Evaluation of mitochondrial dysfunction due to oxidative stress in therapeutic, toxic and lethal concentrations of tramadol.

Tramadol (TR) is a centrally acting analgesic drug that is used to relieve pain. The therapeutic (0.1-0.8 mg/l), toxic (1-2 mg/l) and lethal (>2 mg/l) ranges were reported for TR. The present study was designed to evaluate which doses of TR can induce liver mitochondrial toxicity. Mitochondria were isolated from the five rats' liver and were incubated with therapeutic to lethal concentrations (1.7-600 µM) of TR. Biomarkers of oxidative stress including: reactive oxygen species (ROS), lipid peroxidation (LPO), protein carbonyl content, glutathione (GSH) content, mitochondrial function, mitochondrial membrane potential (MMP) and mitochondrial swelling were assessed. Our results showed that ROS and LPO at 100 µM and protein carbonylation at 600 µM concentrations of TR were significantly increased. GSH was decreased specifically at 600 µM concentration. Mitochondrial function, MMP and mitochondrial swelling decreased in isolated rat liver mitochondria after exposure to 100 and 300 µM, respectively. This study suggested that TR at therapeutic and toxic levels by single exposure could not induce mitochondrial toxicity. But, in lethal concentration (≥100 µM), TR induced oxidative damage and mitochondria dysfunction. This study suggested that ROS overproduction by increasing of TR concentration induced mitochondrial dysfunction and caused mitochondrial damage via Complex II and membrane permeability transition pores disorders, MMP collapse and mitochondria swelling.

Pattern of Suicide Methods and Postmortem Toxicological Findings in Suicide-Related Deaths: A Retrospective 7-Year Forensic-Based Study in Iran.

ABSTRACT: Suicide is a public health threat that leads to morbidity and mortality worldwide. In this study, we evaluated postmortem toxicological finding among forensic autopsies on suicidal deaths from 2010 to 2016 at the Legal Medicine Center of Zanjan Province (northwest of Iran). All suicide fatal cases were investigated to define the cause and manner of death. Toxicological analyses were performed using thin-layer chromatography, high-performance liquid chromatography, gas chromatography/mass spectrometry, headspace gas chromatography, and gas chromatography equipped with nitrogen phosphorus detector. Demographic data (age, sex, educational level, residential location, and marital status), cause of death, and postmortem toxicological findings were extracted from forensic reports and were entered into the designed questioners. During this period, a total of 181 cases of suicide deaths were investigated. Among them, 74% were male. The most often used suicide method was hanging, followed by self-poisoning in young people. Aluminum phosphide was the most frequent poison detected in the fatal suicidal cases (33 cases), followed by opioids. Hanging and self-poisoning were the frequent suicidal method in young male population. It seems that psychological and social supports in young people along with restriction to easy access to drugs and poisons should be considered by policy making and healthcare authorities.

Experimental central composite design-based dispersive liquid-liquid microextraction for HPLC-DAD determination of diazinon in human urine samples: method development and validation.

Diazinon poisoning is an important issue in occupational, clinical, and forensic toxicology. While sensitive and specific enough to analyse diazinon in biological samples, current methods are time-consuming and too expensive for routine analysis. The aim of this study was therefore to design and validate a simple dispersive liquid-liquid microextraction (DLLME) for the preparation of urine samples to be analysed for diazinon with high performance liquid chromatography with diode-array detector (HPLC-DAD) to establish diazinon exposure and poisoning. To do that, we first identified critical parameters (type and volume of extraction and disperser solvents, pH, surfactant, and salt concentrations) in preliminary experiments and then used central composite design to determine the best experimental conditions for DLLME-HPLC-DAD. For DLLME they were 800 µL of methanol (disperser solvent) and 310 µL of toluene (extraction solvent) injected to the urine sample rapidly via a syringe. The sample was injected into a HPLC-DAD (C18 column, 250×4.6 mm, 5 µm), and the mobile phase was a mixture of acetonitrile and buffer (63:37 v/v, pH 3.2; flow rate: 1 mL/ min). Standard calibration curves for diazinon were linear with the concentration range of 0.5-4 µg/mL, yielding a regression equation Y=0.254X+0.006 with a correlation coefficient of 0.993. The limit of detection and limit of quantification for diazinon were 0.15 µg/mL and 0.45 µg/mL, respectively. The proposed method was accurate, precise, sensitive, and linear over a wide range of diazinon concentrations in urine samples. This method can be employed for diazinon analysis in routine clinical and forensic toxicology settings.

