Ingestion of corrosive substances and the endoscopic role in assessing the severity of caustic injury.

Introduction: The ingestion of caustic substances into the upper gastrointestinal tract is an unusual but potentially life-threatening problem. Aim: To evaluate the most commonly ingested corrosive substances, and the endoscopic findings, complications, and final outcomes of caustic intake. Material and methods: This cross-sectional study included 220 inpatient participants with corrosive poisonings during a 3-year period (2017-2019). Data from the national patient electronic system "My term" and from the "Poisoning information centre" at the University Clinic for Toxicology, Skopje were used. Demographic characteristics, type of corrosive substance, endoscopic findings by Kikendall classification, emerging complications, fatal outcome, and hospitalization were analysed. Data obtained were analysed with the SPSS software package, version 22.0 for Windows. Results: During the period 2017-2019, out of 220 hospitalized cases with corrosive substance intake, 132 (60%) were with ingestion of acids, 19 (8.6%) with bases, 32 (14.6%) with bleaches, and 37 (16.8%) with other household products (p = 0.3469). The mean age of patients was 49.89 ±19.86 years. The most severe endoscopy findings (high-grade injury) were significantly more often associated with acid and base ingestion (p = 0.00001). Out of all strictures, 25 (64.1%) were on one location (either oesophagus or stomach), and 12 (30.8%) were on 2 locations. Conclusions: Upper gastrointestinal endoscopy is very important procedure for rapid assessment of severity of caustic injury, early appropriate therapy, as well as the potential development of strictures. The obtained data are very important for the development of a national program for the prevention of corrosive poisoning in our country.

Comparison of rhabdomyolysis in acutely intoxicated patients with psychotropic and chemical substances.

INTRODUCTION: Rhabdomyolysis is characterized by a muscle injury that leads to the release of intracellular muscle contents/constituents into the systemic circulation.

Acute severe poisoning with disinfectant in senior aged patient-case report and overview of literature considering age influence on treatment decision in alcohol-based intoxications.

We present our experiences in the first case of severe suicidal poisoning with 70% ethanol-disinfectant in North Macedonia, in an elderly patient with immunocompromising comorbidities. A 66-year-old unconscious woman was admitted at our clinic, with a history of seropositive rheumatoid arthritis treated with methotrexate. She was in a coma, without signs of serotonin syndrome, recurrent episodes of cardio-respiratory insufficiency under supportive treatment without invasive ventilation, metabolic acidosis, increased D-dimer 3254 ng/mL. The toxicology screening confirmed low benzodiazepines levels and alcoholaemia of 526 mg/dL (5.26 g/L), due to ingestion of 70% ethanol. Considering the decreased biotransformation in the elderly, immunocompromising comorbidities, reports of fatal outcome in poisoned elderly patients with disinfectants under standard fluids supportive protocol, haemodialysis was initiated, with registered associated hypercoagulability which resulted in complete stabilization after 48 h of admission. Treatment protocols of poisoning with ethanol-based disinfectant in the elderly should consider timely performing haemodialysis at lower alcoholaemia levels than recommended.

Unintentional Opioid Overdoses Treated at University Clinic of Toxicology-Skopje in a Nine-Year-Period.

BACKGROUND: The aim of this study was to assess the epidemiological profile of unintentional opioid overdoses, the prevalence and number of psychotropic substances involved in opioid overdoses. METHODS: This was a descriptive study, in which 180 participants were enrolled, and covered a nine-years-period. For collecting data was used the National patient electronic system "My term". The variables as gender, age, duration of opioid dependence, number of overdoses, type of substance, number of antidote ampoules, duration of hospitalization were analyzed. Severity of poisoning was made by using the Poison severity score. RESULTS: Opioid overdose cases were significantly higher among males than females. Mean age with standard deviation (SD) was 32.23 ± 6.71 years. Mean years (±SD) of duration of opioid use disorder was 11.60 ± 5.89 years. The most commonly used primary substance was methadone in 68.89% and heroin in 31.11% cases. Twenty patients were treated with mechanical ventilation because of the severe respiratory depression. Poison severity score was moderate in 51.11%, severe in 45.56% and fatal in 3.33% of the cases. CONCLUSION: Most of the cases, predominantly males used one or two substances. The combination of methadone and benzodiazepine was most frequently used and the most common way was by injecting the abused substances. In most of the subjects PSS score was moderate and severe with no differences between genders.

