Database : MEDLINE
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[PMID]: 29524782
[Au] Autor:Nagasaka H; Hirano KI; Yorifuji T; Komatsu H; Takatani T; Morioka I; Hirayama S; Miida T
[Ad] Address:Department of Pediatrics, Takarazuka City Hospital, Takarazuka, Japan. Electronic address: Nagasaka@cnt-osaka.com.
[Ti] Title:Treatment with medium chain fatty acids milk of CD36-deficient preschool children.
[So] Source:Nutrition;50:45-48, 2017 Nov 29.
[Is] ISSN:1873-1244
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:OBJECTIVE: CD36 deficiency is characterized by limited cellular long chain fatty acid uptake in the skeletal and cardiac muscles and often causes energy crisis in these muscles. However, suitable treatment for CD36 deficiency remains to be established. The aim of this study was to evaluate the clinical and metabolic effects of medium chain triacylglycerols (MCTs) in two CD36-deficient preschool children who often developed fasting hypoglycemia and exercise-induced myalgia. METHODS: Fasting blood glucose, total ketone bodies, and free fatty acids were examined and compared for usual supper diets and for diets with replacement of one component with 2 g/kg of 9% MCT-containing milk (MCT milk). Changes in serum creatine kinase and alanine aminotransferase levels, resulting from replacement of glucose water intake with 1 g/kg of MCT milk and determined by using bicycle pedaling tasks, were examined and compared. Hypoglycemic and/or myalgia episodes in daily life were also investigated. RESULTS: Biochemically, participants' blood glucose and total ketone bodies levels after overnight fasting substantially increased after dietary suppers containing MCT milk. Increases in serum creatine kinase and alanine aminotransferase levels resulting from the bicycle pedaling task were suppressed by MCT milk. Hypoglycemia leading to unconsciousness and tachycardia before breakfast decreased after introduction of dietary suppers containing MCT milk. Occurrence of myalgia in the lower limbs also decreased after intakes of MCT milk before long and/or strenuous exercising. CONCLUSION: Our results suggest that MCTs can prevent fasting hypoglycemia and exercise-induced myalgia in CD36-deficient young children.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180310
[Lr] Last revision date:180310
[St] Status:Publisher

  2 / 67475 MEDLINE  
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[PMID]: 29506499
[Au] Autor:Braun U; Warislohner S; Torgerson P; Nuss K; Gerspach C
[Ad] Address:Department of Farm Animals, Vetsuisse-Faculty, University of Zurich, Winterthurerstrasse 260, CH-8057, Zurich, Switzerland. ubraun@vetclinics.uzh.ch.
[Ti] Title:Clinical and laboratory findings in 503 cattle with traumatic reticuloperitonitis.
[So] Source:BMC Vet Res;14(1):66, 2018 Mar 05.
[Is] ISSN:1746-6148
[Cp] Country of publication:England
[La] Language:eng
[Ab] Abstract:BACKGROUND: The study evaluated the results of clinical examination and haematological and serum biochemical analyses in 503 cattle with traumatic reticuloperitonitis (TRP). RESULTS: The most common clinical findings were abnormal demeanour and general condition (87%), decreased rumen motility (72%), poorly digested faeces (57%), decreased rumen fill (49%), fever (43%) and tachycardia (26%). In 58% of the cattle, at least one of three tests for reticular foreign bodies (pinching of the withers, pressure on the xiphoid and percussion of the abdominal wall) was positive, and in 42% all three tests were negative. The most common haematological findings were decreased haematocrit in 45% of cattle and leukocytosis in 42%. An increase in the concentration of fibrinogen in 69% of cattle and total protein in 64% were the main biochemical findings. The glutaraldehyde test time was decreased with coagulation occurring within 6 min in 75% of cattle. CONCLUSIONS: In many cases, a diagnosis of TRP is not possible based on individual clinical or laboratory findings because even the most common abnormalities are not seen in all cattle with TRP.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180311
[Lr] Last revision date:180311
[St] Status:In-Process
[do] DOI:10.1186/s12917-018-1394-3

  3 / 67475 MEDLINE  
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[PMID]: 29491344
[Au] Autor:Pfirman KS; Haile R
[Ad] Address:Department of Medical Education, Camden Clark Medical Center, Parkersburg, WV, USA.