The effects of amiodarone prophylaxis on cardiac dysrhythmia in acute aluminium phosphide poisoning.

Cardiovascular toxicity is the most common cause of fatality in the first 24 hours of poisoning with aluminium phosphide (AlP). Most often manifesting itself in cardiac dysrhythmias. The aim of this study was to evaluate the benefits of amiodarone prophylaxis against cardiac dysrhythmia in 46 patients with acute AlP poisoning. They were divided in two groups of 23: one receiving amiodarone and the other not (control). The treatment group received amiodarone prophylaxis in the initial intravenous bolus dose of 150 mg, followed by a drip of 1 mg/min for six hours and then of 0.5 mg/min for eighteen hours. Both groups were Holter-monitored for 24 hours since admission. Save for amiodarone, both groups received the same standard treatment. Amiodarone had a significant beneficial effect in reducing the frequency of ST-segment elevation and ventricular fibrillation plus atrial fibrillation (P=0.02 and P=0.01, respectively), but the groups did not differ significantly in mortality (9 vs 11 patients, respectively). The mean time between ICU admission and death (survival time) was significantly longer in the treatment group (22 vs 10 h, respectively; P=0.03). Regardless its obvious limitations, our study suggests that even though amiodarone alone did not reduce mortality, it may provide enough time for antioxidant therapy to tip the balance in favour of survival and we therefore advocate its prophylactic use within the first 24 h of AlP poisoning.

Acute Lidocaine Toxicity; a Case Series.

INTRODUCTION: Parenteral form of lidocaine is the best-known source of lidocaine poisoning. This study aimed to evaluate the characteristics of acute lidocaine toxicity . METHODS: In this retrospective cross-sectional study, demographics, clinical presentation, laboratory findings, and outcome of patients intoxicated with lidocaine (based on ICD10 codes) admitted to Loghman Hakim Hospital, during April 2007 to March 2014 were analyzed. RESULTS: 30 cases with the mean age of 21.83 ± 6.57 year were studied (60% male). All subjects had used either 6.5% lidocaine spray or 2% topical formulations of lidocaine. The mean consumed dose of lidocaine was 465 ± 318.17 milligrams. The most frequent clinical presentations were nausea and vomiting (50%), seizure (33.3%), and loss of consciousness (16.7%). 22 (73.3%) cases had normal sinus rhythm, 4 (13.3%) bradycardia, 2 (6.7%) ventricular tachycardia, and 2 (6.7%) had left axis deviation. 11 (36.6%) cases were intubated and admitted to intensive care unit (ICU) for 6.91 ± 7.16 days. Three patients experienced status epilepticus that led to cardiac arrest, and death (all cases with suicidal intention). CONCLUSION: Based on the results of this study, most cases of topical lidocaine toxicity were among < 40-year-old patients with a male to female ratio of 1.2, with suicidal attempt in 90%, need for intensive care in 36.6%, and mortality rate of 10%.

Outbreak of Mushroom Poisoning in Iran: April-May, 2018.

From April 28 to May 28, 2018, more than 1200 patients with impression of mushroom poisoning were referred to hospital emergency departments in 13 west and northwestern provinces, Iran; 112 (8.9%) patients were hospitalized and 19 were expired (ie, a fatality rate of 1.5%). The outbreak began in Kermanshah province with increasing number of patients presenting with severe abdominal pain, nausea, vomiting, and diarrhea soon after consumption of wild mushrooms. Lepiota brunneioncarnata, Hypholoma fascicalare, and Coprinopsis atramentaria have been involved in this outbreak. To prevent similar outbreaks, raising public awareness about risky behaviors of collecting and consuming wild self-picked mushrooms is of paramount importance. Herein, we present our experience with this outbreak.

Predictive Factors of Mortality in Acute Amphetamine Type Stimulants Poisoning; a Review of 226 Cases.

