Demographic and Clinical Characteristics of 907 Cases with Naltrexone Intoxication; a 14-Year Cross-Sectional Study.

Introduction: Opioids have been the leading cause of death from poisoning in Iran for several years. This study aimed to evaluate the clinical and para-clinical presentations of naltrexone intoxication, its toxic dose, and its epidemiological properties. Methods: This retrospective cross-sectional study was conducted on medical records of patients presenting to Toxicology Department of Loghman Hakim Hospital, Tehran, Iran, following naltrexone intoxication, from 2002 to 2016. Patients' demographic and laboratory data, clinical signs, supposed ingested dose, and intent of naltrexone consumption were collected, analyzed, and then interpreted. Results: 907 patients with the mean age of 36.6 ±11.7 years were evaluated (94.3% male). The mean amount of naltrexone consumed by the intoxicated patients reported in the medical records was 105.8 ± 267.8 mg. One hundred thirty patients (14.3%) used naltrexone to treat substance use disorder. Two hundred eighty-seven poisoned patients (31.6%) were current opium users who intentionally or unintentionally used naltrexone concomitantly. The most common symptoms observed in these patients were agitation (41.8%), vomiting (16.4%), and nausea (14.8%). Among patients with naltrexone poisoning, 25 patients were intubated (2.8%), and three passed away. Aspartate aminotransferase (AST) levels were significantly higher in patients intoxicated with naltrexone who needed intubation (p = 0.02). Conclusion: The probability of intubation of cases with naltrexone intoxication was associated with AST elevation. It seems that, the number of intensive care unit (ICU) admissions and mortality rates are not high among these patients.

Fentanyl versus Methadone in Management of Withdrawal Syndrome in Opioid Addicted Patients; a Pilot Clinical Trial.

INTRODUCTION: The most effective treatment for withdrawal syndrome in Opioid-dependent patients admitted to intensive care units (ICUs) remains unknown. This study aimed to compare fentanyl and methadone in this regard. METHODS: This prospective, single-blinded, controlled pilot study was conducted on opioid-dependent intubated patients admitted to the toxicology ICU of Loghman Hakim Hospital, Tehran, Iran, between August 2019 and August 2020. Patients were alternately assigned to either fentanyl or methadone group after the initiation of their withdrawal syndrome. Duration and alleviation of the withdrawal signs and symptoms, ICU and hospital stay, development of complications, development of later signs/symptoms of withdrawal syndrome, and need for further administration of sedatives to treat agitation were then compared between these two groups. RESULTS: Median age of the patients was 42 [interquartile range (IQR): 26, 56]. The two groups were similar in terms of the patients' age (p = 0.92), sex (p = 0.632), primary Simplified Acute Physiology Score (SAPS) II (p = 0.861), and Clinical Opiate Withdrawal Score (COWS) before (p = 0.537) and 120 minutes after treatment (p = 0.136) with either methadone or fentanyl. The duration of intubation (p = 0.120), and ICU stay (p = 0.572), were also similar between the two groups. The only factor that was significantly different between the two groups was the time needed for alleviation of the withdrawal signs and symptoms after the administration of the medication, which was significantly shorter in the methadone group (30 vs. 120 minutes, p = 0.007). CONCLUSION: It seems that methadone treats the withdrawal signs and symptoms faster in dependent patients. However, these drugs are similarly powerful in controlling the withdrawal signs in these patients.

A 5 Years Assessment of Patients with Acute Digoxin Poisoning: A Toxicoepidemiology Study in Iran.

