ISSN: 2251-8762

Vol. 10 No. 4 (2020)

Original Article (Clinical Toxicology)

Acute Kidney Injury in Poisoned Patients Admitted to ICU

Roghayeh Rashidi, Vahideh Mohamadzadeh, Nasrin Milani, Lida Jarahi, Bita Dadpour

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 30471

Background: Acute Kidney Injury (AKI) is an abrupt decrease in kidney function, leading to the retention of urea and other nitrogenous waste products. Poisoned patients admitted to the Intensive Care Unit (ICU) may develop AKI due to some reasons. This study was done to evaluate the AKI in poisoned patients admitted to ICU.
Methods: 146 patients, admitted to the ICU of Imam Reza Hospital from March 2017 to March 2018 were studied. AKI status was assessed using Acute Kidney Injury Network (AKIN) and Risk, Injury, Failure, Loss of kidney function and End-stage kidney disease (RIFLE) classification. Data analysis was done through SPSS V. 22 software.
Results: Opioids, organophosphates, aluminum phosphide, multiple drugs, and other types of poisoning were the main five poisoning classes. Opioid toxicity was had the highest frequency with 51 patients; cases in this group experienced longer length of hospitalization stay and higher serum creatinine level than others did. Among 146 patients, 19 patients (12.8%) died, and 97 patients (66%) were transferred to the ICU. Of all cases, 18 patients (12.3%) had renal dysfunction (six patients were at risk, five patient at injury, and seven patients were at failure phase based on the RIFLE criteria). Renal replacement therapy was required in 24 cases (16.4%).
Conclusion: It is unlikely to detect a significant difference in the occurrence of AKI between the main poisoning classes. Being the largest group of intoxicated patients admitted to the ICU, the opioid poisoning had the highest rate of AKI

Sepsis Criteria and Revision in Toxicological Intensive Care Unit

Haleh Talaie, Maryam Nazari, Habib Emami

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 31452

Background: Sepsis is one of the significant causes of mortality in hospitalized patients. This cross-sectional study was performed to determine the frequency of positive blood culture and assess sepsis criteria based on Third International Consensus Definitions (related to Sequential Organ Failure Assessment score) and clinical and paraclinical findings (i.e., on-admission leukocytosis, increased lactate level, and fever) in poisoned patients admitted to the Toxicological Intensive Care Unit (TICU).
Methods: Medical records of a total of 2000 poisoned patients admitted to the TICU of Loghman Hakim Hospital from 2016 to 2018 were assessed. Among them, 189 cases (9.45%) with suspected sepsis were considered eligible to be enrolled in the study.
Results: Of 189 cases, 146 (77.24%) had possible signs and symptoms of sepsis as well as SOFA score higher than two with positive blood culture in 81 cases (55%). The Mean±SD serum level of lactate was 25.97±16.32 on admission. The most common pathogen detected in blood culture was coagulase-negative Staphylococci in 35 (24.0%) out of 146 cases. Glasgow Coma Scale (GCS) less than 12, age older than 50 years, and bilirubin more than 1.2 mg/dL were found as independent predictors of sepsis on multivariate analysis.
Conclusion: Based on our findings, it is proposed that the sepsis definition should not be restricted to the guidelines. The patients’ poisoning background and presence of many confounding factors, including poisoning-induced on-admission increased lactate levels, leukocytosis, and disturbed arterial blood gas provide a critical decision-making situation to confirm sepsis according to guidelines.

