ISSN: 2251-8762

Vol. 11 No. 1 (2021)

Original Article (Clinical Toxicology)

Occupational Exposure to Paving Asphalt Fumes, Impact on Liver and Kidney Function Test Parameters

Mahdieh Noroozi, Maryam Akhgari, Alireza Abdollahi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021 , Page 29730

Background: Asphalt is a mixture of aliphatic and aromatic hydrocarbons. It also contains different kinds of heavy metals. Hot mix asphalt emits hazardous volatile substances. Asphalt is used in many industries, causing serious adverse health effects for workers. Therefore, investigation of the health status of workers is of crucial importance. The present study aimed to assess the impact of asphalt vapor on hepatic and renal function tests parameters and the clinical parameters in road paving workers compared to healthy subjects.
Methods: In a cross-sectional study, 41 road asphalt paving workers and 120 healthy non-exposed subjects were selected. The serum enzymes of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), total bilirubin, triglyceride, urea, and creatinine levels were assessed using diagnostic kits. A medical practitioner examined all subjects for any possible medical condition.
Results: Liver and kidney function test parameters were significantly higher in road asphalt paving workers compared to their healthy counterparts (P<0.05 for all parameters). About 63% of workers exposed to asphalt fumes for more than 10 years showed cardiac, pulmonary, and metabolic complications.
Conclusion: Significant elevations in liver and kidney function test parameters suggest that exposure to asphalt fumes is associated with hepatic and renal dysfunction in asphalt-exposed workers.

Ten Years of Experience in Treating Patients With Digoxin Toxicity Without Using Digoxin Fab Antibody

Farzad Gheshlaghi, Anselm Wong, Gholamali Dorooshi, Rokhsareh Meamar, Faezeh Tabesh, Hajar Aminsafaei, Shafeajafar Zoofaghari, Nastaran Eizadi-Mood

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021 , Page 31239

Background: Digoxin is extensively prescribed for cardiac diseases, so its chronic or acute toxicity commonly occur. Although digoxin specific antibodies (anti-digoxin Fab) are recommended to be used in patients with cardiac symptoms of digoxin toxicity, there is ongoing controversy about the effectiveness and dose of anti-digoxin Fab. Because our department lacks access to anti-digoxin Fab and the high cost of the antidote, we evaluated 10 years of experience in treating patients with digoxin toxicity without using digoxin Fab antibodies considering outcomes.
Methods: A retrospective study was performed in Khorshid Hospital, affiliated with Isfahan University of Medical Sciences, from October 2008 to September 2018. Patients with acute or chronic digoxin toxicity were included in the study. The patients’ data were gathered and analyzed according to their medical documents.
Results: Out of 150 cases with digoxin toxicity, 38% (n=57) were acute and 62% (n=93) were chronic. About 64.7% (n=97) were female. The most common non-cardiac manifestations of toxicity were gastrointestinal (67.3%, n=101) and neurological symptoms (52.7%, n=79). Bradyarrhythmia (80.5%, n=33) was the most cardiac manifestation in patients with acute (15.8% n=9) and chronic (25.8%, n=24) toxicity. A total of 144 (96%) cases fully recovered with supportive care, and 6 patients (4%) died. None of the cases received anti-digoxin Fab.
Conclusion: The majority of presentations with acute or chronic toxicity recovered with supportive measures without using anti-digoxin Fab.

The Biochemical Outcome of two Treatment Protocols in Patients with Opium-Associated Lead Poisoning: A Cross-Sectional Study in North of Iran

Ali Reza Badsar , Zeinab Gholami, Morteza Rahbar Taramsari , Zahra Atrkar Roshan, Hamid Mohammadi Kojidi , Monireh Aghajany-Nasab

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021

Background: Lead is a potent toxin that targets heme synthesis and some antioxidant enzymes that induce oxidative stress. Lead exposure remains one of the significant health concerns all over the world. Chelating agents have been used as antidotes for acute and chronic lead poisoning. The present study was conducted to evaluate the biochemical outcome of two different chelating therapies.

