ISSN: 2251-8762

Vol. 10 No. 3 (2020)

Original Article (Clinical Toxicology)

Epidemiology of Acute Poisoning in Mazandaran Province, Iran

Jamal Rezaei, Ebrahim Nasiri, Mostafa Moalemi, Sohrab Padashi, Mahbobeh Hatami

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 27632

Background: Poisoning is a critical medical emergency worldwide. The present study aimed to determine the characteristics and treatment outcomes of patients admitted to the poisoning department.
Methods: This cross-sectional descriptive study was conducted from March 2015 to September 2016 (for 18 months). We explored the epidemiology of poisoned patients hospitalized at Razi and Imam hospitals in Mazandaran Province, Iran. The obtained results were described as the frequency of poisoning, percentages, confidence intervals (95% CI), and mean values. The standard deviation scores were also presented for quantitative variables. The Student t-test and Chi-squared test were used for data analysis.
Results: The prevalence rate of poisoning equaled 4.98% of the total hospitalized patients. Of 71192 of the investigated cases, 3544 patients were hospitalized for acute poisoning. In terms of poisoning type, 65.2% belonged to drug toxicity, (95% CI) (64.7-77.2); 6.7% were related to methadone; 5.7% to an agricultural pesticide; 4.15% to aluminum phosphide (rice tablets); 2.2% to rat poison paste, and the remaining cases were caused by other poisons. There was a gender-wise significant difference in the poisoning method (P<0.001). The mortality rate in this study was calculated as 1.71% of all cases. The most frequent causes of death were aluminum phosphide (33.33%) and narcotics (16.16%) poisonings.
Conclusion: Acute poisoning is a fundamental health problem in Mazandaran Province, i.e., located in the north of Iran. Pharmaceutical medications, opioid agents, and aluminum phosphide were the main means of poisoning in the investigated adult patients. Most cases of poisoning occurred in the young-adult groups. Aluminum phosphide and organophosphate agents consumption generated the most critical states and were the main causes of death. It is suggested that aluminum phosphate be recalled from the market, as appropriate training must be provided for its proper use.

Analyzing Toxic Chemical Components in Illegal Alcoholic Beverages

Mahmoud Abbasi, Kambiz Soltaninejad

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020

Background: The illegal production of alcoholic beverages, due to the non-standard conditions, increases the risk of producing counterfeit and toxic products. The chemical analysis of toxic components in illegally-produced alcoholic beverages is necessary for each country. The present study aimed to identify the existence of methanol and other potentially toxic compounds in the seized illegally-produced alcoholic beverages.
Methods: In this descriptive laboratory-based study, we analyzed the toxic chemical components in sized illegally-produced alcoholic beverages, submitted to the Forensic Toxicology Laboratory of the Legal Medicine Center of Markazi Province, Arak City, Iran, in a year. A total of 100 seized illegally-produced alcohol beverage samples were collected. The qualitative and quantitative analysis of ethanol, methanol, 1-propanol, 2-propanol, and acetone was performed by the Gas Chromatography-Flame Ionization Detection (GC–FID) method.
Results: Methanol was detected in 6% of the evaluated samples (concentration range:1.2%-12%v/v). Acetone was detected in two of the studied samples (mean concentration: 0.7%v/v), and 2-propanol with a concentration of 0.5%v/v was found in one sample. Besides, ethanol was detected in all explored samples (mean concentration: 24%v/v).
Conclusion: Methanol was the main toxic chemical component in illegal alcoholic beverages; thus, it should be considered in public health policy and prevention programs in the country.