Original Article (Forensic Medicine)

The Epidemiology of Human Mortality in West Azerbaijan Province, Iran, 2016

Flora Farivarnia, Rasool Entezarmahdi, Mohammad Delirrad

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 30049

Background: This article presents the most recent mortality data in West Azerbaijan Province (WAP) of Iran in 2016 based on selected characteristics, including age, sex, state of residence, and cause of death.
Methods: After the local Ethics Committee approval, we obtained the data for this systematic database study from the local health registration office. The causes of death are processed following the International Classification of Diseases, tenth revision (ICD-10). The vital statistics were refined from the yearbooks of the National Organization for Civil Registration.
Results: In 2016, a total of 14688 deaths were registered in the Health Death Registration System (HDRS) and 14622 in the Civil Death Registration System (CDRS) of WAP (~4% of Iran’s mortality). The Crude Mortality Rate (CMR) was 4.30 per 1000, showing an increase of 7.5% from the 2011 rate. Of the deceased, 56.9% were males, and 60% were attributed to urban areas. On average, men died 4 years earlier than women (61.2 vs 65.3 years, respectively). The major causes of death in 2016 remained the same as in 2011.
Conclusion: The pattern of human mortality in WAP is comparatively consistent with the other regions of Iran except for the higher rate of neoplasms (19.6% compared to 10.7% of the country average) and the lower ratio of certain infectious and parasitic diseases (1% compared to 3.8% of the national average). There was a significant difference in registering the state of residence between HDRS and CDRS, which is highly recommended for further investigation in future studies.

Original Article (Medical Ethics)

Attitudes of Patients and Their Families Towards Medical Privacy and Competence of Bearer or Receiver of Bad News

Maryam Zaare Nahandi, Mohammad Asghari Jafarabadi, Mehrnoosh Haghighatjou, Kosar Ashrafrezaei, Marziyeh Shakeri Saeedabad, Ahad Banagozar Mohammadi, Ali Banagozar Mohammadi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 28580

Background: Based on the patients’ and relatives’ views on the level of preservation of privacy rights of individuals, we propose a way to reduce problems and disagreements about the competence of the provider and recipient of bad news.
Methods: In the current cross-sectional study, the participants were recruited from the main northwest hospital of Iran. It was also conducted to study the scope of medical privacy and competence of bearers or receivers of bad news. After the literature review, two questionnaires were designed and administered. They contained items pertinent to the scope of medical privacy and competence of bearers and receivers of bad news. Each item of the original questionnaire was scored on a 5-point Likert scale.
Results: The model quality and significance level were obtained using KMO and Bartlett tests. The results (patient’s attitudes questionnaire: KMO=0729 and P<0.05 in the Bartlett test; family attitudes questionnaire: KMO=0.764 and P<0.05 in the Bartlett test) confirmed the model efficiency. According to the results from factor variance and their cumulative rate, the predictive power of the model was obtained as 62.019%, based on the overall factor variance rate. The majority of patients wanted to be informed about their disease conditions. They also considered bad news to be medical privacy and disagreed that their medical information should be opened up with others without permission.
Conclusion: To preserve medical privacy, it is recommended that a system be designed that allows patients at the admission to the medical center to enlist their eligible family members to whom medical information can be delivered.

Original Article (General Medicine)

Nicotine Dependence Severity and Revised Reinforcement Sensitivity Theory: Assessing the Mediating Role of Risky Decision Making Using Path Analysis

Kiomars Cheraghi, Morad Rasouli-Azad, Hamid Reza Banafshe, Ali Yoonessi, Amir Ghaderi, Abdollah Omidi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 30278

