Applying Global Burden of Diseases in Medical Toxicology
Reza
Asadi
Addiction Research Centre (ADRC), Mashhad University of
Medical Sciences, School of Medicine, Mashhad, Iran
author
Reza
Afshari
Addiction Research Centre (ADRC), Mashhad University of
Medical Sciences, School of Medicine, Mashhad, Iran
author
text
article
2014
eng
In the past decade, high attention has been given to the Disability-Adjusted Life Year (DALY) metric. One DALY is one lost year of "healthy" life. DALYs for a disease or a health condition are measured by the sum of (a) the Years of Life Lost (YLL) because of premature death occurred in the target population and (b) the Years Lost due to Disability (YLD) for those living with that condition or its consequences. YLL corresponds to the number of deaths multiply by the standard life expectancy at the age and gender at which death occurs. YLD is estimated by multiplying the number of incidents by the average duration of the disease to a weight factor that reflects the severity of the disease (disability weight or DW). DW is reported on a scale from 0 (perfect health) to 1 (dead). The DWs could be measured by several utility measurement techniques (1). The sum of these DALYs across a population is assumed as the burden of that disease. This is the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of that disease and disability. In a study undertaken by the World Health Organization, it was found that poisoning in individuals was scored 0.611-0.608 while stroke for example was scored 0.920 and cretinism was scored 0.804. On the other side of the spectrum, otitis media, pharyngitis and mild upper respiratory infection were scored 0.023, 0.07 and 0.00 respectively (2). Poisoning in general, therefore, has been considered as a highly disabling condition. Poisoning can be intentional, accidental or criminal (3). Its burden includes physical as well as mental disabilities. While the medical burden of intentional and accidental poisonings seems to be equal for similar severe cases, intentional poisoning often occurs in patients with depression or coping difficulties and may need extra psychological, familial or social attention. It has been shown that burden of suicide (including suicidal poisonings) puts it at 21st rank in the list of most important diseases. Suicide and nonfatal attempted suicide together climb the position to 11th in this ranking of diseases (4). Furthermore, adding the mental suffering from suicidal thoughts will rank suicidal behaviors among the most important diseases (4). In poisonings, type of medication or toxic agent used, dose, route of administration, chronic use, addiction and racial differences as well as health infrastructure, pre-hospital care and availability of antidotes may affect the outcome. Unlike overdose with multivitamins, low dose oral consumption of aluminum phosphide may lead to critical condition and death. In addition, some poisonings such as opioid overdose are easily treatable due to the presence of effective antidotes. These variables may drastically change the weights in different regions. Experts who establish disability weights from pairwise comparisons (5), ranking and person trade off methods should be extra careful in medical toxicology. Extra caution should be given in interpretation of the DW in poisonings. Accidental poisoning should also be considered independently. Perhaps, the burden of each toxic agent should be calculated and interpreted separately in different regions.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
v.
1
no.
2014
1
1
https://apjmt.mums.ac.ir/article_2462_b816c3b80d76286f1a6fd2b638a066f8.pdf
Toxidrome-based Approach to Common Poisonings
Bruno
Mégarbane
Reanimation and Medical Toxicology Department, University Paris-Diderot, Paris, France
author
text
article
2014
eng
Poisoning remains a major cause of hospital admission into the emergency department and intensive care unit. Proper diagnosis is the cornerstone for optimal management of poisoned patients. Since the definitive analytical confirmation of the nature of the toxicant involved in the poisoning cannot be rapidly obtained in the majority of healthcare facilities, diagnosis relies on the medical history and the rigorous clinical examination of the patients well as results of the routine biological tests and the electrocardiogram. Identification of the toxidromes addresses not only the correct diagnosis but also rules out other differential diagnoses. Despite no definitive predictive value, this clinical approach facilitates making decision on empirical treatments and emergent antidotes. Pharmacodynamic tests using specific antidotes including naloxone for opioids and flumazenil for benzodiazepines and its analogues are also helpful to assess the final diagnosis in comatose patients. The objective of this article is to review the toxidrome-based approach to common poisonings before toxicological analysis enables the confirmation of the initially suspected toxic etiology.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
v.