Ultrasound-Assisted Liquid-Liquid Extraction for Analyzing Methadone in Urine Samples by Gas Chromatography-Mass Spectrometry

Ahmad Shekari, Rooholah Valipour, Mehrdad Setareh, Kambiz Soltaninejad

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 29457

Background: Methadone abuse and dependence are a growing concern in some countries. The present study developed and validated a rapid, simple, easy, and sensitive method for analyzing methadone in urine specimens. This approach was intended for use in clinical and forensic toxicology and drug screening laboratories.
Methods: We determined methadone in urine samples by Gas Chromatography / Mass Spectrometry (GC / MS). Besides, we used Ultrasound-Assisted Liquid-Liquid Extraction (UALLE) method for the extraction and preconcentration of methadone before analysis.
Results: The detection limit was 2.1 ng/mL and the limit of quantification equaled 7 ng/mL. The methadone calibration curve was linear and ranged from 7 to 10000 ng/mL, and the correlation coefficient was calculated as 0.9984. The tested method was accurate and precise. Recovery fell in the range of 81.3% to 97.4% and the enrichment factor was measured as 8.7. The method was successfully used for determining methadone in real clinical and postmortem urine samples.
Conclusion: The presented method was a rapid, easy, simple, and sensitive procedure; thus, it could be applied in clinical and forensic toxicology laboratories as a routine approach for analyzing methadone.

The Anti-Inflammatory and Antioxidant Activity of Aspirin in Septic Animal Models

Fariba Yaghmori, Reza Hajihosseini, Seyed Mehrdad Kassaee, Bahram Seifizarei

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 32550

Background: Sepsis is a systemic body reaction to invasive microorganisms, such as bacteria and fungi. Furthermore, it is one of the top ten main causes of death among all patients admitted to the hospital. Multiple potential drug therapies have been investigated in this area; however, an effective pharmacotherapy for sepsis remains undiscovered. Therefore, we explored the effect of Aspirin or Acetylsalicylic Acid (ASA) on the treatment outcomes and reduction of sepsis complications concerning the parameters involved in the oxidative damage of liver tissue. To perform an in vivo experiment, an experimental inflammatory model Cecal Ligation and Puncture (CLP) was performed in rats.
Methods: The investigated rats were divided into 4 groups (n=40), as follows: 1. Controls; 2. Laparotomy (LAP) group; 3. CLP group; and 4. The treatment group with aspirin 2 mg/kg bw for 48 h after CLP induction. Then, the explored rats were anesthetized and blood samples were collected from their hearts. Next, the animals were sacrificed and the liver tissue was separated for histopathologic and biochemical studies.
Results: The obtained data suggested that the treatment of animals with aspirin was effective in adjusting the antioxidant and inflammatory parameters. Pathological studies also indicated that sepsis led to injuries in the liver tissues, which could be improved by interventions.
Conclusion: In conclusion, sepsis caused oxidative damage in the liver tissue, and using aspirin was effective in preventing and improving these injuries.

Original Article (Forensic Medicine)

The Rate and Pattern of Disclosing Medical Errors in Iranian Physicians and Healthcare Staff

Davood Soroosh, Alireza Abadi, Mohammad Nematshahi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 28202

Background: Ethics is of great significance in the medical community, i.e., because of the importance of this profession. How a physician manages a medical error, regardless of its cause, is among the major issues of medical ethics. Given the nature of the medical profession, medical malpractice may occur at any time during treatment. Medical malpractice is frequent in Iran and other countries.
Methods: The present cross-sectional study was conducted using a researcher-made checklist. The study participants attended legal medicine training and refresher courses in Mashhad and Sabzevar Cities, Iran, from June 2012 to June 2017.
Results: During five years, 1537 cases were enrolled in the study. Most of the study participants were female (n=832, 52.89%), with a Mean±SD age of 32.3±3.4 years. All study participants, except for 25 (1.58%) subjects answered “I do not disclose the malpractice” to the question “would you disclose your medical malpractice with treatable harm to the patient, while he/she gets hurt by not revealing the malpractice?”; the rest [1463 (92.94%) individuals] answered “I disclose the malpractice, but I do not mention that the harm is due to malpractice, and 85 (5.40%) participants answered, “I disclose the malpractice to the patient and mention that the harm is due to malpractice and it could be cured.”
Conclusion: The study findings suggested that the majority of study participants did not tend to disclose their malpractice to patients and their families.

