Manganese Encephalopathy Caused by Homemade Methcathinone (Ephedrone) Prevalence in Poland.

Manganese encephalopathy is a known disorder in occupational medicine. A serious phenomenon has been the emergence of manganese encephalopathy in intravenous users of homemade methcathinone (ephedrone). A short survey was developed for clinical environments dealing with people who use psychoactive substances. The data were obtained from 72 rehabilitation therapy centers. Surveys carried out in about a third of Polish centers dealing with providing medical assistance to people addicted to substances other than alcohol and tobacco have shown that over 4% of people treated there had symptoms of manganese encephalopathy, of which more than half are people in whom the probability of a clinical diagnosis of this disorder is significant. It has been shown that knowledge of manganese encephalopathy is none or minimal in more than 70% of the surveyed institutions. An urgent need for personnel training in this field was pointed out. Attention was paid to the importance of disseminating good review articles on new and dynamically developing problem phenomena.

Alcohol-induced thrombocytopenia: Current review.

Thrombocytopenia is a decrease in the platelet count below 150,000 in a microliter of blood, i.e., below the lower limit of the reference range, which is 150,000-400,000/µL. The phenomenon of thrombocytopenia related to heavy drinking began to arouse interest in the 1960s and 1970s. It was initially described in case reports and clinical studies on small groups. In the following years, the phenomenon itself and the significance of alcohol-induced thrombocytopenia was studied. Many methodological difficulties inhibiting objective conclusions from research were encountered. Model pathological mechanisms of alcohol thrombocytopenia and the effects of alcohol on the structure and function of platelets were described. Furthermore, the phenomenon of rapid normalization of the number of platelets in people who stopped drinking was described. Relationships between alcohol use, its intensity and occurrence, and intensity of thrombocytopenia have been demonstrated. Predictive platelet counts for alcohol withdrawal syndrome complications have been proven and calculated. The risk of occurrence of withdrawal seizures or delirium tremens in alcohol withdrawal syndrome increases significantly when the platelet count is less than 119,000/µL. The knowledge of the nature of the phenomenon of alcohol-induced thrombocytopenia in a clinical environment allows decisions that are more rational. The attention of clinicians should be drawn to the importance of results of blood tests routinely collected on admission.

Thrombocytopenia in Patients Hospitalized for Alcohol Withdrawal Syndrome and Its Associations to Clinical Complications.

BACKGROUND: The aim of this study was to assess the predictive value of thrombocytopenia (TP) in alcohol withdrawal syndrome (AWS) as a marker of evolution of non-complicated AWS (nAWS) to severe, complicated AWS (cAWS): delirium tremens (DTs) and withdrawal seizures (wS), and to broaden knowledge about differences between nAWS and cAWS groups in relation to severity of TP. METHODS: This study involved 300 people (236 males and 64 females), aged 19-65 years (M = 44.64, SD = 11.32), hospitalized in the detoxification ward with ICD-10 diagnosis of F10.3 (AWS) or F10.4 (DTs), divided into nAWS and cAWS groups, 150 cases each. AWS severity was measured by CIWA-Ar. Available clinical and laboratory data were analyzed. RESULTS: TP was found in 139 (46%) of all subjects (nAWS = 32, cAWS = 107). nAWS and cAWS did not differ according to age, gender, length and severity of the last binge. A relationship between the occurrence of TP and cAWS was found (P < 0.001). The lower was the number of PLT, the more AWS incidence was observed. In CIWA-Ar, TP subjects had at least moderate AWS (P < 0.001). nAWS had higher PLT values than cAWS cases (Mrang = 195.96 vs. 105.04, P < 0.001). The predictive value of TP in cAWS was confirmed. CONCLUSIONS: The study demonstrates that patients with AWS and TP (in particular <119k/mL) are at higher risk of developing cAWS.

Difficulties to differentiate mood disorders co-occurring with compulsive gambling. Discussion based on a case study. / Trudnosci róznicowania zaburzen nastroju wystepujacych w przebiegu zaburzen uprawiania hazardu. Rozwazania na bazie opisu przypadku.