Non-Opioid Substances Acute Poisonings with Suicidal Intent in Patients with Opioid Use Disorder.

INTRODUCTION: Several epidemiological studies have evaluated the role of illicit drug use in suicide behaviour. AIM: To assess patients with opioid use disorder and suicidal intent related to behavior, severity of acute poisoning and the most commonly used non-opioid substances. MATERIALS AND METHODS: This cross sectional study included 67 patients diagnosed with opioid use disorder. The study was conducted at the University Clinic of Toxicology in Skopje over a 5-year period (2013-2017). The following variables were examined: gender, age, duration and route of opioid administration, duration of hospitalization, and types of substances used in acute poisoning. Assessment of patients' behavior and severity of poisoning was made by using the Suicide Behaviours Questionnaire-Revised and the Poison severity score. RESULTS: The majority of patients were male (88.1%). The mean age of patients was 30±6.1 years. The average duration of opioid use disorder was 8.5±3.9. A single poisoning was found in 62.7%, double poisoning in 25.4%, and triple poisoning in 11.9% of participants. Benzodiazepines were most commonly used by the patients (55.2%). The largest number of patients (32.8%) had minor Poison severity score (PSS), and only 17.9% had severe PSS. None of the patients had a fatal suicide attempt. 86.6% of patients had a score of ≥7 indicating a high risk of repeat suicide attempts. CONCLUSION: Benzodiazepines were most commonly used as a single or combined substance in patients with opioid use disorder. PSS indicated that most of the participants were with minor PSS and with high risk of a repeat suicide attempt.

Pulmonary thrombosis in acute organophosphate poisoning-Case report and literature overview of prothrombotic preconditioning in organophosphate toxicity.

OBJECTIVE: Acute organophosphate (OP) poisonings are presented with acetylcholine-receptor overstimulation. There have been a few case reports of thrombotic complications in acute OP poisonings, as well as prolonged thrombosis preconditions in patients who survived this type of intoxications. The paper presents a case with pulmonary thrombosis (PT) that develops in the subacute phase of intentional acute OP poisoning, treated only with atropine, as well as a literature overview of OP-induced prothrombotic toxicity. CASE REPORT: A middle aged woman was brought to the hospital after ingestion of unknown insecticide with suicidal intentions. She had a history of HTA (arterial hypertension), hyperlipidemia and untreated depression. The clinical features of poisoning were miosis, vomiting, dizziness, abdominal cramps and diarrhea. Soon after admission, she developed difficulties in breathing with decrease of serum pseudocholinesterase (2590...1769...1644...800 U/l), bibasal pulmonary crackles, drop of SpO2 to 84%. Antidote treatment included carbo medicinalis, atropine, and diazepam, without use of oximes. The seventh day pseudocholinesterase, the levels started to rise but the patient's hyposaturation (SpO2 86-88%) persisted. Chest ultrasound detected hypoechoic subpleural lesion to the right. Haemostatic tests showed increased D-Dimmer (2312 ng/ml) with hypercoagulability. The CT pulmonary angiography confirmed PT and after the administration of low molecular heparin, her clinical condition improved. CONCLUSION: Acute organophosphate poisoning treated with atropine showed a potential for inducing prothrombotic coagulation abnormalities, presented with PT. This life-threatening complication may additionally contribute to prolonged morbidity and mortality in OP poisonings, especially in patients with medical history of comorbidites.

Influence of Duration of Heroin Dependence on Humoral Immunologic Indicators.