Jurisprudence-Legal Consideration of Single-Status Childbearing

Mahmood Abbasi, Nazli Mahmoodian

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 32553

Background: Among the achievements of modern fertility technologies available to contemporary humans, we could mention the freezing technique to fertility preservation, and subsequently, unmarried childbearing. The only way for having children was having sexual intercourse with the opposite gender in the past years; however, with the advent of this technology, even without such a relationship, it is possible to have a child. This process could be termed unmarried childbearing or single-status fertilities. This is one of the resent subjects in medical fertility; however, there is no research in this field, in Iran.
Methods: This was an applied and theoretical research in the theology field; thus, no research material was implemented. The main method of this research was the bookcase approach.
Results: In countries such as the USA, UK, and Australia, where there are more coherent laws about employing modern fertility techniques, this issue is addressed and specific laws exist in this regard. However, despite widespread use of this technique in Iran, we have no law in this respect except for the Fetal Donation Act of 2003, which only covers the general issues. In other words, the social fertility mandate has remained silent given permission, prohibition, and its conditions and effects on the child lineage in Iran’s laws. Freezing gametes is practiced in our country for a wide range. Besides, single-status fertility is occurring worldwide.
Accordingly, this seems to be among the problems facing our society, and may also be illegally conducted in some cases, in Iran. In Islamic law, the permissible instances of reproductive rights include births through marriage, not otherwise, as well as births employing reproductive aids in terms of meeting the Islamic law. On the other hand, some individuals believe that this case can be regarded as some kind of inoculation with the involvement of a donor agency, and some jurists have voted to allow it. Therefore, these jurists explicitly accepted the use of donor gamete in the form of marital relations. The legislature of the Islamic Republic of Iran also emphasizes on donation to lawful couples in the law of donation approach. Therefore, using donated gametes for childbearing is excluded in singles. Additionally, Judaism and all branches of Christianity, except for the liberal protestant denomination prohibit unmarried childbearing. While the approach to the issue differs from one country to another, the USA Supreme Court has recognized and protected free relationships, family formation, and decisions on births, as freedom rights. The UK law has subjected the provision of services to single women to the welfare of children resulting from the process. However, in France, the provision of infertility treatment services to single individuals is prohibited. According to Australia law, any single or heterosexual individual without receiving medically-assessed services, i.e., referred to as ‘‘clinically infertile’’ cannot use this technology for having children.
Conclusion: In some countries, like the USA, bearing a child at a single status is legal; however, in some other regions, like the UK and Australia, it is permitted under special conditions. In some countries, like France, this action is prohibited. There is no law about this matter in Iran. The 167 article of the constitution addresses considering the Islamic verses and narrations on preserving the destination of the generation or acquiring the benefits and disposing of the corruption. In conclusion, the only way to have a child and to realize the principle of reproduction is permitted in the framework of religious marriage; thus, bearing a child at a single status is illegal and prohibited, in Iran.

Original Article (Medical Ethics)

Investigating Ethical Skills in Dentists and Dental Students: A Comparative Study

Sahar Vardian Tehrani, Shabnam Bazmi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 27149

Background: Commitment to professional ethics is important for all medical practitioners, including dentists. This skill should be taught to students during their studies. The purpose of this study was to investigate the moral skills of dentistry students and dentists.

Methods: This cross-sectional study was performed on 160 dentistry students and dentists. The Moral skills Inventory (MSI) Questionnaire was cross-culturally adapted and used in this study. The MSI was developed by Chamber’s and has 40 items covering four domains including: moral sensitivity, moral reasoning, moral integrity, and moral courage. Each domain’s scores ranged from zero to 20. The results were analyzed using SPSS software version 21.

Results: comparing with dentists, dentistry students got higher score in moral sensitivity domain (5.5 ± 3.64 vs. 3.87 ± 2.22) and moral integrity (6.4 ± 3.2 vs. 5.78 ± 2.72). However, in moral reasoning, dentists got higher score than students (15.40 ± 2.11 vs. 13.92 ± 2.35). In the moral courage domain, students’ score was 13.47 ± 3.10 and dentists’ was 13.62 ± 2.96. The mean±SD of total score of moral skills in all domains was 39.3± 4.50 for dental students, 38.68 ± 4.48 for dentists, and 38.99 ± 4.49 for all participants.

