Critically Ill Patients Treated for Chimeric Antigen Receptor-Related Toxicity: A Multicenter Study.

OBJECTIVES: To report the epidemiology, treatments, and outcomes of adult patients admitted to the ICU after cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. DESIGN: Retrospective cohort study. SETTING: Nine centers across the U.S. part of the chimeric antigen receptor-ICU initiative. PATIENTS: Adult patients treated with chimeric antigen receptor T-cell therapy who required ICU admission between November 2017 and May 2019. INTERVENTIONS: Demographics, toxicities, specific interventions, and outcomes were collected. RESULTS: One-hundred five patients treated with axicabtagene ciloleucel required ICU admission for cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome during the study period. At the time of ICU admission, the majority of patients had grade 3-4 toxicities (66.7%); 15.2% had grade 3-4 cytokine release syndrome and 64% grade 3-4 immune effector cell-associated neurotoxicity syndrome. During ICU stay, cytokine release syndrome was observed in 77.1% patients and immune effector cell-associated neurotoxicity syndrome in 84.8% of patients; 61.9% patients experienced both toxicities. Seventy-nine percent of patients developed greater than or equal to grade 3 toxicities during ICU stay, however, need for vasopressors (18.1%), mechanical ventilation (10.5%), and dialysis (2.9%) was uncommon. Immune Effector Cell-Associated Encephalopathy score less than 3 (69.7%), seizures (20.2%), status epilepticus (5.7%), motor deficits (12.4%), and cerebral edema (7.9%) were more prevalent. ICU mortality was 8.6%, with only three deaths related to cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome. Median overall survival time was 10.4 months (95% CI, 6.64-not available mo). Toxicity grade or organ support had no impact on overall survival; higher cumulative corticosteroid doses were associated to decreased overall and progression-free survival. CONCLUSIONS: This is the first study to describe a multicenter cohort of patients requiring ICU admission with cytokine release syndrome or immune effector cell-associated neurotoxicity syndrome after chimeric antigen receptor T-cell therapy. Despite severe toxicities, organ support and in-hospital mortality were low in this patient population.

Advances in Supportive Care for Acute Lymphoblastic Leukemia.

PURPOSE OF REVIEW: Tremendous advances have been made in the treatment armamentarium for acute lymphoblastic leukemia in recent years, which have substantially improved outcomes for these patients. At the same time, unique toxicities have emerged, and without early intervention, are life-threatening. This article will review the novel therapies in acute leukemias and highlight the clinically relevant supportive care advances. RECENT FINDINGS: The American Society for Transplantation and Cellular Therapy (ASTCT) has put forth the most recent recommendations in managing the cytokine release syndrome and neurotoxicity after chimeric antigen receptor T cells (CAR-T) and blinatumomab. The hepatic injury incurred by inotuzumab, and the vascular toxicity of tyrosine kinase inhibitors, other relatively novel agents, require subspecialist intervention and multidisciplinary care. Asparaginase, a long-established and key element of pediatric regimens, has made a comeback in the young adult leukemia population. Updated guidelines have been outlined for management of asparaginase thrombotic complications. Lastly, although there have been few changes in the applications of growth factor, antimicrobial prophylaxis, and management of neuropathy, these encompass exceedingly important aspects of care. While the rapidly changing treatment paradigms for acute lymphoblastic leukemia have transformed leukemia-specific outcomes, treatment emergent toxicities have forced much necessary attention to better definitions of these toxicities and on improving supportive care guidelines in acute lymphoblastic leukemia.

High ambient temperature increases the toxicity and lethality of 3,4-methylenedioxymethamphetamine and methcathinone.