Methods: This descriptive cross-sectional study was performed in the Razi University Hospital, Rasht, Guilan. Fifty-six patients with a history of opium use were enrolled in the study who were treated symptomatically. Blood lead levels (BLL), hemoglobin (Hb), red blood cell (RBC), white blood cell (WBC), urea, creatinine, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and alkaline phosphatase (ALP) were evaluated before and after treatment. The BLL more than 100μg/dl with clinical symptoms was considered as severe lead poisoning (n=34) who received 4 days of DMPS (2,3-dimercaptopropane-1-sulfonate) injection. Other cases with BLL of 20-100μg/dl were considered as those with mild poisoning (n=22) that were treated with oral D-Penicillamine for 14 days.

Results: The mean age of patients was 49.73±14.11 years. Data analysis indicated no significant differences between the groups at baseline regarding the demographic variables. A significant reduction was observed in BLL before and after the intervention using the D-Penicillamine from 75.88 ± 26.22 to 44.3 ± 17.51 μg/dl (P = 0.0001).  The BLL reduced  from 105.5 ± 34.04 to 24.51 ± 24.08 μg/dl after treatment with DMSP (P = 0.0001). The levels of ALT, AST, and WBC significantly decreased post-treatment following using D-penicillamine and DMPS (P <0.05). The D-Penicillamine-treated group showed an increase in Hb and RBC (P <0.05).

Conclusion: According to the results, penicillamine improves low to moderate lead toxicity. Although DMSP decreases BLL significantly and reverses liver enzymes, further investigations on Hb and RBC, are needed.

Original Article (Forensic Medicine)

Background: Drug abuse is spreading rapidly all over the world. Methadone and tramadol are among not only the most abused opioids but also important from the forensic point of view. Therefore, we need to devise a simple and sensitive method for the sample preparation and identification of abused drugs in postmortem specimens.
Methods: A simple and rapid dispersive liquid-liquid microextraction (DLLME) technique coupled with ultrahigh performance liquid chromatography (UHPLC) was developed for the extraction and analysis of methadone and tramadol from postmortem vitreous humor samples. Different parameters affecting the extraction recovery, such as the type and volume of extraction and dispersion solvents, pH value, sensitivity, and specificity, were optimized and studied.
Results: Under optimized conditions, the recovery ranges were 82.3%-89.6% and 85.4%-87.1% for methadone and tramadol, respectively. The linear range was 25-100 ng/mL for both methadone and tramadol with a correlation coefficient (R2) of more than 0.98. Limit of detection (LOD) and limit of quantification (LOQ) were 3 and 8 ng/mL for methadone and 6 and 16 ng/mL for tramadol. The accuracy level of the methods for methadone and tramadol detection were 99.4%-100% and 99.7%-99.9%, respectively. The method was specific enough for the qualitative and quantitative determination of methadone and tramadol.
Conclusion: The obtained results showed that DLLME combined with UHPLC is a fast and straightforward method for determining methadone and tramadol in postmortem vitreous humor specimens.

Knowledge and Attitude of Midwives and Obstetricians Towards Therapeutic Abortion Law and its Ethical Pitfalls

Shabnam Bazmi, Mehrzad Kiani, Mahdieh Saidi, Forouzan Akrami

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021

Background: Despite the implementation of a safe motherhood program in many countries, unsafe abortion continues to be a matter of reproductive health. Thus, urgent efforts to make abortion legal and safe have been recommended in developing countries. The present study was done to determine the knowledge of midwives and obstetricians about the therapeutic abortion law as well as their attitude about the ethical pitfalls.
Methods: In this descriptive knowledge and attitude study, a researcher-made questionnaire was used to gather data, after estimating the appropriate Cronbach’s Alpha coefficient. A total of 162 midwives and obstetricians working in public and private medical centers affiliated to Shahid Beheshti University of Medical Sciences in 2018 were included in the study by convenience sampling method.
Results: According to the results, 9.3% of participants had a low level, 72.8% had a moderate level, and only 17.9% had a good level of knowledge. The total mean score of knowledge was 7.17±1.7. The mean score of knowledge in the group of obstetricians (7.60±1.74) was significantly higher than midwives (6.94±1.54), (t=2.29, p=0.024). There was a significant correlation between participants’ age and their knowledge (r=0.912, p=0.001). Also, 47.53% of the participants believed that the therapeutic abortion law has some pitfalls. The most frequent attitude was about the restriction of the therapeutic law up to 19 weeks for fetal indications.
Conclusion: The level of participants’ knowledge was low to moderate. The findings indicated the need for training the professional standards related to prenatal genetic screening and therapeutic abortion.