Background: Digoxin poisoning leads to the development of cardiac and noncardiac complications. Digoxin immune fab is a safe and effective antidote, but clinical trials have not been performed in this regard, and most of the evidence is based on prospective studies. Understanding the toxicoepidemiology pattern of digoxin poisoning could provide valuable context for better managing its acute poisoning. Objectives: This study aimed to assess the toxicoepidemiology pattern of acute digoxin poisoning through a 5-year assessment in Iran. Methodology: In this observational study, the records of 97 patients who were referred with acute digoxin poisoning between 2010 and 2015 were evaluated. Demographic characteristics, past medical history, drug history, chief complaints, vital signs, paraclinical findings, digoxin immune fab administration, and clinical outcomes recorded. Results: The mean age of patients was 34.02 ± 17.87 years old. About 24.7% of patients had underlying diseases, and among them, heart failure was the most prevalent disease (29.2%) 42.3% of patients needed intensive care unit (ICU) admission. The mean duration of ICU stay was 4.00 ± 2.29 days. Digoxin immune fab was administered for 4.1% of patients, and an average of 6.2 ± 2.2 vials were used for them. All patients survived, and no mortality was reported. Conclusions: Digoxin immune fab administration did not alter the mortality rate. Hence, it can be concluded digoxin immune fab is not appropriate in acute poisoning, but it may be considered in chronic poisoning. Furthermore, acute digoxin poisoning is more common in Iran, and it responds appropriately to conventional treatment.

Trend of blood lactate level in acute aluminum phosphide poisoning.

BACKGROUND: Aluminum phosphide (AlP) poisoning is common in the developing countries. There is no specific antidote for the treatment of acute AlP poisoning. Early diagnosis of poisoning and outcome predictors may facilitate treatment decisions. The objective of this study was to determine the trend of blood lactate level in acute AlP poisoning to evaluate its role as a prognostic factor. METHODS: This was a prospective study on acute AlP intoxicated patients during one year. Demographic data, clinical and laboratory data on admission, and outcome were recorded in a self-made questionnaire. Blood lactate levels were analyzed every two hours for 24 hours. RESULTS: Thirty-nine (27 male, 12 female) patients were included in the study. The mortality rate was 38.5%. The mean blood pressure, pulse rate, blood pH and serum bicarbonate level were significantly different between the survivors and non-survivors groups. Blood lactate level was significantly higher in the non-survivors group during 8 to 16 hours post ingestion. CONCLUSION: Blood lactate level could be used as an index of severity of acute AlP poisoning.

Survey on Hypothermia and Hyperthermia in Poisoned Patients in a Unique Referral Hospital, Tehran, Iran.

BACKGROUND: Body temperature is a critical criterion of health. Drugs and a variety of poisons can affect body temperature in poisoned patients, causing hyperthermia and hyperpyrexia. OBJECTIVES: Our previous study's findings in patients poisoned with organophosphate led us to the goal of this study: obtaining the initial tympanic temperature in patients poisoned by a variety of toxins. MATERIALS AND METHODS: A cross-sectional study reviewed the records of poisoned patients who were admitted to the toxicological intensive care unit (TICU) at Loghman Hakim hospital poison center (LHHPC) from February 2014 to February 2015. The data collected included gender, age, type of poisoning, the season during which poisoning occurred, vital signs, initial tympanic temperature (first four hours), presence of seizures, white blood cell (WBC) count, creatinine phosphokinase (CPK), length of stay and patient outcome. We determined the mean (SD) for normally distributed continuous variables, the median and interquartile range for non-normally distributed continuous variables, and the absolute and relative frequency (%) for categorical variables. All were determined using SPSS version 16. RESULTS: Data were collected from 310 eligible patients. The mean patient age was 32.65 (with a standard deviation of 14.40). Of the patients in the study, 183 (59%) were male. Intentional poisoning in an attempted suicide was documented in 253 (81.6%) patients. The most prevalent poisoning agent was aluminum phosphate (18.70%), followed by methadone (10%) and opium (10%). Seventy percent of the patients (n = 217) were diagnosed and classified with fever or hyperthermia. A temperature ≥ 40°C was detected in just three cases. The highest mean temperature was found in patients poisoned with amphetamine, organophosphate and tramadol. Patients with alcohol and phenobarbital poisoning were included in the sample, but these patients were not diagnosed with hypothermia. WBC ≥ 10,000 cells/mL and CPK ≥ 975 IU/L were recorded in 57.7% and 13.2% of subjects, respectively. CONCLUSIONS: Body temperature changes in human poisonings are a matter in need of special attention. A literature review did not reveal any controversy over hypothermia, but poisoning cases exhibit a variety of patterns of fever and hyperthermia. If there are no limits to the diagnosis of fever and hyperthermia, all cases with a poor prognosis which fail to respond to treatment could be categorized as drug-induced hyperthermia. Therefore, a different approach is needed for poisoning cases.