INTRODUCTION: Amphetamine type stimulants (ATS) such as amphetamine and methamphetamine (MA) are one of the most important causes of poisoning in the world. In this study we aimed to define the predictive factors of mortality in acute ATS poisoning patients. METHODS: This is a retrospective cross-sectional study on all cases with acute ATS poisoning who were referred to a referral center for poisoning, Tehran, Iran, from April 2011 to March 2014. Using patients' medical records, demographic data, route of exposure, type and amount of ATS, the cause of poisoning, clinical presentations, and electrocardiogram (ECG) and laboratory findings, as well as patient's outcomes were collected and analyzed regarding the independent predictive factors of mortality. RESULTS: 226 cases with the mean age of 32.9 ± 10.9 years were studied (77% male). MA was the most abused ATS (97.4%) and the most frequent route of exposure was oral (55.3%). The mortality rate was 5.4%. There was a significant association between agitation (p = 0.002), seizure (p = 0.001), loss of consciousness (p < 0.001), creatine phosphokinase level (p = 0.002), serum pH (p = 0.002), serum HCO3 (p = 0.02), and PCO2 (p = 0.01) with mortality. However, serum HCO3 [OR=1.27 (95% CI: 1.07-1.50); p value=0.005], PCO2 [OR=0.89 (95% CI: 0.84-0.96); p value=0.002], and loss of consciousness [OR=0.019 (95% CI: 0.003-0.106); p value=0.000] were the only independent predictive factors of mortality. CONCLUSION: PCO2 ≥ 51 mmHg, serum bicarbonate ≤ 22.6 mEq/L, and loss of consciousness on admission could be considered as prognostic factors of mortality in acute ATS poisoning cases presenting to emergency department.

Lead Poisoning in Opium Abuser in Iran: A Systematic Review.

Substance abuse and its consequences are major health hazards in the world. Opium addiction is a common form of substance abuse in Iran. Adulteration of illegal substances in the process of production and distribution of the drug in black market with many types of materials have been reported. One of the main goals of the adulteration of illegal substances is cutting of the substance for deal and increase of the weight for more benefit. However, adding of adulterating agents to illegal drugs could be considered as a cause of nonspecific and rare toxicity during substance abuse. Although the presence of lead in street-level heroin, marijuana, and amphetamines has been reported from some countries previously, recently, several reports suggested lead poisoning in Iranian opium addicts. Adulteration of opium with lead is a new source of lead poisoning in Iran in which the opium abuse is frequent and it could be a new health problem in the future. In this regard, evaluation of blood lead level would be important for early diagnosis of lead poisoning in opium addicts.

Vitamin E as a novel therapy in the treatment of acute aluminum phosphide poisoning.

BACKGROUND/AIM: Aluminum phosphide (AlP) is commonly used as a fumigant in developing countries. Induction of oxidative stress is one of the most important mechanisms of its toxicity. In this regard, and considering that there is no specific antidote for its treatment, the aim of this study was to evaluate the effect of vitamin E in the treatment of acute AlP poisoning. MATERIALS AND METHODS: This was a clinical trial on acute AlP poisoned patients. All patients received supportive treatment. In addition, the treatment group received vitamin E (400 mg/BD/IM). Level of malondialdehyde (MDA) and total antioxidant capacity of plasma were measured. RESULTS: There was no significant difference between the treatment and control groups with regard to demographic, clinical, or paraclinical data or Simplified Acute Physiology Score II (SAPSII) on admission. Systolic blood pressure significantly increased during the first 24 h in the treatment group (P < 0.05). The plasma MDA level significantly decreased in the treatment group (P < 0.05). Vitamin E administration decreased the necessity (30% vs. 62%, P < 0.05) and duration of intubation and mechanical ventilation (P < 0.05). It significantly reduced the mortality rate in the treatment group compared to the control group (15% vs. 50%, respectively, P < 0.05). CONCLUSION: Vitamin E along with supportive treatment could have a therapeutic effect in acute AlP poisoning.

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.

Trend of blood lactate level in acute aluminum phosphide poisoning / 世界急诊医学杂志（英文）

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.

Simultaneous Determination of Six Benzodiazepines in Spiked Soft Drinks by High Performance Liquid Chromatography with Ultra Violet Detection (HPLC-UV).

