Prognostic Factors in Acute Aluminium Phosphide Poisoning: A Risk-Prediction Nomogram Approach.

Aluminium phosphide (AlP) is a toxic agent associated with a high mortality rate following acute exposure from various routes. The aim of this study was to determine the clinical and laboratory findings useful for predicting the medical outcome of AlP-poisoned patients using established scoring systems. This is a prospective study of AlP-poisoned patients from 2010 to 2015 in Ardabil, Iran. All patients that presented with a confirmed diagnosis of acute AlP poisoning in the study interval were included in the study. Clinical and laboratory data, using Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score II (SAPS II) scoring systems, were compared for their predictive value in determining differences between survived and non-survived patients. Univariate analysis (Mann-Whitney or t-test), multiple logistic regression analysis, receiver operating characteristic (ROC) curve analysis and the Pearson correlation test were performed using STATA/SE 13.0 and the Nomolog Software. A total of 68 AlP-poisoned patients with confirmed acute AlP poisoning were included for evaluation. Of these, 36 were non-survived. Multiple logistic regression analysis was performed using parameters and values derived from patient clinical and laboratory data, and revealed that four factors were significant for predicting mortality: Glasgow coma score (GCS); systolic blood pressure (SBP); urinary output (UOP); and serum HCO3 . A four-variable, risk-prediction nomogram was developed for identifying high-risk patients and predicting the risk of mortality. Study results showed that SBP of <92.5 mmHg (p = 0.006); HCO3- < 12.9 mEq/L (p = 0.01), UOP < 1725 mL/day (p = 0.04); and GCS < 14.5 (p = 0.003) were significant predictors of AlP mortality. Scoring systems analysis showed SAPS II score >24.5, APACHE II score >8.5 and SOFA score >7.5 were predictive of non-survival patients. The results of our study showed that SBP, GCS, UOP and serum HCO3 levels are the best prognostic factors for predicting mortality in AlP-poisoned patients. According to the area under the ROC curve of the APACHE II score, when compared with SOFA and SAPS II scores, the APACHE II score can more effectively discriminate between non-survivors and survived patients.

Effectiveness of teaching cognitive-behavioral techniques on locus of control in hemodialysis patients.

BACKGROUND: Many of the cognitive behavioral models and therapeutic protocols developed so far for psychological disorders and chronic diseases have proved effective through clinical research. OBJECTIVE: This study aimed to determine the effectiveness of teaching cognitive-behavioral techniques on locus of control in hemodialysis patients. METHODS: This controlled clinical trial study was conducted in 2015 with 76 patients selected by census and treated with a hemodialysis machine in the dialysis department of Vali-Asr Hospital in the city of Meshkinshahr. A total of four patients were excluded because of their critical conditions while the rest, who were recruited, were randomly divided into two equal groups of 36 patients as the intervention and control groups. First, the locus of control was measured in both groups through a pretest, and cognitive-behavioral techniques were then taught to the intervention group during eight 45 to 90-minute sessions. The locus of control in patients of both groups was finally re-measured through a posttest. Data were collected using Rotter's Locus of Control Inventory. The Wilcoxon test and Mann-Whitney U test were respectively used in SPSS18 for data analysis. RESULTS: In the pretest and posttest stages respectively, 4.8% and 14.3% of samples in the control group as well as 14.3% and 33.3% of samples in the intervention group enjoyed internal locus of control. The difference between the pretest and posttest scores of internal locus of control in the intervention group was significant (p=0.004), which indicates the positive effect of cognitive-behavioral psychotherapeutic intervention on internalization of locus of control in this group. CONCLUSIONS: Given the external locus of control in most of the study patients and also the positive significant effect of cognitive-behavioral psychotherapy on internalization of locus of control in this group of patients, it appears necessary to have a psychology resident present in the hemodialysis department to teach the necessary cognitive-behavioral techniques to internalize the locus of control. TRIAL REGISTRATION: The trial was registered at the Thai Clinical Trial Registry (http://www.clinicaltrials.in.th) with the TCTID: TCTR20170707003. FUNDING: The authors received no financial support for the research, authorship, and/or publication of this article.