RATIONALE: Methylenedioxymethamphetamine (MDMA) and methcathinone (MCAT) are abused psychostimulant drugs that produce adverse effects in human users that include hepatotoxicity and death. Recent work has suggested a connection between hepatotoxicity, elevations in plasma ammonia, and brain glutamate function for methamphetamine (METH)-induced neurotoxicity. OBJECTIVES: These experiments investigated the effect of ambient temperature on the toxicity and lethality produced by MDMA and MCAT in mice, and whether these effects might involve similar mechanisms to those described for METH neurotoxicity. RESULTS: Under low (room temperature) ambient temperature conditions, MDMA induced hepatotoxicity, elevated plasma ammonia levels, and induced lethality. Under the same conditions, even a very high dose of MCAT produced limited toxic or lethal effects. High ambient temperature conditions potentiated the toxic and lethal effects of both MDMA and MCAT. CONCLUSION: These studies suggest that hepatotoxicity, plasma ammonia, and brain glutamate function are involved in MDMA-induced lethality, as has been shown for METH neurotoxicity. The toxicity and lethality of both MDMA and MCAT were potentiated by high ambient temperatures. Although an initial mouse study reported that several cathinones were much less toxic than METH or MDMA, the present results suggest that it will be essential to assess the potential dangers posed by these drugs under high ambient temperatures.

Survival and Neurologic Recovery After Prompt Diagnosis and Aggressive Management of Severe Idiopathic Hyperammonemic Encephalopathy in a Patient with Acute Myeloid Leukemia.

A case of a 19-year-old female with low-risk acute myeloid leukemia is presented who was diagnosed with idiopathic hyperammonemic encephalopathy following the development of abrupt neurologic decline, respiratory alkalosis, and elevated plasma ammonia levels of unknown etiology. Delayed symptom recognition of this exceedingly rare condition contributes to the often fatal outcomes of idiopathic hyperammonemic encephalopathy. As illustrated by this case, prompt diagnosis and utilization of a variety of ammonia-modulating treatment modalities can result in remarkable clinical recovery. This case provides guidance to clinicians in counseling families about the possibility of neurologic recovery in similar clinical scenarios.

Prevention of pesticide-induced neuronal dysfunction and mortality with nucleophilic poly-Oxime topical gel.

Organophosphate-based pesticides inhibit acetylcholinesterase (AChE), which plays a pivotal role in neuromuscular function. While spraying in the field, farmworkers get exposed to pesticides through the dermal route. Internalized pesticide inhibits AChE, which leads to neurotoxicity, cardiotoxicity, cognitive dysfunction, loss of endurance, and death in severe cases. Here, we present a nucleophilic pyridine-2-aldoxime-functionalized chitosan-based topical gel (poly-Oxime gel) that rapidly deactivates organophosphates, methyl parathion (MPT), on the skin of rats, which leads to reduced AChE inhibition in the blood and tissues. Testing the robustness of poly-Oxime gel, we report reduction in AChE inhibition following repeated dermal administration of MPT in the presence of poly-Oxime gel. Furthermore, poly-Oxime gel prevented MPT-induced neuromuscular dysfunction, loss of endurance, and locomotor coordination. We observe a 100% survival in rats following topical MPT administration in the presence of poly-Oxime gel. This prophylactic gel may therefore help farmworkers by limiting pesticide-induced toxicity and mortality.

Neuroinflammation markers and methyl alcohol induced toxic brain damage.