[Ti] Title:Intracardiac Abscess and Pacemaker Lead Infection Secondary to Hematogenous Dissemination of Methicillin-Sensitive Staphylococcus Aureus from a Prior Diabetic Foot Ulcer and Osteomyelitis.
[So] Source:Am J Case Rep;19:224-228, 2018 Mar 01.
[Is] ISSN:1941-5923
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:BACKGROUND Intracardiac abscesses are an unusual occurrence in developed countries. With the increase in use of implantable cardiac devices, the increase use of and advancements in antibiotics, and the longevity of patients with cardiac devices, one may expect an increase in such infections; however, case reports are rare. We are presenting a case in which hematogenous dissemination of methicillin-sensitive Staphylococcus aureus (MSSA) infection from a lower extremity diabetic ulcer propagated into an infected pacemaker lead and ultimately an intracardiac abscess of the right atrium. CASE REPORT A 77-year-old male with a history of MSSA diabetic foot infection complicated by osteomyelitis presented with fever, syncope, and wide complex tachycardia, and he was found to have an intracardiac abscess and fibrinous lead vegetations. The patient was deemed too ill for invasive surgical intervention given his comorbidities, pacemaker generator replacement requirement, and intermittent ventricular tachycardia. The patient was subsequently sent home with oral antibiotics and home hospice per patient and family wishes. CONCLUSIONS This case demonstrated how hematogenous dissemination of MSSA infections from a diabetic foot ulcer and osteomyelitis can seed pacemaker hardware resulting in an intracardiac abscess. Unfortunately, our patient was too ill to undergo all procedures required to eradicate the abscess and infected pacemaker hardware. The standard of care would be complete hardware removal. Conservative management would include indefinite or prolonged antibiotic therapy, with the notion that intracardiac abscesses cannot be cured with antibiotics alone. This conservative management approach would be deemed necessary in a select population that cannot undergo surgical intervention.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180311
[Lr] Last revision date:180311
[St] Status:In-Process

  4 / 67475 MEDLINE  
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[PMID]: 29448015
[Au] Autor:Johnson LSB; Persson AP; Wollmer P; Juul-Möller S; Juhlin T; Engström G
[Ad] Address:Skåne University Hospital, Department of Clinical Sciences, Malmö, Lund University, Lund, Sweden. Electronic address: linda.johnson@med.lu.se.
[Ti] Title:Irregularity and lack of p waves in short tachycardia episodes predict atrial fibrillation and ischemic stroke.
[So] Source:Heart Rhythm;, 2018 Feb 13.
[Is] ISSN:1556-3871
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:BACKGROUND: Atrial fibrillation (AF) is defined as an irregular supraventricular tachycardia (SVT) without p waves, with duration >30 seconds. Whether AF characteristics during short SVT episodes predict AF and stroke is not known. OBJECTIVE: The purpose of this study was to determine whether irregularity and lack of p waves, alone or in combination, during short SVT episodes increase the risk of incident AF and ischemic stroke. METHODS: The population-based Malmö Diet and Cancer study includes 24-hour ECG screening of 377 AF-free individuals (mean age 64.5 years; 43% men) who were prospectively followed for >13 years. There were 65 AF events and 25 ischemic stroke events during follow-up. Subjects with an SVT episode ≥5 beats were identified, and the longest SVT episode was assessed for irregularity and lack of p waves. The association between SVT classification and AF and stroke was assessed using multivariable adjusted Cox regression. RESULTS: The incidence of AF increased with increasing abnormality of the SVTs. The risk-factor adjusted hazard ratio for AF was 4.95 (95% confidence interval 2.06-11.9; P <.0001) for those with short irregular SVTs (<70 beats) without p waves. The incidence of ischemic stroke was highest in the group with regular SVT episodes without p waves (hazard ratio 14.2; 95% confidence interval 3.76-57.6; P <.0001, adjusted for age and sex). CONCLUSION: Characteristics of short SVT episodes detected at 24-hour ECG screening are associated with incident AF and ischemic stroke. Short irregular SVTs without p waves likely represent early stages of AF or atrial myopathy. Twenty-four-hour ECG could identify subjects suitable for primary prevention efforts.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1802
[Cu] Class update date: 180310
[Lr] Last revision date:180310
[St] Status:Publisher

  5 / 67475 MEDLINE  
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[PMID]: 29269688
[Au] Autor:El-Hawari SF; Sakata H; Oyama N; Tamura J; Higuchi C; Endo Y; Miyoshi K; Sano T; Suzuki K; Yamashita K
[Ad] Address:Department of Surgery, Anesthesiology, and Radiology, Faculty of Veterinary Medicine, Sohag University, Sohag 82524, Egypt.
