Cutaneous Immune-Related Adverse Events Secondary to Immune Checkpoint Inhibitors and Their Management.

Immune checkpoint inhibitors (CPIs) are highly effective in the treatment of various cancers. Immunotherapy enhances antitumor activity by relieving inhibition of T cells responsible for immune surveillance. However, overactivation of T cells leads to immune-related adverse events (irAE), of which cutaneous adverse events are the most common. Examples include pruritus and maculopapular eruption most commonly, psoriasis and bullous dermatoses less commonly, and, rarely, severe, life-threatening eruptions such as Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis. Many of these are autoimmune in nature, and these may present de novo or as recurrence of pre-existing disease. In order to maximize the therapeutic potential of CPIs, it is essential to recognize and effectively manage cutaneous irAE, which can otherwise lead to treatment interruption or discontinuation. This review summarizes the presentation and management of dermatologic adverse events secondary to immune dysregulation as a result of immune checkpoint inhibitor therapy, including the most common (maculopapular eruption, pruritus, lichenoid dermatitis, and vitiligo), less common (psoriasis, bullous pemphigoid, erythema multiforme, eczematous dermatitis, alopecia areata, and granulo-matous and neutrophilic dermatoses), and severe (acute generalized exanthematous pustulosis [AGEP], drug reaction with eosinophilia and systemic symptoms [DRESS], and Stevens-Johnson syndrome or toxic epidermal necrolysis [SJS/TEN]), as well as exacerbation of pre-existing cutaneous autoimmune disease (subacute cutaneous lupus erythematosus, dermatomyositis, eosinophilic fasciitis, leukocytoclastic vasculitis, and scleroderma-like reaction).

[Therapeutic approaches for retinitis pigmentosa]. / Therapeutische Ansätze bei Patienten mit Retinitis pigmentosa.

BACKGROUND: Retinitis pigmentosa (RP) is a clinically and genetically heterogeneous group of hereditary retinal disorders, which lead to progressive loss of vision and finally blindness. Yet there is no approved therapy. Advances in unravelling underlying genetic disorders and pathophysiological mechanisms offer new therapeutic approaches of which some are summarised in this review. METHODS: We performed a systematic literature research for defined key words in PubMed. RESULTS: New approaches to therapy for RP include: gene therapy, pharmacological treatment, neuroprotection, electrical stimulation, retinal prostheses, retinal transplantation and optogenetic therapy. CONCLUSIONS: Recently there have been advances in new approaches for therapy of dystrophic retinal diseases. Advances in the different approaches are being made at different rates. Although there is no approved therapy yet, the future for treating RP at least in some patients looks promising.

[Effects of transcorneal electrical stimulation in patients with Stargardt's disease]. / Transkorneale Elektrostimulation bei Patienten mit Morbus Stargardt.

Stargardt's disease is an autosomal recessive inherited juvenile macular degeneration and at present no acknowledged science-based therapy is available for these patients. Recently, reports have been published on the effectiveness of electrical stimulation in experimental animal models and in patients with neurodegenerative ocular disease, particularly retinitis pigmentosa. This study included 12 patients with Stargardt's disease who were randomized into one of three groups (n = 4) with 0% (sham), 66% or 150% of the individual electrically stimulated phosphene threshold. Outcome measures of the study were safety and efficacy of transcorneal electrical stimulation (TES) with DTL electrodes in subjective and objective parameters of visual function under therapy. In general TES was well tolerated and no adverse or serious events were noted. Neither Ganzfeld, multifocal ERG, OCT nor visual field testing showed statistically significant changes in any group.

[Does acupuncture influence the cardiac autonomic nervous system in patients with minor depression or anxiety disorders?]. / Beeinflusst Akupunktur die autonom kardiale Regulation bei Patienten mit leichten depressiven Episoden oder Angststörungen? Eine randomisierte, plazebokontrollierte Verlaufsstudie.