Background: Gray’s revised Reinforcement Sensitivity Theory (r-RST) is a neuropsychological
explanation of personality that has been broadly used in substance use disorders. Although the
Behavioral Approach System (BAS) is strongly related to nicotine dependence, findings in
Behavioral Inhibition System (BIS) are controversial and there is little information about the
role of the Fight/Flight/Freeze System (FFFS) in nicotine dependence. The purpose of the
present study was to evaluate the mediating role of Risky Decision Making (RDM) in this
relationship to clarify the controversy and fill the gap.
Methods: The final sample of this correlation study comprised of 347 university students (age,
Mean±SD 23.2±6.7) who completed two self-report measures, including the Fagerstrom Test
For Nicotine Dependence (FTND), Jackson-5 questionnaire of r-RST, and a computerized
Iowa Gambling Task (IGT) to measure RDM. Pearson correlation and a path analysis
framework were used to determine the simple, direct, and indirect effects of r-RST systems on
nicotine dependence severity through RDM.
Results: Using Amos, path analyses demonstrated significant direct and indirect effects of
BAS and FFFS/BIS on tobacco use. Also, the relationship between BAS/FFFS/BIS and
tobacco use was shown to be mediated by RDM.
Conclusion: It was demonstrated that the relationship among BAS /FFFS/BIS and tobacco
use can be partly explained using maladaptive RDM strategies, suggesting that decreasing
reliance on decision-making in risky situations, while increasing the use of decision-making
skills educations in risky situations, and increasing the use of alternative sensation and fun
seeking by smoking and emotion regulation and mindfulness-based therapies

The Effects of Quetiapine on Craving and Withdrawal Symptoms in Methamphetamine Abuse: A Randomized, Double-Blind, Placebo-Controlled Trial

Najme Sadat Javdan, Amir Ghaderi, Hamid Reza Banafshe

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 29374

Background: Patients with Methamphetamine Abuse (MA) are susceptible to many complications like craving, and withdrawal symptoms. These trials were designed to evaluate the effect of quetiapine administration on craving and withdrawal symptoms in MA abuse.
Methods: This trial was conducted on 60 people with MA abuse to receive either 100 mg quetiapine (n=30), or placebo (n=30) every day for 2 months. The Desire for Drug Questionnaire (DDQ) and Amphetamine Withdrawal Questionnaire (AWQ) scores were evaluated at baseline and after 2 months’ intervention. For data analysis, t test, and the Chi-square test were applied in SPSS v. 18.
Results: Quetiapine significantly decreased DDQ (P=0.002) and AWQ symptoms (P=0.001) compared to the placebo. Furthermore, there was a significant difference among groups in terms of the frequency of negative urine tests (P<0.001).
Conclusion: This trial showed that administration of quetiapine supplements for 2 months in individuals with MA abuse had beneficial effects on craving and withdrawal syndrome.

Short Communication

Factors Affecting Tramadol-Associated Seizure

Maryam Zaare Nahandi, Sayna Abbaszadeh, Mostafa Mansouri, Haniyeh Elahifard, Ali Banagozar Mohammadi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 26674

Background: Tramadol is a widely prescribed analgesic and due to its opioid-like effects, the potential for abuse of tramadol is noticeable. Besides, the complications of tramadol abuse have become a public health concern. This study aimed to investigate the affecting factors on the seizure, as one of the most common complications of tramadol consumption.
Methods: A total number of 64 patients from 315 patients who were referred to Sina Hospital, Tabriz, Iran because of tramadol toxicity were included in this 9 months cross-sectional retrospective study.
Results: There were 52 males and 12 females in the study. The seizure happened in 53.1% of the subjects and the Mean±SD time between tramadol consumption and seizure was 5.9±7.36 hours. There was no significant association between seizure and sex, age, the dose of tramadol, and previous tramadol consumption history. A significant association was seen between the dose of tramadol and the time of seizure.
Conclusion: Seizure that happens due to tramadol overdose is not dependent on sex, age, and previous history of tramadol consumption. As the dose of tramadol is higher, the seizure happens later. More research is needed to understand why the seizure occurs later in higher doses.

Review Article

Endocrine-Disrupting Chemicals Role in Drug Abuser: A Review Study

Idha Arfianti Wiraagni, Mustafa Ali Mohd, Rusdi Abdul Rashid, Didi Erwandi Bin Mohamad Haron

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 26324

Endocrine-disrupting Chemicals (EDCs) are exogenous chemicals that influence many aspects of natural hormone actions. Bisphenol is used in the industry, for increasing the thickness and durability of materials in certain plastics and resins. Paraben is used as preservatives in many pharmaceuticals, cosmetics, and some food products. EDCs can increase estrogen levels inside the body, and estrogen itself can increase the monoamine effect (dopamine, serotonin), neuronal excitability, neuropeptide transmitter mechanism, and drug metabolism. In drug abusers, this effect can develop greater craving behavior, addiction, and relapse.