1
no.
2014
2
12
https://apjmt.mums.ac.ir/article_2463_255ff60fca394e9ee4195d6890c40b96.pdf
dx.doi.org/10.22038/apjmt.2014.2463
The Suicide Pandemic of Hydrogen Sulfide Poisoning in Japan
Ken
Iseki
Department of Regional Emergency Medicine, Fukushima Medical University School of medicine, Fukushima, Japan.
Department of Emergency and Critical Care Medicine, Yamagata University School of Medicine, Yamagata, Japan
author
Akiko
Ozawa
Department of Regional Emergency Medicine, Fukushima Medical University School of medicine, Fukushima, Japan.
Department of Emergency and Critical Care Medicine, Yamagata University School of Medicine, Yamagata, Japan
author
Keiko
Seino
Department of Emergency and Critical Care Medicine, Yamagata University School of Medicine, Yamagata, Japan.
Department of Anatomy and Cell Biology, Yamagata University School of Medicine, Yamagata, Japan
author
Kaoru
Goto
Department of Anatomy and Cell Biology, Yamagata University School of Medicine, Yamagata, Japan
author
Choichiro
Tase
Department of Emergency and Critical Care Medicine, Fukushima Medical University School of Medicine, Fukushima, Japan
author
text
article
2014
eng
Background: Hydrogen sulfide (H2S) suicides have been frequent in Japan in recent years. This study was performed to describe the epidemiologic profile of an outbreak of H2S suicides in Japan. Methods: In September 2008, questionnaires about patients involved in H2S suicides were sent to 250 hospitals in Japan. Data collected from each patient included gender, age, clinical manifestations, date of event, location of suicide, source of H2S, treatments and neurological outcome. Results: A total of 90 subjects (60 men, 30 women) were enrolled in this study. In this outbreak, the first case was reported in September 2006 and subsequent cases reached a peak in April 2008. There were 60 cases of attempted suicide by generating H2S gas (suicide group) and 30 cases of secondary exposure (secondary exposure group). The suicide group included mostly subjects in their twenties. Cardiopulmonary arrest at the scene was reported in 39 cases (65%). Clinical features of the suicide group inpatients included coma (14 cases), convulsion (1 case), and lung edema (1 case). Patients in suicide group were significantly younger than secondary exposure group (P < 0.001). The development of cardiopulmonary arrest was significantly higher in suicide group (65% vs. 10%; P < 0.001). Death was more frequent in suicide group (70% vs. 10%; P < 0.001) and patients with secondary exposure were discharged with better neurological outcomes (Table 1). Conclusion: Suicide with H2S poisoning has recently been a serious social problem especially in younger generation in Japan. There is extensive information on H2S suicide methods on the internet. Management of access to websites describing suicide methods is an immediate necessity together with counseling for suicide prevention. How to cite this article: Iseki K, Ozawa A, Seino K, Goto K, Tase C. The Suicide Pandemic of Hydrogen Sulfide Poisoning in Japan. Asia Pac J Med Toxicol 2013;3:13-7.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
v.
1
no.