The Correlation of Serum Brain Natriuretic Peptide and Interleukin-6 with Quality of Life Using the Chronic Obstructive Pulmonary Disease Assessment Test.

OBJECTIVE: The aim of this study was to determine the levels of serum pro-brain natriuretic peptide (pro-BNP) and interleukin (IL)-6 in patients with stable chronic obstructive pulmonary disease (COPD) and to correlate these markers with health-related quality of life using the COPD assessment test (CAT). MATERIALS AND METHODS: Serum pro-BNP and IL-6 levels were measured in 82 patients with stable COPD. Serum pro-BNP and serum IL-6 levels, pulmonary function, and oxygen saturation (SpO2) were measured according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage and CAT score. Also, the associations of both pro-BNP and IL-6 with the clinical parameters of patients were tested. RESULTS: The serum levels of IL-6 (7.57 [5-11.16] pg/mL) and pro-BNP (120.55 [92.89-144.20] pg/mL) were higher with enhancing disease severity based on the GOLD classification (p = 0.034 and 0.068, respectively). Also, serum levels of pro-BNP (120.55 [89.50-147.90] pg/mL) and IL-6 (6.68 [4.40-11.97] pg/mL) were increased in patients with high CAT scores (p = 0.004 and 0.017, respectively). There was a significant positive correlation between plasma pro-BNP and IL-6 levels (r = 0.332, p = 0.002). CONCLUSION: The results demonstrated that with increased severity of obstruction based on the GOLD criteria both IL-6 and pro-BNP were elevated. This increase in inflammatory markers was associated with a reduced quality of life and the severity of hypoxia. These findings indicated that lowering IL-6 and pro-BNP could be useful in the management of COPD patients.

Main predictors for repetition of suicidal behaviour among women referred to a single public sector tertiary care hospital in Iran.

OBJECTIVE: To assess the main predictors for repetition of suicidal behaviour among women. METHODS: This cross-sectional study was conducted at Loghman Hakim Hospital, Tehran, Iran, in 2014, and comprised women patients. The patients were divided into two groups, i.e. women repeating suicide and women without repeating suicide. Data was collected through a checklist and then analysed with SPSS 20. RESULTS: Of the 300 women, 121(40.3%) repeated suicide and 179(59.7%) did not. The overall mean age was 26.9±9.1 years (range: 14-80 years). High prevalence of psychological drug usage, alcohol use, history of self-mutilation (self-harm), psychotic disturbances, sexual relationships, as well as smoking and opium addition was revealed as major factors in repeated suicidal behaviour in women when compared with other women. The result of multivariate logistic regression model showed two factors of self-mutilation (odds ratio =2.692, p=0.002) and underlying psychotic disorders (odds ratio = 2.780, p<0.001) as main predictors of suicide in women. In this regard, demographic characteristics could not predict repeating suicidal attempts (p>0.05). CONCLUSIONS: The presence of underlying psychotic disorders and self-mutilation were main predictors for repetition of suicidal behaviour.

Blood Lead Levels in Asymptomatic Opium Addict Patients; a Case Control Study.

INTRODUCTION: One of the newest non-occupational sources of lead contamination is drug addiction, which has recently been addressed as a major source of lead poisoning in some countries. The present study aimed to investigate the blood lead level (BLL) of asymptomatic opium addicts. METHODS: This case-control study was conducted during a one-year period to compare BLL of three groups consisting of opium addicts, patients under methadone maintenance therapy (MMT), and healthy individuals. RESULTS: 99 participants with the mean age of 55.43±12.83 years were studied in three groups of 33 cases (53.5% male). The mean lead level in opium addicts, MMT and control groups were 80.30 ± 6.03 µg/L, 67.94 ± 4.42 µg/L, and 57.30±4.77 µg/L, respectively (p=0.008). There was no significant difference in BLL between MMT and healthy individuals (p=0.433) and also between opium addicts and MMT individuals (p=0.271).Oral opium abusers had significantly higher lead levels (p = 0.036). There was a significant correlation between BLL and duration of drug abuse in opium addict cases (r=0.398, p=0.022). The odds ratio of having BLL ≥ 100 in oral opium users was 2.1 (95% CI: 0.92 - 4.61; p = 0.43). CONCLUSION: Based on the result of present study, when compared to healthy individuals, opium addicts, especially those who took substance orally had significantly higher levels of blood lead, and their odds of having BLL ≥ 100 was two times. Therefore, screening for BLL in opium addicts, particularly those with non-specific complaints, could be useful.

