Is there any potential management against COVID-19? A systematic review and meta-analysis.

PURPOSE: A recent survey has shown that the COVID-19 pandemic has culminated in dramatical and critical treatment particularly in acute infected patients. In fact, this systematic review-meta-analysis was directly pertained to estimation at the efficient value of some clinical managements to confront the COVID-19 infection. METHODS: Pubmed, Embase, Scopus, Cochrane, and Scholar databases were searched from inception to July 1, 2020, to identify studies reporting the current treatment process and medications (e.g. hydroxychloroquine, antiviral therapy, convalescent plasma, and immunomodulatory agents) for COVID-19. A random-effects model meta-analysis was performed to calculate the relative risk (RR) with 95% confidence intervals (CI). The outcomes of this study were the frequency of negative conversion cases, clinical improvements, mechanical ventilation demand, intensive care unit (ICU) entry, and mortality. The standard treatment refers to the published guidelines and specialist experience which varies in different articles, and the proposed treatment refers to the kind of interest suggested in the included studies. RESULTS: A number of 45 articles met the eligibility criteria (out of 6793 articles). Among them, 26 articles involving 3263 patients were included in quantitative analysis. Anti-COVID-19 interventions could significantly increase clinical improvement (RR 1.17, 95% CI 1.08-1.27; I2 = 49.8%) and reduce the mortality rate (RR 0.58, 95% CI 0.35-0.95; I2 = 74.8%). Although in terms of negative conversion, ICU entry, and mechanical ventilation demand, clinical intervention had no beneficial effect. The clinical effect of immunomodulatory agents (especially tocilizumab and anakinra) was noticeable compared to other medications with RR of 0.22 (95% CI 0.09-0.53; I2 = 40.9%) for mortality and 1.25 (95% CI 1.07-1.46; I2 = 45.4%) for clinical improvement. Moreover, Antivirals (RR 1.13, 95% CI 1.01-1.26; I2 = 47.0%) and convalescent plasma therapy (RR 1.41, 95% CI 1.01-1.98; I2 = 66.6%) had significant beneficial effects on clinical improvement. CONCLUSION: Based on our findings, all the included interventions significantly declined the mortality and enhanced clinical improvements with no effect on negative conversion and mechanical ventilation demand. Especially, immunomodulators and plasma therapy showed favorable outcomes. An evaluation on the efficacy of proposed treatment against COVID-19.

High sensitivity versus low level of vancomycin needs to be concern for another alternative anti- Staphylococcus aureus as the first- line antibiotic.

BACKGROUND AND AIM: Vancomycin has been the first-line therapy for MRSA infection disease for many years. According to standard guidelines, the therapeutic vancomycin trough concentration should be above 10 mg/L and optimally between 15-20 mg/L. The aim of this study was to evaluate vancomycin trough level concentration in patients infected with MRSA. METHODS: This cross- sectional study included a sample of 170 patients admitted to the ICU of Loghman hospital. We used a standard questionnaire, then applied appropriate statistical tests. All collected data had been analyzed and interpreted by IBM SPSS Statistics 19.0. RESULTS: Among this study population, 71.8% was male. Just 20.8% of the patients can reach the therapeutic level trough even after changing the dose. It should be noted that a significant percentage of toxicity was observed after increasing the dose. CONCLUSIONS: Even though high sensitivity against vancomycin disc has been seen in antibiogram tests, sufficient efficiency has not been distinguished, in the sense that, just a few patients by low trough level concentration, reached to therapeutic level after the dose change. Based on some sources, because of the side effects and limited safe range of vancomycin, we should consider a new approach to the alternative antibiotics. (www.actabiomedica.it).

Survey on Hypothermia and Hyperthermia in Poisoned Patients in a Unique Referral Hospital, Tehran, Iran.

