Original Article (Clinical Toxicology)


Background & aim: Determining cause of death among drug addicts in residential rehab campuses (RRCs) is of paramount importance, since it may prevent and reduce morbidity and mortality rates. Therefore, the present study aimed to investigate cause of death among drug addicts in RRCs in Kahrizak Dissection Hall, Tehran Province, Iran, from September 2011 to September 2019.


Methods: In this descriptive cross-sectional study, a total number of 166 drug addicts, who had died in the RRCs located in Tehran Province, Iran, were examined, and the findings were analyzed using the SPSS Statistics software (version 26). Moreover, the Chi-square test was utilized to compare the results.


Results: In this study, the most important causes of death, were infections, drug side effects, myocardial infarction (MI) and drowning, respectively. The highest frequency of death had occurred in the 31-40-year-old age group and mostly observed in the unmarried individuals. The most common cause of death were infection among the single and divorced ones and that was MI for married cases. Toxicological results were generally negative in 60.84% of the cases. As well, 86.74% of the cases were non-pathological with regard to the brain tissue samples and 65.66% of the individuals had no pathological cardiac lesions. Besides, the most common microscopic findings of the lungs were associated with pulmonary edema. In the trauma group and also drug side effects and drowning groups, the most frequent pathological findings were pulmonary hemorrhage and pulmonary edema, respectively. As a whole, 69.87% of the deaths had occurred in the RRCs and 55.42% of them were assumed natural in terms of mode of occurrence.


Conclusion: The majority of the deaths in the RRCs must not have occurred, if the given centers were authorized and the illegal ones had been closed down. Moreover, these centers needed to have proper management with the presence of resident physicians and trained medical staff as well as necessary medical equipment, proper nutrition, no access to drugs and other illicit substances, along with adherence to hygienic principles to minimize mortality rates among the drug addicts living in the RRCs.


 

Evaluation Of The Effectiveness Of Ampicillin-Sulbactam In The Treatment Of Aspiration Pneumonia In Patients With Opioid Overdose: A Randomized Controlled Clinical Trial

Mohammadreza Tabatabaei, Rasool Soltani, Gholamali Dorvashy, Shiva Samsamshariat, Rokhsareh Meamar , Ali Mohammad Sabzghabaee

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 34657
https://doi.org/10.32598/ijmtfm.vi.34657

Background and aim: Aspiration pneumonia is one of complications of overdose requiring timely appropriate treatment. The aim of this study was to evaluate the effectiveness of Ampicillin/Sulbactam compared to our usual regimen ceftriaxone + clindamycin in the treatment of aspiration pneumonia opioid-poisoned patients.


Methods: In a randomized controlled clinical trial, opioid-poisoned patients with aspiration pneumonia were randomly divided into experimental and control groups to receive ampicillin-sulbactam 3 g IV every 6 hours (experimental group) and ceftriaxone 1 g IV every 12 hours + Clindamycin 600 mg IV every 8 hours (control group) followed by co-amoxiclav 625 mg every 8 hours and cefixime 400 mg once daily + clindamycin 600 mg every 8 hours in experimental and control groups, respectively, to complete a 7-day course of therapy. White blood cell count and temperature (axillary) at baseline and the 3rd day of the intervention as well as the outcome of treatment at the 3rd day of intervention, defined as either complete response, partial response, or failure, were evaluated and recorded for all patients.


Results: Except for the number of cases of leukocytosis on the third day of the intervention which was lower in the control group (5 patients, 26.30%) than the experimental group (13 patients, 68.40%) (P = 0.020), no significant difference was observed between the two groups regarding other outcome variables. Clinical response was similar between the groups, so that 10.50% and 63.20% of patients in experimental group as well as 21.10% and 47.4% of patients in control group had complete and partial response, respectively (P = 0.550).


Conclusion: ampicillin-sulbactam is an effective antibiotic for the treatment of aspiration pneumonia in patients with opioid overdose, in which case it has the same efficacy as the two-drug regimen of ceftriaxone + clindamycin.