We undertook this study to evaluate the effects of needle acupuncture on cardiac autonomic nervous system (ANS) function in patients with minor depression or anxiety disorder. Patients (n = 36) were randomly distributed into a verum acupuncture (VA) group (needles were applied at classical acupuncture points, e. g. He7, Pe6, Du20, Bl62, Ex6) or a placebo (PL) group (needles were applied only epidermal at non-acupuncture points). Both groups underwent standardized measurements of the 5-minute resting heart rate variability (HRV), which were performed before the first and after the 9th acupuncture session of an acupuncture series, and also three times (before the start and 5, respectively, 15 minutes after needle application) during the third acupuncture session. Demographic data between the VA and PL group did not differ. Before the start of acupuncture there were also no significant differences in HRV data between these groups. Compared to PL the VA group showed a significant decrease of the mean resting heart rate both, 5 and 15 minutes after needle application, combined with a trend towards an increase of the high frequency (HF; 0.15 - 0.4 Hz) and a decrease of the low frequency (LF; 0.04 - 0.15 Hz) spectral power. The latter effects resulted in an overall significant decrease of the mean LF/HF ratio in VA compared to PL treated patients. This pattern of findings suggests that in patients with minor depression or anxiety only verum acupuncture 1.) leads to a relative increase of cardiovagal modulation of heart rate and 2.) facilitates the physiological regulatory ANS function in response to alterations of external or internal environment. Clinical implications of these findings are discussed.

Increased weakness after pancreas and kidney transplantation.

BACKGROUND: Already there is evidence that simultaneous pancreas and kidney (SPK), or pancreas after kidney (PAK) transplantation, in patients with type 1 diabetes mellitus and end-stage kidney disease prevents worsening of diabetic polyneuropathy, but neuropathic improvement is delayed and incomplete. METHODS: In 85 patients with type 1 diabetes mellitus who underwent SPK or PAK transplantations, we performed sequential neuromuscular evaluations before, every 3 months after, and yearly after transplantation, quantitating muscle weakness separately from overall severity of polyneuropathy. RESULTS: We found that, on average, the weakness subscore of the Neuropathy Impairment Score of the lower limbs [NIS(LL)-W] was significantly worse at 3, 6, 9, and 12 months (by about 5 points) than at baseline. By contrast, for these times after transplantation, a composite score of nerve conduction abnormalities, an independent measure of severity of polyneuropathy, was not significantly worse and, in fact, was significantly improved. In multivariate analysis, length of hospital stay correlated with the increased weakness. CONCLUSIONS: We conclude that: (1) increased neuromuscular impairment after transplantation is mainly due to muscle weakness and not to worsening polyneuropathy; (2) in multivariate analysis, duration of hospitalization after transplantation was significantly associated with this increased weakness; (3) increased weakness is probably due to development of myopathy, which may be related to graft rejection, immunosuppression, sepsis, and intercurrent infections; (4) in future transplantation trials, weakness should be evaluated separately from neuropathic status, and the lowest efficacious dosages of immunotherapy should be used; and (5) essentially all diabetic patients reported that SPK or PAK transplantation was worthwhile because it freed them from diabetic lifestyle concerns.

New possibilities in scintigraphy detection of carbon monoxide cardiotoxicity.

The blood clearance of Tc99m MIBI is rapid and biexponential, with an initial fast phase followed by a slow phase. The fundamental myocellular uptake mechanism involves passive distribution across plasma and mitochondrial membranes, and at equilibrium, sestamibi is sequestered within the mitochondria by the larger negative mitochondrial transmembrane potential. Reverse distribution into blood stream is stopped by the high membrane potential of the cardiac cells. Scintigraphic changes followed by the metabolic abnormalities in patients after acute carbon monoxide poisoning can be necrosis or only the transitory ischemia. It seems to detect accurately the extension of the early necrosis (unreversible) of the myocardium. Amiscan kit for the preparation of Tc99m-glucarate is being developed as a radiopharmaceutical diagnostic agent for the imaging of and diagnosis of acute myocardial necrosis. Cellular and subcellular uptake studies have shown that Tc99m-glucarate localizes in necrotic tissues binding primarily to the nucleoprotein sub-fractions and to a lesser extent to the DNA fractions. Glucarate is taken up rapidly by necrotic myocardium and cleared relatively rapidly from the circulation resulting in early, hight target-to-background ratios. In studies of Amiscan in patients with acute myocardial infarction, sensitivity was found to be 100% when Amiscan is administered within 9 hours of the onset of chest pain. In our preliminary study the scintigraphic scans using Tc99m-glucarate were performed in 10 patients after acute carbon monoxide poisoning. The study can confirm that some patients during acute CO poisoning have typical myocardial necrosis, but part of them have hibernating and/or stunned myocardium.