BACKGROUND: Body temperature is a critical criterion of health. Drugs and a variety of poisons can affect body temperature in poisoned patients, causing hyperthermia and hyperpyrexia. OBJECTIVES: Our previous study's findings in patients poisoned with organophosphate led us to the goal of this study: obtaining the initial tympanic temperature in patients poisoned by a variety of toxins. MATERIALS AND METHODS: A cross-sectional study reviewed the records of poisoned patients who were admitted to the toxicological intensive care unit (TICU) at Loghman Hakim hospital poison center (LHHPC) from February 2014 to February 2015. The data collected included gender, age, type of poisoning, the season during which poisoning occurred, vital signs, initial tympanic temperature (first four hours), presence of seizures, white blood cell (WBC) count, creatinine phosphokinase (CPK), length of stay and patient outcome. We determined the mean (SD) for normally distributed continuous variables, the median and interquartile range for non-normally distributed continuous variables, and the absolute and relative frequency (%) for categorical variables. All were determined using SPSS version 16. RESULTS: Data were collected from 310 eligible patients. The mean patient age was 32.65 (with a standard deviation of 14.40). Of the patients in the study, 183 (59%) were male. Intentional poisoning in an attempted suicide was documented in 253 (81.6%) patients. The most prevalent poisoning agent was aluminum phosphate (18.70%), followed by methadone (10%) and opium (10%). Seventy percent of the patients (n = 217) were diagnosed and classified with fever or hyperthermia. A temperature ≥ 40°C was detected in just three cases. The highest mean temperature was found in patients poisoned with amphetamine, organophosphate and tramadol. Patients with alcohol and phenobarbital poisoning were included in the sample, but these patients were not diagnosed with hypothermia. WBC ≥ 10,000 cells/mL and CPK ≥ 975 IU/L were recorded in 57.7% and 13.2% of subjects, respectively. CONCLUSIONS: Body temperature changes in human poisonings are a matter in need of special attention. A literature review did not reveal any controversy over hypothermia, but poisoning cases exhibit a variety of patterns of fever and hyperthermia. If there are no limits to the diagnosis of fever and hyperthermia, all cases with a poor prognosis which fail to respond to treatment could be categorized as drug-induced hyperthermia. Therefore, a different approach is needed for poisoning cases.

Central Nervous System Depressants Poisoning and Ventilator Associated Pneumonia: An Underrated Risk Factor at the Toxicological Intensive Care Unit.

BACKGROUND: Ventilator-Associated Pneumonia (VAP) is the main cause of nosocomial infection at intensive care units (ICUs), which causes high mortality and morbidity. OBJECTIVES: The objective of the present survey was to identify the VAP risk and prognostic factors among poisoned patients, who were admitted to the toxicological ICU (TICU), especially central nervous system (CNS) depressants due to their prevalence and importance. PATIENTS AND METHODS: A case-control study was conducted at the Loghman Hakim hospital between March 2013 and March 2014. Among 300 poisoned patients with mechanical ventilator ≥ 48 hours, 150 patients, who had developed microbiologically-confirmed VAP were considered as the VAP group and 150 without VAP were defined as the control group. The following data were collected; age, gender, type of poisoning, glasgow coma score, Acute physiology and chronic health evaluation (APACHE) II score, length of hospital stay, previous antibiotic use, microbial culture of the trachea, body temperature, leukocyte count, and patients' outcome. Based on the type of poisoning, patients were divided into three groups including: opioid, CNS depressants and others. All data were expressed as means (SD) for continuous variables and frequencies for categorical variables. Logistic regression was used to determine the relationship between risk factors and VAP. RESULTS: The mean age of the patients was 33.9 ± 14.3 years. The probable VAP incidence and mortality were 22% and 18.6%, respectively. The rate of CNS depressant versus opioid use (odds ratio, 3.74; P < 0.027), APACHE II (odds ratio, 1.28; P < 0.000) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent risk factors for VAP. While, the APACHE II score (odds ratio, 1.12; P < 0.044) and length of hospital stay (odds ratio, 2.15; P < 0.000) were the independent predictors of VAP mortality among these patients. The most common microorganisms in VAP cases were Methicillin-Resistant Staphylococcus aureus (MRSA) and Acinetobacter sp. (56.7% and 12.7%, respectively). CONCLUSIONS: Central nervous system depressant was an important risk factor for VAP among poisoned patients. Hypoventilation due to CNS depression can lead to VAP. The APACHE II and length of hospital stay were shown as independent predictors of VAP and mortality among these patients.

Hypo and hyperglycemia among tramadol overdose patients in Loghman Hakim Hospital, Tehran, Iran.

Tramadol is a synthetic and centrally active analgesic. Hypoglycemia as another possible major side effect among abusers has not been known well. Our objective is evaluation of the Blood Glucose Level (BGL) among tramadol-overdosed patients. This prospective cross-sectional study was performed from Feb to June 2013; BGL was measured at the time of admission, 8 and 12 hours later. All patients with hypoglycemia received infusion of 0.5-1 gr/kg of hypertonic dextrose and their BGL was checked every hour until normal BGL. Patients' demographic, clinical and paraclinical data were collected. Totally, 128 patients with a mean (SD) age of 24.5 (6.9) years were recruited; 127 (99.2%) were male. Seizure occurred in 59.4% cases. Mean ± SD admission BGL was 94.88 ± 21.5mg/dL. Fourteen patients experienced hypoglycemia within 12 hours period. Hyperglycemia was experienced in 8 patients (6.25%) on admission day. There was no significant relation between the dose of tramadol and BGL. In conclusion, hypoglycemia must be considered as an important side effect of tramadol-overdose. It is suggested that serial BGL monitoring in cases of Tramadol-overdose should be done for early recognition of hypoglycemia and its timely management. Also hyperglycemia may be revealed.