Epidemiological study of snakebites in Ardabil Province (Iran).

INTRODUCTION: Average annual incidence of snakebite worldwide is between 5.5 to 1.2 million, and at least 125,000 of them are fatal. In Iran, around 4,500-11,000 snakebites occur annually, and a small number of them are fatal. Snake bites can cause intoxity and immediate death in patients, and the aim of this study was to investigate the epidemiological study of snakebites in Ardabil Province. METHODS: This study was a cross-sectional that has been done on 67 snakebite patients who were admitted to the Imam Khomeini Hospital of Ardabil during 2008-2013. Information included: age and sex of victims, region of incidence, site of bite, hospitalized duration and symptoms. Data analyzed by descriptive statistical methods using SPSS version 19. RESULTS: There was significant difference between the two sexes (p=0.001). There was no significant difference between the mean age of male and female victims (p=0.68). Most of the victims were in the age group of 20-29 years (34.3%). All snakebites happened in rural areas. There was no significant relation between gender of victims and the residential location of victims (p=0.32). Most snakebites happened during 11 a.m. to 4 p.m. (32.8%). Most of the snakebites occurred in spring and summer seasons. Results showed that most of the bites in yearly months was seen in the summer season and the difference between seasons is significant. (p=0001). Most snakebites, with 38 cases (56.7%), were observed on lower limbs and among them right limbs with 20 cases (52.6%) had the greatest number. There was significant difference between organs of bites in victims because the most organs were in the right lower limb (p=0.002). Of all cases, 66 (98.5%) were injured by a species of viper snake. All patients, showed symptoms of pain, swelling, erythema and ecchymosis bite. Twenty-seven (40.3%) of all cases, suffered fainting. Nausea and vomiting were two other common symptoms. The antidote used in patients was 5.1±1.3 vials. The mean incidence rate of snakebite was an estimated 4.1 per 100000. CONCLUSIONS: Possible risk factors include male gender and young age. It was also found that the stings reach peak in the morning and noon. These reports are all in rural areas, and mostly occurred in the warm months. Snakebites in rural parts around Ardebil were prevalent. Severe side effects were rare, but the incidence of other complications was common among the victims.

Toxic megacolon as a rare complication following atropine therapy due to organophosphate poisoning: A case report.

The main therapeutic basis for a case of organophosphate poisoning is a combination therapy which includes atropine as an anticholinergic drug and pralidoxime. If the poisoning is severe, a high dose of this combination of medicines may be needed, but this may cause serious side effects: paralytic ileus or even megacolon; however, these gastrointestinal events are very rare. Here, we report a case of organophosphate poisoning where atropine therapy was given and led to drug-associated toxic megacolon.

Successful Treatment of Severe Metabolic Acidosis Due to Acute Aluminum Phosphide Poisoning With Peritoneal Dialysis: a Report of 2 Cases.

Aluminum phosphide poisoning is common in our region. It can cause severe metabolic acidosis and persistent hypotension, which lead to cardiogenic shock and subsequently mortality. Oliguric or anuric acute kidney injury is seen in almost all patients with aluminum phosphide poisoning. Renal replacement therapies are recommended in these patients to improve metabolic acidosis and increase the rate of survival. We report 2 cases of severe acute aluminum phosphide poisoning treated successfully with peritoneal dialysis.

Breast and cervical cancer-screening uptake among females in Ardabil, northwest Iran: a community-based study.

