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.

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.

Respiratory complications from acute corrosive poisonings in adults.

INTRODUCTION: Acute corrosive poisonings are caused by ingestion of corrosive chemicals which are most commonly used as household agents. Intoxications with these kind of agents produce numerous and severe post-corrosive complications of the upper gastrointestinal tract. On the other hand, our experience showed that corrosive agents may also cause injuries of the respiratory system, which makes the treatment very hard and additionally complicates the severe clinical condition of the patient. OBJECTIVE: The aim of the study is to show the incidence of respiratory complications in acute corrosive poisonings, the need of various clinical investigations and also the treatment and final outcome of these kind of poisoning. METHODS: We retrospectively analyzed clinical records of 415 patients hospitalized and treated at the University clinic for toxicology and urgent internal medicine, in Skopje, Republic of Macedonia, in the period between 2007 and 2011. The protocol consisted of methods for analyzing the systemic complications, with an accent on the post-corrosive respiratory complications. RESULTS: From the total number of patients even 98 (23.61%) exhibited systemic complications, from which 51 (52.04%) are respiratory complications. The majority of patients are female (n=40, 78.43%) and the most common complication is pneumonia (n=47). The youngest patient in this study was 14 and the oldest was 87 years old. CONCLUSION: Besides the gastrointestinal complications in the acute corrosive poisonings respiratory complications are also very often. They complicate the clinical state of patient and very often lead to fatal endings.

Severe renal function impairment in adult patients acutely poisoned with concentrated acetic acid.

Acetic acid is a widely used organic acid with corrosive properties that depend on its concentration. If acetic acid is ingested in concentrations above 30 % it may severely damage the upper gastrointestinal tract and cause intravascular haemolysis, which can result in severe kidney and liver disorders and disseminated intravascular coagulation. In this retrospective study, we analysed acetic acid ingestion data collected at the University Clinic for Toxicology of Skopje, Macedonia from 1 January 2002 to 31 December 2011. The analysis included systemic complications, kidney damage, and the outcomes in particular. Over the ten years, 84 patients were reported at the Clinic to have ingested highly concentrated acetic acid. Twenty-eight developed kidney disorders, while the remaining 56 had no complications. Fatal outcome was reported for 11 patients, seven of whom had systemic complications and four severe gastrointestinal complications.

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.

Corrosive poisonings in adults.

Ingestion of corrosive substances may cause severe to serious injuries of the upper gastrointestinal tract and the poisoning can even result in death. Acute corrosive intoxications pose a major problem in clinical toxicology since the most commonly affected population are the young with psychic disorders, suicidal intent and alcohol addiction. The golden standard for determination of the grade and extent of the lesion is esophagogastroduodenoscopy performed in the first 12-24 hours following corrosive ingestion. The most common late complications are esophageal stenosis, gastric stenosis of the antrum and pyloris, and rarely carcinoma of the upper gastrointestinal tract. Treatment of the acute corrosive intoxications include: neutralization of corrosive agents, antibiotics, anti-secretory therapy, nutritional support, collagen synthesis inhibitors, esophageal dilation and stent placement, and surgery.

Plasma apo/lipoproteins disturbances as a precondition for metabolic syndrome in HCV seronegative heroin addicts.

BACKGROUND: Dyslipidemia in heroin addicts is considered to be a precondition for developing metabolic syndrome. OBJECTIVES: The aim was to evaluate the frequency in serum lipid disturbances of hepatitis C virus (HCV) seronegative heroin addicts; the capacity of high-density lipoprotein (HDL)-C and apolipoprotein B (apoB)/apolipoprotein A-I (apoA-I) for predicting hypertriglyceridemia/low HDL-C profile; correlation of HDL-C with the apoB/apoA-I and their correlation to plasma apo/lipoproteins. MATERIALS AND METHODS: Sixty-six heroin addicts, seronegative for HCV and HIV, without liver morphological changes were divided into two groups according to their decreased/normal HDL-C concentrations. RESULTS: We registered decreased HDL-C in 58.8% of the addicts; decreased apoA-I in 50.9%, increased triglyceride (TGL) in 35.9%, and increased apoB/apoA-I in 3.8% of the patients; and 25.7% had hypertriglyceridemia/low HDL profile. Addicts with low HDL-C had higher TGL (1.73 ± .91 vs. 1.31 ± .71, pр = .02) compared with addicts with normal HDL-C and the controls. Low HDL-C group had higher apoB/apoA-I compared with addicts with normal HDL-C (.62 ± .28 vs. .42 ± .11, pр = .000). HDL-C inversely correlated to apoB/apoA-I (p = -.452, pр = .001). ApoB/apoA-I showed stronger correlation with the observed apo/lipoproteins than the HDL-C. The logistic regression model showed that apoB/apoA-I index (OR 89.1, 95% CI 1.3-5971.2) is more significant predictor in developing hypertriglyceridemia/low HDL profile than HDL-C. CONCLUSION: Heroin addiction is associated with decreased plasma concentrations of HDL-C, apoA-I, apoB, and increased TGL concentrations. In heroin addicts, HDL-C concentrations are significantly associated with the apoB/apoA-I index, which correlates to all lipid fractions and is a stronger predictor of metabolic syndrome lipid profile in heroin addicts.

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.