CYP3A4 Mediates Oxidative Metabolism of the Synthetic Cannabinoid AKB-48

Synthetic cannabinoid designer drugs have emerged as drugs of abuse during the last decade, and acute intoxication cases are documented in the scientific literature. Synthetic cannabinoids are extensively metabolized, but our knowledge of the involved enzymes is limited. Here, we investigated the metabolism of N-(1-adamantyl)-1-pentyl-1H-indazole-3-carboxamide (AKB-48), a compound identified in herbal blends from 2012 and onwards. We screened for metabolite formation using a panel of nine recombinant cytochrome P450 (CYP) enzymes (CYP1A2, 2B6, 2C8, 2C9, 2C18, 2C19, 2D6, 2E1, and 3A4) and compared the formed metabolites to human liver microsomal (HLM) incubations with specific inhibitors against CYP2D6, 2C19, and 3A4, respectively. The data reported here demonstrate CYP3A4 to be the major CYP enzyme responsible for the oxidative metabolism of AKB-48, preferentially performing the oxidation on the adamantyl moiety. Genetic polymorphisms are likely not important with regard to toxicity given the major involvement of CYP3A4. Adverse drug-drug interactions (DDIs) could potentially occur in cases with co-intake of strong CYP3A4 inhibitors, e.g., HIV antivirals and azole antifungal agents.

Electronic supplementary material

The online version of this article (doi:10.1208/s12248-015-9788-7) contains supplementary material, which is available to authorized users.KEY WORDS: adamantyl, cytochrome P450, metabolism, metabolites, synthetic cannabinoids     

Reductions in NO2 burden over north equatorial Africa from decline in biomass burning in spite of growing fossil fuel use, 2005 to 2017

Socioeconomic development in low- and middle-income countries has been accompanied by increased emissions of air pollutants, such as nitrogen oxides [NO_x: nitrogen dioxide (NO₂) + nitric oxide (NO)], which affect human health. In sub-Saharan Africa, fossil fuel combustion has nearly doubled since 2000. At the same time, landscape biomass burning—another important NO_x source—has declined in north equatorial Africa, attributed to changes in climate and anthropogenic fire management. Here, we use satellite observations of tropospheric NO₂ vertical column densities (VCDs) and burned area to identify NO₂ trends and drivers over Africa. Across the northern ecosystems where biomass burning occurs—home to hundreds of millions of people—mean annual tropospheric NO₂ VCDs decreased by 4.5% from 2005 through 2017 during the dry season of November through February. Reductions in burned area explained the majority of variation in NO₂ VCDs, though changes in fossil fuel emissions also explained some variation. Over Africa’s biomass burning regions, raising mean GDP density (USD⋅km⁻²) above its lowest levels is associated with lower NO₂ VCDs during the dry season, suggesting that economic development mitigates net NO₂ emissions during these highly polluted months. In contrast to the traditional notion that socioeconomic development increases air pollutant concentrations in low- and middle-income nations, our results suggest that countries in Africa’s northern biomass-burning region are following a different pathway during the fire season, resulting in potential air quality benefits. However, these benefits may be lost with increasing fossil fuel use and are absent during the rainy season.