Conclusion: The professional ethics skills are relatively low in all four domains among dentistry students and dentists. Workshops, reviewing the syllables of medical ethics course, and practicing moral skills during training courses and monitoring professional performance can help to improve moral skill.

Original Article (General Medicine)

Computed Tomography Angiography-Based Evaluation of Anatomical Variations of the Celiac Trunk and Renal Arteries

Sara Besharat, Parima Safe, Husain Karrabi, Nasser Malekpour Alamdari

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 27797

Background: The abdominal aorta and its main branches, such as the celiac trunk and the renal arteries are manipulated during various radiologic, surgical, and oncologic procedures. This study aimed at evaluating the anatomical pattern of these vessels to assist surgeons and radiologists reduce the risk of intra- as well as postoperative complications.
Methods: A retrospective analysis of 536 Computed Tomography Angiography (CTA) studies of living potential kidney donors was conducted from January 2012 to December 2018.
Results: The anatomical variations of the celiac trunk was found in 9.5% of the cases. Among these cases, the most frequent variation was the Left Gastric Artery (LGA) as the first branch of the celiac trunk (80.4% of the cases). Gender was not overall significantly associated with the variations of the celiac trunk (P=0.670); however, there was a significant correlation between male gender and the most prevalent form of the celiac trunk variation (P=0.004). Variations of the renal artery occurred in 22.94% of the cases, with the left accessory renal artery being the most common variant (28.45% of the cases). Gender and the involved side (right / left) were not significantly related to the renal artery variations (P=1.000 & P=0.546, respectively). No concomitant variation of the celiac trunk and the renal artery was detected in our study.
Conclusion: The anatomical variations of the celiac trunk and the renal arteries occur commonly; thus, the branching pattern of these arteries should be assessed prior to any procedure concerning them.

Risk Factors of Hospital-acquired Thrombocytopenia in Toxicological Intensive Care Unit

Haleh Talaie, Sayed Masoud Hosseini, Maryam Nazari, Mehdi Salavati Esfahani, Behjat Barari

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 32256

Background: Platelet count is a readily available biomarker predicting disease severity and risk of mortality in the intensive care units (ICU). This study aims to describe the frequency, to assess the risk factors, and to evaluate the impact of thrombocytopenia on patient outcomes in a Toxicological ICU (TICU).
Methods: In this prospective observational Cohort study, we enrolled 184 patients admitted to our TICU from October 1st, 2019, to August 23rd, 2020. Mild/moderate and severe thrombocytopenia were defined as at least one platelet counts less than 150×103/µL and 50×103/µL during the ICU stay, respectively.
Results: Of 184 enrolled patients, 45.7% had mild to moderate thrombocytopenia and 5.4% had severe thrombocytopenia. Old age (OR: 1.042, 95%CI: 1.01-1.075, P=0.01), male gender (OR: 4.348, 95%CI: 1.33-14.22, P=0.015), increased international normalized ratio (INR) levels (OR: 3.72, 95%CI: 1.15-112, P=0.028), and administration of some medications including heparin (OR: 3.553, 95%CI: 1.11-11.36, P=0.033), antihypertensive drugs (OR: 2.841, 95%CI: 1.081-7.471, P=0.034), linezolid (OR: 13.46, 95%CI: 4.75-38.13, P<0.001), erythromycin (OR: 19.58, 95%CI: 3.23-118.86, P=0.001), and colistin (OR: 10.29, 95% CI 1.44-73.69, P=0.02) were the risk factors of hospital-acquired thrombocytopenia. The outcomes of patients with normal platelet count were significantly better than those who developed thrombocytopenia (P<0.001).
Conclusion: We found that thrombocytopenia could develop in almost 50% of patients admitted to TICU, which is associated with poor prognosis. Additionally, the platelet counts should be closely monitored to administer some medications (heparin, antihypertensive drug, and linezolid), especially in old patients.

