Original Article

Assessing the Clinical Features and Blood Biochemistries of Acute Organophosphorus Chemical Warfare Agents in Iranian Veterans

Khosrow Agin, Babak Mostafazadeh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 32857

Background: Nerve Agents (NAs) are a chemical weapons, and their use is prohibited. They were used for numerous-times in the warfare of Iraq against Iran. The present study aimed to assess the clinical features and laboratory findings of the acute poisoning manifestations of organophosphorus chemical warfare agents (NAs) in Iranian veterans early after exposure.
Methods: A total of 25 male NAs-exposed cases were enrolled in the present study. We used the medical records of early combat in 1990 for data collection. The data of the exposed-victims were unavailable for a long time. Clinical features were evaluated and fasting blood glucose, sodium, potassium, insulin level, and protein electrophoresis were measured on the first day of exposure.
Results: Potassium, sodium, fasting blood glucose, and protein electrophoresis were abnormally noticeable on the first day post-exposure. The clinical features of the studied cases were manifested in the muscarinic and nicotinic systems, and Central Nervous Systems (CNS). Miosis, cramp, restlessness, and respiratory symptoms were dominant features in the study subjects.
Conclusion: The investigated exposed-victims of NAs indicated hypokalemia, hyperkalemia, hypoglycemia, normal insulin levels, and abnormal protein electrophoresis. The clinical features of the cholinergic crisis were markedly significant in three levels of the muscarinic, nicotinic, and CNS manifestations. Our findings suggested that the exposed cases were against a significant dose of NAs.

Original Article (Clinical Toxicology)

Cardiovascular Conditions in Patients With Aluminum Phosphide Poisoning

Zahra Ataei, Bita Dadpour, Anahita Alizadeh, Seyed Reza Mousavi, Mohammad Moshiri, Zahra Sheikhveisi, Alireza Banaye Yazdipour

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 30188

Background: Aluminum Phosphide (AlP) is a well-known rodenticide and insecticide, used as a fumigant to control pests and rodents in grain-storage facilities. Its intoxication presents a medical emergency that requires early rigorous management. This study aimed to investigate cardiac function by Electrocardiogram (ECG) changes in patients with AlP intoxication. We also explored the potential relationship between low bicarbonate and cardiac function.
Methods: This cross-sectional study investigated 42 patients in the age range of 17-47 years, with a history of orally-administered AlP poisoning, known as “rice tablet”, admitted to the toxicology ward of Imam Reza Hospital from March 2019 to March 2021. The study patients’ demographic data were collected by trained interviewers, using pretested questionnaires. Systolic and diastolic blood pressure, as well as blood samples, were measured 12 hours from admission. Echocardiography was performed during the first 12 hours and on the fifth-day post-admission. All statistical analysis was performed using R 3.6.1. The significance level was set at 0.05 for all statistical tests.
Results: In total, 48.78% of patients presented normal bicarbonate levels, and 24.39% and 26.83% had moderate and severe acidity, respectively. Moderately and severely decreased Left Ventricular Ejection Fraction (LVEF) was observed among 21 (51.2%) and 10 (24.4%) patients, respectively. Furthermore, mild Right Ventricular (RV) function was observed among 11 (26.8%) patients. A statistically significant association was observed between bicarbonate level and RV function (P<0.001) and LVEF (P<0.001). Besides, 19.5% of the explored patients expired. The proportion of expired patients was significantly higher in patients with mild RV function, compared to the other patients (P<0.001).
Conclusion: Acute AlP intoxication is a worldwide serious problem. Severe metabolic acidosis and ECG abnormalities are associated with poor outcomes in this respect. Thus, conducting early ECG and echocardiography could be desirable instruments to predict prognosis. There is no antidote for AlP poisoning; thus, the replacement of a safer agent for in-store grain protection is strongly suggested.