Brain Death According to the Sunni Jurisprudence

Mahmood Abbasi, Jahandar Amini, Nazli Mahmoodian

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 27388

Background: Brain death is a new medical term that appeared in the second half of the 20th century. Some research about it has already conducted in law, but no academic research in this field from the Sunni jurisprudents point of view.
Methods: Because this is a theoretical study in theology, our primary research method is library research.
Results: There are different opinions about brain death in Sunni jurisprudence, which can be divided into three groups of supporters, opponents, and neutrals. Some jurisprudents do not recognize brain death due to their respect for the human soul. According to principles such as asceticism and the observance of the custom of the universe, the death of patients with brain death is not certain, and subsequently, it is not allowed to separate assist devices from the patient and the perception of their members. However, the second group, considering the lack of human life and according to the theory of medical commission, which is the same convention, brain death is considered to be a definite death, so it is allowed to separate the assist devices from the patient and the withdrawal of its members. The neutrals consider brain death as one of the examples of definitive death, but for some jurisprudential rulings, legal rights are not considered in the death sentence.
Conclusion: The brain death is the complete cessation of the activities of the brain, including the brain stem and cortex. By diagnosis and announcing the brain death, the patient is considered as a dead body regardless of lungs and heart function even with the help of a resuscitator. It seems the reasons of the supporters of brain death are favorable. So the resuscitator should be separated from the patient with brain death.

Case Report

Successful Management of an Aluminum Phosphide Poisoned Patient Following Ventricular Tachycardia

Shahin Hallaj, Ali Banagozar Mohammadi, Anahita Ghorbani, Ali Ostadi, Maryam Zaare Nahandi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 30473

Aluminum Phosphide (ALP) poisoning is regarded as fatal; however, it is commonly used in
developing countries. In some countries, such as India and Iran, it is still being used to protect
grain against pests at home. As yet, no known antidote is reported to be effective against ALP
poisoning. ALP acts through blockage of cell respiration, alteration of cell permeability, and
induction of oxidative stress. Some factors can worsen the prognosis of its intoxication, which
include hyperglycemia on admission, ingestion of fresh tablets, cardiac abnormality, especially
Ventricular Tachycardia (VT), severe metabolic acidosis, cardiogenic shock and other types
of shocks, electrolyte disturbances, end-organ damage, and a need for mechanical ventilation.
ALP kills its victims by induction of multi-organ failure.
In this study, we controlled the patient’s VT using MgSO4, electric shock, amiodarone, and
lidocaine. We also encountered the cardiogenic shock using norepinephrine, High-Dose Insulin
(HDI), antioxidants, sodium bicarbonate, and normal saline. Moreover, myocardial ischemia,
recurrent VTs, and adverse cardiac effects were protected via tight control of magnesium and
other electrolytes.

Risperidone-Induced Erythema Multiforme Minor: A Case Report

Sina Negintaji, Reza Bidaki, Javad Zare Kamali, Fatemeh Saghafi, Maryam Naseri Bafrouie, Nilofar Tabaei Zadeh, Hossein Azadi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 28119

Erythema Multiforme (EM) is a hypersensitivity reaction that can be triggered by an infection or particular medications. Erythema multiforme minor (EM minor) represents localized skin lesions with minimal or no mucosal involvement. Only a few case of EM associated with risperidone are found in the scientific literature. In this case report, the administration of the risperidone resulted in the rapid appearance of skin lesions. Erythematous lesions were recovered upon discontinuation of the drug and no new skin lesion was observed. A 52-year-old male patient was admitted to the psychiatry hospital because of developing schizophrenic symptoms. At the time of admission, risperidone was added to her previous drug regimen. Two weeks later, the patient returned with a complaint of progressively increasing rashes over his body. The patient was diagnosed with EM minor. The prescribed risperidone was discontinued due to its side-effect profile and the patient’s drug regimen was changed entirely to the olanzapine, haloperidol, and topical clobetasol. At one month follow up visit, his skin lesions were satisfactorily controlled.