Criminal poisoning: A Hospital-Based Survey in an Academic Center of Iran

Maryam Salari Moghaddam, Mitra Rahimi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 34778
https://doi.org/10.32598/ijmtfm.vi.34778

Background: One of the most common medical emergencies all over the world is deliberate or accidental poisoning. As the matter of fact ever increasing consumption of toxins and fatal drugs are getting more important by the time. The purpose of deliberate poisoning is to harm themselves and others which includes purpose like robbery sexual abusing (rape). sedative and hypnotic drugs used by perpetrators could sedate patients and make them sleepy.


Methods: The present study is an Descriptive cross-sectional study investigating the suspected DFC (drug-facilitated crime) patients admitted and OPD (outpatient department) in the emergency room and toxicology ward. A researcher-made questionnaire was filled out for each patient. The biological samples (urine, blood) were sent to a clinical toxicology lab.


Results: Information of forty suspected DFC patients were analyzed. 70% of intoxicated patients were men, and 30% were women. The patients’ mean age was 31 to 43 years,42% of whom were low education, and 37% self-employed. 75% of total intoxicated patients had a lethargic level of consciousness. About 92.5% had one positive substance test, and 7.5% had negative lab test results. The most used drug was Diazepam by 70%. The motivation for poisoning was 80% robbery, 12.5% for rape, and 7.5% were no diagnostic.


Conclusion: The prevalence of poisoning, especially deliberate poisoning, is dramatically growing in this part of the world. Accordingly, this study reveals the flexibility of criminals in Tehran. So the ministry of health should seriously control legal and illegal drugs purchase. 

Prognostic Factors Of In-Hospital Mortality In Adult Patients With Aluminum Phosphide (ALP) Poisoning In Southern Iran (2014-2018)

Mahdi Alibeigi, Razieh Sadat Mousavi-Roknabadi, Najmeh Ahmadzadeh Goli, Mehrdad Sharifi, Faramarz Farahmand

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 34976
https://doi.org/10.32598/ijmtfm.vi.34976

Introduction: The suicide with aluminum phosphide (ALP) which is known as rice tablet has increased significantly. This study aimed to investigate the epidemiology of ALP poisoning and determining the in-hospital mortality prognostic factors in adult people referring due to ALP poisoning to one of the main poisoning center in southern Iran.


Methods: This retrospective cross-sectional study (21/March/2014 to 21/March/2018) was conducted on all adult patients (> 16 years) with ALP poisoning, who were referred to Ali-Asghar Hospital (affiliated by Shiraz University of Medical Sciences). All data were extracted from the patients' medical files. The patients were categorized as two groups of survived and non-survived. Univariate and multivariate logistic regression analysis were applied to determine prognostic factors for in-hospital mortality, and odds ratios (ORs) were reported.


Results: Totally, 97 patients were enrolled. The mean±SD of age was 29.3±12.2. Both groups were the same in most of demographic and poisoning characteristics. Nausea (62.9%) and vomiting (49.5%) were the most symptoms at the time of admission. Castor oil (66%), N-Acetyl Cysteine (56.7%), and magnesium sulfate (52.6%) were the most frequent treatment in these patients. The multivariate analysis showed that age (OR=1.12, 95%CI; 1.03-1.22), be illiterate (OR=39.95, 95%CI=0.85-11887.59), temperature (OR=0.02, 95%CI=0.01-0.48), resistant acidosis (OR=77.10, 95%CI; 5.05-1176.86), and taking sodium bicarbonate (OR=12.35, 95%CI; 1.25-122.10) were the prognostic factors of in-hospital mortality.


Conclusion: The in-hospital mortality rate in patients with ALP poisoning was 29.9%. Age, be illiterate, body temperature, resistant acidosis, and taking sodium bicarbonate were the prognostic factors of in-hospital mortality in these patients.

Original Article (Forensic Medicine)


Profile of Hanging Cases at Vijayanagar Institute of Medical Sciences (VIMS), Ballari District, Karnataka, India: Retrospective analysis of cases from 2016 to 2020.

Gururaj Biradar, Charan Kishor Shetty, Pavanchand Shetty H, V Yogiraj

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 33924
https://doi.org/10.32598/ijmtfm.vi.33924

Background: Death by hanging is an important health hazard worldwide and is classified as violent mechanical deaths resulting from asphyxia. Manner of death in hanging is suicide in majority of the cases, accidental hanging is less common and homicidal hanging is still less common.The study was aimed towards analysing socio- demographic pattern, precipitating factors for committing hanging at Vijayanagar Institute of Medical Sciences (VIMS), Ballari, India


Methods: A retrospective study was conducted at the mortuary of Vijayanagar Institute of Medical Sciences (VIMS), Ballari, Karnataka, India.  During the period from 01 January 2016 to 31 December 2020, 356 cases of alleged history of hanging cases were brought to the mortuary for postmortem examination and the cause of death was attributed to hanging. Data was collected with help of history, inquest report, meticulous postmortem examination etc. Results were obtained after tabulating and data analysed with cross sectional study.