Electrocardiogram Changes in Patients With Acute Ethanol Poisoning

Gholamali Dorooshi, Mahsa Akafzadeh Savari, Farzaneh Nayeri, Rokhsareh Meamar, Mohammad Javad Tarrahi, Nastaran Eizadi-Mood

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 33353

Background: Alcohol consumption leads to a significant number of deaths, mostly in men, worldwide. Considering the effect of ethanol toxicity on the heart, we studied various Electrocardiographic (ECG) changes in patients with acute ethanol poisoning.
Methods: A cross-sectional study was performed on patients admitted to Khorshid Hospital (affiliated to Isfahan University of Medical Sciences) due to ethanol poisoning. All 15- to 50-year-old patients with acute ethanol intoxication were included in the study (N=250). The patients’ information, including the demographic characteristics, clinical manifestations, and ECG changes were recorded and analyzed. Different variables were compared between the patients with or without ECG changes.
Results: Most of the research patients (n=208) were men (83.82%). The Mean±SD age of the study patients was 26.8±8.87 years. About 54.8% of the patients presented abnormal ECG. The changes in ECG were not significantly different based on the demographic characteristic and clinical manifestations. The time interval between ethanol consumption and admission was significantly higher in patients with abnormal ECG, compared to those with normal ECG (Mean±SD: 7.09±10.67 vs. 4.77± 4.54 hours, respectively) (P=0.03).
Conclusion: ECG changes are common in patients with ethanol poisoning. The time interval between ethanol consumption to hospital admission may be an important factor in the occurrence of ECG changes.

Hypoglycemia in Patients With Pure Benzodiazepine Poisoning

Fazel Goudarzi, Razieh Sadat Mousavi-Roknabadi, Maryam Abdollahpour, Robab Sadegh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 32702

Background: Various studies investigated the effects of benzodiazepines on insulin and blood glucose levels and provided contradictory results. The present study aimed to evaluate the clinical effects of benzodiazepine poisoning on hypoglycemia.
Methods: This retrospective cross-sectional study (from 22/June/2018 to 22/December/2018) was conducted on all medical records of adult patients with benzodiazepine poisoning who were referred to Ali-Asghar Hospital. The required data were collected using a data-gathering form and then analyzed.
Results: In total, 61 patients were enrolled in this study. Furthermore, 19 (31.2%) patients developed hypoglycemia. Besides, 50 (82%) patients used benzodiazepine for a suicide attempt, i.e. higher in patients with hypoglycemia (P<0.0001). Multivariate logistic regression test data indicated that benzodiazepine consumption for suicide attempt (OR=47.978, P=0.001, 95%CI, 5.313-433.277), and the respiratory rate at the time of suicide (OR=0.549, P=0.023, 95%CI, 0.328-0.920) were predictive factors for hypoglycemia in patients with benzodiazepine poisoning.
Conclusion: Our study data suggested that 31% of patients who were poisoned with benzodiazepines developed hypoglycemia. The suicidal use of drugs and respiratory rates were predictive factors for hypoglycemia in these patients.

The Prognostic Factors of Aluminum Phosphide Poisoning in Urmia: A-five-years Cross-sectional Study