Frequency of Patient Complaints Before and After Legal Medicine Consultation in Orthopedic Ward of Taleghani Hospital of Tehran, Iran From Spring 2011 to Winter 2017

Reza Zandi, Mohammadreza Moshari, Mohammadreza Minator Sajjadi, Farnoosh Davari, Amir Ali Mafi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021

Introduction: Patient who complain of the health community are unpleasant and may endanger the honor of the medical community. However, patients' complaints can improve the quality of medical services, increase the accuracy of the medical staff, and reduce diagnostic and treatment costs. The aim of this study was to investigate the prevalence of patients' complaints before and after legal medicine consultation in the orthopedic ward of Taleghani hospital in Tehran, Iran.

Methods: This retrospective cross-sectional study investigated the frequency of the complaints of 460 patients before and after legal medicine consultation from spring 2011 to winter 2017. Data were analyzed by excel.

Results: The results of this study showed that the frequency of complaints was lowest in spring and highest in fall. The number of complaints and frequencies also decreased over time compared with the previous year. The lowest number of complaints was in 2011 and the highest in 2013.

Conclusion: In this study, performing legal medicine consultation in Taleghani hospital in Tehran, Iran reduced the number of registered complaints.


Original Article (General Medicine)

Comparison of Short-term Outcome of Thoracoscopic-Laparoscopic Esophagectomy Versus Transhiatal Esophagectomy for Resectable Esophageal Cancer

Touraj Asvadi Kermani, Seyed Ziaeddin Rasihashemi, Moein Hoseinpour Feyzi, Seyed Ehsan Mousavai Toomatari

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021 , Page 31113

Background: Esophagectomy is performed in all patients with resectable esophageal cancer. Transthoracic-Laparoscopic Esophagectomy (TLE) is a minimally invasive method and considered to be the most appropriate method. In this study, we aim to evaluate and compare the perioperative outcome, and 1-year overall survival of TLE and Transhiatal Esophagectomy (THE) approaches.
Methods: In this retrospective study, we reviewed the medical records of 108 patients with esophageal cancer undergoing TLE (n=44) or THE (n=64) between 2015 and 2018. The patients were followed for one year. The intraoperative and postoperative findings, as well as 1-year overall-survival, were compared between the two groups.
Results: TLE compared to THE had a longer surgery duration (278.63±33.28 vs 223.28±33.99 min, P=0.001), a higher number of dissected lymph nodes (15.06±2.95 vs 10.21±2.58, P=0.001), less blood loss (345.45±178.76 vs 585.15±294.75 mL, P<0.001), and need for transfusion (20.5% vs 45.3%, P=0.006) during surgery as well as lower ICU stay (2.59±0.77 vs 3.90±0.83 days, P<0.001) and ward stay (8.77±0.96 vs 11.42±1.71 days, P<0.001). THE had somewhat higher complication than TLE, but with no significant differences.
Conclusion: TLE had a similar rate of complication to THE approach, but with lower blood loss and lower ICU and hospital stay, it is a more appropriate method for esophagectomy.

Short Communication

Assessment of Risk Factors and the Effect of Drug Abuse on the Incidence of Ischemic Heart Disease in Patients Less Than 40 Years Old

Javad Karimi, Mohamadreza maghsoudi, Lida Shojaei Arani, Shahrooz Yazdani, Nami Mohammadian Khonsari, Kiumars Bahmani, Hoorvash Faraji Dana

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021

Introduction: in this study, we examined the risk factors and the effects of substance abuse on the incidence of ischemic heart disease in patients less than 40 years old in Shahid Rajaei Hospital in Karaj from 2019-2020.

Materials and Methods: This case-control study was done on 70 patients in the cases and 70 cases in the control groups. All demographic data, including age, gender, place of residence, weight, height, body mass index, cardiovascular (CVD) risk factors, including hypertension, high levels of blood fats, diabetes, a history of smoking cigarettes, tobacco, crystal meth, and cocaine, alcohol consumption, as well as a history of taking supplements for bodybuilding, and sex-enhancing drugs were obtained. Afterward, blood levels of glucose and fats were evaluated and urine analysis for the presence of drugs, such as amphetamine, methamphetamine, buprenorphine, benzodiazepines, cannabinoids, cocaine, morphine, methadone, tramadol, and tricyclic antidepressants (TCA) was done. SPSS software version 22 was used for data analysis.