Socioeconomic development and population growth in low- and middle-income countries have been widely associated with increased environmental degradation, including rapid increases in emissions of air pollutants (1–3). In contrast, in countries with a high per capita gross domestic product (GDP), various socioeconomic, institutional, and regulatory factors often cause economic growth to be accompanied by reductions of some pollutant emissions, though these emissions may simply be outsourced to lower income countries (4). The relationship between income level and environmental pressure—known as the Environmental Kuznets Curve—has often been conceptualized as an inverted U-shaped curve, but a wide array of functional relationships is possible (3). For emissions of air pollutants, the relationship has generally been described as an inverted U-shaped curve, though carbon dioxide generally does not follow such a curve (3, 5). Some researchers argue that low- and middle-income countries can mitigate or shorten the period of rapid emissions growth that tends to accompany socioeconomic development for at least some pollutants (4). Africa, and sub-Saharan Africa in particular, is characterized by countries with low but growing per capita GDP and rapid population growth, which have been linked to increases in emissions of carbon dioxide and particulate matter (6). As these countries continue their trajectories of economic development, emissions of air pollutants from fossil fuel and biofuel combustion are expected to experience explosive growth (7).Nitrogen dioxide (NO₂) is a reactive gas and air pollutant with a lifetime in the atmosphere on the order of hours (8). In the atmosphere, NO₂ interconverts rapidly with nitric oxide (NO), and the two species are collectively referred to as NO_x. NO₂ itself is toxic, is regulated by the US Environmental Protection Agency, and has been associated with premature mortality and asthma [though its direct effects on health are not clear (9) and it may instead function as a proxy for other pollutants, such as ozone and aerosols that have direct health and mortality impacts (10)]. NO_x is also a key precursor to the formation of tropospheric ozone (O₃), which is damaging to both crop productivity and human health; anthropogenic O₃ contributes to roughly half a million premature deaths annually, of which nearly 20,000 are in Africa (11). In addition, NO_x is involved in reactions with atmospheric ammonia (NH₃) to form nitrate aerosols, which contribute to particulate matter pollution (12) as well as in reactions with volatile organic compounds (VOCs), which form organic nitrates (13). Because of the short lifetime of NO₂, and because it can function as an indicator for other pollutants, it can serve as an indicator of overall changes in air quality.NO and NO₂ are emitted from a variety of natural and anthropogenic sources. Fossil fuel combustion and anthropogenic alterations to soils through fertilization or livestock management are the primary sources of NO_x in many parts of the world. In sub-Saharan Africa (excluding South Africa), fossil fuel combustion and fertilizer use has been considerably lower than elsewhere, and natural soils and biomass burning have historically been more important sources (14). This is true even in Nigeria (15), which experiences substantial emissions of VOCs from the oil and gas industry (16). NO_x emissions from Lagos have been shown to be either lower than (15) or comparable to other megacities (17), and NO₂ concentrations are generally low during the rainy season, but air quality can become heavily degraded during the biomass burning season (15, 18). However, fossil fuel combustion in the region nearly doubled between 2000 and 2016 (19) and associated emissions of NO_x are projected to increase sixfold by 2030 in the absence of regulation, as compared to 2005 levels (7).This increase in fossil fuel combustion is occurring against the backdrop of Africa’s unique, fire-prone savanna ecosystems, home to 70% of the global area burned each year (20). Biomass burning in Africa is estimated to be responsible for NO_x emissions of roughly 4 Tg N⋅yr⁻¹, equivalent to about half of all NO_x emissions for the continent (21), and one third to half of NO_x emissions from biomass burning globally (21–23). The majority of biomass burning in Africa occurs in northern and southern bands of savanna, savanna-forest mosaic, and woodland ecoregions, with a seasonality that follows the migration of the intertropical convergence zone.The early part of the 21st century has been accompanied by a global decline in burned area, with some of the largest declines occurring in Africa’s northern fire band (24). Some of the burned area decline in the northern fire band can be attributed to changes in precipitation that, in turn, affect the quantity and moisture content of available fuels (24–26). However, active anthropogenic suppression of fire has also played an important role (24, 25). Burning is thought to be used as a management strategy—among other uses, humans ignite fires to mineralize nutrients, improve grazing, and reduce fuel loads and the potential for large, uncontrolled fires (27). Increased population density and the introduction of agricultural land into African savanna landscapes—reflecting socioeconomic transitions from traditional nomadic pastoralist lifestyles (28)—have been associated with a sharp decrease in burned area as people either reduce ignition or suppress fires to protect villages and farms, with a reduction in the amount of pasture area to be maintained (25).Unfortunately, sub-Saharan Africa remains a severely understudied region—for example, agricultural soil NO fluxes have only been measured directly for two sites (29, 30), and surface air quality monitoring is extremely limited compared to other parts of the world (31). Remote sensing products provide an important tool for filling some of these data gaps. The short NO₂ lifetime in the planetary boundary layer makes it possible to use satellite observations to directly evaluate emissions sources, especially in regions with high temperatures, which tend to shorten the NO₂ lifetime, and in relatively polluted regions, where total column densities and surface emissions are highly correlated (ref. 8 and references therein). Although recent remote sensing work has evaluated long-term trends in NO₂ concentrations around the world, recent trends in the biomass burning region of northern Africa have not been explicitly evaluated, and the relative impacts of socioeconomic development—the possibility of reduced NO_x emissions because of anthropogenic fire suppression and of increasing NO_x emissions from growing fossil fuel use—remain unknown. In general, studies on global trends in NO₂ tend not to focus on Africa, likely because the regions with the highest NO₂ concentrations are in China, Europe, and the United States (e.g., refs. 1, 21). Some earlier studies observed a decline in NO₂ VCDs over north equatorial Africa (32, 33), but others did not (34). These and other large-scale studies (e.g., refs. 8, 34, 35) did not identify mechanisms for the observed NO₂ dynamics, but rather focused on understanding anthropogenic influences on trends in other regions.Indoor air pollution from biomass combustion for fuel is an important health concern (36). We do not focus on this source. Biofuel combustion is responsible for emissions of 0.6 Tg NO annually across all of Africa (37), which is less than 10% of the magnitude of landscape biomass burning emissions estimated by the Global Fire Emissions Database version 4s [GFED4s (38)] and represents a much smaller proportion of NO_x emissions from landscape biomass burning regions during the dry season.Here, we use observations of NO₂ by the Ozone Monitoring Instrument [OMI (39)] and burned area from the Moderate Resolution Imaging Spectroradiometer [MODIS (40)] to demonstrate that the recent decline in burned area in the productive savannas of north equatorial Africa—home to over 275 million people—is associated with large declines in tropospheric NO₂ VCDs during the biomass burning season from 2005 through 2017, though positive trends explained in part by increasing fossil fuel combustion were observed in other seasons, especially over Nigeria.     