Mohammad Majidi, Mohammad Jamalpour, Solmaz Nekoueifard

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 32663

Background: Aluminum phosphide is a highly toxic fungicide. It causes such severe adverse effects as cardiac arrhythmias, metabolic acidosis, acute renal failure, shock, and even death. Therefore, this study investigated the prognostic factors of aluminum phosphide poisoning.
Methods: In this cross-sectional study, all hospitalized patients due to aluminum phosphide poisoning admitted to the poisoning center at Taleghani Hospital, Urmia City, Iran, from 2015 to 2019 were evaluated. The demographics characteristics, clinical findings, and laboratory profiles were retrospectively studied by an investigator-made checklist and evaluated concerning the explored patients’ treatment outcomes. Then, the obtained data were analyzed by descriptive and analytical statistics using SPSS V. 16.
Results: The present study investigated 134 patients (96 males & 38 females). The mortality rate was equal to 29.8% (22.4% males & 7.4% females) in the study patients. The research patients’ Mean±SD age was 28.6±11.5) years. The Mean±SD ingestion amount of aluminum phosphide was 1.48±1.06 g (min=0.2 g, max=15 g). Nausea and vomiting with 119 (88.8%), hypotension: 89 (66.4%), vertigo: 80 (59.7%), and sinus tachycardia: 74 (55.2%) were the most signs and symptoms in the study patients, respectively. Statistically significant relationships (P<0.05) were found between the patients’ treatment outcomes and white blood cells, direct bilirubin, Hco3, base excess, magnesium, Aspartate Aminotransferase, Alanine Aminotransferase, Blood Urea Nitrogen, creatinine, blood glucose, pH, prothrombin time, and the international normalized ratio. Furthermore, significant relationships were detected between the patients’ treatment outcomes and leukocytosis, hypokalemia, hyperglycemia, and hypoglycemia (P<0.05).
Conclusion: Such prognostic factors as demographics characteristics, clinical findings, laboratory profiles, and electrolytes could be used as good indices of the severity of toxicity in patients; accordingly, such data are beneficial for the proper management of patients by healthcare providers. Therefore, prognostic factors should be considered in the diagnosis, treatment, and follow-up stages for these patients.

Prevalence of Opioid Poisoning and Related Factors in Under 17-year-olds

Mahdi Foroughian, Davood Soroosh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 32392

Background: Poisoning is among the leading causes of childhood injuries. With the increasing prevalence of substance dependence in the community, there is a rise in the frequency of children admitted to hospitals with drug intoxication. Therefore, we investigated the prevalence of acute opioids poisoning in children.
Methods: The present cross-sectional study was performed on children under 17 years of age who were admitted to Sabzevar hospitals with a diagnosis of opioids poisoning. A researcher-made checklist was used for data collection, including the patient’s age, gender, intoxication agent, drug consumption route and form, hospitalization length and outcome, family’s educational level, occupational status, and living area. Besides, descriptive tests were used in SPSS to analyze the obtained data.
Results: In total, 129 cases of opioids poisoning were reported during the study period. The mean±SD age of the studied children was 2.74±3.05 years. The minimum and maximum ages of poisoned children were 1 and 16 years, respectively. The liquid-soluble form was the most common form of opioids used (38.3%). Opium was also the most commonly used substance (68.45%). In 85 (65.89%) children, a decrease in Glasgow Coma Scale (GCS) was observed at baseline. Moreover, 7 of the explored children have died. Besides, 90.7% of their fathers and 95.3% of their mothers had an educational level of a diploma or below. The most common factor associated with opium poisoning was the family’s substance dependence in 120 (93%) cases. Substance dependence in children was mostly observed in those aged 3-5 years.
Conclusion: Poisoning with opium is the most common type of children’s opioid poisoning in Sabzevar. A decreased level of consciousness is the most frequent manifestations in these patients. Therefore, in all children, by observing a sudden decrease in the level of consciousness without apparent reasons, especially along with other symptoms, such as acute diarrhea, restlessness, etc., it is recommended to consider opioids poisoning.

Assessing Substances Abuse-Induced Mortality Rates by Autopsy Method in Iran

Fatemeh Baberi, Amir Kavousi, Davood Mirtorabi, Nader Parsa, Seyed Amirhosein Mahdavi, Seyed Saeed Hashemi Nazari