2014
13
17
https://apjmt.mums.ac.ir/article_2464_95a64e4756f795ad4fc2829df9f616e4.pdf
dx.doi.org/10.22038/apjmt.2014.2464
Development of Latrodectus Envenomation Severity Score (LESS); a Severity Index for Widow Spider Bite: Initial Step
Seyed
Monzavi
Addiction Research Centre (ADRC), Mashhad University of
Medical Sciences, School of Medicine, Mashhad, Iran
author
Reza
Afshari
Addiction Research Centre (ADRC), Mashhad University of
Medical Sciences, School of Medicine, Mashhad, Iran
author
text
article
2014
eng
Background: In order to describe the patients and evaluate the effectiveness of treatments for widow spider envenomation, investigators require a reliable assessment tool. In this paper, the development of a clinical index for measuring the widow spider bite severity, Latrodectus Envenomation Severity Score (LESS), is described. Methods: According to the valid methods for index development, a Delphi group process was applied. A panel of 13 experienced medical toxicologists and physician experts in treatment of black widow spider bites was assembled in December 2013. The participants were asked to score clinical manifestations of Latrodectus envenomation based on their importance on the severity and patients’ prognosis. Hence, an initial draft of the severity index was developed and in the second phase of study, the draft was discussed in a focus group of experts to finally comment on each variable and vote about the final scores. Results: The proposed version of LESS comprises of 34 clinical items categorized in 8 organ systems. The index includes definition of each clinical variable to help users of the index how to ascertain or rule out the clinical finding. The maximum theoretical score according to LESS is 87. Acute renal failure, myocarditis, pulmonary edema and ileus received the highest scores in this index. Conclusion: The LESS is a new assessment tool that is designed to more objectively evaluate the severity and progression of envenomation in victims of widow spider bite. The prognostic-ability, reliability and sensitivity to change of the index should be investigated in future studies. How to cite this article: Monzavi SM, Afshari R. Development of Latrodectus Envenomation Severity Score (LESS); a Severity Index for Widow Spider Bite: Initial Step. Asia Pac J Med Toxicol 2014;3:18-22.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
v.
1
no.
2014
18
22
https://apjmt.mums.ac.ir/article_2465_fc3e345f12060c23881f1510ef6ed043.pdf
dx.doi.org/10.22038/apjmt.2014.2465
Effect of Intensive Atropine Doses (Rapid Incremental Loading and Titration) for Management of Organophosphorus Pesticide Poisoning: a Case Series
Abu Saleh
Ahmed
Dhaka Medical College Hospital, Dhaka, Bangladesh
author
Ariful
Basher
Mymensingh Medical College Hospital, Mymensingh, Bangladesh
author
Mohammad
Amin
Dhaka Medical College, Dhaka, Bangladesh
author
Mohammad
Faiz
Professor and Former Director General of Health Services, Ministry of Health, Bangladesh
author
text
article
2014
eng
Background:Acute poisoning with organophosphorus (OP) pesticides is a common method of suicide and entails considerable mortality in Bangladesh. The objective of this study was to evaluate the effects and outcomes of a protocol for treatment of OP poisoning that included titrated incremental atropine as loading dose and slow infusion for maintenance. Methods:In this prospective descriptive case series, definitive OP poisoned patients were enrolled in an adult medicine unit of Dhaka Medical College Hospital from April 2006 to April 2007. Clinical examinations were done as soon as the patient entered the ward. Patient’s demographics, comorbid conditions and the occurrence of specific clinical outcomes including death, need for assisted ventilation and clinical complications were recorded. The patients were treated according to the protocol. Results: A total of 56 patients were enrolled over the study period. The median age of the study population was 22.5 years. Most patients were men (67.8%). The most common clinical presentation was miosis (58.9%). In total, 11 patients died (19.6%). Intermediate syndrome developed in 12 patients (21.4%) and 6 of them died. Assisted ventilation was required in 16 cases (28.5). Patients with diastolic blood pressure ≤ 70 mmHg and/or GCS ≤ 10 were significantly less likely to survive (P = 0.02, 0.006, respectively). Moreover, early respiratory failure (P < 0.001) and the need for assisted ventilation (P < 0.001) were significantly higher among deceased cases. The mortality rate in this study was similar to previous studies. The frequency of atropine toxicity in the present study (1.8%) was considerably lower than conventional regimen used in previous studies. Conclusion:Using the new protocol, lower rate of atropine toxicity developed in victims. Hence, the new protocol appears to be safer and its effectiveness should be further evaluated in case control studies in Bangladesh. How to cite this article: Ahmed AS, Basher A, Amin MR, Faiz MA. Effect of Intensive Atropine Doses (Rapid Incremental Loading and Titration) for Management of Organophosphorus Pesticide Poisoning: a Case Series. Asia Pac J Med Toxicol 2014;3:23-6.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
v.