Contemporary literature does not take a clear position on the issue of determining civil and criminal liability of persons diagnosed with pathological gambling, and all the more so in case of possible comorbidity of or interference with other mental disorders. Diagnostic difficulties are demonstrated by a clinical picture of a patient with problem gambling who underwent forensic and psychiatric assessments to evaluate the process of making informed (and independent) decisions in view of numerous concluded civil law (mainly financial) agreements. The patient had been examined 5 times by expert psychiatrists who, in 4 opinions, diagnosed her with bipolar affective disorder, including 1 diagnosis of rapid cycling of episodes. Based on the current state of scientific knowledge about the relationship between problem gambling and mood disorders, bipolar affective disorder was not confirmed. Diagnostic difficulties, resulting both from diagnostic haziness and unreliable information obtained during patient interview, that emerged in the course of case study point to the need for multi-dimensional clinical diagnosis of persons with suspected mood disorders and behavioral addictions.

Recognition of emotional facial expressions in benzodiazepine dependence and detoxification.

INTRODUCTION: The study investigates how benzodiazepine (BZD) use and detoxification affects empathy and the recognition and intensity rating of emotional facial expressions. The sample comprised 43 participants in three groups: (1) during detoxification (N = 13), (2) after detoxification (N = 15), (3) a matched control group (N = 15). Clinical subjects were recruited from in-patients of an addiction treatment unit. METHODS: Empathy levels were tested with the Empathy Quotient (EQ-Short). Recognition accuracy and emotion intensity rating were based on a computerised task displaying static and dynamic facial expressions of joy, anger, sadness, and fear. RESULTS: The controls proved more accurate than both experimental groups in identifying facial expressions of negative emotions. Joy recognition proved most accurate overall. Among the clinical subjects, women in particular exhibited an impaired ability to correctly identify negative emotions from facial expressions. Dynamic stimuli were better recognised than static ones albeit only in the experimental groups. No significant differences were found for emotion intensity ratings and EQ scores. CONCLUSION: Our findings suggest that the impaired facial emotion recognition accuracy is not caused by deficits in empathy. No improvement was recorded post-detoxification which may indicate impaired interpersonal functioning among BZD users. Further research is warranted in light of this study's limitations.

[Cognitive dysfunctions caused by excessive exposure to manganese compounds. Cognitive disturbances in intravenous users of ephedrone (methcathinone) with manganese compounds]. / Zaburzenia funkcji poznawczych spowodowane nadmierna ekspozycja na zwiazki manganu. Zaburzenia funkcji poznawczych u dozylnych uzytkowników preparatów efedronu (metkatynonu).

Intravenous injection of self-produced ephedrone (metcathinone) using potassium permanganate as an oxidant can lead to severe, fixed encephalopathy. This risk applies mainly to young individuals experimenting with "home-made" drugs and results in an irreversible aggravation of overall functioning. Besides multiple neurological symptoms and movement disorders, affected individuals also experience cognitive dysfunction. No systematic research has been conducted in this field. Single case reports and small group descriptions show that assessment with screening tools such as the Mini-Mental State Examination (MMSE) is ineffective. Neuropsychological assessment conducted with other tests indicates significant dysarthric speech disorders, psychomotor function impairment, attentional disorders of varying intensity as well as dysfunctions of verbal and visual working memory processes. Some studies of this group of subjects also indicate working memory and executive function disorders. These dysfunctions seem to be permanent and do not recede following manganese use discontinuation and an improvement of the neuroradiological picture in MRI assessment. A standard test battery should be developed enabling the assessment of both cognitive and neurological dysfunctions that otherwise render some tests impossible to administer.

[Misuse and abuse of quetiapine]. / Niewlasciwe uzywanie i naduzywanie kwetiapiny.

Quetiapine is an atypical antipsychotic agent, frequently used in psychiatry, often for symptomatic treatment against a number of mental disorders differing from the registration indications. One of the use is to soothe the clinical conditions caused by the use of various psychoactive substances. The paper presents and discusses the reports of quetiapine misuse, abuse, and even mental addiction, as well as symptoms similar to the so-called discontinuation syndrome, often mixed with withdrawal syndrome occurring in the course of addiction. Most reports concern males, and especially those with a history of other psychoactive substance abuse, and personality disorders, often in conflict with the law. Therefore, clinicians should be cautious when prescribing quetiapine to such patients. The article discusses potential mechanisms responsible for quetiapine abuse. This is probably related to its sedative and anxiolytic activity which results in the frequent use with stimulants. Also, high affinity for the H1 receptor, as antihistamines agents causes rewarding action.

Repeated self-mutilation of testicles in the context of methamphetamine use - A case report and brief review of literature.