Anal incontinence in women with recurrent obstetric anal sphincter rupture: a case control study

Objectives: To determine the risk of recurrent anal sphincter rupture (ASR), and compare the risk of anal incontinence (AI) after recurrent ASR, with that seen in women with previous ASR who deliver by caesarean section or vaginally without sustaining a recurrent ASR.

Methods: Women with recurrent ASR between January 2000 and June 2011 were identified at two delivery wards in Copenhagen. The women answered a questionnaire with a validated scoring system for AI (St. Mark`s score), and the results were compared with those obtained in two control groups: women with subsequent uncomplicated vaginal delivery or caesarean section.

Results: There were 93?437 vaginal deliveries. ASR occurred in 5.5% (n?=?2851) of the nulliparous and 1.5% (n?=?608) of the multiparous women. Recurrent ASR occurred in 8% (n?=?49) of whom 50% reported symptoms of AI. We found no difference in the occurrence of AI between women with recurrent ASR, and those who delivered vaginally without repeat ASR (p?=?0.37; OR?=?2.0) or by caesarean section (p?=?0.77; OR?=?1.3).

Conclusion: Women with a past history of ASR have an 8% risk of recurrence. AI affects half of the women with recurrent ASR. Larger studies are required to confirm our findings.     

A critical assessment of early warning score records in 168,000 patients

The national early warning score (NEWS) is recommended to detect deterioration in hospitalised patients. In 2013, a NEWS-based system was introduced in a hospital service with over 250,000 annual admissions, generating large amounts of NEWS data. The quality of such data has not been described. We critically assessed NEWS data recorded over 12 months. This observational study included NEWS records from adult inpatients hospitalized in the Capital Region of Denmark during 2014. Physiological variables and the use of supplementary oxygen (NEWS variables) were recorded. We identified implausible records and assessed the distributions of NEWS variable values. Of 2,835,331 NEWS records, 271,103 (10%) were incomplete with one or more variable missing and 0.2% of records containing implausible values. Digit preferences were identified for respiratory rate, supplementation oxygen flow, pulse rate, and systolic blood pressure. There was an accumulation of pulse rate records below 91 beats per minute. Among complete NEWS records, 64% had NEWS?≥?1; 29% had NEWS?≥?3; and 8% had NEWS?≥?6. In a large set of NEWS data, 10% of the records were incomplete. In a system where data were manually entered into an electronic medical record, digit preferences and the accumulation of pulse rate records below 91 beats per minute, which is the limit for NEWS point generation, showed that staff practice influenced the recorded values. This indicates a potential limitation of transferability of research results obtained in such systems to fully automated systems.     