[Ti] Title:Anesthetic and cardiorespiratory effects of single-bolus intravenous alfaxalone with or without intramuscular xylazine-premedication in calves.
[So] Source:J Vet Med Sci;80(2):361-367, 2018 Mar 02.
[Is] ISSN:1347-7439
[Cp] Country of publication:Japan
[La] Language:eng
[Ab] Abstract:The anesthetic and cardiorespiratory effects of xylazine-alfaxalone combination were evaluated in calves. Six calves (age: 6-9 months old; weight: 114-310 kg) were anesthetized with intravenous alfaxalone 15 min after administration of intramuscular saline (0.5 ml/100 kg) or xylazine (0.1 mg/kg; 0.5 ml/100 kg of a 2% xylazine solution). Anesthesia induction was smooth and orotracheal intubation was achieved in all calves. The calves anesthetized with xylazine-alfaxalone required a smaller induction dose of alfaxalone (1.23 ± 0.17 mg/kg, P=0.010) and accepted endotracheal intubation for a significantly longer period (16.8 ± 7.2 min, P=0.022) than the calves anesthetized with alfaxalone alone (2.28 ± 0.65 mg/kg 7.3 ± 1.6 min). At 5 min after induction, tachycardia (heart rate: 166 ± 47 beats/min of heart rate), hypertension (mean arterial blood pressure: 147 ± 81 mmHg) and hypoxemia (partial pressure of arterial blood oxygen [PaO ]: 43 ± 10 mmHg) were observed in the calves anesthetized with alfaxalone alone, whereas hypoxemia (PaO : 47 ± 7 mmHg) and mild hypercapnia (partial pressure of arterial blood carbon dioxide: 54 ± 5 mmHg) were observed in the calves anesthetized with xylazine-alfaxalone. Premedication with xylazine provided a sparing effect on the induction dose of alfaxalone and a prolongation of anesthetic effect. Oxygen supplementation should be considered to prevent hypoxemia during anesthesia.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1712
[Cu] Class update date: 180311
[Lr] Last revision date:180311
[St] Status:In-Process
[do] DOI:10.1292/jvms.17-0512

  6 / 67475 MEDLINE  
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[PMID]: 28449090
[Au] Autor:Brunner S; Herbel R; Drobesch C; Peters A; Massberg S; Kääb S; Sinner MF
[Ad] Address:Department of Medicine I, University Hospital Munich, Ludwig Maximilians University, Marchioninistr. 15, 81377 Munich, Germany.
[Ti] Title:Alcohol consumption, sinus tachycardia, and cardiac arrhythmias at the Munich Octoberfest: results from the Munich Beer Related Electrocardiogram Workup Study (MunichBREW).
[So] Source:Eur Heart J;38(27):2100-2106, 2017 Jul 14.