We report a case of recurrent genital self-mutilation (GSM) after use of methamphetamine. A 29-year-old male with borderline personality and polydrug misuse attempted the GSM twice. Firstly, he self-amputated his left testicle, and one year later he injected printer ink in his right testicle. An open revision of the injured area revealed a puncture wound in the right testicle, with a palpable accumulation of fluid. No ink was found inside the scrotal sac suggesting that the substance was injected directly to the testis. Due to the absence of left testicle, the urologist decided against orchiectomy. Blue colour of serum, urine and sperm was observed for nine days, and then spontaneously disappeared. An ultrasound imaging showed enlargement of the right testis with hypoechogenic fluid/ink collection. Pathomorphological examination of the testicular tissue revealed focal necrosis and diffuse suppurative inflammation of the testicular tunic. Examination of the sperm showed significantly reduced amount of sperm, with majority of dead spermatocytes. Follow-up examination at six months and two years showed absence of spermatocytes. Some attempts of GSM can be repeated. Therefore, specific preventive measures should be undertaken whenever a standard advice and motivational interviewing proved ineffective. Depending on local and general toxicity of an injected xenobiotic, orchiectomy should be considered as a treatment option of GSM. Injection of potentially low toxic ink into the testicle can lead to its permanent damage and infertility.

MRI brain findings in ephedrone encephalopathy associated with manganese abuse: Single-center perspective.

BACKGROUND: Manganese (Mn) is a well-known toxic agent causing symptoms of parkinsonism in employees of certain branches of industry. Home production of a psychostimulant ephedrone (methcathinone), involving the use of potassium permanganate, became a new cause of intoxications in Poland. CASE REPORT: This article presents clinical symptoms, initial brain MRI findings and characteristics of changes observed in follow-up examinations in 4 patients with manganese intoxication associated with intravenous administration of ephedrone. All patients in our case series presented symptoms of parkinsonism. T1-WI MRI revealed high intensity signal in globi pallidi in all patients; hyperintense lesions in midbrain were observed in three patients, while lesions located in cerebellar hemispheres and pituitary gland in just one patient. The reduction of signal intensity in the affected brain structures was observed in follow-up studies, with no significant improvement in clinical symptoms. CONCLUSIONS: Brain MRI is helpful in the assessment of distribution as well as dynamics of changes in ephedrone encephalopathy. Regression of signal intensity changes visible in brain MRI is not associated with clinical condition improvement. Although brain MRI findings are not characteristic for ephedrone encephalopathy, they may contribute to diagnosing this condition.

[Encephalopathy caused by intravenous potassium permanganate used for illegal production of methcathinone (ephedrone) from medicines containing pseudoephedrine]. / Encefalopatia spowodowane dozylnym uzywaniem preparatów zawierajacych nadmanganian potasu stosowany jako reagent w produkcji metkatynonu (efedronu) z leków zawierajacych pseudoefedryne.

Encephalopathy caused by manganese compounds used for illicit production of ephedrone (methcathinone) is described. The onset of disease could be observed after some months of regular intravenous use of ephedrone contaminated with manganese. In clinical picture dominate neurological signs and symptoms, mainly extrapyramidal syndromes: parkinsonism, tremor, muscle distonia, pro- and retropulsion. Some other symptoms may be observed: hypophonia or dysarthria, gain disturbances, impairment of precise movement, and micrographia. In cranial NMR often appears bilaterally an increase of an intensity of T1 signal in globus pallidus and in some other brain structures. Elimination of manganese with the use of chelating therapy as well as symptomatic treatment, mainly with the antyparkinsonic drugs, seems to be ineffective.

[Management of alcohol withdrawal syndromes]. / Postepowanie w alkoholowych zespolach abstynencyjnych.

Paper presents proposal of guidelines concerning management of alcohol withdrawal syndromes. The paper is based on scientific medical societies standards, meta analyses and significant papers supporting some controversial questions. There are represented some practices used in intensive care units, that are not present in standards.

[Misuse of substances theoretically without abuse potential--case series]. / Naduzywanie substancji teoretycznie bez znanego potencjalu uzalezniajacego--przeglad przypadków.

The aim of our study was to present cases of misuse of different substances theoretically without abuse potential. In the last few years such behavior became an increasing problem in toxicological and emergency units. Lack of typical signs of intoxication with psychoactive substances, and negative results of standard toxicological tests may be a challenge for toxicologists and emergency medicine practitioners.

Misuse of xylometazoline nasal drops by inhalation.

Six male prisoners who misused xylometazoline nasal drops by inhalation were interviewed by a prison physician in 2006. The prisoners received xylometazoline drops during regular visits in the prison ambulatory service. In order to get the medication, the subjects reported false symptoms of rhinosinusitis and allergic reactions. Psychoactive effects of inhaled xylometazoline were described as "stimulation," "excitation," and "feeling of strength." Although preliminary, our findings suggest that topical adrenergic decongestants can produce rewarding effects when administered by inhalation.

