Original Article (Clinical Toxicology)

Using the Extended Cox Model to Determine Factors Affecting the Length of Hospitalization in Patients with Drug Poisoning

Sara Sabbaghian Tousi , Roya Jabbari, Bita Dadpour, Hosein Roghangaran Khiabani, Rosita Salari, Parastoo Golpour

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 36738

Background: Poisoning is a medical emergency, and is considered as a common cause of morbidity and mortality worldwide. In this study, the extended Cox model was used to determine the factors affecting the length of hospitalization in those with drug poisoning.
Methods: The sample size included 2408 patients with opioids poisoning referring to the Emergency Department of Imam Reza Hospital in Mashhad, Iran from March 21, 2018 to March 20, 2019. Extended Cox model was fitted to determine the effect of five covariates (age, gender, marital status, type of poisoning, and type of opioids). In survival analysis, the length of hospitalization was considered as a time covariate (T). Patients’ recovery was also regarded as an event.
Results: Of 2408 patients, 399 (16.6%) were censored and 2009 (83.4%) were uncensored. The risk of failure in complete recovery from poisoning in males was 1.189 times more compared to females. The risk of failure in complete recovery for the 15-24, 25-44, 45-64, and >65 years age groups were 0.277, 0.241, 0.289, and 0.481 times lower, respectively compared to the <2 years age group. For the married patients, the risk was 0.291 times lower compared to the divorced patients. For those poisoned accidentally, the risk was 0.490 times lower than compared to those poisoned intentionally. For those used methadone, morphine, opium, and tramadol, the risk was 1.195, 1.243, 1.193, and 1.147 times more, respectively compared to those used marijuana. By increasing the time (day) of hospital stay, the risk of failure for the 25-44, 45-64, and >65 years age groups were 1.024, 1.028, and 1.040 times more, respectively compared to the <2 years age group. Moreover, for those poisoned accidentally, the risk was 1.197 times more compared to those poisoned intentionally by the time (day) of hospital stay.
Conclusion: The factors affecting the length of hospitalization in those poisoned by drugs are gender, marital status, and type of opioids covariate as time-independent covariate, and age and type of poisoning as time-dependent covariates. Since the complications of drug poisoning impose many costs on the health system, knowledge of these covariates can help take some measures for complete recovery of poisoned patients in a shorter length of hospital stay.

Original Article (Forensic Medicine)

Height Estimation Based on 3-Dimensional CT Scan of 12th Thoracic, 1st and 5th Lumbar Vertebrae

Seyed Reza Saadat Mostafavi, Azadeh Memarian, Omid Motamedi , Khalil Sharboo, Mohammadreza Khaleghi, Shirin Habibi, Ramin Emami

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 35789

Background: Identification of victims is one of the main challenges of forensic medicine. Height is one of the key measurements of the biological profiles of individuals. This study aimed to evaluate height based on measuring three-dimensional CT scan indices of twelfth thoracic (T12), first lumbar (L1), and fifth lumbar (L5) vertebrae in Iranian adults.
Methods: The present study was a cross-sectional study performed on 100 patients who underwent a spinal CT scan. Vertebral T12, L1, and L5 indices were measured in these individuals. Finally, the evaluated indices were statistically compared and the diagnostic effect of each was evaluated to estimate the height. Independent t-test and linear regression were used using SPSS software v. 21. A P value less than 0.05 was considered significant.
Results: The results showed that the mean difference between T12, L1, and L5 indices in the two groups of male and female patients was statistically significant. With one unit increase in the Transverse process distance T 12 (TDM T12), there is an increase of 0.42 units in height (P=0.02).
Conclusion: According to the results of the present study, the measurements of the T12, L1, and L5 vertebral indices have a significant relationship with gender. Among the measurements of the T12, L1, and L5 vertebral indices, just TDM T12 can be a predictive factor to estimate the height of the Iranian population.

Demographic Characteristics and Personality Disorders in People With Gender Dysphoria in East Azerbaijan Province, Iran

Ali Reza Shafiei Kandjani, Sona Sadeghpour, Bahram Samadirad, Arezoo Mehrara, Parisa Hosseinnejad, Behzad Shalchi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 36056