Results: Among the studied underlying factors and drugs, family history, high blood pressure, diabetes, smoking, and low-density lipoprotein (LDL) levels above 130 mg / dL were significantly associated with a higher risk of acute myocardial infarction (MI) (P <0.05). Interestingly, alcohol consumption and the use of tobacco, opium, methadone, heroin, cocaine, cannabis, amphetamines, methamphetamine, tramadol, benzodiazepines, TCA, buprenorphine, and anabolic steroids were not significantly associated with acute MI under 40 years (P> 0.05).

Conclusion: according to the results of the present study, it seems that a positive family history of MI under the age of 55, hypertension, diabetes, smoking, and LDL levels above 130 mg/dL are more significant risk factors for acute MI in patients under 40 years of age in comparison with the consumption of alcohol and the use of hookah, opium, methadone, heroin, cocaine, cannabis, amphetamine, methamphetamine, tramadol, benzodiazepines, TCA, buprenorphine, and anabolic steroids. It should be noted that further studies in this area are recommended.

The Modification of the Education System in a Medical Faculty in Iran During the COVID-19 Outbreak

Kamran Aghakhani, Azadeh Memarian, Mohammadreza Shalbafan

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021

The coronavirus disease 2019 (COVID-19) pandemic has had an important effect on medical education. Universities around the world responded to the crisis by announcing the immediate closure and substituted the in-person sessions with online ones. Iran University of Medical Sciences has designed a platform for medical students. To maintain the social distance, only one-third of students living in the dormitory are present at the dormitory in this condition. Some training courses have been divided into two parts and each group is supposed to participate in given courses in-person for 15 days. The crash courses are trained on all days of the week. Then, the first group left the dormitories and was replaced with the second group, and they use dormitories for 15 days after being disinfected. Besides, for the best use of time, students who cannot present in these 15-day training courses will take part in virtual training programs. Using this platform, the number of trainees, as well as the gathering of students at dormitories, will be reduced. It will depopulate the educational sessions at hospitals and classes in educational sectors. Besides, using the virtual classroom software given by the university, students can take part in virtual training programs.

Systematic Review Article

Clinical Poisonings Imposed by the COVID-19 Pandemic

Maryam Vahabzadeh, Babak Mostafazadeh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021 , Page 33859

Background: Along with the COVID-19 pandemic, a new problem has appeared in the healthcare facilities: toxicities and poisonings caused by medications and home remedies, by which people have been trying to protect themselves from acquiring the virus. The authors of this paper aim to notify the global scientific society of several substances and medications that either have led to poisonings thus far or have the potential for an outbreak.
Methods: Medical English literature reporting cases of poisonings during this pandemic between January and December 2020. Substances and drugs that could be a potential concern to public health are also reviewed.
Results: Alcohols and chemical substances have been the main causes of poisonings during this pandemic. Opioids, household products and herbal remedies were partly to blame. Global spread of incorrect information related to the COVID-19 prevention and treatment is a major risk to human lives, particularly in this difficult situation where healthcare systems are overwhelms with high rate of COVID-19 morbidity and mortality.
Conclusion: As additional waves of the coronaviruses may hit countries in the upcoming winter, confinements may as well continue. Therefore, emergency physicians must be prepared for possible outbreaks of poisonings and be able to predict any unusual pattern of toxicities.

Review Article

Complications of Central Venous Catheter Insertion in Patients Undergoing Hemodialysis in Iran: A Systematic Review and Meta-analysis

Mohamad Karimian, Somayeh Afsharloo, Atieh Okhli, Ali Gholami, Asma Tarjoman, Milad Borji, Somayeh Mahdikhani

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021 , Page 31443

Background: Regarding the prevalence of chronic renal disease and CVC (central venous catheterization) complications, this systematic review and meta-analysis was performed to determine the prevalence of CVC complications in Iran.
Methods: In this systematic review and meta-analysis, based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol, all Iran and international databases from 2000 to 2019 were investigated using keywords of fever during or after dialysis, redness of the catheter insertion site, swelling, tenderness (touch sensitivity), infection, thrombosis, inadequate catheter (catheter malfunction), hemothorax, and pus outflow (pus drainage). The search was conducted by two members of the research team (MB, AT). In case of any disagreement between them, the quality of the investigation was examined by the third person (AB). In the present study, we analyzed data using comprehensive meta-analysis software.
Results: According to this study’s findings, 12 articles with a total sample of 1395 patients were included in the systematic review and meta-analysis. Our findings were as follows: the prevalence of hemodialysis infection was 26.6% (95%CI: 16.2%–40.6%) (I2=95.5, P<0.001, Q=236.66), the prevalence of thrombosis was 18.3% (95%CI: 11.2%-28.6%), and the prevalence of inadequate catheter (catheter malfunction) was 16.1% (95%CI: 9.2%-26.7%).
Conclusion: The prevalence of CVC complications was significant in hemodialysis patients. Therefore, appropriate interventions should be provided to reduce these complications.