[Is] ISSN:1522-9645
[Cp] Country of publication:England
[La] Language:eng
[Ab] Abstract:Aims: Alcohol is a risk factor for cardiac arrhythmias. Retrospective analyses suggest supraventricular arrhythmias consecutive to acute alcohol consumption, but prospective data are limited. We intended to prospectively associate acute alcohol consumption with cardiac arrhythmias. Methods and results: At the 2015 Munich Octoberfest, we enrolled 3028 voluntary participants who received a smartphone-based ECG and breath alcohol concentration (BAC) measurements. ECGs were analysed for cardiac arrhythmias (sinus tachycardia, sinus arrhythmia, premature atrial/ventricular complexes, atrial fibrillation/flutter) and respiratory sinus arrhythmia. By multivariable adjusted logistic regression we associated BACs with cardiac arrhythmias. Similarly, we analysed 4131 participants of the community-based KORA S4 Study (Co-operative Health Research in the Region of Augsburg) and associated cardiac arrhythmias with chronic alcohol consumption. In our acute alcohol cohort (mean age 34.4 ± 13.3 years, 29% women), mean BAC was 0.85 ± 0.54 g/kg. Cardiac arrhythmias occurred in 30.5% (sinus tachycardia 25.9%; other arrhythmia subtypes 5.4%). Breath alcohol concentration was significantly associated with cardiac arrhythmias overall (odds ratio (OR) per 1-unit change 1.75, 95% confidence interval (CI) 1.50-2.05; P < 0.001) and sinus tachycardia in particular (OR 1.96, 95%CI 1.66-2.31; P < 0.001). Respiratory sinus arrhythmia measuring autonomic tone was significantly reduced under the influence of alcohol. In KORA S4, chronic alcohol consumption was associated with sinus tachycardia (OR 1.03, 95%CI 1.01-1.06; P = 0.006). Conclusions: Acute alcohol consumption is associated with cardiac arrhythmias and sinus tachycardia in particular. This partly reflects autonomic imbalance as assessed by significantly reduced respiratory sinus arrhythmia. Such imbalance might lead to sympathetically triggered atrial fibrillation resembling the holiday heart syndrome. ClinicalTrials.org accession number: NCT02550340.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1704
[Cu] Class update date: 180311
[Lr] Last revision date:180311
[Cl] Clinical Trial:ClinicalTrial
[St] Status:In-Process
[do] DOI:10.1093/eurheartj/ehx156

  7 / 67475 MEDLINE  
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[PMID]: 29523919
[Au] Autor:Iwasawa S; Uyeda T; Saito M; Ishii T; Inage A; Hamamichi Y; Yazaki S; Yoshikawa T
[Ad] Address:Department of Pediatric Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu, Tokyo, 183-0003, Japan. shinya.iwasawa.r3@dc.tohoku.ac.jp.
[Ti] Title:Efficacy and Safety of Low-Dose Amiodarone Therapy for Tachyarrhythmia in Congenital Heart Disease.
[So] Source:Pediatr Cardiol;, 2018 Mar 09.
[Is] ISSN:1432-1971
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:Amiodarone (AMD) is a class III anti-arrhythmic drug that is highly effective for tachyarrhythmia treatment. AMD is widely used in adults with congenital heart disease (CHD); however, higher doses of AMD (> 200 mg/day) can cause various non-cardiac side effects. The purpose of this study was to assess the efficacy, safety, and adverse events of low-dose AMD (≤ 200 mg/day) for tachyarrhythmia in patients with CHD. We retrospectively studied 80 patients with CHD and tachyarrhythmia who received oral low-dose AMD (≤ 200 mg/day) from January 2004 to March 2016. Low-dose AMD therapy was used to treat supraventricular tachycardia (SVT) in 51 patients and ventricular tachycardia (VT) in 29 patients. After a mean follow-up of 2.9 years for SVT and 3.2 years for VT, 36% and 65% of the patients with SVT and VT, respectively, were free from a first tachyarrhythmia recurrence for 3 years. The incidence of AMD-induced side effects was 23%, and all these cases consisted of thyroid dysfunction. Low-dose AMD was effective for the treatment of tachyarrhythmia in patients with CHD and had a relatively low incidence of side effects. These findings suggest that low-dose AMD is useful and effective for decreasing the frequency of tachyarrhythmia in patients with CHD and has a low incidence of side effects.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180310
[Lr] Last revision date:180310
[St] Status:Publisher
[do] DOI:10.1007/s00246-018-1853-4

  8 / 67475 MEDLINE  
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[PMID]: 29523389
[Au] Autor:Arnold AC; Ng J; Raj SR
[Ad] Address:Department of Neural and Behavioral Sciences, Penn State College of Medicine, 500 University Drive, Mail Code H109, Hershey, PA, USA; Autonomic Dysfunction Center, Division of Clinical Pharmacology, Vanderbilt University Medical Center, Nashville, TN, USA.