Methyl alcohol intoxication is a global problem with high mortality and long-term visual sequelae and severe brain damage in survivors. The role of neuroinflammation in the mechanisms of methyl alcohol-induced toxic brain damage has not been well studied. We measured the acute concentrations and dynamics of lipoxins LxA4 and LxB4 and the interleukins IL-4, IL-5, IL-9, IL-10, and IL-13 in the serum of patients treated with methyl alcohol poisoning and the follow-up concentrations in survivors two years after discharge from the hospital. A series of acute measurements was performed in 28 hospitalized patients (mean age 54.2 ±â€¯5.2 years, mean observation time 88 ±â€¯20 h) and the follow-up measurements were performed in 36 subjects who survived poisoning (including 12/28 survivors from the acute group). Visual evoked potentials (VEP) and magnetic resonance imaging of the brain (MRI) were performed to detect long-term visual and brain sequelae of intoxication. The acute concentrations of inflammatory mediators were higher than the follow-up concentrations: LxA4, 62.0 ±â€¯6.0 vs. 30.0 ±â€¯5.0 pg/mL; LxB4, 64.0 ±â€¯7.0 vs. 34.0 ±â€¯4.0 pg/mL; IL-4, 29.0 ±â€¯4.0 vs. 15.0 ±â€¯1.0 pg/mL; IL-5, 30.0 ±â€¯4.0 vs. 13.0 ±â€¯1.0 pg/mL; IL-9, 30.0 ±â€¯4.0 vs. 13.0 ±â€¯1.0 pg/mL; IL-10, 38.0 ±â€¯5.0 vs. 16.0 ±â€¯1.0 pg/mL; IL-13, 35.0 ±â€¯4.0 vs. 14.0 ±â€¯1.0 pg/mL (all p < 0.001). The patients with higher follow-up IL-5 concentration had prolonged latency P1 (r = 0.413; p = 0.033) and lower amplitude N1P1 (r = -0.498; p = 0.010) of VEP. The higher follow-up IL-10 concentration was associated with MRI signs of brain necrotic damage (r = 0.533; p = 0.001) and brain hemorrhage (r = 0.396; p = 0.020). Our findings suggest that neuroinflammation plays an important role in the mechanisms of toxic brain damage in acute methyl alcohol intoxication.

Seizures in patients with acute pesticide intoxication, with a focus on glufosinate ammonium.

The incidence and clinical aspects of seizures remain to be elucidated in patients with acute pesticide intoxication. The present study included subjects who ingested pesticide with the intention of committing suicide and were treated at Soonchunhyang University Hospital (Cheonan, Korea) between January 2011 and December 2014. We analyzed the incidence and characterized the type and frequency of seizure, from the medical records of 464 patients with acute pesticide intoxication, according to the pesticide class. The effect of seizure on the clinical outcome was assessed. The incidence of seizure was 31.5% in patients who ingested glufosinate ammonium {2-amino-4-[hydroxyl (methyl) phosphinoyl] butyrate; ammonium DL-homoalanin-4-yl (methyl) phosphinate}, followed by those who ingested pyrethroid (5.9%) or glycine derivatives (5.4%). All of the seizures developed between 12 and 24 h of pesticide ingestion and had ceased by 72 h after seizure initiation, following treatment with antiseizure medication. Generalized tonic-clonic seizures were the most commonly observed (85.7% of the cases). Multivariable logistic regression analysis showed that the effect of seizure on mortality was not statistically significant. In conclusion, glufosinate ammonium herbicide is the most common seizurogenic pesticide class. Seizure itself was not a risk factor for mortality in patients with acute glufosinate ammonium intoxication.

Association of renal function and symptoms with mortality in star fruit (Averrhoa carambola) intoxication.

BACKGROUND: Star fruit (SF) is a commonly available fruit produced and eaten in tropical and subtropical countries. Since 1993, various reports have described neurotoxicity after eating SF, but this clinical condition remains unfamiliar. We aimed to describe this clinical entity, the role of renal dysfunction in this disorder, treatment strategies, and prognosis of patients with SF intoxication. METHODS: We conducted a search of PubMed and Google Scholar databases from 1993 to 2016. We included reports describing patients with a clear history of SF ingestion with acute symptoms. We described the demographic characteristics, reported SF intake, treatments used, and outcomes. RESULTS: We reviewed totally 126 patients (male:female = 1.5:1) from 33 articles with mean age 54.4 ± 11 (range: 30-84). The most common symptom was hiccups (65%), whereas confusion and seizure were the most common symptoms associated with mortality (42% and 61%, respectively). Pre-intoxication renal function also affected mortality. While there was no mortality in patients with normal renal function (NRF), the mortality of patients among reported cases with chronic renal insufficiency and end-stage renal disease undergoing dialysis were 36% and 27%, respectively. With the inclusion of patients reported to have NRF, the overall mortality was 24%. Consistently, the number of SF consumed was substantially higher in the patients with NRF than those with renal functional impairment. The most common treatment strategy was hemodialysis (59%). CONCLUSIONS: Patients with impaired renal function were at higher risks of SF intoxication. Severe neurologic symptoms mandate immediate medical intervention because of the association between their occurrence and high mortalities. Toxin removal through dialysis, rather than symptomatic relief, seems to be beneficial to patient survival. Early and continuous dialysis appears to alleviate severe symptoms and prevent symptom rebounds.