A high performance liquid chromatographic method with ultra violet detection for simultaneous analysis of six benzodiazepines (BZDs) (chlordiazepoxide, diazepam, clonazepam, midazolam , flurazpam, and lorazepam) has been developed for forensic screening of adulterated non-alcoholic drinks. Samples were analyzed after a simple procedure for preparation using pH adjustment and filtering. Isocratic elution on a C18 column (250mm × 4.6 mm, 5µm) in the temperature 45ºC with a mobile phase consisting of 15mM phosphate buffer: methanol (50:50 v/v) at a flow rate 1.4 mL/min has been done. The column eluent was monitored with a UV detector at 245 nm. This allowed a rapid detection and identification as well as quantization of the eluting peaks. Calibration curves for all drugs in the range of 0.5- 10 µg/ mL that all the linear regression and has more than 0.996. Recovery rates for the BZDs were in the range 93.7- 108.7%. The limits of detection were calculated between 0.01- 0.02 µg/ mL. Also, the limits of quantification were 0.03- 0.05 µg/mL. Within-day and between -day coefficient of variation for all BZDs at all concentrations in the range of 0.45 - 7.69 % was calculated. The procedure can provide a simple, sensitive and fast method for the screening of six BZDs in adulterated soft drinks in forensic analysis.

Risk Factors for Mortality and Endotracheal Intubation after Methadone Intoxication.

This was a retrospective chart review to evaluate various risk factors associated with in-hospital mortality and intubation risk in acute methadone overdose. All patients admitted to an academic hospital in Tehran, Iran, during a 10-year period (2000-2009) constituted the study sample. Exclusion criteria were significant comorbidities and age under 18 years. Outcome variables were in-hospital mortality and being intubated during admission. A total of 802 patients were enrolled in the study. There were 15 (1.8%) deaths due to methadone overdose or its complications. The number of yearly admissions was 15 patients in 2000, 16 in 2001, 16 in 2002, 18 in 2003, 23 in 2004, 38 in 2005, 59 in 2006, 110 in 2007, 206 in 2008 and 301 in 2009. Based on logistic regression analysis, the most important independent variable predicting mortality was length of admission in toxicology ward [OR (95% CI): 1.6 (1.1-2.3)]. For the prediction of intubation, independent variables were Glasgow Coma Scale (GCS) score of 5-9 [OR (95% CI): 356.5 (9.8-12907.4)] in the emergency department (ED), miosis in the ED [356.9 (1.4-87872.5)] and respiratory rate in the ED [1.5 (1.1-2.1)]. Linear regression model for length of hospitalization showed patient age as the most important variable for prediction of this outcome. Despite a relatively low mortality rate, the increasing number of methadone-poisoned patients requires special attention to this common intoxication. Careful disposition of patients from ED to ordinary wards or intensive care units and also from higher to lower levels of care should be considered in methadone overdose.

Acute tramadol poisoning and its clinical and laboratory findings.

BACKGROUND: Tramadol is a centrally acting analgesic with opioid and nonopioid properties, which extensively used in the relief of mild to moderate pain. Tramadol poisoning is a common cause of acute pharmaceutical poisoning in Iran. There are a few studies about clinical and laboratory findings related to acute tramadol poisoning. Therefore, the aim of this study was to demonstrate the clinical and laboratory findings in tramadol acute poisoning cases. MATERIALS AND METHODS: This was a retrospective descriptive study of patients with acute tramadol poisoning who referred to Loghman Hakim Hospital Poison Center during January to April 2012. Data such as patient's age, sex, time of ingestion, ingested dose, cause of poisoning, mean duration of hospitalization, patient's clinical presentations, laboratory findings, therapeutic measures, and patient's outcome have collected in a predesigned checklist. RESULTS: A total of 144 patients including 111 men (77%) and 33 women (23%) with acute tramadol poisoning was included in this study. The mean ingested dose was 1971.2 mg (100-20000 mg). Seizure (47.91%) was the most frequent clinical symptom. Blood gas on admission showed pH (7.3 ± 0.1), PCO2 (49.7 ± 8.6 mmHg) and HCO3 (-) (24.1 ± 3.8 mEq/L), indicating pure acute respiratory acidosis may be occurred in tramadol-intoxicated patients. There were significant differences between tramadol-intoxicated cases with and without a seizure with regard to the time interval between ingestion and admission on hospital, ingested dose and PCO2. CONCLUSION: Seizure and rise of PCO2 were the most findings in this study.