Central Nervous System Depressants Poisoning and Ventilator Associated Pneumonia: An Underrated Risk Factor at the Toxicological Intensive Care Unit.

BACKGROUND: Ventilator-Associated Pneumonia (VAP) is the main cause of nosocomial infection at intensive care units (ICUs), which causes high mortality and morbidity. OBJECTIVES: The objective of the present survey was to identify the VAP risk and prognostic factors among poisoned patients, who were admitted to the toxicological ICU (TICU), especially central nervous system (CNS) depressants due to their prevalence and importance. PATIENTS AND METHODS: A case-control study was conducted at the Loghman Hakim hospital between March 2013 and March 2014. Among 300 poisoned patients with mechanical ventilator ≥ 48 hours, 150 patients, who had developed microbiologically-confirmed VAP were considered as the VAP group and 150 without VAP were defined as the control group. The following data were collected; age, gender, type of poisoning, glasgow coma score, Acute physiology and chronic health evaluation (APACHE) II score, length of hospital stay, previous antibiotic use, microbial culture of the trachea, body temperature, leukocyte count, and patients' outcome. Based on the type of poisoning, patients were divided into three groups including: opioid, CNS depressants and others. All data were expressed as means (SD) for continuous variables and frequencies for categorical variables. Logistic regression was used to determine the relationship between risk factors and VAP. RESULTS: The mean age of the patients was 33.9 ± 14.3 years. The probable VAP incidence and mortality were 22% and 18.6%, respectively. The rate of CNS depressant versus opioid use (odds ratio, 3.74; P < 0.027), APACHE II (odds ratio, 1.28; P < 0.000) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent risk factors for VAP. While, the APACHE II score (odds ratio, 1.12; P < 0.044) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent predictors of VAP mortality among these patients. The most common microorganisms in VAP cases were Methicillin-Resistant Staphylococcus aureus (MRSA) and Acinetobacter sp. (56.7% and 12.7%, respectively). CONCLUSIONS: Central nervous system depressant was an important risk factor for VAP among poisoned patients. Hypoventilation due to CNS depression can lead to VAP. The APACHE II and length of hospital stay were shown as independent predictors of VAP and mortality among these patients.

Hypo and hyperglycemia among tramadol overdose patients in Loghman Hakim Hospital, Tehran, Iran.

Tramadol is a synthetic and centrally active analgesic. Hypoglycemia as another possible major side effect among abusers has not been known well. Our objective is evaluation of the Blood Glucose Level (BGL) among tramadol-overdosed patients. This prospective cross-sectional study was performed from Feb to June 2013; BGL was measured at the time of admission, 8 and 12 hours later. All patients with hypoglycemia received infusion of 0.5-1 gr/kg of hypertonic dextrose and their BGL was checked every hour until normal BGL. Patients' demographic, clinical and paraclinical data were collected. Totally, 128 patients with a mean (SD) age of 24.5 (6.9) years were recruited; 127 (99.2%) were male. Seizure occurred in 59.4% cases. Mean ± SD admission BGL was 94.88 ± 21.5mg/dL. Fourteen patients experienced hypoglycemia within 12 hours period. Hyperglycemia was experienced in 8 patients (6.25%) on admission day. There was no significant relation between the dose of tramadol and BGL. In conclusion, hypoglycemia must be considered as an important side effect of tramadol-overdose. It is suggested that serial BGL monitoring in cases of Tramadol-overdose should be done for early recognition of hypoglycemia and its timely management. Also hyperglycemia may be revealed.

VAP or poisoning; which one has more effect on patients' outcomes in toxicological ICU?