1
no.
2014
23
26
https://apjmt.mums.ac.ir/article_2466_d1ba36cc7b40bbc4d444f51955e7c495.pdf
dx.doi.org/10.22038/apjmt.2014.2466
Investigating the Effect of Emotional Intelligence on the Addiction Relapse after Quitting
Zeinab
Raisjouyan
Addiction Research Centre (ADRC), Mashhad University of Medical Sciences, School of Medicine, Mashhad, Iran
author
Mahdi
Talebi
Addiction Research Centre (ADRC), Mashhad University of Medical Sciences, School of Medicine, Mashhad, Iran.
Department of Family Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
author
Fatemeh
Ghasimi Shahgaldi
Addiction Research Centre (ADRC), Mashhad University of Medical Sciences, School of Medicine, Mashhad, Iran
author
Ebrahim
Abdollahian
Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, School of Medicine, Mashhad, Iran
author
text
article
2014
eng
Background: Addiction is multi-dimensional medical problem and psychologic defects have a major role on its establishment. This study was designed to determine the effect of emotional quotient (EQ) on the rate of addiction relapse after quitting. Methods: This was a prospective cross-sectional study on 22 to 51 year old subjects who were being treated at chemical dependency rehabilitation centers in Mashhad, Iran, during December 2012 to May 2013. For assessment of EQ, the Persian version of Bar-On EQ questionnaire was employed at first visit of each patient. During the rehabilitation therapy, the subjects were visited monthly. The data of patients were collected during the first 6 months post-quitting. Results: One-hundred sixty subjects were studied which 87% of them were men. Mean (SD) score of patients' EQ was 11.9 (2.8). The mean number of addiction relapses was 2.1 (2.8). Data analysis showed that there was a significant inverse correlation between EQ score and the number of relapses (r = -0.82, P = 0.05). In addition, it was found that the EQ score had a direct significant relationship with age (r = 0.33, P = 0.05). No significant correlation between type of abused substance and the number of relapses was found. Conclusion: EQ has a positive impact on preventing addiction relapse. Increasing EQ through educational programs can be used as a preventive measure for treating addict persons. How to cite this article: Raisjouyan Z, Talebi M, Ghasimi Shahgaldi F, Abdollahian E. Investigating the Effect of Emotional Intelligence on the Addiction Relapse after Quitting. Asia Pac J Med Toxicol 2014;3:27-30.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
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1
no.
2014
27
30
https://apjmt.mums.ac.ir/article_2467_a952dc2bb0682fbaa211746a304b1de5.pdf
dx.doi.org/10.22038/apjmt.2014.2467
The Current State of Poison Control Centers in Pakistan and the Need for Capacity Building
Nadeem
Khan
Department of Emergency Medicine, The Aga Khan University, Karachi, Pakistan
author
Mohammed
Mir
Department of Emergency Medicine, The Aga Khan University, Karachi, Pakistan
author
Uzma
Khan
Department of Emergency Medicine, Aga Khan University, Karachi, Pakistan
author
Afshan
Khan
Department of Emergency Medicine, The Aga Khan University, Karachi, Pakistan
author
Jamal
Ara
Jinnah Post Graduate Medical Center, Karachi, Pakistan
author
Khurram
Raja
Provincial Poison Control Center, Allied General Hospital, Faisalabad, Pakistan
author
Farhat
Mirza
Department of Forensic Medicine, Civil Hospital, Karachi, Pakistan
author
text
article
2014
eng
Background: Chemical exposure is a major health problem globally. Poison control centers (PCCs) play a leading role both in developed and developing countries in the prevention and control of poisonous chemical exposures. In this study, we aimed to assess the current state of PCCs in Pakistan and highlight capacity building needs in these centers. Methods: A cross-sectional survey of the two registered PCCs was done during August – December 2011. Necessary services of the PCCs were evaluated and the data were recorded on a predesigned checklist. Results: Both PCCs are affiliated to a tertiary care hospital. Clinical services to poisoned patients were available 24 hours a day / 7 days a week. Information on common local products was available to poison center staff. Both centers were involved in undergraduate and post graduate teaching. Telephone poison information service was not available in either of centers. There was a limited capacity for qualitative and analytical toxicology. Common antidotes were available. There were limited surveillance activities to capture toxic risks existing in the community and also a deficiency was observed in chemical disaster planning. Conclusion: PCCs in Pakistan need capacity building for specialized training in toxicology, toxicovigilance, chemical disaster planning, analytical laboratory tests and telephone service for consultation in poisoning cases. How to cite this article: Khan NU, Mir MU, Khan UR, Khan AR, Ara J, Raja K, et al. The Current State of Poison Control Centers in Pakistan and the Need for Capacity Building. Asia Pac J Med Toxicol 2014;3:31-5.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
v.