Results: Out of the 356 cases of hanging, majority of the cases were in the age group of 31-40 (140 cases i.e., 39.32%). Male preponderance was seen in 235 (66%) cases and most victims were married 199 (56%) cases. In relation to seasonal variation, we noted that, maximum number of suicides by hanging were reported in the month of July to September 141 (39.60%).  Out of 356 hanging cases, 178 (50%) were employed. Pre-disposing factor was Chronic illness in 136 (38.20 %) cases followed by financial stress and psychological problems in 120 (33.70%) and 50 (14.04%) cases, respectively.  Majority of the victims belonged to Hindu religion 290 (82%) cases.  320 (90%) of cases did not have a suicide note.


Conclusion: Hanging is difficult to prevent, due many concomitant factors but psychological counselling, economic support and education can reduce the incidence of hanging.

Epidemiological And Demographic Status Of Violence And Strife In The Emergency Department Of Sabzevar Emdad Hospital

Mahdi Foroughian, Davood Soroosh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 34370
https://doi.org/10.32598/ijmtfm.vi.34370

Introduction: Violence and strife are among the most important causes of health threats and are the cause of more than half a million deaths per year especially at young ages. Given the young population of our country and the occurrence of identity crisis in the young age group and the fact that this phenomenon is costly for our country's health care system; this study was conducted to investigate the factors related to violence and strife and its mortality in patients admitted to Sabzevar Emdad Emergency department.


Methods: In this descriptive cross-sectional study, 207 patients who were admitted to Sabzevar Emdad Hospital in 2017 following strife were included in the study. Inclusion criteria were hospitalized patients who were referred to the Emergency department following the strife and exclusion criteria were incomplete registration of patients' information. The data collection tool of this study was a researcher-made checklist. Data analysis was performed using SPSS software version 18.


Results: The mean age of patients was 34.81±14.75. Most patients were from urban living places; while the mortality rate, gender, and the cause of trauma were not statistically associated with patients’ residence place. The most common type of lesions following strife was Bruising, tearing, and scratching including nearly 70% of cases. The most common site of injury was bruising and scratching in the head and neck, followed by tears and fractures in the limbs. In general, the most common site of injury was the upper extremity followed by the head and neck area. The majority of patients (52%) underwent medical treatment including receiving medication, dressing, and splinting; while 37% of patients were referred to the operation room for surgery. A significant relationship was observed between mortality rate and the site of injury (P =0.001).


Conclusion: The results showed that in Sabzevar city, the prevalence of strife ‎ is higher among men. Also, the most common effects following these types of trauma are bruising, scratching, and tearing. It seems that by providing appropriate solutions and creating a culture and increasing people's awareness of injuries caused by strife, it would be possible to pave the way for reducing such injuries in the future.

Original Article (Medical Ethics)


An Approach To The Anthropological Theory Of The Qur'an And Hadith And Its Role In Reducing Environmental Degradation

Hossein Masoumbeigi, Narjes Malek Mohammadi, Hossein Shamsi Gooshki, Abolfazl Khoshi, Mehdi Mesri, Fath Allah Najjarzadegan, Ali Esrafili, Majid Kermani, Norouz Mahmoudi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 36166
https://doi.org/10.32598/ijmtfm.vi.36166

Background: According to the Qur'an, man is the servant and the successor of Allah, the representative of prosperity on earth and the responsible for the universe. This approach will cause a constructive human interaction with the environment. The environmental degradation is against the Will of Allah. It originates from ignorance, human selfishness and passions and evil temptations, which manifest themselves in greed, arrogance and extravagance. If man can control these abnormal factors and reduce their roots in himself through the Qur’anic teachings, he will enjoy a healthy environment that is a universal right. This paper seeks to study the anthropological theory of the Qur'an and its role in reducing environmental degradation.