Prematurity Reduces Functional Adaptation to Intestinal Resection in Piglets

Background: Necrotizing enterocolitis and congenital gastrointestinal malformations in infants often require intestinal resection, with a subsequent risk of short bowel syndrome (SBS). We hypothesized that immediate intestinal adaptation following resection of the distal intestine with placement of a jejunostomy differs between preterm and term neonates. Methods: Preterm or term piglets were born by cesarean section and fed enterally for 2 days. On day 2, piglets were subjected to 50% distal intestinal resection with placement of a jejunostomy. On the following 4–5 days, piglets received parenteral nutrition with gradually increasing doses of enteral nutrition (bovine colostrum). Intestinal tissue samples were collected at delivery and 2 and 6–7 days after birth for histological examination and assessment of digestive enzyme activities. Results: Preterm and term piglets showed similar increases in intestinal weight and digestive enzyme activities from birth to 2 days. On days 6–7 after birth, the remnant intestine showed a similar density (g/cm) and mucosal mass in term and preterm piglets, but villus height, crypt depth, enzyme activities (sucrase, maltase, dipeptidyl peptidase IV [DPPIV]), and hexose uptake capacity were significantly higher in term piglets (P < .05). Preterm piglets were more prone to develop hypoglycemia, respiratory distress syndrome, dehydration, and circulatory instability after surgery compared with term piglets. Conclusion: Studies on intestinal adaptation after resection are feasible in both preterm and term piglets, but intensive clinical support is required when rearing preterm piglets with SBS. Physiological instability and immaturity of the intestine may explain the fact that immediate adaptation after resection is reduced in preterm vs term neonates.     

Electrocardiographic gated (99m)Tc-sestamibi SPECT immediately after primary percutaneous coronary intervention characterizes reperfusion success

Following an acute myocardial infarction, the size of the infarct and the resulting left ventricular volume and function are important predictors of mortality. Identifying patients with impaired tissue level perfusion after percutaneous coronary intervention (PCI) for myocardial infarction therefore could have prognostic implications. To obtain combined measures of left ventricular perfusion, volumes and function we applied a gated myocardial perfusion imaging by (99m)Tc-sestamibi single photon emission computerized tomography to 19 patients immediately after revascularization by PCI and repeated this after 3 months. The results of the acute myocardial perfusion imaging significantly correlated to final infarct size, left ventricular volumes and function 3 months later. It is concluded that the method holds the potential for risk stratifying patients immediately after revascularization for acute myocardial infarction.     

High levels of complement-activation capacity in sera from patients with cystic fibrosis correlate with high levels of IgG3 antibodies to Pseudomonas aeruginosa antigens and poor lung function

Heat-stable opsonins from sera of cystic fibrosis (CF) patients were investigated for their ability to activate complement. Complement activation by Pseudomonas aeruginosa after opsonization with patient serum was examined in a complement-consumption assay. Absorption of patients' sera with formalin-treated and boiled bacteria removed specific antibodies and the complement activation decreased. We found a positive correlation between serum complement-activation ability and IgG3 antibody levels to lipopolysaccharide (LPS), alginate, and a crude mixture of P. aeruginosa antigens (sonicate) in a group of patients with high levels of anti-Pseudomonas precipitins. In the same group of patients a significant negative correlation was found between complement activation and lung function. Eighteen patients have been followed longitudinally with serum samples covering the pre-infection, the early, and the late stages of chronic infection. Patients with poor lung function showed significantly higher levels of complement-activation capacity. We conclude that patients with high levels of specific IgG3 antibodies are able to induce a high level of complement activation and then develop more aggressive pulmonary tissue damage, probably secondary to local immune complex formation. Pediatr Pulmonol. 1995; 20:71–77 . © 1995 Wiley-Liss, Inc.