Protective effects of N-acetylcysteine on aluminum phosphide-induced oxidative stress in acute human poisoning.

OBJECTIVE: Aluminum phosphide is used as a fumigant. It produces phosphine gas (PH3). PH3 is a mitochondrial poison which inhibits cytochrome c oxidase, it leads to generation of reactive oxygen species; so one of the most important suggested mechanisms for its toxicity is induction of oxidative stress. In this regard, it could be proposed that a drug like N-acetylcysteine (NAC) as an antioxidant would improve the tolerance of aluminum phosphide-intoxicated cases. The objective of this study was to evaluate the protective effects of NAC on acute aluminum phosphide poisoning. METHODS: This was a prospective, randomized, controlled open-label trial. All patients received the same supportive treatments. NAC treatment group also received NAC. The blood thiobarbituric acid reactive substances as a marker of lipid peroxidation and total antioxidant capacity of plasma were analyzed. RESULTS: Mean ingested dose of aluminum phosphide in NAC treatment and control groups was 4.8 ± 0.9 g vs. 5.4 ± 3.3 g, respectively (p = 0.41). Significant increase in plasma malonyldialdehyde level in control group was observed (139 ± 28.2 vs. 149.6 ± 35.2 µmol/L, p = 0.02). NAC infusion in NAC treatment group significantly decreased malondialdehyde level (195.7 ± 67.4 vs. 174.6 ± 48.9 µmol/L, p = 0.03), duration of hospitalization (2.7 ± 1.8 days vs. 8.5 ± 8.2 days, p = 0.02), rate of intubation and ventilation (45.4% vs. 73.3%, p = 0.04). Mortality rate in NAC treatment and control groups were 36% and 60%, respectively with odds ratio 2.6 (0.7-10.1, 95% CI). CONCLUSION: NAC may have a therapeutic effect in acute aluminum phosphide poisoning.

Role of clinical and paraclinical manifestations of methanol poisoning in outcome prediction.

BACKGROUND: Methanol poisoning is one of the most important poisoning due to drinking of illegal and non-standard alcoholic beverage in some countries. Relatively limited studies have been carried out to identify the prognostic factors in methanol poisoning. MATERIALS AND METHODS: We performed a retrospective study on acute methanol-intoxicated patients, which were admitted on the Loghman Hakim Hospital Poison Center (Tehran, Iran) over a 24-month period. The demographic data, clinical manifestations and paraclinical findings, therapeutic interventions and outcome (survivors with or without complications and non-survivors) were extracted. RESULTS: We evaluated 30 patients with methanol poisoning during 2 years. All of the patients were male; with the median age of 25.5 years. Visual disturbances, respiratory manifestations, and loss of consciousness were the most common clinical manifestations on admission time. The results of paraclinical manifestations on admission time were as following: The median of blood methanol level was 20 mg/dL. The median of pH, PaCO2 and HCO3 was 7.15, 22.35 mmHg and 7.2 mEq/L, respectively. Hyperglycemia was observed in 70% of the patients and the median of blood glucose was 184.5 mg/dL. In fourteen of the patients hemodialysis was performed. Median duration of hospitalization was 48 h. Nine of the patients died. There was a significant difference between survivors and non-survivors with regard to coma, blood methanol level, and PaCO2 and blood glucose. Furthermore, we did not observe a significant difference between these two groups regarding to pH, HCO3 level, and time interval between alcohol ingestion to hospital admission and beginning of hemodialysis. CONCLUSION: Regarding the results of this study, it can be suggested that coma, PaCO2 and hyperglycemia on admission time could be used as strong predictors of poor outcome.

Electrocardiographic findings and cardiac manifestations in acute aluminum phosphide poisoning.