1
no.
2014
31
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https://apjmt.mums.ac.ir/article_2468_7dfcf0655d8847f7c11aabfcab89ddc2.pdf
dx.doi.org/10.22038/apjmt.2014.2468
Profile of Acute Poisoning Cases Treated in a Tertiary Care Hospital: a Study in Navi Mumbai
Amit
Patil
Department of Forensic Medicine and Toxicology, Padmashree Dr. D Y Patil Medical College, Hospital and Research Center, Navi Mumbai, India
author
Rahul
Peddawad
Department of Forensic Medicine and Toxicology, Padmashree Dr. D Y Patil Medical College, Hospital and Research Center, Navi Mumbai, India
author
Vikas Chandra Sahay
Verma
Department of Forensic Medicine and Toxicology, Padmashree Dr. D Y Patil Medical College, Hospital and Research Center, Navi Mumbai, India
author
Hemangi
Gandhi
MBBS UG Student, Padmashree Dr. D Y Patil Medical College, Hospital and Research Center, Navi Mumbai, India
author
text
article
2014
eng
Background: Periodic epidemiological studies are necessary to understand the pattern of poisoning in each region. This study was designed to evaluate the pattern of acute poisoning cases treated in a tertiary care hospital in Navi Mumbai, India. Methods: This cross sectional study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre during July 2012 to July 2013. All cases of poisoning admitted to the hospital were included in this study. The patients’ data were obtained from medical records and were documented on a pre-structured proforma. Results: A total of 74 cases of acute poisoning were studied, of which 51.4% were men. Most of the patients aged 20 to 29 years (44.6%). In majority of cases, the route of exposure to poison was oral (86.5%). Most of the patients reside in urban areas (52.7%). Most of the patients were Hindus (85.1%) followed by Muslims (14.9%). The exposure mostly occurred between 6:00 pm to 12:00 am (30% of cases). The majority of poisonings (44.6%) was due to consumption of household products followed by pesticides (14.9%) and pharmaceutical agents (13.5%). Neurologic manifestations were the most common clinical findings (64.8%) followed by gastrointestinal manifestations (37%). All patients were treated successfully with no mortality. There was a significant correlation between gender and intention of poisoning (P < 0.001), as the suicidal attempts were higher in women (69.4%). Moreover, a significant relationship existed between marital status and intention of poisoning (P = 0.016) as the suicidal poisonings were most common among married individuals (45.7%). Conclusion:The trend in poisoning is never static. Household products were identified as the main cause of poisoning in urban areas of India. Educational programs with more emphasis on preventive measures are necessary to create awareness among the general public. How to cite this article: Patil A, Peddawad R, Verma VCS, Gandhi H. Profile of Acute Poisoning Cases Treated in a Tertiary Care Hospital: a Study in Navi Mumbai. Asia Pac J Med Toxicol 2014;3:36-40.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
v.
1
no.