PURPOSE: Breast and cervical cancers are the most commonly diagnosed type of cancer and cause of cancer-related deaths in Iranian females. In contrast to previous studies, this study was carried out with a large sample size for assessment of breast self-examination (BSE)-, clinical breast examination (CBE)-, mammography-, and Pap smear-uptake rates and determination of associations among these screening behaviors with sociodemographic and cognitive variables in Azeri females. MATERIALS AND METHODS: This was a cross-sectional, community-based study that was carried out among 1,134 females 20-60 years old during March-June 2016. Data-collection variables included sociodemographic questions, screening behaviors for breast and cervical cancer, self-efficacy, beliefs, and barriers to breast and cervical cancer screening. Collected data were analyzed by SPSS version 13 using χ2, Mann-Whitney U, and logistic regression tests. RESULTS: Among the 1,134 participants, 53.9%, 9.8%, and 28.1% had done BSE, CBE, and Pap smear tests, respectively, and among the 625 females aged >40 years, 187 (29.9%) had done the mammography test. Moreover, 416 (36.7%), 103 (16.5%), and 64 (5.6%) females had done BSE, mammography, and CBE regularly, respectively. Beliefs, barriers, income, health insurance, number of children, and age were all important factors for BSE and regular BSE and mammography. Females who had high belief scores were more likely to undertake mammography (odds ratio [OR]: 1.2, 95% confidence interval [CI]: 1.03-1.5), regular mammography (OR: 4.2, 95% CI: 1.9-9.3), regular CBE (OR: 1.25, 95% CI: 1.2-1.3), and Pap smears (OR: 1.2, 95% CI: 1.1-1.4). Also, females who had high self-efficacy scores were more likely to perform regular BSE (OR: 1.8, 95% CI: 1.4-2.5) and mammography (OR: 2.5, 95% CI: 1.4-4.6) than females with lower self-efficacy scores. CONCLUSION: The frequency of breast and cervical cancer screening was low in our study. The findings of this study indicated that beliefs, self-efficacy, and barriers were important predictive factors of cancer-screening behavior among the females studied.

The Epidemiology of Hospital-Referred Head Injury in Ardabil City.

Background and Purpose. Trauma is the leading cause of death for youth in developing countries. Given the prevalence of head trauma (HT) in society and its complication and burden, the epidemiologic study of head trauma is necessary and is the main aim of this study. Materials and Methods. This retrospective population-based survey describes the epidemiology of head injury in a defined population in Ardabil city. It includes all 204 patients with head injury referred to the University Hospital of Ardabil, Iran, during 2013-2014. Data were collected by a checklist and analyzed by statistical methods in SPSS.19. Significance level p < 0.05 was considered. Results. Of all registered cases, 146 (71.6%) were male and the rest of them were female. Most of HT patients lived in Ardabil city (60.8%). The mean age of patients was 22.6 ± 25.9 and most of victims were young. 24.5% of traumatic patients have injuries in severe to critical level (grade 3-4). The most cause of trauma was accidents (41.7%). Most of injuries occurred in night (55.9%) and in summer season (42.2%). Causes were traffic accident in 41.7%. Conclusion. Results showed that the leading cause of head trauma especially in the warm seasons is accidents and so, designing programs to reduce road accidents can dramatically reduce the rate of trauma in the future in Ardabil province.

Explaining the role of organizational culture on succession-planning at the Ministry of Health and Medical Education: A qualitative study.

BACKGROUND: Developing and guiding new knowledge are futile unless the organizational culture can also be transformed. Future leaders cannot emerge out of an organizational environment that is not conducive to the accumulation of experiences. OBJECTIVE: The aim of this study was to explore the role of organizational culture in creating a succession-planning system at the Ministry of Health and Medical Education in 2014. METHODS: The present qualitative framework analysis held interviews with 23 director generals, administrative directors and deputies from the headquarters of the Iranian Ministry of Health and Medical Education in 2014 who were selected through snowball sampling. The data obtained were analyzed in MAXQDA-10. Codes were extracted using inductive techniques. RESULTS: The cultural factors affecting succession-planning at the Ministry of Health and Medical Education were identified and classified under three main areas, including the cultural factors related to the directors with four themes (Directors' job security, Constructive competition, Transparency and trust development, Creating opportunities), to the personnel with four themes (Organizational identity and loyalty, Trust in the organization, Talent and merit, Peer envy) and to the system with two themes (Values and beliefs, Politicization). CONCLUSION: Findings of the study show that establishment and institutionalization of the succession planning to the Ministry of Health and Medical Education is deeply affected by the components of organizational culture. Accordingly, unprofessional organization culture can deprive the organization of numerous advantages in multiple-succession planning.