Aluminium phosphide (AlP) poisoning has a high mortality due to cardiovascular involvement. In this study, we evaluated the frequency of cardiac manifestations and electrocardiographic (ECG) findings in 20 patients with acute AlP poisoning, who were admitted to the intensive care unit (ICU) in Tehran, Iran, over a period of 6 months (between October 2008 and April 2009). The sex, age, cause and manner of ingestion, number of ingested AlP tablets, cardiac and ECG manifestations, creatine phosphokinase (CPK), CPK-myocardial band (CPK-mb) and troponin-T (TnT) were extracted from the patients' files. All data were analysed with Statistical Package for the Social Sciences (SPSS) software. The majority (60%) of patients were male. The mean age was 27 ± 8.7 years. The mortality rate was 40%. In all of the patients, the cause of poisoning was intentional suicide and ingestion was the route of exposure. The mean number of ingested AlP tablets per patient was 2.2 ± 1.1. The average time interval between admission and cardiovascular manifestations or ECG findings was 168.8 ± 116.2 min. The range of systolic (SBP) and diastolic blood pressure was 60-130 mmHg and 40-70 mmHg, respectively. Dysrhythmia was observed in nine (45%) cases. Elevation of the ST segment was seen in nine cases (45%). Seven patients (35%) had prolonged QTc intervals. Bundle branch block (BBB) was observed in four (20%) patients. In nine (45%) patients, the serum cardiac TnT qualitative assay was positive. There were no significant differences between normal and abnormal ECG groups according to sex, age, number and manner of ingested AlP tablets and SBP. There was a significant correlation between cardiac manifestations and ECG findings and TnT-positive results with mortality in acute AlP poisoning.

Recurrent seizures in tramadol intoxication: implications for therapy based on 100 patients.

Tramadol is an atypical opioid analgesic used in the treatment of mild to moderate pain. Despite being a GABA(A) agonist, seizures are a prominent complication with its therapeutic use, abuse or overdose. For patients who have had a tramadol-induced seizure, the likelihood of recurrent seizures and the need for emergent anticonvulsant prophylaxis is unknown. However, treatment of patients with anticonvulsants prophylactically may cause adverse effects and increased morbidity in tramadol poisoning. We studied the outcome and frequency of recurrent seizures in tramadol-intoxicated patients in an attempt to determine the need for prophylactic anticonvulsant therapy. This was a retrospective cohort study of tramadol-intoxicated patients who had at least one seizure. Patients' age, sex, cause(s) of intoxication, route of poisoning, dose or number of capsules or tablets taken, vital signs, other signs or symptoms, numbers of seizures, length of stay, co-ingestions and past medical history were ascertained. Exactly 100 patients met the inclusion criteria. Eighty-two per cent were men, and 50% were between 21 and 30 years old. By our standard clinical protocol, none were treated with seizure prophylaxis after their first seizure. Only 7% had recurrent seizures and all patients recovered without sequelae. Because of the low risk of multiple seizures in tramadol poisoning and the lack of morbidity in patients who do seize, it appears to be unnecessary to administer prophylactic anticonvulsant therapy in patients with tramadol poisoning, even if they have an initial seizure.

Fatal aluminum phosphide poisoning in Tehran-Iran from 2007 to 2010.

BACKGROUND: Aluminum phosphide (AlP) is also known as "rice tablet" in Iran. Due to the high incidence of acute AlP poisoning and its associated mortality in Iran, the authorities banned AlP-containing tablets in 2007. The aim of this study is to evaluate the trend of acute fatal AlP poisoning subsequent to this restriction. MATERIALS AND METHODS: 0 This is a retrospective chart review of patients with acute "rice tablet" poisoning who were admitted to Loghman Hakim Hospital Poison Center, Tehran, Iran, from 2007 to 2010. Collected information included gender, age, type of poisoning, marital status, duration of hospitalization, and outcome. RESULTS: There were 956 cases with a mortality rate of 24.06%. The incidence of fatal AlP poisoning was 2.1 and 5.81 per one million populations of Tehran in 2007 and 2010, respectively. In 223 of the fatal cases (97%) and 697 of the non-fatal cases (96%), the poisoning was intentional. The male to female ratio in the fatal and non-fatal cases was 1.04:1 and 1:1.3, respectively. Most of the fatal cases (n = 122, 53%) were unmarried. The mean age was 27.32 ± 11.31 and 24.5 ± 8.19 years in fatal and non-fatal cases, respectively. In 196 (85.2%) of the fatal cases and in 577 (79%) of non-fatal cases, the duration of hospitalization was less than 24 hours and between 48-72 hours, respectively. CONCLUSION: The results of this study showed the incidence of "rice tablet" poisoning, and its mortality increased since 2007 in spite of the ban. It seems that legislative means alone without other interventions, such as suicide prevention and public education, will not always be able to control or prevent acute intentional poisonings.