Short Communication

Estimating Chronological Age by Dental Measurements on the Periapical Radiographs in Iranian Adults

Mitra Akhlaghi, Zahra Ghoncheh, Lida hatami

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 28500

Objectives: This study aimed to assess the accuracy of chronological age estimation based on dental measurements made on periapical (PA) radiographs of an Iranian adult population.

Materials and Methods: This study evaluated 90 parallel PA radiographs of sound maxillary canine teeth of 39 males and 51 females. Tooth length, root length, pulp length, pulp width and root width at points A, B and C according to the Kvaal’s method were measured on PA radiographs using Scanora software. Data were analyzed using SPSS.

Results: Maximum Root width at point A had the highest accuracy for sex estimation (77.7%). A significant correlation was noted between maximum pulp width at points B and C with age and a regression formula for age estimation was obtained.

Conclusion: Maximum pulp width at points B and C can be used for age estimation in adult population beside other parameters.

Examining Metabolic Profiles in Opioid-Dependent Patient

Nader Molavi, Amir Ghaderi, Hamid Reza Banafshe

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 28681

Background: Drug abuse is a social burden and a public health disorder. Previous evidence suggested numerous illicit substances (e.g., opioids, amphetamines, cocaine, & cannabis) affect immune system functions, oxidative stress mechanisms, inflammatory cytokines, and reactive oxygen species production.
This study aimed to determine the extent of these metabolic parameters in opioid-dependent patients. We also compared these patients with a healthy control group.
Methods: This study was conducted in Amirie Clinic, Kashan, Iran. Plasma and serum samples from 50 illicit opioid users (study group) and 50 non-opioid users (control group) were studied. Metabolic levels for MDA, NO, TAC, GSH, Insulin, HOMA-IR, and hs-CRP were assessed in both research groups (N=100).
Results: There was a significant difference in the status of MDA (P=0.003), NO (P=0.01), TAC (P=0.003), GSH (P=0.001), insulin (P=0.04), HOMA-IR (P=0.02), and hs-CRP (P=0.001) between the study and control groups. Furthermore, there was a significant correlation among the duration of illicit opioid use and MDA concentrations (r=-0.424, P=0.002), as well as TAC levels (r=0.314, P=0.02).
Conclusion: The study results suggested metabolic profiles were impaired in the study group, compared to the controls.

Case Report

Investigating Possible Etiologies of Post-Exposure Prophylaxis Failure and Deaths From Rabies Infection: Case Reports

Azadeh Rasooli, Behzad Pourhossein, Rouzbeh Bashar, Mohammad Reza Shirzadi, Behzad Amiri, Elmira Vadaye Kheiri, Babak Mostafazadeh, Maryam Fazeli

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 27378

Rabies virus, as a neurotropic agent, is transmitted to humans usually after animal biting. Rabies is endemic in most Middle Eastern countries. Pre-exposure Prophylaxis (PrEP) program is recommended for high-risk populations in endemic areas. The present study reported 7 deaths from rabies infection despite human Post-Exposure Prophylaxis (PEP) and the evolution of their possible etiologies from 2014 to 2018 in Iran. In this study, 29 rabid human deaths were evaluated despite PEP in 2014-2018. Seven people deceased despite receiving PEP. The most damaged organs were hands and face (71.43%). Injecting anti-Rabies Immunoglobulin (RIG) around the wound, improper cleansing, and delayed PEP were the main causes of PEP failure. In addition, immunodeficiency in a patient was another cause of failure. Our obtained data suggested that immediate precise measures after exposure based on the World Health Organization (WHO) recommendation, maintaining the temperature integrity (cold chain) of vaccines, and RIGs during transportation, and performing detailed injection schedule could prevent PEP failure in most cases. Furthermore, society’s awareness plays a key role in controlling the disease, especially in endemic areas.