BACKGROUND: Ventilator-associated pneumonia (VAP) is the main cause of acquired infections in ICUs. Every year, millions of people suffer from poisoning by various substances. Our aim was to determine the association between VAP incidence and different kinds of toxicity among Toxicological ICU (TICU) patients.  MATERIALS AND METHODS: Poisoned patients with diagnosis of VAP were enrolled to our retrospective study at TICU of Loghman Hakim Hospital. Data was collected through the medical records. The statistical analysis was performed with SPSS (version 16, Chicago, IL, USA). RESULTS: Among 675 patients with MV > 48 h, 150 patients had the diagnosis of VAP.  Mean age was 36.6 years. 74.7% were males. Intentional poisoning was 70.3%. The incidence of VAP was 22%. The higher incidence of VAP was recorded in anti depressants and opioid toxicities. The majority of bacterial isolates (81.3%) were multi drug resistance. MRSA accounted for 50.7% of VAP cases. Non survivors' hospital length of stay (mean = 18.7days) was significantly higher than survivors (12.8). The hospital length of stay in VAP patients was highest in the Acinetobacter spp (mean > 20 days). Mortality rate of VAP cases was 18.6%. CONCLUSION: No specific association was detected between incidence of VAP and different kinds of toxicity, while Anti Depressants and opioids had high VAP incidence, in a Quarter of this population. It is noticeable that pesticide had the lowest incidence for its short hospitalization. In our TICU, MRSA and Acinetobacter spp were the main agents leading to VAP and prolonged ICU stay, respectively. (www.actabiomedica.it).

Multidrug-resistant Acinetobacter baumannii infection in intensive care unit patients in a hospital with building construction: is there an association?

BACKGROUND: Acinetobacter baumannii (A. baumannii) has emerged globally as a significant pathogen in hospitals. It is also present in soil and water. In a previous study, we discovered that the A. baumannii class 2 integron occurred most frequently. Here, we determined whether the A. baumannii class 2 integron is in the soil around our hospital, and if the soil is the cause for increasing numbers of A. baumannii infections in our intensive care unit (ICU) patients. METHODS: This cross-sectional prospective study was conducted in two ICUs at Loghman-Hakim Hospital, Tehran, Iran, from November 2012 to March 2013. Patient, soil, and hospital environment samples were collected. All isolates were identified using standard bacteriologic and biochemical methods. The phenotypes and genotypes were characterized. The standard disc diffusion method was utilized to test antimicrobial susceptibility. Integron identification was performed by multiplex polymerase chain reaction. RESULTS: A total of 42 A. baumannii clinical strains were isolated, all from patient samples; 65% of the isolated species were classified as class 2 integrons. The strains were 100% resistant to piperacillin, piperacillin-tazobactam, ceftazidime, ceftriaxone, cotrimoxazole, cefepime, ceropenem, and cefotaxime. However, all of the strains were sensitive to polymyxin B. A. baumannii was detected around the lip of one patient. CONCLUSIONS: Further research is necessary to establish a relationship between A. baumannii and soil, (especially in regards to its bioremediation), as well as to determine its importance in nosocomial infections and outbreaks in the ICU.

Teicoplanin as an anti-methicillin resistant Staphylococcus aureus agent in infections of severely poisoned intensive care unit patients/ Tehran- Iran.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia is related to high morbidity and mortality. Glycopeptide antibiotic is the choice of treatment in MRSA infections. Teicoplanin is a semi synthetic glycopeptide antibiotic with a spectrum of activity similar to vancomycin.  Our objective is the evaluation of efficacy and safety of Teicoplanin in MRSA infections among severely poisoned intensive care unit (ICU) patients. METHOD: During a 6 months period, in a prospective cross sectional study 54 eligible patients from 80 clinically suspicious with MRSA infections were recruited. The efficacy and safety of Teicoplanin was evaluated 5 times. The clinical findings, laboratory data, and bacteriologic responses were defined as cure, improvement and failure. RESULTS: The mean age of the patients was 36.3 years (range, 20-72, SD = 13.3). 75.9% were male. Suicidal attempts were recorded in 63%. The most common poisoning was TCAs, BZDs, tramadol and opium. 94.4% were unconscious and under mechanical ventilation. Tracheal cultures were positive in 98.1% by VAP diagnosis. Length of stay in the ICU was between  4-54 days. Total clinical effectiveness was 90.4%, and failure 9.6%. Mortality rate of the patient, was 9/54 (16.6 %) which 3 of them were for lack of a clinical response. On the fourth visit, the adverse effects included: rash (11.10%), anemia (36.17%), nephrotoxicity (17.02%) and thrombocytopenia < 150000 (100%). Other side effects such as: leucopenia, severe thrombocytopenia (< 50000), pancytopenia and red man syndrome were not detected. CONCLUSIONS: Teicoplanin is suggestible for MRSA infections among severely poisoned patients according to its efficacy, safety, half life and tolerance.