The role of the NADPH oxidase derived brain oxidative stress in the cocaine-related death associated with excited delirium: A literature review.

Excited delirium syndrome (ExDS) is a term used to describe a clinical condition characterized by bizarre and aggressive behaviour, commonly associated with the use of psychoactive compounds, especially cocaine. The pathophysiology of ExDS is complex and not yet fully understood. In addition to a central dopamine hypothesis, other mechanisms are thought to be involved in cocaine-related ExDS, such as increased reactive oxygen species production by the family of the NADPH oxidase NOX enzymes. In this review, we will summarize current knowledge on the crucial contribution of brain NADPH oxidase derived oxidative stress in the development of cocaine-induced ExDS. Data from animal models as well as human evidence will be discussed.

Diphenyl Diselenide Protects Against Mortality, Locomotor Deficits and Oxidative Stress in Drosophila melanogaster Model of Manganese-Induced Neurotoxicity.

Several experimental and epidemiological reports have associated manganese exposure with induction of oxidative stress and locomotor dysfunctions. Diphenyl diselenide (DPDS) is widely reported to exhibit antioxidant, anti-inflammatory and neuroprotective effects in in vitro and in vivo studies via multiple biochemical mechanisms. The present study investigated the protective effect of DPDS on manganese-induced toxicity in Drosophila melanogaster. The flies were exposed, in a dietary regimen, to manganese alone (30 mmol per kg) or in combination with DPDS (10 and 20 µmol per kg) for 7 consecutive days. Exposure to manganese significantly (p < 0.05) increased flies mortality, whereas the survivors exhibited significant locomotor deficits with increased acetylcholinesterase (AChE) activity. However, dietary supplementation with DPDS caused a significant decrease in mortality, improvement in locomotor activity and restoration of AChE activity in manganese-exposed flies. Additionally, the significant decreases in the total thiol level, activities of catalase and glutathione-S-transferase were accompanied with significant increases in the generation of reactive oxygen and nitrogen species and thiobarbituric acid reactive substances in flies exposed to manganese alone. Dietary supplementation with DPDS significantly augmented the antioxidant status and prevented manganese-induced oxidative stress in the treated flies. Collectively, the present data highlight that DPDS may be a promising chemopreventive drug candidate against neurotoxicity resulting from acute manganese exposure.

A retrospective study of use of polyvalent anti-snake venom and risk factors for mortality from snake bite in a tertiary care setting.

AIMS: Envenomation with poisonous snakes is associated with considerable morbidity and mortality. The present study was undertaken with the objectives of assessing anti-snake venom (ASV) use, early adverse reactions to ASV, premedication and clinical outcomes in snake bite patients. Association of various risk factors (age, gender, dose of ASV, time gap between snake bite and ASV administration, use of mechanical ventilation and type of snake bite) with mortality was also assessed. SETTINGS AND DESIGN: This retrospective study was conducted at two Tertiary Care Teaching Hospitals. SUBJECTS AND METHODS: The medical records of 176 patients of snake bite with documented use of ASV were retrospectively analyzed to retrieve relevant data. STATISTICAL ANALYSIS: Descriptive statistics was used to express results about ASV use, early adverse reactions to ASV, premedication and clinical outcomes. Univariate and multivariate analysis was performed to find out significant risk factors associated with mortality. RESULTS: The main indication for ASV was vasculotoxic snake bite (75%) followed by neurotoxic snake bite (16%). Mean dose of ASV was 18.63 ± 14.52 vials. Prophylactic premedication with corticosteroids alone or in combination with antihistaminic was used in more than 70% patients. Early adverse reactions to ASV were seen in 4% patients. Neurotoxic snake bite was a significant risk factor associated with mortality in multivariate analysis. CONCLUSIONS: Neurotoxic snake bite is an independent predictor of mortality in snake bite patients. Currently used polyvalent ASV may be less effective in treating neurotoxic snake bite.