The Successful Treatment of High Lethal Dose Paraquat Poisoning With Hemoperfusion

Ali Banagozar Mohammadi, Maryam Zaare Nahandi, Soraya Mohammadian

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 26726

Paraquat (PQ), as an herbicide, is mostly used by farmers, especially in the north-west of Iran. Easy access to PQ is the reason for PQ intoxication in farm­ers. However, poisoning with PQ is rare. Most of the PQ-poisoned patients ingest it deliberately and following a suicidal attempt. PQ poisoning treatment has a poor outcome; only a small dose of slightly more than 10 mL PQ could be harmful and damage lungs forever. Under the conditions of no specific clinical feature, proper history, and diagnostic test, diagnosis is usually difficult. The ingestion of PQ in toxic doses could be fatal, destroying the lungs, kidney, heart, gastrointestinal tract, liver, and other organs. To remove PQ from the blood and intoxicants, one of the best recommendations is Hemo­perfusion (HP), as an extracorporeal method. In this case report, according to our treatments, early management of high lethal dose PQ poisoning, especially with HP could reduce the morbidity and mortality rates.

Menorrhagia in Women After the Administration of Novel Oral Anticoagulants, Like Rivaroxaban: A Case Report

Jalil‎ Feizi, Department of Infectious Diseases, School of Medicine, Ilam University of Medical Sciences, Ilam, Iran., Abbas‎ Ghaysouri, Mahtab Bonyadi, Elham Shafiei

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 29640

Background: The Novel Oral Anticoagulants (NOACs), despite numerous benefits, such as the ease of use and less drug involvement, provide extensive adverse effects. One of the most significant, but rare side effects of them in women is severe and dangerous bleeding
Case presentation: In this study, we reported a case of severe vaginal bleeding (manometric hemorrhage) in a woman receiving rivaroxaban to prevent pulmonary thrombosis.
Conclusion: The oral anticoagulant rivaroxaban could present a rare adverse effect on women.

Total Gastric Necrosis as a Presentation of Aluminum Phosphide Poisoning: A Case Report

Arash Mohammadi Tofigh, Javad Zebarjadi Bagherpour, Parham Nikraftar

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 31244

Background: Rice pill poisoning is among the most frequent causes of death among poisoners. Despite advances in the treatment of this poisoning, its mortality rate remains high. The symptoms of Aluminum Phosphide (AlP) poisoning are varied and progressive. One of the essential foundations of diagnosis is based on the history of swallowing the pill by the patient or their companions.
Case Report: A 20-year-old woman with generalized abdominal pain and a diagnosis of peritonitis was operated. The operative finding was total gastric necrosis. After the operation, the patient’s husband claimed that she had consumed some rice pills, intending to commit suicide. Despite all efforts, she remained in persistent septic shock and multi-organ failure and passed away after surgery.
Conclusion: Total gastric necrosis could be among the lethal complications of rice tablet (AlP) poisoning.

Treating Ichthyotoxin Poisoning Induced by Gar Eggs Ingestion

Hailey Martin, Peter Akpunonu

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 3 (2020), 27 September 2020 , Page 31548

Background: A Gar is a primarily freshwater fish that resides in North America. The flesh of a garfish is edible; however, the eggs and any meat surrounding the eggs are highly toxic to humans. The toxicity is induced by the protein ichthyotoxin.
Case Report: The studied patient was an 18-year-old male who ingested 2-3 spoons full of gar eggs in their residence place. Each spoon full contained 40-50 eggs. The estimated total amount of consumed eggs equaled 3 teaspoons. Approximately one hour after eating the eggs, the patient began to feel unwell. Upon arrival at the local Children’s Hospital, the patient was experiencing nausea, vomiting, diarrhea, and sweating.
Conclusion: Patients affected by gar eggs should be treated symptomatically, given there is no antidote or specific treatment for ichthyotoxin. Further research is required on the mechanism that makes ichthyotoxin toxic. Luckily, the presented patient presented no seizures due to the toxin and the care providers could manage the related symptoms.