Methods: Based on the descriptive-analytical method of the present review study, the article uses 70 verses of the Holy Qur’an in which the words samā’, 'ard, mas’ūl, khalīfah, shaytān and those are cognate with the Arabic verbs sa-khkha-ra, ha-ra-sa, sa-ra-fa, ki-ba-ra, ha-wā, ‘a-ba-da, and ‘a-ma-ra, as well as the related articles, books, and philological and exegetical sources. It investigates the Qur’an to find the effect of awareness and more attention of human beings to the dimensions of their creation on reducing environmental degradation. These issues will be discussed in two parts: 1) the anthropology and the dimensions of human creation in the Qur’an, and 2) the roots of environmental degradation.


Results: The results of this study showed that the necessity of survival of life and human enjoyment of a healthy environment is enough knowledge of oneself, seeking help from Allah and following the Qur'anic guidelines. This leads to effective control of internal and external roots in environmental degradation including ignorance, egoism, selfishness and evil temptations, and it destroys the roots of greed, arrogance and extravagance in the human being. For this reason, Allah demands from human the earth development, care and rescue from any destruction, avoidance of extravagance and observance of justice.


Conclusion: Meditating in the Qur’an, man knows his creative dimensions and environmental degradation factors that are incompatible with nature and are rooted in some of the inner and outer dimensions of human personality. Hence, he will consciously enjoy the environment basically on the sustainable development and maintaining the health environment. This will then reduce anomalies in the environment on his part.

Systematic Review Article


Postmortem Liver Pathology Findings In Patients With Covid-19: A Systematic Review

Mehdi Forouzesh, Behnam Behnoush, Anahita Sadeghi, Hengameh Shahnavaz, Abdolrazagh Barzegar, Elham Bazmi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 35042
https://doi.org/10.32598/ijmtfm.vi.35042

The coronavirus disease 2019 (COVID-19) pandemic quickly became a major public health challenge with extra-pulmonary manifestations, including liver damage. Postmortem examination is crucial for gaining a better understanding of these manifestations and improving the management of patients. This study summarizes the current knowledge of the postmortem liver pathology of patients with COVID-19. This review was conducted according on studies evaluating the postmortem macroscopic and microscopic findings of liver in patients with COVID-19 by searching four electronic databases (PubMed, Scopus, Google Scholar and Web of Science) until June 2021. From the 317 screened articles, 16 articles examining a total of 332 patients who had died with COVID-19 were selected. The major findings of liver were moderate macro and micro vesicular steatosis with mild sinusoidal dilation, active lobular and portal vein thrombosis, mildly-increased lymphocyte filtration in sinusoidal space and multifocal hepatic necrosis. Also, the most common comorbidities were hypertension and other metabolic diseases. In conclusion, liver damage due to COVID-19 infection occurs with various manifestations in patients who have died with COVID-19. Therefore, monitoring liver function during the course and treatment of this disease is necessary for the better management of the patients and to decrease the mortality rate due to COVID-19.

Review Article


A Study of Patient's rights in Iran and Iraq

Murtadha Al-Khafaji, Noorh Sajit, shabnam bazmi, Mehrzad Kiani

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 34653
https://doi.org/10.32598/ijmtfm.vi.34653

Objective: The aim of this study was to compare, review and evaluate the prior studies about patients right that have been made, to this point, regarding patient rights in Iran and Iraq.


Methods: This is a review study conducted by searching the Iranian and Iraqi databanks such as: Scientific Information Database(SID), Iranian Research Institute for Information Science and Technology, Iran Medex and Academic scientific journals Iraqi and google scholar for both Iranian and Iraqi articles from 2002 to 2017 using the keywords such as "Patient Rights", "Patient Rights Charter", "Patient Rights Observance", "Iraq", "Iran", and "Patient Awareness and Rights".


Results: Total of 32 Iranian and Iraqi articles, only 25 of which achieved the goal of our study. Conclusion: The growing number of articles published indicates that from 1999 forwards, this topic began to attract the attention of Iranian researchers in a gradual manner, as for the Iraqi researchers, their attention has been attracted from 2013 onwards. and despite the poor knowledge of physicians about the patients' rights in Iran; they have shown acceptable awareness and attitude regarding some patients' rights. The same is true for Iraqi doctors and health care providers, but they have shown unsatisfactory consequences for some of the rights of Iraqi patients.