[Evaluation of health status in participants from a methadone treatment program in Krakow after one year of maintenance treatment]. / Ocena stanu zdrowia uczestników programu metadonowego w Krakowie po roku leczenia substytucyjnego.

Methadone treatment programme for 50 opiate addicts has been conducted at the Department of Clinical Toxicology for a one year. The aim of the study was to evaluate the health state including psychological condition and also a social status of the opiate dependent patients after one year methadone maintenance medication. Also, considering the results of clinical examination, a trial of elaboration of system for dependence scoring was undertaken. An improvement of general health state of addicts was observed. No new cases of HIV positive patients were noted. An increase in number of addicts who start professional activity, and those who live in procreative families and even in formally confirmed marriage. A three pregnant women, and five who already gave birth to a child (one of them is completely drug free at present) were noted. A significant behavioural changes, reduced level of criminal activity and restored personal relationships with family were observed. A moderate psychopathological symptoms are still observed in patients with double diagnosis.

[Alcohol related hospitalization in the Department of Clinical Toxicology and Medicine Detoxification Ward of the Krakow Special Hospital of J. Babinski in Krakow]. / Alkohol jako przyczyna hospitalizacji w Klinice Toksykologii Collegium Medicum UJ i Oddziale Detoksykacji Szpitala Specjalistycznego im. J. Babinskiego w Krakowie.

The patients hospitalised because of acute ethanol intoxication or ethanol withdrawal syndrome at the Kraków Department of Clinical Toxicology and Detoxification Ward of J. Babinski Specialistic Hospital in the years 1997-2000 were subjected to the study. A significant increase in number of ethanol related hospitalisation was noted at the Department of Clinical Toxicology (from 1381 patients in year 1997 up to 1771 in year 2000), and at the Detoxification Ward of Babinski Hospital from 369 in 1997 and 849 patients in 2000 respectively. A significant increase in number of ethanol dependent patients admitted to the Department of Clinical Toxicology because of acute ethanol intoxication and the patients hospitalised because of ethanol withdrawal syndrome or signs of delirium tremens was noted. The same and even stronger trends in hospitalisation, particularly of those ethanol addicts presenting clinical symptoms of acute ethanol intoxication were observed at the Detoxification Ward of Babinski Hospital.

Determination of opiates in serum, saliva and hair addicted persons.

In the last ten years advances in analytical methods have enabled the determination of xenobiotics in alternative material such as sweat, saliva, and hair. The aim of this study was to develop an analytical method and measure the concentration of the main opiates in serum saliva and hair of subjects from a detoxification and methadone treatment programme. The analytical strategy in the presented study, based on enzymoimmunoassay screening of opiates in urine and GC/MS confirmation, meets the needs of forensic and clinical toxicology. Blood and saliva samples from thirty seven patients and hair from twenty three with a history of intravenous opiate use were collected for analysis. The ranges of morphine in serum and saliva were 0-2081 and 0-208 ng/ml respectively; corresponding concentrations of codeine were 0-580 and 0-428 ng/ml respectively. The concentration of morphine, codeine and 6-MAM in hair of addicts ranged respectively from 0-32.4, 0-12.5 and 0-2.8 ng/mg. From the clinical toxicology point of view, hair analysis is supplementary to urine, serum or saliva determination, but in drug testing at the workplace it can play a crucial role.

Usefulness of rest and forced perfusion scintigraphy (SPECT) to evaluate cardiotoxicity in acute carbon monoxide poisoning.