Key findings from the WHO collaborative study on substitution therapy for opioid dependence and HIV/AIDS.

AIMS: Opioid substitution treatment has been studied extensively in industrialized countries, but there are relatively few studies in developing/transitional countries. The aim of this study was to examine the effectiveness of opioid substitution treatment (OST) in less resourced countries. DESIGN: Longitudinal cohort study. SETTING: Purposively selected OST sites in Asia (China, Indonesia, Thailand), Eastern Europe (Lithuania, Poland, Ukraine), the Middle East (Iran) and Australia. PARTICIPANTS: Seven hundred and twenty-six OST entrants. MEASUREMENTS: Participants were interviewed at treatment entry, 3 and 6 months. Standardized instruments assessed drug use, treatment history, physical and psychological health, quality of life, criminal involvement, blood-borne virus (BBV) risk behaviours and prevalence of human immunodeficiency virus (HIV) and hepatitis C. FINDINGS: Participants were predominantly male, aged in their early 30s and had attained similar levels of education. Seroprevalence rates for HIV were highest in Thailand (52%), followed by Indonesia (28%) and Iran (26%), and lowest in Australia (2.6%). Treatment retention at 6 months was uniformly high, averaging approximately 70%. All countries demonstrated significant and marked reductions in reported heroin and other illicit opioid use; HIV (and other BBV) exposure risk behaviours associated with injection drug users (IDU) and criminal activity, and demonstrated substantial improvement in their physical and mental health and general wellbeing over the course of the study. CONCLUSIONS: OST can achieve similar outcomes consistently in a culturally diverse range of settings in low- and middle-income countries to those reported widely in high-income countries. It is associated with a substantial reduction in HIV exposure risk associated with IDU across nearly all the countries. Results support the expansion of opioid substitution treatment.

Combining markers of nephrotoxicity and hepatotoxicity for improved monitoring and detection of chronic alcohol abuse.

BACKGROUND: Most of the commonly used markers of chronic alcohol abuse reflect alcohol hepatotoxicity; however, such abuse is deleterious to the kidneys as well. Combined use of serum markers of liver origin and urinary markers of kidney origin may be of diagnostic advantage. METHODS: The study was performed in 73 male alcoholics undergoing detoxification and 36 male alcoholics who had maintained abstinence for > or =6 weeks. Factor analysis, discriminant analysis and receiver operating characteristic (ROC) analysis were used to assess the discriminative power of two urinary markers of alcohol nephrotoxicity, namely beta-N-acetylhexosaminidase (Hex, EC 3.2.1.52) and alanine aminopeptidase (EC 3.4.11.2), and of three serum markers of alcohol hepatotoxicity, namely aspartate aminotransferase (EC 2.6.1.1), alanine aminotransferase (EC 2.6.1.2) and gamma-glutamyltransferase (GGT, EC 2.3.2.2), and of their quantitative combinations. RESULTS: The discriminative power of the urinary markers matched that of the serum markers. Hex and GGT appeared to be the best for discriminating the study groups. Their combination given by the equation G&H=0.62 x ln(GGT)+0.72 x ln(Hex) showed excellent discriminative ability (ROC area under the curve 0.92) that was significantly higher than that of any single marker in this report, indicating superior diagnostic accuracy of the compound marker. CONCLUSIONS: Kidney-derived urinary markers, particularly Hex, can complement or replace, if necessary, serum markers of chronic alcohol abuse that relate to alcohol hepatotoxicity. The compound marker proposed seems a promising tool for the monitoring and perhaps detection of chronic alcohol abuse and warrants further studies.

[A double-blind controlled study of the efficacy and acceptability of tianeptine in comparison with fluvoxamine in the treatment of depressed alcoholic patients]. / Skutecznosc i tolerancja tianeptyny w leczeniu zaburzen depresyjnych u pacjentów uzaleznionych od alkoholu. wieloosrodkowe badanie kontrolowane metoda podwójnie slepej próby z uzyciem fluwoksaminy.