Guillain-Barre Syndrome Due to Tramadol

Ali Banagozar Mohammadi, Ali Ostadi, Maryam Paeezi, Babak Mostafazadeh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 27146

Tramadol is a powerful prescription medication used for pain relief of varying intensities. Tramadol was initially produced in Germany to alleviate postsurgical and chronic pains. We describe a case of a 22-year-old male with no past medical history who took tramadol for the second time and then had a tonic-clonic seizure episode that worsened the weakness of his inferior limbs and followed by loss of consciousness. According to physical examination, clinical and paraclinical tests, he was diagnosed with Guillain-Barre syndrome. After treatment with intravenous immunoglobulin, he was improved and discharged 9 days after treatment. He was recommended to continue physiotherapy. The relation between tramadol using and Guillain-Barre syndrome development is unknown but it can be due to reactive oxygen species generation.


Severe Accidental Organophosphorus Poisoning in Two Children

Alireza Aminisefat, Khadijeh Saravani, Mahdieh Saravani

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 30128

Background: Organophosphorus (OP) compounds have intense anticholinesterase activity and are commonly used as insecticides and pesticides. OP poisoning is a global health problem and poses a threat to human health.
Case Report: Here we report two sisters, aged 3 and 4 years, who had inadvertently eaten agricultural pesticides. These patients had a decreased level of consciousness, nausea, and vomiting. We do not have pralidoxime in this center and the adjacent center, so we used atropine as the primary drug in treating these patients. However, after 4 days, the 3-year-old patient felt a weakness in upper and lower limb movements.
Conclusion: In the treatment of OP poisoning, it is necessary to pay special attention to delayed complications such as intermediate syndrome.

Letter to the Editor

A Concise Review of Intellectual Disability and Puberty Problems Based on the Laws of Different Countries

Shahrokh Mehrpisheh, Azadeh Memarian, Kamran Aghakhani

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 27266

Intellectual Disability (ID) is characterized by limitations in intellectual functioning and behavioral adaptations. Patients with ID have a wide range of problems affecting the quality of life in these cases and their parents, as well.

COVID-19- or Tramadol-induced Seizure: A Differential Diagnosis in Young People

Solmaz Nekoueifard, Mohammad Majidi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 32009

Coronavirus disease 2019 (COVID-19) was first declared in December 2019 from Wuhan, China [1, 2]. It then has been reported a pandemic in March 2020 by the World Health Organization [3]. Clinical features of COVID-19 are different from asymptomatic to mild to moderate symptoms, such as fever, headache, myalgia, sore throat, anosmia, cough, fatigue headache, hemoptysis, and dyspnea to the life-threatening complications, including shock, pneumonia, acute respiratory distress syndrome, myocarditis, myocardial infarction, acute kidney injury, multi-organ failure, and even death [1, 2].

Efficacy of Lofexidine in the Outpatient Management of Tramadol Withdrawal Syndrome

Mohammad Majidi, Solmaz Nekoueifard

International Journal of Medical Toxicology and Forensic Medicine, Vol. 10 No. 4 (2020), 16 November 2020 , Page 32270

Tramadol is recognized as an opioid with non-opiate properties. It has a low affinity for opioid receptors and prevents reabsorption of norepinephrine and serotonin at synapses. It also increases the level of Gamma Aminobutyric Acid (GABA) in the central nervous system [1, 2]. Tramadol is an analgesic for patients suffering from moderate to severe pain [1]. In addition, previous studies have shown that tramadol abuse and suicidal attempts have increased in Iran [3, 4].