Background: Gender identity is an important part of human identity. It is a personal conception of oneself as male or female. One of the major goals of treatment for individuals with Gender Dysphoria (GD) is to treat comorbid psychological and psychiatric disorders such as personality disorders. The present study aims to investigate demographic characteristics and personality disorders in people with GD seeking gender reassignment therapy in East Azerbaijan Province, Iran.
Methods: In this descriptive cross-sectional study, study population consists of all patients with GD referred to the forensic medicine centers in East Azerbaijan province during 2016-2020, of whom 61 (21 males and 40 females) were selected using a convenience sampling method. Their age, gender, educational level, and marital status were recorded and their personality profile was assessed by the Millon Clinical Multiaxial Inventory–III.
Results: The frequency (percentage) of Cluster A, B and C personality disorders in males were 0(0%), 9(50%) and 2(11.10%), while in females they were 1(5.56%), 4(22.40%), and 2(11.10%), respectively. The frequency (percentage) of antisocial, obsessive, borderline, avoidant, narcissistic, histrionic, and paranoid personality disorders in males were 4(22.2%), 2(11.10%), 3(16.67%), 0(0%), 0(0%), 2(11.10%), and 0(0%), while in females they were 4(22.20%), 1(5.56%), 3(16.67%), 1(5.56%), 1(5.56%), 2(11.10%), and 1(5.56%), respectively. The prevalence of different clusters (P=0.34) and types (P=0.18) of personality disorders was not significantly different between males and females.
Conclusion: Personality disorders are comorbid with GD. They exist in one-third of patients with GD in East Azerbaijan Province. Personality disorders are significantly more prevalent in male patients with GD than in females.

Background: Attention Deficit Disorder/Attention-Deficit/Hyperactivity Disorder (ADD/ADHD) is one of the most prevalent childhood diseases, and it may substantially influence social behaviors, legal issues, and disputes. The goal was to see how cognitive rehabilitation training affected executive functioning and impulsivity in children with ADHD in Tehran, District 5.
Methods: A quasi-experimental design was used, with two groups (experimental and control) and a pretest-posttest. All students with ADHD disorder aged 7 to 12 years were included in the statistical population. The sample comprised 30 kids who were age-matched and randomly split into two groups. They were tested for two months in February and March 2021. Slow cognitive rehabilitation training was given to the experimental group. Both groups were given a pretest and a posttest. Information was gathered using the BRIEF (parent form) and Conners’ (parent form) questionnaires. MANCOVA was used to analyze the data, using the SPSS software v. 26, with a significance threshold of 0.05.
Results: There was a significant difference in executive function variables (inhibition, attention transfer, emotional control, initiation, working memory, planning, material organization, and control) and reduced impulsivity (attention deficit , hyperactivity, opposition, and ADHD) (P≤0.001).
Conclusion: Cognitive rehabilitation improves executive skills and impulsivity in children with ADHD aged 7-12 years. Cognitive rehabilitation training should be utilized with other educational approaches to rectify social behaviors, minimize conflict, and improve executive functions.

The Rate of Suicide and its Reasons in Children Under the Age of 18 Years

Mehdi Forouzesh, Abdolrazagh Barzegar, Seyed Amirhosein Mahdavi, Masoud Ghadipasha, Seyed Shahram Mousavi, Roya Kordrostami, Nahid Dadashzadeh, Rohollah Valizadeh

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 35084

Background: The type of suicide is determined by various factors, such as accessibility to drugs, economic problems, and psychological disorders.This study aimed to assess the rate of suicide and its reasons in children <18 years.
Methods: This was a cross-sectional study carried out on 350 autopsy bodies less than 18 years of age in Tehran Forensic Medicine Center in 2010-2020 who had struggled with suicide. Data were analyzed using SPSS software v. 18.
Results: Mean±SD age of children was 16.36±1.76 years. The most common method in children less than 15 years and over 15 years was hanging (n=36) and poisoning with chemical substances (n=139), respectively (P<0.001). The most common method of suicide was poisoning with chemical substances (n=147, 42%). The most common method of suicide in girls and boys was poisoning with chemical substances (n=81) and hanging (n=75), respectively. The highest number of children who struggled were residents in the outskirt of Tehran (n=113, 32.5%). The suicide rate in people with depressive disorder and tentative injury was 10% (n=35) and 18.6% (n=65). In 13 patients, vitreous humor alcohol was positive (Mean±SD alcohol: 60.61±43.03 mg/dl). The most common toxin observed in toxicology was rice tablet or aluminum phosphide (n=90, 25.7%). Regarding drug toxicity in toxicology, 52.6% (n=86) was not positive. Opium was found in 7.4% of cases (n=26).
Conclusion: The suicide rate has been on the rise during the past ten years through hanging and poisoning with chemical substances, such as aluminum phosphide, opium, and tricyclic antidepressants, especially in the outskirts.