OBJECTIVE: The incidence of autoantibodies may be associated with the duration of drug use. In this study, we assessed the association between the duration of heroin dependence and various humoral immunologic indicators, including IgA, IgG, IgM, complement component 3, complement component 4, rheumatoid factor, anti-ß2-glycoprotein 1 (IgA, IgG, IgM), antinuclear antibody, circulating immune complexes, and cryoglobulins. METHODS: A total of 363 patients with heroin dependence were enrolled in this cross-sectional and prospective study over a 3.5-year period. Depending on the duration of heroin use, participants were divided into 3 groups: up to 3 years, 4 to 7 years, and more than 7 years of heroin dependence. All patients were analyzed for the indicators. RESULTS: There was a significant difference between the duration of heroin dependence and increased concentration of IgA (P = 0.0000), IgG (P = 0.0000), IgM (P = 0.0001), complement component 3 (P = 0.042), rheumatoid factor (P = 0.0001), anti-ß2-glycoprotein 1 (IgA, P = 0.0098; IgG, P = 0.0000; IgM, P = 0.0000), the presence of antinuclear antibody (P = 0.01) and cryoglobulins (P = 0.0000), and decreased concentration of complement component 4 (P = 0.002). There was no significant difference in circulating immune complex concentration (P = 0.097). CONCLUSIONS: A longer duration of heroin dependence was associated with increased concentrations of IgA, IgG, IgM, complement component 3, rheumatoid factor, anti-ß2-glycoprotein 1 (IgA, IgG, IgM), presence of antinuclear antibodies and cryoglobulins, and decreased concentrations of complement component 4, but there was no influence on circulating immune complex values.

Heroin dependence duration influences the metabolic parameters: mechanisms and consequences of impaired insulin sensitivity in hepatitis C virus seronegative heroin dependents.

OBJECTIVE: Carbohydrate metabolism disorder in heroin dependence is an issue with long history and contradicting results. The aim of the study was to evaluate basal insulin sensitivity in hepatitis C virus seronegative heroin dependents with normal body mass index, taking into consideration the duration of heroin dependence. METHOD: 78 heroin dependents and 32 healthy controls were enrolled in the cross-sectional, prospective study. The dependents were observed in 2 groups: group 1 with dependence duration less than or equal to 3 years and group 2 with more than 3 years. Homeostasis Model Assessment for Insulin Resistance (HOMA-IR) and ß-cell function (HOMA-B%) were used to define basal glucose-insulin homeostasis. RESULTS: The group with longer dependence duration had HOMA-IR (2.23 ± 3.15) significantly higher compared with the control group (1.23 ± 0.53, P = 0.016) but lower compared with the group with the shorter dependence duration (2.65 ± 2.66, P = 0.024), after adjustment for HOMA-B%, waist circumference, and aspartate aminotransferase. The decrease in HOMA-IR during prolonged heroin addiction was significantly associated with the reduced ß-cell function (P < 0.001) and waist circumference (P = 0.004). CONCLUSIONS: Heroin dependence is associated with increased insulin resistance in hepatitis C virus seronegative heroin dependents. Prolonged heroin use is associated with reduction of basal ß-cell pancreatic function with decreased insulin resistance controlled for waist circumference, but still inducing significantly decreased basal insulin sensitivity.

Program of the university clinic of toxicology, skopje, republic of macedonia in treatment of drug addiction (buprenorfin treatment protocol).

The program of our Clinic includes, not only treatment of acute intoxication with opioids and other drugs, but also comprehends clinical investigations and treatment of the somatic complications of this population. For the first time in our country our Clinic offers to this population the alternative way of treatment with Buprenorfin. The Clinic started with this protocol on August 1, 2009. During a period of two years, the treatment with Buprenorfine has been initiated in 353 patients, of which 211 regularly attend the medical check ups. This model is used according to the national clinical guidelines and procedures for the use of buprenorfine in the treatment of opioid dependence The dose of this medicament depends on the evolution of the withdrawal symptoms. We have used the objective and subjective opioid withdrawal scale for the observation of these symptoms (OOWS ; SOWS - Handelsman et al 1987). This protocol starts with a complete clinical investigations, (i.e. where all patients undergo the inclusion and exclusion criteria with a written consent). Afterwards, the patients are hospitalized and start with a Buprenorfin teratment. After period of 7-10 days hospitalization they come to our Clinic, like outpatients for a regular controls. We have precise evidence for every patient who comes for control (e.g. medical record with all biochemical and toxicological screenings). All patients are recommended a tight cooperation with psychiatrists who are specialized to treat the problematic drug addictions.