The aim of the study was to evaluate myocardial perfusion in acute carbon monoxide poisoned patients using rest and stress Tc 99m-MIBI SPECT scintigraphy. There were 29 study patients (15 men and 14 women) aged from 14 to 46 years poisoned acutely with CO at home. Measurement of COHb, blood lactate level, duration of exposure and ECG examination were performed on admission to the Clinic. The enzymes activity (ALT, AST, CBK) were evaluated after 24 hours. The first rest Tc99m-MIBI SPECT was performed in all patients two to five days after intoxication. Fifteen of the patients underwent the control examination: stress and rest scintigraphy six months after CO exposure. Moving track exercise according to the Bruce protocol was used in each the patients. The control rest scintigraphy was performed 48 hours after exercise. Abnormal, differently intensified scans were noted in all the subjects: 5 patients had a I degree of pathological changes, 7 patients had II degree, 16--III degree and 1 patient had a IV degree of pathological changes. In 14 of the patients with pathological scintigraphic scans the normal EKG curves were noted. The mean COHb level was 35.0 +/- 7.22%, the blood lactate concentration was 4.4 +/- 3.7 mmol/L. The average duration of exposure was 108.4 +/- 163.9 min. Effort related ischemia was not noted in 10 of the patients who underwent control examination. An improvement in rest scintigraphic scans was stated in 12, and no changes were observed in 3 of the controlled patients. Deterioration was not found in any patient. No correlation between ECG results and scintigraphic image of myocardium was found. Tc 99m-MIBI SPECT scintigraphy is a more sensitive method than electrocardiography and measurement of enzymes activity for the evaluation of CO cardiotoxicity in acute poisoning. The method enables evaluation of the localization and disease extent.

[A trial for the complex risk assessment of repeated suicide predictors in patients after suicidal poisoning attempts, hospitalized in the Department of Clinical Toxicology CM UJ in Krakow. I. Influence of socio-demographic factors]. / Próba kompleksowej oceny predyktorów ryzyka ponowienia samobójstwa u pacjentów po samobójczym zatruciu lekami, hospitalizowanych w Klinice Toksykologii CM UJ w Krakowie. Czesc I. Wplyw czynników socjodemograficznych.

The study included 180 patients aged 18-79 (average 36) hospitalized for suicide attempts (drug intoxication) in Department of Clinical Toxicology CMUJ from March to December 2000. Examined group was composed of 49 men and 131 women. Structured investigation and medical documentation were used to estimate crucial socio-demographic risk factors of repeated suicide attempt. The following socio-demographic traits were taken into consideration in analysis: age, sex, marital status, place of living, education, employment, family background. We distinguished among patients under examinations: patients after first suicide attempt (I) and group after another suicidal attempt (II). The second group consisted of 15 men (27.8% of the total) and 39 women (72.2% of the total). Young people under 30 constituted 37.2% of the whole examined population. In population of women after repeated suicide attempt the percentage of divorced ones increased considerably (from 2.2% to 10.2%). Both in men and women after repeated suicide attempt the percentage of persons with only elementary education increased (from 34.1% to 53.7%). We observed high unemployment rate (from 26.6% to 29.6%) in both groups. Percentage of pensioners increased from 23.5% after first suicidal attempt to 33.3% after repeated suicidal attempt in men and from 25.5% to 35.9% in women. Men after repeated suicide attempt more often live with their parents, while women from the second group more often live alone with their children. It seems that some of the analysed predictors which are expression of social unadjustment may make risk factor for repeated suicidal attempts.

[A trial for the complex risk assessment of repeated suicide predictors in patients after suicidal poisoning attempts, hospitalized in the Department of Clinical Toxicology CM UJ in Krakow. II. Clinical predictors]. / Próba kompleksowej oceny predyktorów ryzyka ponowienia samobójstwa u pacjentów po samobójczym zatruciu lekami, hospitalizowanych w Klinice Toksykologii CM UJ w Krakowie. Czesc II. Predyktory kliniczne.