Prevalence of Helicobacter felis and Helicobacter heilmannii and Co-infection With Helicobacter pylori in Gastric Biopsy Specimens in Endoscopy Ward of Shahid Beheshti Hospital, Hamadan City, Iran

Alireza Khalilian, Pezhman Karami, Somayeh Bakhtyari, Razieh Ezati, Sara Khosravi, Razieh Amini, Seyed Saman Talebi, Fatemeh Torkaman Asadi, Maryam Fazeli, Somayeh Soleimani, Shahab Mahmoudvand, Hadi Ghasemi, Shadi Baniardalan, Farid Azizi Jalilian

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 33088

Background: Helicobacter pylori (H. pylori) has various strains associated with human infections. H. pylori, H. heilmannii, and H. felis are the most common strains in humans. H. pylori is associated with several human diseases such as chronic gastritis, peptic ulcer, mucous membrane lymphoma, and gastric adenocarcinoma. This study aimed to determine the prevalence rates of H. felis and H. heilmannii and the effect of co-infection with H. pylori in gastric biopsy specimens of patients.
Methods: Totally, 80 gastric biopsy specimens were taken by a physician from the patients referred to Shahid Beheshti Hospital, Hamadan City, Iran. PCR test was used to confirm the presence of H. pylori in samples that had positive rapid urease tests. Moreover, the ureB gene and ureA and ureB genes were used for H. heilmannii and H. felis, respectively.
Results: Of the study patients, 61.5% were females, and 38.5% were males with a mean age of 37.8 years. Of 80 biopsies, 50% were H. pylori-positive, 53.8% were H. heilmannii-positive, but no H. felis was identified in any sample. Results indicate that smoking, having a history of gastrointestinal diseases, and taking certain medications can be risk factors for H. pylori.
Conclusion: Any agent contributing to gastric mucosal damage can enhance the susceptibility to bacterial contamination. Overall, the results indicate a low probability of interactions between H. pylori, H. heilmannii, and H. felis.

Original Article (Medical Ethics)

Entanglement Of The Rights Of The Child, Well-Being And Justice: A Conceptual Framework For Child Protection And Well-Being

Forouzan Akrami, Alireza Zali, Mahmoud Abbasi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 36827

Background: Human Rights (HRs) framework supports improving human health status and the reduction of health inequalities through action on Social Determinants of Health (SDH). Given the shortcoming of HRs to protect the children, the question is, how can we ensure child protection and well-being rather than just child health?
Methods: In this conceptual analysis study, first, we explain the fundamental rights of the child and the steering role of them in moving towards health equity through action on SDH; second, meanwhile argue the shortcoming of rights-based protection, provide a list of the core capabilities and corresponding rights of the child; and third, we represent a conceptual framework for child protection and well-being using both HRs norms and moral entitlements based on recent ethical theories of justice, with a preventive approach.
Results: According to the framework, HRs instruments should lead to the protection of the child and the development of core capabilities through addressing social determinants and providing equal opportunities, of which the ability to live a healthy life is just one. In addition, actualizing these capabilities depends on the context. Since achieving well-being rather than just the health, in addition to acquiring the core capabilities as states of beings, implies their function as doings, that requires considering the socioecological context to provide means necessary to meet the essential dimensions of well-being at the level of adequacy.
Conclusion: Implementing the suggested framework requires that each country create a national action framework and determine the role and duties of the responsible organizations.

The Ethical Considerations in the Main Practices of the Iranian Legal Medicine Organization: A Qualitative Study

Mohammadnader Sharifi, Masoud Ghadipasha, Amirahmad Shojaei, Saharnaz Nedjat, Roya Rashidpouraie, Hamideh Moosapour, Seyed Mahmood Tabatabaei

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 36486

Background: Effective and acceptable practice in Legal Medicine (LM) requires special attention to ethical and professional behaviors. In LM, the importance of practitioners’ compliance with ethical standards is higher. LM covers a wide range of practices, requiring specific ethical considerations. This study aims to identify the ethical principles for considerations in Iranian Legal Medicine Organization (ILMO) from the perspective of experts in LM.
Methods: This is an applied and qualitative study using in-depth interviews and conventional content analysis. The study was conducted in three steps: 1) Determination of the main areas of work by reviewing academic texts، surveying 131 experts in this field with a questionnaire. 2) Qualitative Study for determination of ethical considerations of these areas by structured and in-depth interviews with 49 owner’s Forensic and medical ethics experts obtained by purposive sampling and theoretical saturation and analysis of interviews by the conventional approach of content analysis to specify propositions and confirm the reliability of 80% research in coding through the double-coder agreement method. 3) Drafting ethical guidelines by the research group (students، supervisors، and consultants) in the focus group meetings based on the results of the second step.
Results: The ethical principles of LM were categorized as general and specific principles according to the perspective of experts in LM. General ethical principles included virtue ethics, professional and ethical behavior, and proper environment and working conditions. The specific ethical principles included six principles related to the entire organization, legal physical examinations, legal mental examinations, dissection rooms and crime scenes, LM laboratories, and LM commissions.
Conclusion: Developing and implementing general and specific ethical guidelines for ILMO is recommended. The comprehensive and holistic view of ethical considerations for main practices of LM in Iran provided by this study can be seen as a good taxonomy and a preliminary step to develop local ethical guidelines.