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 32400

Background: Substance abuse is among the main causes of preventable diseases and premature deaths worldwide. Despite legal efforts to prevent substance abuse, it has increased and imposed significant economic costs on societies. This analytical cross-sectional study aimed to explore the rate of substance abuse-induced mortality in the provinces of Iran, in 2017. We elaborated an evaluation structure to identify nationwide different substance abuse-related mortality rates.
Methods: We employed the retrospective data extracted from autopsy, forensic medicine examination, and demographic characteristics from the recordings in the Iranian Legal Medicine Organization (ILMO). Stata and ArcGIS were applied for data analysis.
Results: Nationwide, 3089 substance abuse-related deaths were recorded in the ILMO; the incidence rate was 38.17 per million subjects. The deaths mostly occurred in the 30-39 age group and males accounted for 90% of cases. The provinces of Kermanshah, Lorestan, Fars, Hamadan, and Semnan reported significantly higher rates, compared with the provinces of Mazandaran, West-Azerbaijan, and Golestan with the lowest mortality rates per million (74.72, 69.81, 63.42, 61.70, 58.53 vs. 10.82, 12.11, 14.30, respectively). Mortality rates due to the abuse of methadone (20.29), morphine (12.34), amphetamine (5.32), methamphetamine (7.05), codeine (4.21), tramadol (5.96), benzodiazepine (1.47), and diphenoxylate (0.05) were calculated per million populations of Iran.
Conclusion: The obtained data suggested that preventive interventions should focus on the 20-40 age group. Methadone, morphine, and methamphetamine were associated with the highest mortality, compared to other substances; thus, they require effective treatment and preventive programs. Iranian Drug Control Headquarters, police department, and policymakers should act more efficiently regarding a preventive strategic plan in this respect.

Original Article (Forensic Medicine)

Comparing Log-based and Exponent-based Functions to Predict Human Height by Foot Length

Fozia Anwar, Khurram Saleem Alimgeer, Ramesh Kumar, Ratana Somrongthong

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 30902

Background: Human height estimation is critical in medicolegal cases. This anthropometric measurement not only reveals racial differences but also aids police investigation to narrow down. Foot size varies in different races and ethnic groups, because of genetic influence on development height. The present study aimed to explore the relationship between foot size and the height of a person in a particular context. The current research also compared log-based function and exponent-based function to explore which best fits the relation between age, foot size, and height.
Methods: This cross-sectional study included foot measurements from 240 participants of 6 different age groups in the age range of 2-21 years. Foot length and height were recorded as per standard methods after obtaining ethical approval from the Institutional Review Board of COMSATs University Islamabad Pakistan and gaining consent from the study participants. Correlation and regression analyses were performed using SPSS V 23. In this study, two mathematical functions of log-based and exponent-based were compared to more accurately predict the behavior of two variables. The appropriateness of these candidate functions was evaluated using statistical parameters, including the Sum of Squared Errors (SSE), R2, adjusted R2, and Root Mean Square Error (RMSE).
Results: The mean height of male participants of the age group of 3-5 years was higher than that of the female participants. Among 6-10-year-olds and 11-15-year-olds, female participants presented a greater height than males. In the age groups of 16-20 and ≥21 years, males were taller than females. The average foot size of males and females of all age groups was 22.09 cm and 20.44 cm, respectively. The exponent-based candidate functions best fitted the relationship between age, foot size, and height, compared to the log-based candidate function.
Conclusion: Foot size indicated the highest correlation with height and minimum standard error in the estimation of stature. Therefore, foot size provided the highest reliability and accuracy in estimating height.

Original Article (General Medicine)

Comparing Tuberculin Anergy Skin Test Reactions and Lymphoblastic Transformation in Medical Student