 Recommendation: Patient education through media and careful observation of the Patient Rights Charter, and educating healthcare professionals, and developing professional training on patients' legal rights by engaging them in educational sessions and lectures on patient rights is necessary. Adequate monitoring of practice according to the Patient Charter is strongly suggested.

A Review of Ethical Considerations in Conducting Clinical Trials

Shahriar Mousavinejad, Shabnam Bazmi, Mostafa Rezaei-Tavirani, Ehsan Shamsi-Gooshki, Seyed Ali Enjoo, Mehrzad Kiani

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 34863
https://doi.org/10.32598/ijmtfm.vi.34863

Clinical trials are known as the golden key in medical science researches with human participants. Therefore, they have always been considered interesting topics by researchers and scientists working in this field. On the other hand, due to the “human participants”, they need to be performed very carefully. In this article, we have examined the ethical necessities and considerations in these researches in four stages: Research Design and Question-proposal review , approval - Supervision, implementation and publication of the results We have dealt with them using articles published between 2010 and 2019, and we have identified significantly important and prominent issues or even neglected cases.


During this study, it was found that the Research Design and Question stage were the most discussed and challenged stages and the authors' sensitivity about them has been more than the other three stages. On the other hand, the results publishing stage with the least number of references in articles has been considered less sensitive.


During this study, it was found that the Research Design was the most discussed and challenged stages and the authors' sensitivity about them has been more than the other three stages. On the other hand, the results publishing stage with the least number of references in articles has been considered less sensitive.

Case Report


Vasculitis, Thrombotic Thrombocytopenic Purpura (TTP) and Disseminat-Ed Intravascular Coagulation (DIC) Associated With Methamphetamine in-Toxication: A Case Report

Navid Khosravi , Anahita Babaei, Hanieh Azizi, Hamidreza Samaee

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 32864
https://doi.org/10.32598/ijmtfm.vi.32864

Amphetamines and methamphetamines are two groups of substance which their use are increasing globally. Poisoning of the methamphetamines may develop different sympathetic symptoms; however, developing some complications such as vasculitis, central nervous system involvement and kidney injury is extremely rare. In this study, we report a case of methamphetamine poisoning that presented with loss of consciousness and develop TTP, DIC and pulmonary pseud vasculitis.

Subcutaneous Injection Of Organophosphate: A Case Report Of Unusual Poisoning

Shafeajafar Zoofaghari, Afshar Fazeli Dehkordi, Kourosh Nemati, Mozhdeh Hashemzadeh, Arman Otroshi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 34343
https://doi.org/10.32598/ijmtfm.vi.34343

Background: Organophosphate (OP) poisoning is prevalent in developing countries. Toxicity occurs by voluntary injection, inhalation and absorption. Self-injection is rare.


Case report: Current case report describes a 61-y/o male with subcutaneous self-injected 1 cc OP poisoning presenting with delayed drowsiness, nausea and vomiting. He treated and showed a good clinical response to treatment with pralidoxime, and had a successful recovery.


Conclusion: Diagnosis OP compound toxicity by parenteral route is a challenge. Through the observation of patients, the dose and the time between poisoning until time to start treatment we can conclude different presentations and outcomes of OP poisoning.

Deep Venous Thrombosis And Pulmonary Thromboembolism In A Physically Nonprepared Trekker In The Himalayas – An Autopsy Report.

Senthil KR, Bansal YS, Vaishnav D, Lakshmi NJ

International Journal of Medical Toxicology and Forensic Medicine, Vol. 11 No. 4 (2021), 17 November 2021 , Page 34555
https://doi.org/10.32598/ijmtfm.vi.34555

Deep venous thrombosis (DVT) and subsequent pulmonary thromboembolism (PTE) in high altitude climbers is a well-known concept.  The acclimatization process at high altitude is itself a thrombogenic event. Having said that, when a physically nonprepared individual with preexisting thrombogenic risk factors attempts trekking at high altitude, he may end up with fatal thromboembolic events. Here we report a case of a low lander with multiple thrombogenic risk factors who developed DVT and PTE when he went for a trekking trip in the Himalayas. The risk factors, autopsy findings and possible mechanism of developing fatal pulmonary embolism, in this case, are discussed here.

Letter to the Editor