Europe and the United Kingdom in the 2000s.Andcathinone,analkaloidderived from east Africa’s khat plant, has been chewed by people for hundreds of years for its stimulant effect. Promoted as providing a “legal high” that can escape detection in drug tests, bath salts are intended to mimic the hallucinogenic and euphoric highs of methamphetamine or cocaine. At lower doses, they’ve also been marketed as a substitute for methylphenidate (Ritalin) to sharpen mental concentration and as an aphrodisiac. Adding to the attraction is the cheap price; a 200-mg package of bath salts—which may be 3 hits—sells for as little as $15 to $20. “Bath salts are basically amphetamine derivatives and carry all the same cardiovascular risks,” which include hypertension, tachycardia, hyperthermia, diaphoresis, seizures, arrhythmias, and respiratory distress, says Louis Nelson, MD, professor of emergency medicine, New York University School of Medicine, New York City. “And they can be deadly for people with underlying cardiovascular disease.” Cases of myocardial infarction, stroke, cerebral edema, coma, cardiovascular collapse, and death have been reported in people using bath salts. The effects of the drugs also vary based on the route of administration; they can be swallowed, snorted, injected, or inserted into the rectum or vagina.

Differential Diagnosis in Otolaryngology–Head and Neck Surgery

Department of Otolaryngology–Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana, U.S.A. [email protected] The author discloses no conflict of interest.