Khosrow Agin, Mojtaba Ziaei, Seid Davood Mansouri

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 32680

Background: Tuberculin Skin Test (TST) reaction is an accepted screening test for diagnosing acute and latent Tuberculosis (TB) infection among at-risk populations. It is performed with a standard Protein Purified Derivative (PPD) solution. The skin reaction of PPD is unreliable to distinguish natural infection from the Bacillus Calmette Guerin (BCG) effect. The present survey aimed to determine the prevalence of Tuberculin Anergy (TA) reactions among medical students. Accordingly, we evaluated its sensitivity, specificity, and efficiency by applying the Recall Panel Antigen Test (RPAT) and the Lymphoblastic Transformation Test (LTT).
Methods: The participants were sequentially enrolled in this study according to the designed protocol. The current study was conducted on healthy medical students before registering for the hospital training course. All research subjects were healthy, having a cicatrix of Bacillus Calmette Guerin (BCG) vaccination on the arm, and at a young age (20-24 years).
Results: In total, 180 medical students met the inclusion criteria of the study. The study subjects’ Mean±SD age was 22±3.07 years (male=89, female=91). Moreover, 75 (42%) subjects presented a TA reaction in the first step of TST screening. Furthermore, 13 (64%) individuals presented a negative result of the RPAT. The sensitivity and specificity of the TST reactions, compared with the LTT were 100% and 94.4 %, respectively.
Conclusion: Significant TA reactions were found among medical students with positive cicatrix post-vaccinated. The obtained data suggested that the BCG protection for individuals may be decreased as time expired. Consequently, the medical students will especially be at high risk for TB infection during the clinical training course. The collected data highlighted the patient-safety from the viewpoint of forensic medicine.

Review Article

Prevalence of Vascular Trauma and Related Factors in Iran: A Systematic Review

Mohammad Karimian, Atieh Okhli, Abdollah Noormohammadi-Dehbalaee, Ali Gholami, Alireza Abdi, Ebrahim Salimi, Milad Borji, Asma Tarjoman, Somayeh Mahdikhani

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 31441

Background: Managing patients with Vascular Trauma (VT) is essential. This study aimed to
determine the prevalence of VT and its related factors in Iran.
Methods: This systematic review was performed by two skilled researchers. To access all the
Persian and English articles on VT and its influencing factors (from 2000 to August 2019),
in addition to Google Scholar search engine, other international databases, such as PubMed/
Medline, Scopus, Embase, Cochrane Library, Science Direct, Web of Science (ISI), and
domestic databases, such as Magiran, IranDoc, National Library of Iran Organization, SID,
and Barakatkns were used. Data analysis was conducted by MA (CMA) software.
Results: The incidence of lower Lower Vascular Trauma (LVI) trauma was equal to 58.4
(95%CI: 41.1-73.8) (I2= 94.67, Q=112.57, P<0.001); the prevalence of upper LVI trauma was
measured to be 31.5 (95%CI: 17.7-49.7) (I2=94.48, Q=108.70, P<0.001); the prevalence of
penetrating trauma was calculated as 61.3 (95% CI: 49.5-71.9); the prevalence of ulnar nerve
injury equaled 9.8 (95%CI: 2.8-28.6); the prevalence of radial nerve trauma was equal to 7.7
(95%CI: 1.2-35.4); the prevalence of death cases was reported as 12.3 (95%CI: 5.1-26.9);
the prevalence of amputation rate was observed as 8.8 (95%CI: 5.7-13.4); the prevalence
of fasciotomy rate was equal to 22.2 (95%CI: 13.2-34.5); the prevalence of complete artery
cutting equaled 55.7 (95% CI: 35.4-74.3),and the prevalence of incomplete artery cutting was
measured as 25.5 (95%CI: 12.1-45.9).
Conclusion: According to the study results, VT has led to various complications in patients;
thus, it is critical to provide the necessary conditions to preserve the patient’s life and prevent
life-threatening complications. Such goals could be achieved by preventing this type of trauma
and its related complications.