Outbreaks of unexplained neurologic illness - Muzaffarpur, India, 2013-2014.

Outbreaks of an unexplained acute neurologic illness affecting young children and associated with high case-fatality rates have been reported in the Muzaffarpur district of Bihar state in India since 1995. The outbreaks generally peak in June and decline weeks later with the onset of monsoon rains. There have been multiple epidemiologic and laboratory investigations of this syndrome, leading to a wide spectrum of proposed causes for the illness, including infectious encephalitis and exposure to pesticides. An association between illness and litchi fruit has been postulated because Muzaffarpur is a litchi fruit-producing region. To better characterize clinical and epidemiologic features of the illness that might suggest its cause and how it can be prevented, the Indian National Centre for Disease Control (NCDC) and CDC investigated outbreaks in 2013 and 2014. Clinical and laboratory findings in 2013 suggested a noninflammatory encephalopathy, possibly caused by a toxin. A common laboratory finding was low blood glucose (<70 mg/dL) on admission, a finding associated with a poorer outcome; 44% of all cases were fatal. An ongoing 2014 investigation has found no evidence of any infectious etiology and supports the possibility that exposure to a toxin might be the cause. The outbreak period coincides with the month-long litchi harvesting season in Muzaffarpur. Although a specific etiology has not yet been determined, the 2014 investigation has identified the illness as a hypoglycemic encephalopathy and confirmed the importance of ongoing laboratory evaluation of environmental toxins to identify a potential causative agent, including markers for methylenecyclopropylglycine (MCPG), a compound found in litchi seeds known to cause hypoglycemia in animal studies. Current public health recommendations are focused on reducing mortality by urging affected families to seek prompt medical care, and ensuring rapid assessment and correction of hypoglycemia in ill children.

Lack of neuropathological changes in rats administered tedizolid phosphate for nine months.

Tedizolid, a novel oxazolidinone antibacterial, was administered to Long Evans rats by oral gavage once daily for up to 9 months at doses near the maximum tolerated dose (MTD) to evaluate for potential neurotoxicity. Mean plasma exposures of tedizolid at the low-, medium-, and high-dose levels (7.5, 15, and 30 mg/kg of body weight/day for males; 2.5, 5, and 10 mg/kg/day for females) were similar between males and females and were 1.8-, 3.9-, and 8.0-fold greater than exposures in patients at the therapeutic dose (200 mg once daily). Evaluated endpoints included survival, clinical observations, body weight, and food consumption. At 1, 3, 6, and 9 months, ophthalmic examinations, functional observational batteries, and locomotor activity measures were conducted, brain weights/sizes were recorded, and perfusion-fixed tissues were collected from 12 rats/sex/group/time point. A detailed morphological assessment was conducted on brain, eyes, optic nerve/tract, spinal cord, peripheral nerves (includes sciatic, sural, tibial, peroneal, trigeminal), and skeletal muscle. At the end of 9 months, less body weight gain was seen in high-dose males (-6.7%) and females (-5.8%) compared with that seen in controls. There were no tedizolid-related adverse neurobehavioral effects or tedizolid-related histopathologic changes in the central/peripheral nervous systems, including the optic nerve. Results of this study indicate that tedizolid was not neurotoxic when administered long term to pigmented rats at doses near the MTD, which were up to 8-fold higher than the human therapeutic exposure.

PLANT POISONING IN THAILAND: A 10-YEAR ANALYSIS FROM RAMATHIBODI POISON CENTER.