2014
36
40
https://apjmt.mums.ac.ir/article_2469_f02b8c997780a8d515e76285f56e2d3f.pdf
dx.doi.org/10.22038/apjmt.2014.2469
Acute Kidney Injury Following Rhabdomyolysis due to Multiple Wasp Stings (Vespa affinis)
Fazle
Chowdhury
Department of Medicine, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh
author
Mohammad
Bari
Department of Medicine, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh
author
Abdul
Shafi
Department of Medicine, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh
author
Abdul
Ruhan
Department of Medicine, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh
author
Mohammad
Hossain
Department of Medicine, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh
author
Sonia
Chowdhury
Department of Medicine, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh
author
Mohammad
Hafiz
Department of Medicine, Sylhet M.A.G. Osmani Medical College, Sylhet, Bangladesh
author
text
article
2014
eng
Background: Wasp stings are quite commonly observed in Bangladesh though they are under reported. However, rhabdomyolysis following multiple wasp stings is a rare entity. Case report: A middle aged physician was stung by a swarm of wasps at multiple sites of the body. He felt severe pain at the sites of the stings and was primarily treated with intravenous hydrocortisone and chlorpheniramine. Within few hours he developed oliguria with dark color. The dipstick urine test was positive for myoglobin and negative for red blood cell. His serum creatinine was 1.65 mg/dl, and creatine phosphokinase was 3963 IU/L, on admission. Subsequently, creatinine increased for the next three days. He was given forced diuresis with furosemide for three days and other supportive treatments. Clinical and biochemical picture started to improve including urine output and color and normalized on 6th day post-admission. The species Vespa affinis was confirmed by a zoologist as the offending insect. Discussion: Wasp sting usually results in pain and allergic reactions, though severe anaphylaxis may occasionally occur. Mass envenomation can cause systemic reactions and organ dysfunction including rhabdomyolysis, hemolysis, coagulopathy, and hepatic, renal, cardiac and neurological complications. Rhabdomyolysis is a distinguished cause of acute kidney injury in patients with wasp sting. Vespa affinis is the species commonly found in this region which can bring catastrophe. Conclusion: Multiple wasp stings may cause rhabdomyolysis followed by renal failure. Immediate supportive treatment (including copious hydration and sodium bicarbonate) is the mainstay to reduce morbidity and mortality in such cases. How to cite this article: Chowdhury FR, Bari MS, Shafi AM, Ruhan AM, Hossain ME, Chowdhury S, et al. Acute Kidney Injury Following Rhabdomyolysis due to Multiple Wasp Stings (Vespa affinis). Asia Pac J Med Toxicol 2014;3:41-3.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
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1
no.
2014
41
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https://apjmt.mums.ac.ir/article_2470_c45b2904c6c5593df2180ddeef4cff67.pdf
dx.doi.org/10.22038/apjmt.2014.2470
Miosis, Bradypnea and Loss of Consciousness with Several Compacted Solid Materials in Rectum and Colon in Abdominal X-Ray
Alireza
Ghassemi Toussi
Addiction Research Centre (ADRC), Mashhad University of Medical Sciences, School of Medicine, Mashhad, Iran
author
Gholam
Zare
Medical Toxicology Centre, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
author
text
article
2014
eng
Case: A 26-year-old man referred to emergency service with coma, bradypnea (respiratory rate = 4 breaths per minute) and pinpoint pupil. On chest auscultation, diffuse coarse crackle and on abdominal auscultation, decrease of abdominal sounds were found. At first evaluation, pulse oximetry showed 19% saturation of oxygen. After oxygen therapy with facial mask and infusion of 8.4 mg naloxone in divided doses, he regained consciousness with normal respiratory rate (16 breaths per minute) with 98% saturation of oxygen. The patient denied use of any illicit substances; however, due to triad of bradypnea, miosis and decreased level of consciousness, and also responsiveness to naloxone, the physician suspected opioid overdose and decided to admit the patient in Mashhad Medical Toxicology Center in Imam Reza Hospital. Forty minutes later, the patient deteriorated with decrease of oxygen saturation, tachypnea and decrease of consciousness. Chest X-ray showed diffuse infiltration in both lungs. In the urine screen test morphine metabolites were detected. Abdominal plain X-ray showed several compacted solid materials in rectum and colon (Figure 1). What are the differential diagnoses and appropriate management of this patient?