The study included 180 patients aged 18-79 (average 36) hospitalized for suicide attempts (drug intoxi-cations) in the Department of Clinical Toxicology CM UJ from March to December 2000. Examined group was composed of 49 men and 131 women. The following tests were used in this study: structured questionnaire, psychological tests: Beck Depression Inventory, Hamilton Depression Scale, Hopelessness Scale, Suicidal Intent Scale, Life Events Scale, SOC 29 (by Antonovsky). Besides, we used data from patients' history. The aim of our study is to analyse clinical data of suicidal attempters--after first and repeated suicidal attempts. We took into consideration the severity of coma, severity of intoxication, the kind of substances used in the attempt, the presence of alcohol, previous psychiatric treatment, cases of suicide among the patients' close friends or relatives and duration of hospitalization. Then the psychiatric diagnosis was stated. The analysis of severity of intoxication (divided into three stages: severe, moderate, and light according to the Poisoning Severity Score (PSS) indicated that in the group of repeated suicide attempters the percentage of severe intoxications was greater (9.2%) then in first time attempters. In the population of second time female attempters there is a greater percentage of persons who took neuroleptics (15.4%) compared to group first attempters (5.4%). In both groups the majority were taking anxiolytisc, sleep-inducing and mixed drugs. There was a greater percentage of persons drinking alcohol during the attempt among repeated suicidal attempters (38.8%) than among the first time attempters (26%). The percentage of persons with diagnosis of mental disease (treated in ambulatory or in hospital) is higher in the group of repeated suicide attempters (25.9%) then after first attempters (6.3%). In both groups a lot of persons had reactive depression, often associated with personality disorders, rarely endogenic depressions or psychosis. We observed that addiction to alcohol is often a problem in men who attempt suicide (I group--32.3%, II group--33.3%). The analysis of medical documentation indicated in the group of repeated suicide attempters a high percentage of people with cases of suicide among their close friends or relatives.

[Use of buprenorphine as a substitute treatment for opiate dependence in the Toxicology Clinics--introductory clinical report]. / Zastosowanie buprenorfiny w leczeniu substytucyjnym uzaleznienia od opiatów w Klinice Toksykologii--wstepne doniesienie kliniczne.

That the problem of drug addiction is still growing up, so there is the necessity for widen of treatment panel for psychoactive substances abuse, especially for opiates. Because of the fact, that substituting treatment became to be popular in patients' opinion, more attention were paid on new medicine-buprenorphine. It is an agonist- antagonist of opiates' receptors. Buprenorphine has been successfully used in long-term treatment in United States and in Western Europe. Treatment with buprenorphine has been started in Poland in Toxicological Department in Kraków. This article shows outcomes of substituting treatment with buprenorphine in period from December 2000 to February 2001.

[Psychoactive agents: an analysis based on cases from the Department of Clinical Toxicology College of Medicine of the Jagiellonian University in Kraków in the years 1997-1999]. / Substancje uzalezniajace w materiale Kliniki Toksykologii Collegium Medicum Uniwersytetu Jagiellonskiego w Krakowie w latach 1997-1999.

The aim of the study was to evaluate the frequency of acute poisoning with psychoactive substances in adult abusers of Kraków population in 1997, 1998 and 1999 and to compare the number of poisoned patients suffering withdrawal syndrome as predominant. 27.2% (n = 945) of all 3472 acute poisonings treated in the Department of Clinical Toxicology in 1997, 36.9% (n = 1193) of all 3236 treated in 1998 and 47.9% (n = 1546) of all 3233 treated cases that were acute poisoning with psychoactive substances among the abusers of Kraków adult population. Ethanol followed by narcotics in 1998, and by drugs coingested with ethanol and by narcotics in 1997 and 1999 was predominant psychoactive agent in all the analysed years. Organic solvents and glue sniffing and drug dependency increased again in 1999. Opiate derivatives produced at home from poppy straw or juice of poppy head were still the most common narcotic detected in body fluids, but decrease in number of acute opiates poisoning was noted in 1999 as compared to previous analysed years. The most of ethanol abusers aged from 30-49 years. The highest incidence of narcotic and drug dependency was noted in age between 20-29 years.