Plant poisoning is not uncommon in Thailand. The objective of this study was to determine the incidence, type, clinical manifestations, severity and outcomes of plant poisoned patients in Thailand over a 10-year period. We retrospectively reviewed data from the Ramathibodi Poison Center Toxic Exposure Surveillance System for 2001-2010. A total of 2,901 poisonous plant exposure cases were identified, comprising 3.1% of the 92,392 poison cases recorded during the study period. This was the fifth most common type of poisoning recorded. Children aged < 13 years comprised the largest percent (69.8%) of the cases. The major type of exposure was unintentional ingestion. Ninety-nine types of poisonous plants were recorded as the causative agents among 99.1%of the cases. Gastrointestinal symptoms were reported in 72.0% of cases with Jatropha curcas (physic nut) comprising 54.1% of these. Most patients had only minor signs and symptoms. The mortality rate among the total plant poisoning cases was 0.9%, with 26 deaths. Thirteen deaths occurred in children aged < 13 years. The greatest number of fatalities were due to ingestion of Manihot esculenta (cassava), primarily due to multi-system organ failure. Children aged < 13 years are at the greatest risk for plant poisoning in Thailand; mostly unintentional. Most cases were minor and the mortality rate was low. Jatropha curcas was the most common cause of poisoning and Manihot esculenta was the most common cause of death. Public education is important to minimize these poisonings.

Poisoning by Poiretia punctata in cattle and sheep / Intoxicação por Poiretia punctata em bovinos e ovinos

Poiretia punctata (Willd.) Desv. was associated with cattle and sheep poisoning on nine farms in the State of Sergipe, northeastern Brazil. The animals were found dead or died later after showing clinical signs for up to 18 hours. Two sheep that ingested 40g/kg body weight (g/kg) of fresh P. punctata died three and eight hours after ingestion, respectively. Another sheep that ingested 40g/kg five days after plant collection showed mild clinical signs and recovered after 24 hours. Two sheep that received 20g/kg and another that ingested three daily doses of 20g/kg showed clinical signs, but recovered. Two cattle that ingested 20g/kg of the fresh plant exhibited clinical signs and recovered. The clinical observations of poisoning were depression, ataxia, loss of equilibrium, broad-based stance, head down, falls, mandibular trismus, opisthotonous, nystagmus, and recumbence. Significant gross and histologic lesions were not observed. Samples of P. punctata were analyzed for nitrates, cyanogenic glycosides, and sodium monofluouracetate with negative results. It is concluded that P. punctata is a toxic plant that caused death in cattle and sheep in the State of Sergipe.

Poiretia punctata (Willd.) Desv. foi associada a intoxicações em bovinos e ovinos em nove fazendas no estado de Sergipe, nordeste do Brasil. Os animais eram encontrados mortos ou morreram após apresentar sinais clínicos com evolução de até 18 horas. Dois ovinos que ingeriram P. punctata, fresca, na dose de 40g/kg de peso corporal (g/kg) morreram após a ingestão da planta em três e oito horas, respectivamente. Outro ovino que ingeriu a planta coletada cinco dias antes de ser oferecida ao animal na dose de 40g/kg apresentou sinais clínicos leves e se recuperou depois de 24 horas. Dois ovinos que receberam 20g/kg e outro que ingeriu, durante três dias consecutivos, doses de 20g/kg apresentaram sinais clínicos leves e se recuperaram. Dois bovinos que ingeriram a planta fresca, na dose de 20g/kg apresentaram sinais clínicos e se recuperaram. As observações clínicas da intoxicação foram depressão, ataxia, perda de equilíbrio, postura de base ampla, cabeça baixa, quedas, trismo mandibular, opistótono, nistagmo e decúbito. Não foram observadas lesões macroscópicas nem histológicas de significância. Amostras de P. punctata foram analisadas para nitratos, glicosídeos cianogênicos, e monofluoracetato sódio com resultados negativos. Conclui-se que P. punctata é uma planta tóxica que causa morte de bovinos e ovinos no estado de Sergipe.

The neuroprotective effect of tropisetron on vincristine-induced neurotoxicity.