Review Article

Potential Ameliorating Role of Spironolactone in Trastuzumab-induced Cardiotoxicity: A Narrative Review

Amir Ghabousian, Azin Alizadehasl, Niloufar Ansari, Mehrdad Haghazali

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 36127

Background: Around 20% of breast cancers (BCs) overexpress Human Epidermal Growth Factor Receptor 2 (HER-2). HER-2 overexpression is associated with increased tumor aggressiveness and poor prognosis. Trastuzumab (an anti-HER2 monoclonal antibody) has been reported to improve overall survival in early-stage and metastatic BCs, but at the expense of increasing cardiac morbidity. In the current review study, we aims to discuss the pathogenesis of trastuzumab-induced cardiotoxicity and the potential ameliorating role of spironolactone in this regard.
Methods: The search strategy aimed to identify both published and unpublished studies. First off, we identified keywords and index terms, including trastuzumab, cardiotoxicity, heart failure, and spironolactone to conduct a broad search in PubMed, Embase, Scopus, and Web of Science, using the aforementioned keywords either individually or in combination. Lastly, the reference list of all identified articles was also evaluated. Our study included observational and interventional studies, case-reports, and systematic reviews and meta-analyses.
Results: Trastuzumab could deteriorate mitochondrial function and subsequently leads to the accumulation of Reactive Oxygen Species (ROS) in cardiomyocytes. Published clinical studies offered conflicting results regarding the efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in respect of trastuzumab-induced cardiotoxicity. On the other hand, spironolactone was found to have both antioxidant and anti-inflammatory properties. Recent in-vivo studies supported the cardioprotective effect of spironolactone through maintaining mitochondrial ultrastructure and reducing ROS production.
Conclusion: Although spironolactone mitigates oxidative stress and mitochondrial dysfunction, there is a lack of clinical evidence to support the effectiveness of spironolactone in trastuzumab-induced cardiotoxicity. Design and implementation of clinical trials are recommended to determine the potential beneficial effects of spironolactone on trastuzumab-induced cardiotoxicity.

Case Report

Hyperinsulinemic Euglycemia Therapy for Acute Nitroglycerin Poisoning: Case Report

Maryam Vasheghani Farahani, Siamak Soltani, Sayed Mahdi Marashi

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 37176

Nitroglycerin, a vasodilator, is commonly administered to treat ischemic heart disease. Adverse effects after toxicity are light-headedness, nausea, blurry vision, and syncope due to low systolic blood pressure as well as methemoglobinemia. A 19-year-old female was admitted to our toxicology department after suicidal ingestion of 320 mg extended-release nitroglycerin about 45 minutes before the admission. She was conscious, and her initial blood pressure was 98/65 mm Hg, which was decreased to 77 mmHg within 1.5 hours despite administration of 1 liter of normal saline. Due to severe hypotension, norepinephrine infusion was started for systolic blood pressure maintenance above 80mm Hg; however, she started complaining of palpitation and chest pain. So, the dose of norepinephrine was reduced, and glucose, insulin, and potassium protocol were started. After 3 hours of therapy, her hemodynamic condition stabilized with systolic blood pressure above 90mm Hg; hence norepinephrine was discontinued. She was discharged on the 3rd day after the psychiatric consultation, with regular clinical and paraclinical examinations.

Posterior Reversible Encephalopathy Syndrome: An Unusual Complication of Benzodiazepine Poisoning: A Case Report

Vedpal Singh Punia, Shaavi Mittal, Apoorva Shetty, Naman Bansal, Prashant Garg, Prem Kumar, Neelabh Pratap

International Journal of Medical Toxicology and Forensic Medicine, Vol. 12 No. 2 (2022), , Page 36863

Posterior Reversible Encephalopathy Syndrome (PRES), also known as Reversible Posterior Leukoencephalopathy Syndrome, presents with rapid onset symptoms, including headache, seizures, altered consciousness, and visual disturbance. It is seen most frequently in settings of acute hypertension and is usually related to eclampsia. Only a few cases in the literature described PRES syndrome following benzodiazepines. We present a young male with benzodiazepine poisoning brought to the hospital in a deep coma, hypoxia, acidosis, and shock. Diagnosis of PRES was made on history, clinical examination, and radiologic findings of symmetric bilateral hyperintensities on T2 weighted Magnetic Resonance Imaging (MRIs) representing vasogenic edema.