Case Report

Successful Treatment of Acute Aluminum Phosphide Poisoning by Aloe Vera Syrup: A Case Report

Masihallah Shakeri, Davood Soroosh, Heshmatollah Shakeri, Navid Kalani, Naser Hatami, Mahdi Foroughian

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 33016

Background: Aluminum phosphide, known as rice pill in Iran, is a very effective pesticide for commercial and industrial ‎use. The high lethality of Aluminum phosphide is due to Phosphine gas (PH3) which is released by its ‎reaction with water. One of the most important properties of aluminum phosphide, which despite being ‎very lethal to almost all living creatures, still makes it one of the most widely used pesticides, is its very ‎high yield, ease of use, and, most importantly, the absence of residues in products after application; while ‎its exposure to the human body is associated with high mortality.‎
Case Presentation: In this article, we reported the successful treatment of rice pill-induced poisoning in a 30-year-old man using a novel approach. Accordingly, we used sodium bicarbonate (50 ccs) and aloe vera syrup (1-2 L), followed by olive oil (150 cc olive oil was given every 2 hours).
Conclusion: While numerous studies recommend observing patient conditions as the treatment approach, our presented case was a successful experience of treating acute aluminum phosphide poisoning.

A 10-year Institutional Retrospective Analysis of Retroperitoneal Abscess

Fariborz Rashno, Manoochehr Ebrahimian, Esmaeil Hajinasrollah, Rouzbeh Shadidi Asil, Saman Rostambeigi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 2 (2021), , Page 33297

Background: Retroperitoneal Abscess (RA) is a rare and often insidious disease, i.e., difficult to diagnose. RA could originate from different retroperitoneal or intra-abdominal organs. The disease manifests various clinical symptoms and is usually treated with a combination of antibiotics and therapeutic interventions.
Methods: Data from a total of 25 patients who were admitted to Loghman Hospital in Tehran City, Iran with a diagnosis of RA from 2010 to 2020 were reviewed in this research. Clinical findings, diagnostic tools, treatment approaches, and microbiology data were considered and analyzed.
Results: Out of the 25 patients, the most frequent sources of RA were primary infections (36%), followed by gastrointestinal origin (20%). Fifty-two percent of patients presented no underlying disease; however, diabetes mellitus was the most prevalent underlying disease in the remaining ones. Fever, chills, and back or flank pain (56%) were the most common symptoms in the studied patients. Besides, a high erythrocyte sedimentation rate (mean: 93.58%) was found in most of the researched patients. Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) could reliably diagnose the disease with an accuracy of 100% and 92.3%, respectively. Seventy-two percent of the study patients eventually underwent surgery. By taking advantage of CT scan, 24% of abscesses were drained and only 4% required medications to achieve remission. Mycobacteria and Klebsiella pneumonia were the most prevalent pathogens among the explored patients. The total mortality rate was equal to 12%; it occurred in cases with RA of a gastrointestinal (8%) or genitourinary (4%) origin.
Conclusion: There exist 3 major choices for treating abscesses, including surgery, image-guided percutaneous drainage, and medical therapy. Image-Guided drainage is recommended in primary infections; however, extra-peritoneal surgery is useful to treat secondary infections, especially those of a gastrointestinal source.

Background: Spontaneous pneumomediastinum or mediastinal emphysema is relatively a rare disease that occurs in viral and bacterial infections with the benign entity.
Case: The patient was a 57-year-old man who, after a week of self-isolation at home, coming to the COVID-19 triage center of the hospital with severe shortness of breath. He was admitted to the Intensive Care Unit (ICU) due to acute respiratory failure. The patient was treated as the protocol designed and respiratory support with high flow nasal oxygen and Non-Invasive Positive Pressure Ventilation (NIPPV). Spontaneous pneumomediastinum was developed during viral pneumonia infection. The known risk factors included age, male sex, and abnormal laboratory finding. All the biochemical and hematological findings such as lymphopenia, thrombocytopenia, raised CRP, LDH, and ferritin were detected in our cases. They indicate a possible prognosis for the development of acute respiratory failure and adverse clinical outcomes.
Conclusion: Spontaneous pneumomediastinum has usually a benign outcome in COVID-19 Pneumonia and its prognosis is related to background conditions in patients.