[Ti] Title:Postural tachycardia syndrome - Diagnosis, physiology, and prognosis.
[So] Source:Auton Neurosci;, 2018 Feb 28.
[Is] ISSN:1872-7484
[Cp] Country of publication:Netherlands
[La] Language:eng
[Ab] Abstract:Postural tachycardia syndrome (POTS) is a heterogeneous clinical syndrome that has gained increasing interest over the past few decades due to its increasing prevalence and clinical impact on health-related quality of life. POTS is clinically characterized by sustained excessive tachycardia upon standing that occurs in the absence of significant orthostatic hypotension and other medical conditions and or medications, and with chronic symptoms of orthostatic intolerance. POTS represents one of the most common presentations of syncope and presyncope secondary to autonomic dysfunction in emergency rooms and in cardiology, neurology, and primary care clinics. The most sensitive method to detect POTS is a detailed medical history, physical examination with orthostatic vital signs or brief tilt table test, and a resting 12-lead electrocardiogram. Additional diagnostic testing may be warranted in selected patients based on clinical signs. While the precise etiology remains unknown, the orthostatic tachycardia in POTS is thought to reflect convergence of multiple pathophysiological processes, as a final common pathway. Based on this, POTS is often described as a clinical syndrome consisting of multiple heterogeneous disorders, with several underlying pathophysiological processes proposed in the literature including partial sympathetic neuropathy, hyperadrenergic state, hypovolemia, mast cell activation, deconditioning, and immune-mediated. These clinical features often overlap, however, making it difficult to categorize individual patients. Importantly, POTS is not associated with mortality, with many patients improving to some degree over time after diagnosis and proper treatment. This review will outline the current understanding of diagnosis, pathophysiology, and prognosis in POTS.
[Pt] Publication type:JOURNAL ARTICLE; REVIEW
[Em] Entry month:1803
[Cu] Class update date: 180310
[Lr] Last revision date:180310
[St] Status:Publisher

  9 / 67475 MEDLINE  
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[PMID]: 29523179
[Au] Autor:Ralapanawa DMPUK; Kumarihamy KWMPP; Sundararajah M; Jayalath WATA
[Ad] Address:Department of Medicine, University of Peradeniiya, Peradeniya, Sri Lanka. udayapralapanawa@yahoo.com.
[Ti] Title:A young female presenting with heart failure secondary to eosinophilic myocarditis: a case report and review of the literature.
[So] Source:BMC Res Notes;11(1):168, 2018 Mar 09.
[Is] ISSN:1756-0500
[Cp] Country of publication:England
[La] Language:eng
[Ab] Abstract:BACKGROUND: Eosinophilic myocarditis is one of the fatal complications of idiopathic hypereosinophilic syndromes. Given the rarity of this form of myocarditis, it is often under-recognized. We describe a young girl who presented with features of heart failure. To our knowledge, this is the first reported case of eosinophilic myocarditis in a young Sri Lankan female. CASE PRESENTATION: A previously healthy 21 year old Sri Lankan female admitted with shortness of breath for 1 week duration with associated low grade fever and profuse sweating. She was mildly febrile and dyspnoeic with absent ankle oedema. She was tachycardic and had elevated Jugular venous pressure with negative Kussmaul sign. Blood pressure was 100/70 mmHg. Clinically there was no cardiomegaly and heart sounds were slightly muffled with gallop rhythm. Bilateral basal fine end inspiratory crackles and mild hepatosplenomegaly were noted. The laboratory examinations showed leucocytosis with severe eosinophilia with no abnormal cells. Her ESR, Troponin I and Brain natriuretic peptide were elevated with normal CRP and electrocardiogram showed sinus tachycardia with wide spread ST depression. Heart failure was evident on chest X-ray and 2D-echocardiogram showed global left ventricular hypokinesia with 40% ejection fraction