Differential diagnoses: The principle problems of this patient were relapse of unconsciousness in addition to miosis and apnea or bradypnea that suggest a) opioid toxicity, b) body packer, c) body stuffer, d) acute respiratory distress syndrome (ARDS), e) clonidine toxicity, f) parasympathomimetic agents toxicity, g) organophosphate toxicity, h) carbamate toxicity, i) sedative hypnotic toxicity, j) ethanol toxicity and k) barbiturate toxicity (Table 1).
Approach: the presence of miosis, bradypnea and decrease of consciousness in addition to positive response to naloxone, is highly suggestive of opioid toxicity (1). Notwithstanding, recurrent decrease of consciousness can be attributed to release of high amount of opioid in blood circulation which mostly occurs in opioid body packers and body stuffers (2).
Treatment: After admission to medical toxicology department, the patient became intubated with mechanical ventilation support with high positive end expiratory pressure (PEEP). Consequently, O2 saturation increased to 89%. Whole bowel irrigation with 70 g polyethylene glycol (PEG) was prescribed in 1000mL water per hour and after 4 doses, the patient defecated 23 intact packs with 1 semi open pack that contained raw opium (Figure 2). Subsequent to 2 other doses of PEG, the patient defecated only lucid water with no remaining pack. Due to the presence of tachypnea, coarse crackle on chest auscultation, and clinical suspicion of the opioid induced lung injury (ARDS), further doses of naloxone were not administered. In addition, ceftriaxone (2 g stat and 1 g q 12 h) and clindamycin (600 mg q 8 h) were administered intravenously. In the next abdominal X-ray no pack was seen.
Etiology: Body packers are illicit drug smugglers that swallow many packs with careful packing for the aim of transferring illicit substances including opioids, amphetamines and cocaine between two specific locations (1-4). On condition that the packs are torn in the alimentary tract, the substance leaks and the person can be influenced by active ingredients of the substance (5). The active ingredients can be absorbed through entroentric cycle or entrohepatic cycle. Hence, recurrent opioid triads occur refractory to naloxone therapy. The other similar but more life-threatening situation is body stuffer. These people swallow packets of illicit substances that are not carefully wrapped on due to having limited time when they are on escape or on police arrest. This group is prone to severer toxicity (2,6).
Outcome: This patient was on mechanical ventilation for 30 hours. His pulmonary function upturned to normal condition. Then he was weaned off and extubated. The patient was discharged on the third day post-admission with good condition.
Conclusion: Body packers may give misleading history. Moreover, physician may neglect body packer as one of differential diagnoses for triad of bradypnea, miosis and loss of consciousness. Hence, body packers may sometimes be missed until they die and the packs (Figure 2) are revealed in autopsy (5,7). Perhaps a patient with miosis, relapse of bradypnea and loss of consciousness is candidate to undergo abdominal radiography or preferably abdominal computed tomography (CT) scan (Figure 3) immediately after initial stabilization (7). For cases with definite diagnosis of body packer, all packs should be irrigated with either laxative (PEG) or surgical procedure (8). Discharge of these patients predicates upon normal abdominal and pelvic CT Scan without any pack and regaining consciousness with normal respiratory rate (9).
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
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1
no.