The effect of N-acetyl cysteine (NAC) on aluminum phosphide poisoning inducing cardiovascular toxicity: a case-control study.

BACKGROUND: Aluminum phosphide (AlP) is a very effective indoor and outdoor pesticide. We investigated the effects of N-acetyl cysteine (NAC) on the survival time, hemodynamics, and cardiac biochemical parameters at various time intervals in some cases of AlP poisoning. METHODS: This research was a case-control study to evaluate 63 AlP poisoned patients during 2010-2012. Patients with cardiovascular complications of AlP to be treated with intravenous NAC plus conventional treatment were considered as the case group and compared with patients who did not receive NAC. NAC infusion was administered to the case group at 300 mg/kg for 20 h. The data gathered included age, sex, heart rate, Systolic blood pressure (SBP), creatine phosphokinase (CPK), creatine kinase MB (CK-MB), and ECG at the admission time and 12, 18, and 24 h after admission. Analysis of repeated measures was performed to check the variability of parameters over time. RESULTS: The mean ages in the case and control groups were 26.65 ± 1.06 (19-37 years) and 28.39 ± 1.11 (18-37 years), respectively (P = 0.266). Most of the patients were female (56.5%). CK-MB means were significantly different between the two groups, but no differences between the other variables were observed. Also, CK-MB, CPK, heart rate, and systolic blood pressure means became significantly different over time (0, 12, 18, and 24 h) in both groups (P < 0.001). NAC prevented sharp heart rate fluctuations in AlP patients in the case group. Regarding the outcomes, 17 patients died (10 patients in the control and 7 patients in the case groups). No side-effects of NAC were observed. CONCLUSION: Our patients could be managed by the positive role of NAC as the biochemical index of cardiotoxicity was found to elevate in both the case and control groups. Therefore, for the management protocol optimization, NAC evaluation should be done in further cases.

Analysis of Relationships between Altitude and Distance from Volcano with Stomach Cancer Incidence Using a Geographic Information System.

Gastric cancer (GC) is the fifth most common cancer in the world, with a wide variation in incidence rates across different geographical areas. In Iran GC is the most common cancer in males and it is reported to be the third most prevalent after breast and colorectal in females. A geographical information system (GIS) allows investigation of the geographical distribution of diseases. The purpose of the present study was to explore the relationship between gastric cancer and effective climatic factors using GIS. The dispersion distribution and the relationship between environmental factors effective on cancer were measured using Arc GIS. Of all cases, 672 (73.8%) were in males with a sex ratio of 3 to 1. The highest incidence by cities was seen in Namin with 137.5 per 100,000. The results of this study showed that the distribution of GC around the Sabalan volcanic mountain was significantly higher than other places in the same province. These results can be considered as a window to future comprehensive research on gastric cancer.

Does organophosphate poisoning cause cardiac injury?

Organophosphates are insecticides which are widely used as a suicidal agent in Iran. They are associated with different types of cardiac complications including cardiac arrest and arrhythmia, however their role in cardiac injury is not known yet. The aim of this study was to investigate the presence of myocardial damage in patients with cholinesterase poisoning.It was a prospective study conducted from January 2008 to March 2010. Cohorts of patients with cholinesterase poisoning due to suicidal attempt who have been referred to Loghman hospital were selected. Patients who have taken more than one poison or were used concomitant drugs were excluded. Physical examination was performed on admission to discover warning sign. Peripheral arterial blood gases, creatine kinase, creatine kinase-myocardial band, troponin-T measurements were performed in all cases. There were 24 patients, 7 of them women, with the mean age of 41.2±15.05 who were included in this study. Non-survivors had significantly higher levels of systolic blood pressure, partial pressure of oxygen in arterial blood, partial pressure of carbon dioxide, bicarbonate Glasgow Coma Scale scoring and longer duration of mechanical ventilation. Our findings showed that cardiac injury is an important cause of death in organophosphate poisoning. It could be hypothesized that cardiac injury is a strong predictor of death in patients with organophosphate poisoning.

Carcinoid tumor with localized bronchiectasis.