[Concentration of zinc, copper and magnesium in the serum of drug addicts]. / Stezenie cynku, miedzi i magnezu w surowicy krwi osób uzaleznionych od narkotyków.

The aim of this study was to determine the concentration of zinc, copper and magnesium in the blood serum of drug addicts in order to ascertain whether drug abuse has an effect on the concentration of these metals. The study was carried out on a group of 33 addicts undergoing treatment at the Department of Clinical Toxicology, Collegium Medicum, Jagiellonian University in Kraków. The control group consisted of 22 young, healthy, drug free, male volunteers. Analyses were performed using flame atomic absorption spectrometry. The results demonstrate that zinc serum concentrations in the examined group of addicts before therapy (mean 0.82 mg/l) were reduced in relation to the control group (mean 1.12 mg/l), and was slightly enhanced after the detoxification process (mean 0.86 mg/l). The opposite effect was observed in the case copper serum concentration. The copper level in the group of addicts on admission to hospital (mean 1.35 mg/l) increased in relation to the control group (mean 1.11 mg/l) and was lower during hospitalisation (mean 1.18 mg/l). The concentration of magnesium in the serum of drug addicts did not change during therapy and was in the same range as in the control group (mean concentrations were 20.3 mg/l, 20.2 mg/l and 20.6 mg/l respectively).

[Comparison of ventilatory efficiency in alcohol and opiate abusers]. / Porównanie sprawnosci wentylacyjnej u osób przewlekle uzaleznionych od alkoholu i osób uzaleznionych od opiatów.

The aim of this study was to evaluate the respiratory efficiency in alcohol and opiate abusers. There were 220 persons under examination: 144 alcohol abusers (group I), 36 opiate abusers (group II) and 40 healthy persons (control group). Both groups of dependent persons were treated in the Detoxication Unit of the Department of Clinical Toxicology CMUJ. During hospitalization the functional state of respiratory system was monitored. Ventilation efficiency was determined on the basis of the results from a "flow-volume" loop, spirometry and the measurements of the respiratory tract resistance in a computerised system Lungtest-MES company (Poland). In the examination performed directly after admission to the Clinic the normal respiratory efficiency was noted in 36.1% in ethanol abusers and 54.9% in opiate abusers. 63.9% of alcohol abusers (group I) and 45.1% of opiate abusers (group II) suffered from the bronchial obturation. In the examination performed after hospitalisation and 9 days of total abstinence in 33.3% of the alcohol dependent patients and in 38.5% of the opiate dependent patients respiratory obturation was observed. The values of respiratory tract resistance in both groups of dependent patients in examination on admission and after treatment were increased compared to controls. The changes of ventilatory parameters can be explained mainly by withdrawal syndrom revealing that it is connected with initial (9 days lasting) period of controlled and total abstinence.

[Comparison of respiratory regulation in alcohol and opiate abusers]. / Porównanie regulacji oddychania u osób przewlekle uzaleznionych od alkoholu i osób uzaleznionych od opiatów.

Opioid drugs and alcohol, both central nervous system depressants, may also have a depressive action on the brain stem centre responsible for breathing control. Disorders of breathing regulation are reflected in respiratory efficiency. The aim of this study was to evaluate the regulation of breathing by measuring the respiratory pattern and occlusion pressure of abusers of opiates and alcohol. There were 180 persons under examination: 84 alcohol abusers (group I), 36 opiates abusers (group II) and 40 healthy persons (control group). Both groups of dependent persons were treated in the Detoxication Unit of the Department of Clinical Toxicology CMUJ. Respiratory regulation was evaluated "on line" by means of synchronous measurements of the respiratory pattern (according to Milic-Emili assumptions) and occlusion pressure P 0.1 (according to Whitlaw assumptions). The central respiratory drive (VT/Tin) and the timing component of the breathing cycle (Tin/Ttot) were simillar in both groups of abusers. In comparison to the control group, in the group of opiates abusers, values of VT/Tin were higher during examination performed after treatment, and values of Tin/Ttot were elevated (in group I--only before treatment; in group II--before and after treatment). Examination of respiratory pattern and occlusion pressure is based on recording spontaneous breathing, which this can be performed even in unconscious patients in very early stage of poisoning.