AIM: The main objective of the study was the evaluation of therapeutic efficacy of tianeptine (T) (37.5 mg/day) in comparison with fluvoxamine (F) (100 mg/day) in depressed patients with alcohol dependence or harmful use who had abstained from alcohol, in a 6-week treatment period. The secondary objectives were the assessment of the acceptability of both drugs and analysis of the alcohol craving behaviour regarding both treatments. METHOD: Outpatients who met ICD-10 criteria for depression and alcohol dependence or harmful use were randomised to a double-blind 6-week comparative trail. Responders (50% or more reduction in baseline HDRS) were proposed to continue the same treatment up to 90 days. The antidepressant efficacy was assessed with the use of the HDRS (main criterion). Other scales used in the study were HARS, CGI and OCDS. Tolerance was evaluated by monitoring of adverse events. RESULTS: A total of 298 (150 in T group and 148 in F group) were randomized. Both drugs showed good efficacy in the treatment of depressive symptoms. In Full Analysis Set (FAS) mean HDRS score significantly decreased in both groups from 22.2 at baseline to 10.6 at end-point in T group and from 21.8 to 11.4 in F group. There was no statistical difference between groups. The number of patients found to be responders at end-point was 72.1% in the T group and 67.1% in the F group. There was significant improvement in both treatment groups in HARS and CGI. Also analysis of alcohol craving by the OCDS scale showed significant improvement in both groups. No significant difference between treatment groups regarding those scales was noted. In a 6-week treatment period, statistically significantly more patients continued the study in the T group. Tolerability of both drugs was good. 16.7% of the patients experienced at least one adverse event in the T group and 20.3% in the F group. CONCLUSION: Tianeptine and fluvoxamine are effective and safe in the treatment of depression in the group of patients with alcohol dependence.

Recreational amitriptyline abuse.

UNLABELLED: Amitriptyline is a potent anticholinergics, rarely used as a drug of abuse. Two cases of amitriptyline dependency lasting for almost twelve months were described. According to the patients the abuse with amitriptyline guarantee them safety not to be uncovered by parents and doctors who systematically checked their urine with typical narcotic tests. CASE REPORT: Two patients with a history of abuse with amphetamine and clonazepam were admitted to the Clinic because of intoxication with amitriptyline. They denied the suicidal attempt and explained that they used amitriptyline in a dosage of 100 to 200 mg per day as a drug of abuse. On the day of admission one of the patients had increased the dosage up to 600 mg which caused an acute intoxication. CONCLUSION: Antidepressants should be treated as a drugs with possible abuse ability.

Self-reported effects of methadone on cigarette smoking in methadone-maintained subjects.

Subjects maintained on methadone evidence a high level of interest in quitting cigarette smoking. Readiness to quit may result, at least partially, from direct pharmacological interactions between methadone and brain nicotinic acetylcholine receptors. The aim of the present study was to assess: (1) self-reported changes in smoking habits after admission to a methadone maintenance treatment (MMT) program; (2) acute effects of methadone administration on smoking behavior in MMT patients. The study was conducted between May and December 2001, in two public outpatient MMT clinics located in Warsaw, Poland. The patients (41 men, 30 women) reported smoking fewer cigarettes after admission to the program. Most subjects (67.6%) changed their favorite brand of cigarettes after admission. Mean nicotine content (mg/cigarette) significantly decreased. On the other hand, the subjects did not report any effects of methadone administration on smoking parameters. The above findings suggest that initiation of MMT is associated with positive changes in smoking behavior. However, these changes may not be related to direct pharmacological interactions between methadone and nicotine.

Polymorphisms of apolipoprotein E and angiotensin-converting enzyme genes and carotid atherosclerosis in heavy drinkers.

AIMS: To investigate the influence of apolipoprotein E (APOE) and angiotensin-converting enzyme (ACE) gene polymorphisms on carotid artery atherosclerosis in alcoholism. METHODS: Polymorphism of both genes was identified by DNA analysis in 130 male alcohol-dependent patients. Intima-media thickness (IMT) was measured ultrasonographically. RESULTS: Multivariate regression analysis showed that of all the known risk factors the greatest impact on carotid atherosclerosis in alcoholics was exerted by age, hypertension, LDL cholesterol and fasting plasma glucose levels. Subjects carrying the APO E epsilon4 allele were more liable to develop atherosclerotic changes in carotid arteries compared with subjects with the epsilon3/3 genotype, which showed statistical significance in patients under 50 years of age. No association was shown between ACE I/D polymorphism and carotid atherosclerosis. CONCLUSIONS: APO E polymorphism can increase the risk of carotid atherosclerosis development in an alcoholic subject. The association of the APO E epsilon4 allele with carotid atherosclerosis was significant in younger patients. Since the elevated carotid IMT is considered to be a good marker of increased risk of generalized atherosclerosis the consequences could involve both cardiac and cerebrovascular events.