Vincristine (VCR) peripheral neuropathy is a dose-limiting side effect. Several studies have shown that tropisetron, a 5-HT3 receptor antagonist, exerts anti-inflammatory and immunomodulatory properties. Current study was designed to investigate a suppressive effect of tropisetron on VCR-induced neuropathy and whether this effect exerts through the 5-HT3 receptor or not. Neuropathy was induced in rats by administration of vincristine (0.5mg/kg, 3 intraperitoneal injections on alternate days) and in treatment group, tropisetron (3mg/kg); m-chlorophenylbiguanide (mCPBG), a selective 5-HT3 receptor agonist (15mg/kg); tropisetron (3mg/kg) plus mCPBG (15mg/kg); granisetron, another selective 5-HT3 receptor antagonist (3mg/kg) were administered intraperitoneally 1h prior to vincristine injection. Hot plate, open field tests (total distance moved, mean velocity and percentage of total duration of the movement) and motor nerve conduction velocity (MNCV) were performed to evaluate the sensory and motor neuropathy. Further, plasma levels of tumor necrosis factor-alpha (TNF-α) and interleukin-2 (IL-2) and the level of TNF-α in sciatic nerve were assessed as well as histological examination. In only VCR-treated rats hot plate latencies were significantly increased, total distance moved, mean velocity, total duration of the movement and sciatic MNCV significantly decreased compared with control. In tropisetron and tropisetron plus mCPBG groups, one injection of tropisetron prior to each VCR injection robustly diminished TNF-α and IL-2 levels, and also prevented mixed sensory-motor neuropathy, as indicated by less mortality rate, better general conditions, behavioral and electrophysiological studies. Moreover, pathological evidence confirmed the results obtained from other findings. But granisetron and mCPBG had no significant effect on the mentioned parameters. In conclusion, these studies demonstrate that tropisetron significantly suppressed VCR-induced neuropathy and could be a neuroprotective agent for prevention of VCR-induced neuropathy via a receptor-independent pathway.

Aggravation of cyclophosphamide-induced acute neurological disorders under conditions of artificial acidification of chyme in rats.

The effect of artificial acidification of the intestinal content on neurological manifestations of acute severe cyclophosphamide intoxication was studied in rats. The animals were gavaged with 20 ml/kg sulfuric (0.05 M), hydrochloric, boric, or lactic acids (0.1 M) 3 h before intraperitoneal injections of the cytostatic in doses of 0, 200, 600, or 1000 mg/kg. The decrease in pH (by.0) and ammonia-producing activity of the cecal chyme developed within 3 h after administration of acids. Cyclophosphamide caused hyperammonemia; glutamine/ammonia and urea/ammonia ratios in the blood decreased. These changes augmented after administration of acids (boric acid produced maximum and lactic acid minimum effects). Acid treatment resulted in greatest elevation of ammonia level in the portal venous blood and a lesser elevation in the vena cava posterior blood. Acid treatment promoted manifestation of cyclophosphamide neurotoxic effect and animal death. Hence, acidification of the chyme inhibited the formation of ammonia in it, while ammonia release from the gastrointestinal tract into the blood increased; the treatment augmented hyperammonemia and aggravated the neurological manifestations of cyclophosphamide intoxication.

[Use of cytoflavin into the complex intensive therapy of acute cerebral insufficiency caused by poisoning].

In the result of treatment of 147 patients with toxic acute brain insufficiency were revealed that the employment of citoflavin (20 ml with 400 ml 5% glucosae twice a day) in 7 days intensive therapy of acute brain insufficiency leaded to decrease of hypoxic brain damages and intensity of brain depression, what was revealed in improvement of brain bioelectric activity. Rehabilitation of central nervous system regulation function and life-support systems leaded to quick rehabilitation of respiratory part of oxygen transport. These changes in acute period leaded to quick reparation of cognitive-mnestic functions and social adaptation. The employment of citoflavin leaded to improvement of clinic of toxicohypoxic encephalopathy and to decrease of secondary lung complications (decrease of coma-period from 45,3 ± 8,2 to 27,7 ± 6,9 hours; decrease of secondary lung complications from 72,7% to 35,9%).