Changes in serum copper level during detoxification of acutely poisoned drug addicts.

Although it is known that drug addicts are a high-risk group for disruption of many homeostatic processes, little is know about changes in serum trace elements concentrations after taking the psychoactive substances. The aim of the study was to check the influence of the taking homemade heroin on serum level of copper. Blood samples were taken from 30 opiate addicts, and copper concentrations were measured by the means of atomic absorption spectrophotometry. The result of the study show that in the examined group, copper serum concentrations (1.35 mg/L) upon admission to the clinic were higher than in the control group (1.11 mg/L) but decreased during hospitalization (1.18 mg/L). There was no correlation between duration of stay at the hospital and changes in serum copper concentration.

[Comparison between the poisoning severity score and specific grading scales used at the Department of Clinical Toxicology in Krakow]. / Porównanie skali Poisoning Severity Score i specyficznych skal ciezkosci zatrucia uzywanych w Klinice Toksykologii Collegium Medicum UJ.

The aim of the present study has been to assess the concordance in severity grading when using the Poisoning Severity Score (PSS), proposed by IPCS/EC/EAPCCT vs. some specific grading scales. Cases of acute poisoning admitted to the Department of Clinical Toxicology in Kraków during months January, March, May, July, August and October 1998 (n = 820) were evaluated. Severity grading was performed in all cases using both the PSS and special grading scales developed by the poisons centre in Kraków. The PSS is assessing severity on the basis of observed clinical signs and symptoms (at their maximum), but does not take into account potential risks or plasma/serum concentrations. The Kraków scales include both clinical symptoms on admission and results of toxicological analyses. Ethanol (39.4%), drugs (36.2%) and carbon monoxide (7.9%) were the most commonly involved toxic agents. Overall concordance between the PSS and the Kraków scales was at hand in 596 cases (72.7%). The lack of concordance was most evident for ethanol and carbon monoxide cases--the PSS generally giving a lower grade. The discordance was less pronounced for grade 3 (life-threatening) poisonings. Significant number of ethanol poisoning in Kraków centre require medicolegal certification thus ethanol concentration (blood or expired air) is considered while evaluating the poisoning severity. Moreover majority (more than 70%) of acutely ethanol poisoned patients treated at the Department are chronic alcoholics so clinical evidence of intoxication may be minimal at blood ethanol levels higher than 3.0 g/L. For ethanol intoxication the blood ethanol concentration was considered in the Kraków scale but not in the PSS, and when the blood concentrations were disregarded and clinical symptoms only were evaluated the concordance improved between the different systems from 72.7% to 92.3%. Thereby also the overall concordance in the study increased to 82.9%. The less satisfying concordance for carbon monoxide cases was mainly caused by discrepancies in the evaluation of neurological symptoms. Also the blood lactate concentration, COHb level, duration of exposure and patient's age are considered in the Kraków scale but not in PSS. The PSS is intended as a general scheme for grading severity of acute poisoning. In this study an acceptable concordance between the PSS and some locally developed grading scales was at hand in the majority of cases, but it seems that for specific poisons, like carbon monoxide, some modifications and additional criteria may be justified. Further studies to test the reliability of the PSS are encouraged.

[Methods of poison elimination--controversies and actual views about their use]. / Metody eliminacji trucizn--kontrowersje i aktualne poglady na ich stosowanie.

This paper presents controversies and current ideas about application of poison elimination methods in acute poisonings. Indications and contra-indications for single dose of activated charcoal, gastric lavage, cathartics and whole bowel irrigation are discussed. Rationale and indications for forced diuresis, repeated doses of activated charcoal, hemodialysis and hemoperfusion, enhanced elimination methods, are described.