Case Report

N-Acetylcysteine Overdose: A Case Report

Karim Naraki, Seyed Hadi Mousavi , Leila Etemad, Seyed Mohsen Rezazadeh-Shojaie , Toktam Sadeghi , Mohammad Moshiri

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021

Background: N-Acetylcysteine (NAC) is a cost-effective antioxidant and very useful treatment for several diseases.
Methods: Here we report a rare case of iatrogenic NAC overdose following the mistake in calculation of the loading dose.
Results: The patient was 14 years old girl referred to a local hospital due to history of intentional ingesting about 7grams acetaminophen. The physician prescribed her 6 grams NAC as a loading dose but 42grams NAC were infused by mistake. After infusion, the patient showed signs of anaphylactic shock and then transferred to Imam Reza toxicology-unite with weakness, lethargy, extreme fatigue, nausea, and dizziness. NAC overdosing, in a short period of time, led to coagulopathy, reduced platelet count, acute renal failure and metabolic acidosis. After 24 h, the patient died. The Medical forensic examination showed minor lung hemorrhage and presence of little amount of Aluminum phosphide in tissues they did not find no vital organ hemorrhage. It is unclear related to NAC overdose, phosphine intoxication or synergic effects.
Conclusion: Massive transfusion of NAC was associated with impairment of coagulation factors, intracranial hypertension, renal failure and metabolic acidosis. Thus, NAC administration should be with caution. The medical history of patients committed suicide are not always accurate and complete evaluation are recommended.

Clinical and Medicolegal Aspects of Fatal Imidacloprid Deliberate Self-Poisoning: A Case Report

Vida Shiri-Ghaleh, Salim Khani, Mehrdad Moradi, Kambiz Soltaninejad

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021

Background: Imidacloprid is a neonicotinoid insecticide and agonist of nicotinic acetylcholine receptors. Despite its low toxicity profile, there are rare studies on its fatal poisoning. In this report, we described clinical and postmortem findings of a fatal imidacloprid poisoning.

Case report: A 33-year-old female presented to the emergency department with a history of deliberate consumption of unknown insecticide. On admission, she was drowsy and hypotensive with tachycardia and miotic pupils. Despite supportive therapy, she continued to be unconscious, with severe metabolic acidosis and developed a cardio-respiratory arrest and expired. A forensic autopsy was performed. The result of the toxicological analysis showed that imidacloprid concentrations were 267.8 µg/mL in femoral blood, 144.5 µg/mL in stomach content, and 292.3 µg/mL in bile.

Conclusion: Although imidacloprid is generally less toxic to humans high concentrations in biological samples could be considered lethal. Therefore, the educational programs about its toxicity should be considered for health care providers.

A Complicated Maternal Death in the context of Genetic Disorder: A Case Report

Arash Alipourtabrizi, Jafar Bordbar Azari, Reza Raoofian, Arya Hedjazi, Maliheh Dadgarmoghaddam, Maryam Sajadian

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 1 (2021), 23 January 2021

Background: Investigation of the maternal cause of death and pregnancy-related death is one of the most important responsibilities of a forensic pathologist. From the public health point of view, it may help to prevent losses during and following pregnancy and save the lives of women, especially in developing countries. We report a case of maternal death with a history of neurofibromatosis type 1 who presented asymptomatic and normotensive with normal laboratory test results.

Case report: The first attack after delivery was associated with pulmonary edema, which led to death. Investigation during the medico-legal autopsy discovered a left suprarenal tumor with the diagnosis of pheochromocytoma, which was confirmed by further histopathology testing.

Conclusions: We believe that although the association of neurofibromatosis type 1 and normotensive pheochromocytoma during pregnancy has been reported rarely, the possibility must be considered for evaluation before elective operations to adopt proper preoperative protocols.

Letter to the Editor