and a thin layer of pericardial effusion. Mild hepatosplenomegaly without lymphadenopathy was detected in the ultrasound scan. Bone marrow biopsy showed hypereosinophilia with no evidence of bone marrow infiltration. FIP1L1-PDGFRA fusion transcript and BCR-ABL transcript were not detected. Secondary causes for hypereosinophilia were excluded and the diagnosis of idiopathic hypereosinophilic syndrome and eosinophilic myocarditis was made. She had good response to steroids clinically and biochemically with complete recovery of left ventricular function. She is now on steroid to be continued at least 6 months to 1 year. CONCLUSION: Eosinophilic myocarditis is a rare but fatal disease if left untreated. Hence clinicians should have high index of suspicion to diagnose eosinophilic myocarditis in clinical context of heart failure due to myocarditis. The diagnoses of eosinophilic myocarditis may often be challenged especially in a poor recourse setting. However available investigation should be used to diagnose this condition without delay. Early treatment with systemic steroids may prevent fatal outcome and therapies for this disease have yet to be validated in large prospective studies.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180310
[Lr] Last revision date:180310
[St] Status:In-Process
[do] DOI:10.1186/s13104-018-3273-1

  10 / 67475 MEDLINE  
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[PMID]: 29522717
[Au] Autor:Patton AL; Seely KA; Yarbrough AL; Fantegrossi W; James LP; McCain KR; Fujiwara R; Prather PL; Moran JH; Radominska-Pandya A
[Ad] Address:Arkansas Department of Health, Arkansas Public Health Laboratory, 4815 W Markham St, Little Rock, AR, 72205, USA; Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR, 72205, USA. Electronic address: amy.patton@pinpointtest
[Ti] Title:Altered metabolism of synthetic cannabinoid JWH-018 by human cytochrome P450 2C9 and variants.
[So] Source:Biochem Biophys Res Commun;, 2018 Mar 06.
[Is] ISSN:1090-2104
[Cp] Country of publication:United States
[La] Language:eng
[Ab] Abstract:Synthetic cannabinoids (SCBs), synonymous with 'K2', 'Spice' or 'synthetic marijuana', are psychoactive drugs of abuse that frequently result in clinical effects and toxicity more severe than those classically associated with Δ -tetrahydrocannabinol such as extreme agitation, hallucinations, supraventricular tachycardia, syncope, and seizures. JWH-018 is one of the earliest compounds identified in various SCB products, and our laboratory previously demonstrated that JWH-018 undergoes extensive metabolism by cytochromes P450 (P450), binds to, and activates cannabinoid receptors (CBRs). The major enzyme involved in the metabolism of JWH-018 is CYP2C9, a highly polymorphic enzyme found largely in the intestines and liver, with *1 being designated as the wild type, and *2 and *3 as the two most common variants. Three different major products have been identified in human urine and plasma: JWH-018 (ω)-OH, JWH-018 (ω-1)-OH(R), and JWH-018 (ω-1)-OH(S). The (ω-1)-OH metabolite of JWH-018 is a chiral molecule, and is thus designated as either (ω-1)-OH(R) or (ω-1)-OH(S). Here, in vitro enzyme kinetic assays performed with human recombinant CYP2C9 variants (*1, *2, and *3) revealed that oxidative metabolism by CYP2C9*3 resulted in significantly less formation of (ω)-OH and (ω-1)-OH metabolites. Surprisingly, CYP2C9*2 was roughly 3.6-fold more efficient as the CYP2C9*1 enzyme based on V /K , increasing the rate of JWH-018 metabolism and allowed for a much more rapid elimination. These results suggest that genetic polymorphisms of P450 enzymes result in the production of varying levels of biologically active JWH-018 metabolites in some individuals, offering a mechanistic explanation for the diverse clinical toxicity often observed following JWH-018 abuse.
[Pt] Publication type:JOURNAL ARTICLE
[Em] Entry month:1803
[Cu] Class update date: 180309
[Lr] Last revision date:180309
[St] Status:Publisher


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