Suicide epidemiology and characteristics among young Iranians at poison ward, Loghman-Hakim Hospital (1997-2007).

BACKGROUND: Suicide is a critical public health problem. In developing countries, the highest suicide rate is found in young adults with remarkable increasing rate. In this study, we have evaluated the epidemiology and characteristics of 8-16-year-old individuals who attempted suicideand were hospitalized in Loghman-Hakim Hospital, Tehran, Iran from 1997 to 2007. METHODS: A total of 6414 hospitalized patients, ages 8-16, who attempted suicide and were residents of Loghman-Hakim Hospital were investigated. We performed a retrospective chart review to study the characteristics of cases in a 10-year period by review of psychiatric and medical records. RESULTS: Out of 6414 patients, 22.6% were males, 5978 patients were 12-16 years old and the rest were aged 8-12 years. During the 10-year period, suicides showed a rising trend among adults, while in children no significant increase was detected. Communicative disorders were the most common underlying risk factors, particularly in females. One patient out of five cases had psychiatric disorders, of which adjustment disorders were the most predominant. A remarkable peak in suicides was observed in May and July, while winter had the highest suicide rate among seasons. CONCLUSIONS: Suicide due to drug overdose is higher in females than males in young population. This increasing trend is a psychiatric concern and should be resolved by improving mental and public health.

A survey on microorganisms and their sensitivity by E-test in ventilator-associated pneumonia at Toxicological-Intensive Care Unit of Loghman-Hakim Hospital.

INTRODUCTION: Ventilator associated pneumonia (VAP) is the most common nosocomial infection at ICUs, with high mortality and morbidity. The diagnostic method for VAP is based on the combination of clinical, radiological, and microbiological criteria. Lower respiratory tract culture results are useful to confirm the etiology of VAP and adjusted antibiotics. Endotracheal aspiration (EA) is the simplest noninvasive technique for performing lower respiratory tract culture, with high sensitivity and moderately high specificity. The aim of this survey was to evaluate the quantitative cultures of endotracheal aspirates in VAP patients and the sensitivity patterns of microorganisms through E-test. METHOD: Among 582 ICU admitted patients who were under mechanical ventilation for more than 48 hours, 72 suspected patients of VAP were prospectively evaluated during a 10 month period. Evaluation of our ICU standards by APACHE III scoring, and GCS were carried out on the first day of admission in all patients. Quantitative cultures of EA were performed on all 72 patients. Antibiotic resistance pattern of isolated pathogens was defined by E-test. RESULTS: VAP was confirmed in 46 out of 72 cases (50, 69.4% males and 22, 30.6% females - mean age was 33 +/- 12 years) through quantitative cultures of EA samples. The probable incidence of VAP was 7.9% (per ventilated patients > or = 48 hours). The mean APACHE III score was 31.28 +/- 16. GCS in most of the patients was between 8 and 12. Staphylococcus aureus was the most frequently isolated organism (58.7%), with high sensitivity to Amikacin, Ciprofloxacin, and Teicoplanin (>92%); Pseudomonas aeruginosa was the second most frequent organism (17.4 percent); Acinetobacter isolates were potentially drug resistant, and only Amikacin was effective. CONCLUSION: Tracheal aspirates in combination with clinical findings show important roles in the management of VAP and decrease inappropriate antimicrobial therapy. S. aureus is the main agent leading to VAP in the TICU of the Loghman Hakim Hospital.

Gastrointestinal and urinary tract bleeding in methanol toxicity.

Methanol is a clear, colourless liquid with a smell and taste similar to ethanol. Intoxications with methanol are still frequent in large parts of the developing world. Haemodialysis should be done in cases of severe toxicity to eliminate toxic metabolites. In this case report, we describe a 37-year-old chronic alcohol abuser with methanol poisoning, who developed haematuria and upper gastrointestinal (GI) bleeding after haemodialysis. The upper GI endoscopic findings showed only low grade oesophageal ulceration. Haematuria and upper GI bleeding in our patient might also have cause by the effect of heparinisation during haemodialysis.