2014
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https://apjmt.mums.ac.ir/article_2471_8f09613c56099d79d5462fc2969a028e.pdf
dx.doi.org/10.22038/apjmt.2014.2471
Comment on "Empowerment of Medical Toxicology in Asia Pacific Region" - Indian Perspective
Surjit
Singh
Postgraduate Institute of Medical Education and Research, Chandigarh, India
author
text
article
2014
eng
In the editorial by Dr. Reza Afshari “Empowerment of Medical Toxicology in Asia Pacific Region” published in the Asia Pacific Journal of Medical Toxicology (APJMT) (1), the role of Asia Pacific Association of Medical Toxicology (APAMT) in promoting medical toxicology has been discussed and some suggestions have been made regarding how to promote this field of medical sciences in the region. The stated goal of APAMT is to promote chemical safety, poison control and treatment in the region and to some extent the organization has been successful in achieving these objectives. In the editorial, a few suggestions have been put forward to further achieve these objectives.
As far as India is concerned, poison control and treatment centers do not practically exist and most of the acutely poisoned patients are being managed either in general medical departments or intensive care units. The clinical toxicologists are practically non-existent and toxicology is still a part of forensic medicine in undergraduate curriculum and emergency medicine is not developed. There is no society of medical toxicology and the Indian society of toxicology is mostly membered by forensic specialists. A few poison information centers exist in major cities. Most of the research has been done in few centers by interested clinicians as supportive structure is lacking. Hence, a national society of medical toxicology which promotes the
objectives of APAMT is needed. We also need to develop poison control and treatment centers and not only information centers as poisonings are more often due to chemicals and require specialized care.
In most parts of South East Asia, majority of population lives in rural areas and is involved with agriculture. We also need to extend facilities to rural and semi-urban areas. These centers can play an important role in further promoting of public health, poison control and disaster control and also can assist in informing public about dangers of poisons and collection of harmonized data. To achieve these objectives, we need funding which has to be absorbed from government and non-governmental organizations. There is also a need to start educational activities such as post-doctoral fellowships in management of acute poisonings (2,3). This will go in a long way to promote and empower the medical toxicology in the region as India can help several developing countries in fulfilling the objectives of APAMT.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
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47
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https://apjmt.mums.ac.ir/article_2473_c2c832da5ad701150f261eb5364f5667.pdf
dx.doi.org/10.22038/apjmt.2014.2473
Comment on "Aluminum Phosphide Poisoning: a Case Series in North Iran"
Seyed
Mirakbari
Department of Forensic Medicine and Toxicology, Bu Ali Hospital, Qazvin University of Medical Sciences, Qazvin , Iran
author
text
article
2014
eng
Dear Editor,
I read with great interest the brief report entitled "Aluminum Phosphide Poisoning: A Case Series in North Iran" presented by Nosrati et al. and published recently in your journal (1). I have a question from authors and also a suggestion regarding aluminum phosphide (AlP) poisoning- related studies.
I would like to ask authors how they validate the study results, since it is not clear in the methods section how the cases were diagnosed and / or what confirmation method was applied. Were the study outcomes relied on AlP-poisoned cases diagnosed with just a history of ingesting rice tablet or depended on valid evidence?
As you know, in Iran, the term "rice tablet" is attributed to a) AlP tablet that is packaged in aluminum canisters b) a novel non-toxic herbal fumigant preparation named "garlic tablet" that is available in all drug stores nationwide and is packaged in plastic canisters (2). For a case with a history of rice tablet poisoning that the tablet(s) could not be found in the vicinity of the patient, the treatment strategy may be confounded, because the both situations are possible and so they may be treated interchangeably.
In our experience, the cases with garlic tablet ingestion are frequently presented to emergency department with gastrointestinal disturbances and mild to moderate hypotensive episodes with resultant metabolic acidosis in some instances that may imitate AlP poisoning. It is suggested that in the studies related to AlP poisoning, clinicians confirm the poisoning with: a) silver nitrate impregnated paper test (3) or b) observation of the rice tablet (AlP or garlic) consumed by the patient or its package where the test is not available or feasible.
Asia Pacific Journal of Medical Toxicology
Mashhad University of Medical Sciences
2322-2611
3
v.
1
no.
2014
48
48
https://apjmt.mums.ac.ir/article_2472_3fe93c7f7f6e897476b0bdaf13e5a239.pdf
dx.doi.org/10.22038/apjmt.2014.2472