Bronchial carcinoid tumor comprises 1 to 3% of lung neoplasms. The common age of onset is mainly post-puberty although atypical carcinoid tumors occur at ages 44 to 55. Carcinoid tumors cause two groups of symptoms in patients: symptoms due to obstruction and symptoms due to the production and release of active neuropeptides. Histologically, carcinoid tumors are categorized into two groups of typical and atypical while in terms of location of lesion, they are grouped into central and peripheral types. Differentiation between malignant and benign carcinoid tumors is based on presence or absence of metastasis. Bronchoscopy and endobronchial biopsy are the best diagnostic measures in these patients. Serologic evaluation and assessment of active metabolites in case of liver metastasis also help the diagnosis. Surgical resection is the treatment of choice for this condition. This report discusses a patient with carcinoid tumor who was receiving bronchodilator treatment for a couple of months because of chronic cough with possible diagnosis of asthma and had received several courses of antibiotic therapy with possible diagnosis of lung infection until he eventually developed bronchiectasis in the right lower lobe. In patients with chronic pulmonary symptoms especially with localized bronchiectasis, diagnostic bronchoscopy must be included in the diagnostic work-up to rule out intrabronchial lesions.

A novel protocol for gastric lavage in patients with aluminum phosphide poisoning: a double-blind study.

Aluminum phosphide poisoning (ALPP) still has no efficient and approved antidote. Supportive care and hemodynamic monitoring are the only choices of treatment. We proposed a new lavage formulation in addition to evaluation of its efficacy and defining the impact of clinical characteristics of patients on their prognosis. During eight months period of time, 120 patients were enrolled to the study and randomly received two different gastric lavage protocols. Our new lavage protocol had positive impact on patients' survival and the P-value in comparison with the classic gastric lavage method was close to significant level (P=0.054). On hospital arrival indication for intubation-ventilation as well as sense of thirst, sore throat and absence of nausea indicate worse outcome. Using our novel approach, indication for intubation-ventilation as well as sense of thirst, sore throat and absence of nausea can be considered as applicable prognostic factors in survival of ALPP patients. Further studies are required to set this approach as preferred treatment.

Depilatory Agents intoxication and factors contributing to its mortality: a 9-year review.

Poisoning with depilatory agents is a rather uncommon entity in western countries. In this study, we describe poisoning with a corrosive arsenic-based depilatory agent (CABD) and factors related to its mortality in a poisoning center in Tehran. In a retrospective study, the medical records of all patients with CABD intoxication who attended the emergency ward of Loghman-Hakim hospital, the only poisoning center in Tehran, over a 9-year period between 2000 and 2009 were reviewed. The majority of patients were men (78.7%, n = 122 vs. women: 21.3%, n = 33). The mean age was 35.55 ± 16.68 years. Mean time of arrival to hospital was 3.63 hours (SD = 4.07). The mortality rate was 5.8% and increased significantly with higher amounts of ingestion and delay in arrival to hospital. CABD poisoning may be lethal if not treated promptly and correctly. Restriction or, if not practical, reduction of harmful components of this substance should be considered.

Blood levels of methemoglobin in patients with aluminum phosphide poisoning and its correlation with patient's outcome.

Although methemoglobinemia following aluminum phosphide (AlP) intoxication has been reported, probable effect of blood level of methemoglobin (Met-Hb) on outcome of AlP-poisoned patients has not yet been investigated. This study aimed to evaluate blood levels of methemoglobin in patients with AP intoxication and its correlation with patient's outcome. This prospective study was carried out at the Loghman-Hakim poison hospital from April 2009 to August 2009. All patients aged >12 years who had ingested AlP and were admitted at the hospital were enrolled in the study. Using the co-oximetry, blood Met-Hb level was measured at the time of admission and 24 h later if the patient survived. Forty-eight patients with AlP intoxication including 24 males were evaluated. Mean age of the patients was 25.5±9.5 years. There was significant association between blood level of Met-Hb at the time of admission and mortality (2.4%±7.1% in survivors versus 15.2%±13.5% in non-survivors, P<0.001). The same association was found at the 2nd day of admission (2.9%±8.2% in survivors versus 26.5%±9.9% in non-survivors, P=0.02). The present study found an association between blood level of Met-Hb and mortality in patients with AlP intoxication. Effect of administration of vitamin C and methylene blue on outcome of patients with AlP intoxication should be investigated in future studies.