Lethal toxic encephalopathy due to childhood shigellosis or Ekiri syndrome.

Lethal toxic encephalopathy due to shigellosis or Ekiri syndrome is a rare complication of shigellosis with a high fatality rate. Data are very limited on factors that can predict this encephalopathy, so we evaluated clinical and laboratory characteristics for these patients. In this study children with extreme toxicity and convulsions followed by rapid neurological deterioration resulting in brain edema and fatal outcome without sepsis and severe dehydration were selected as having lethal toxic encephalopathy. There were 1295 children with shigellosis during the 10 years of the study. Five children (0.4%) had lethal toxic encephalopathy due to shigellosis. Death occurred following rapid neurological detoriation resulting in brain edema despite intensive treatment. Evidence of brain edema may be a prediction factor for death. Early recognition of encephalopathy and measures to prevent brain edema may improve patient outcome.

Clinical toxicology of newer recreational drugs.

INTRODUCTION: Novel synthetic 'designer' drugs with stimulant, ecstasy-like (entactogenic) and/or hallucinogenic properties have become increasingly popular among recreational drug users in recent years. The substances used change frequently in response to market trends and legislative controls and it is an important challenge for poisons centres and clinical toxicologists to remain updated on the pharmacological and toxicological effects of these emerging agents. AIMS: To review the available information on newer synthetic stimulant, entactogenic and hallucinogenic drugs, provide a framework for classification of these drugs based on chemical structure and describe their pharmacology and clinical toxicology. METHODS: A comprehensive review of the published literature was performed using PUBMED and Medline databases, together with additional non-peer reviewed information sources, including books, media reports, government publications and internet resources, including drug user web forums. EPIDEMIOLOGY: Novel synthetic stimulant, entactogenic or hallucinogenic designer drugs are increasingly available to users as demonstrated by user surveys, poisons centre calls, activity on internet drug forums, hospital attendance data and mortality data. Some population sub groups such as younger adults who attend dance music clubs are more likely to use these substances. The internet plays an important role in determining the awareness of and availability of these newer drugs of abuse. CLASSIFICATION: Most novel synthetic stimulant, entactogenic or hallucinogenic drugs of abuse can be classified according to chemical structure as piperazines (e.g. benzylpiperazine (BZP), trifluoromethylphenylpiperazine), phenethylamines (e.g. 2C or D-series of ring-substituted amfetamines, benzodifurans, cathinones, aminoindans), tryptamines (e.g. dimethyltryptamine, alpha-methyltryptamine, ethyltryptamine, 5-methoxy-alphamethyltryptamine) or piperidines and related substances (e.g. desoxypipradrol, diphenylprolinol). Alternatively classification may be based on clinical effects as either primarily stimulant, entactogenic or hallucinogenic, although most drugs have a combination of such effects. CLINICAL TOXICOLOGY: Piperazines, phenethylamines, tryptamines and piperidines have actions at multiple central nervous system (CNS) receptor sites, with patterns of effects varying between agents. Predominantly stimulant drugs (e.g. benzylpiperazine, mephedrone, naphyrone, diphenylprolinol) inhibit monoamine (especially dopamine) reuptake and are characteristically associated with a sympathomimetic toxidrome. Entactogenic drugs (e.g. phenylpiperazines, methylone) provoke central serotonin release, while newer hallucinogens (e.g. 5-methoxy-N,N-diisopropyltryptamine (5-MeO-DiPT), 2,5-dimethoxy-4-bromoamfetamine (DOB)) are serotonin receptor agonists. As a result, serotoninergic effects predominate in toxicity. CONCLUSIONS: There are limited reliable data to guide clinicians managing patients with toxicity due to these substances. The harms associated with emerging recreational drugs are not fully documented, although it is clear that they are not without risk. Management of users with acute toxic effects is pragmatic and primarily extrapolated from experience with longer established stimulant or hallucinogenic drugs such as amfetamines, 3,4-methylenedioxymethamfetamine (MDMA) and lysergic acid diethylamide (LSD).