VAP or poisoning; which one has more effect on patients' outcomes in toxicological ICU?

BACKGROUND: Ventilator-associated pneumonia (VAP) is the main cause of acquired infections in ICUs. Every year, millions of people suffer from poisoning by various substances. Our aim was to determine the association between VAP incidence and different kinds of toxicity among Toxicological ICU (TICU) patients.  MATERIALS AND METHODS: Poisoned patients with diagnosis of VAP were enrolled to our retrospective study at TICU of Loghman Hakim Hospital. Data was collected through the medical records. The statistical analysis was performed with SPSS (version 16, Chicago, IL, USA). RESULTS: Among 675 patients with MV > 48 h, 150 patients had the diagnosis of VAP.  Mean age was 36.6 years. 74.7% were males. Intentional poisoning was 70.3%. The incidence of VAP was 22%. The higher incidence of VAP was recorded in anti depressants and opioid toxicities. The majority of bacterial isolates (81.3%) were multi drug resistance. MRSA accounted for 50.7% of VAP cases. Non survivors' hospital length of stay (mean = 18.7days) was significantly higher than survivors (12.8). The hospital length of stay in VAP patients was highest in the Acinetobacter spp (mean > 20 days). Mortality rate of VAP cases was 18.6%. CONCLUSION: No specific association was detected between incidence of VAP and different kinds of toxicity, while Anti Depressants and opioids had high VAP incidence, in a Quarter of this population. It is noticeable that pesticide had the lowest incidence for its short hospitalization. In our TICU, MRSA and Acinetobacter spp were the main agents leading to VAP and prolonged ICU stay, respectively. (www.actabiomedica.it).

Multidrug-resistant Acinetobacter baumannii infection in intensive care unit patients in a hospital with building construction: is there an association?

BACKGROUND: Acinetobacter baumannii (A. baumannii) has emerged globally as a significant pathogen in hospitals. It is also present in soil and water. In a previous study, we discovered that the A. baumannii class 2 integron occurred most frequently. Here, we determined whether the A. baumannii class 2 integron is in the soil around our hospital, and if the soil is the cause for increasing numbers of A. baumannii infections in our intensive care unit (ICU) patients. METHODS: This cross-sectional prospective study was conducted in two ICUs at Loghman-Hakim Hospital, Tehran, Iran, from November 2012 to March 2013. Patient, soil, and hospital environment samples were collected. All isolates were identified using standard bacteriologic and biochemical methods. The phenotypes and genotypes were characterized. The standard disc diffusion method was utilized to test antimicrobial susceptibility. Integron identification was performed by multiplex polymerase chain reaction. RESULTS: A total of 42 A. baumannii clinical strains were isolated, all from patient samples; 65% of the isolated species were classified as class 2 integrons. The strains were 100% resistant to piperacillin, piperacillin-tazobactam, ceftazidime, ceftriaxone, cotrimoxazole, cefepime, ceropenem, and cefotaxime. However, all of the strains were sensitive to polymyxin B. A. baumannii was detected around the lip of one patient. CONCLUSIONS: Further research is necessary to establish a relationship between A. baumannii and soil, (especially in regards to its bioremediation), as well as to determine its importance in nosocomial infections and outbreaks in the ICU.

Teicoplanin as an anti-methicillin resistant Staphylococcus aureus agent in infections of severely poisoned intensive care unit patients/ Tehran- Iran.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia is related to high morbidity and mortality. Glycopeptide antibiotic is the choice of treatment in MRSA infections. Teicoplanin is a semi synthetic glycopeptide antibiotic with a spectrum of activity similar to vancomycin.  Our objective is the evaluation of efficacy and safety of Teicoplanin in MRSA infections among severely poisoned intensive care unit (ICU) patients. METHOD: During a 6 months period, in a prospective cross sectional study 54 eligible patients from 80 clinically suspicious with MRSA infections were recruited. The efficacy and safety of Teicoplanin was evaluated 5 times. The clinical findings, laboratory data, and bacteriologic responses were defined as cure, improvement and failure. RESULTS: The mean age of the patients was 36.3 years (range, 20-72, SD = 13.3). 75.9% were male. Suicidal attempts were recorded in 63%. The most common poisoning was TCAs, BZDs, tramadol and opium. 94.4% were unconscious and under mechanical ventilation. Tracheal cultures were positive in 98.1% by VAP diagnosis. Length of stay in the ICU was between  4-54 days. Total clinical effectiveness was 90.4%, and failure 9.6%. Mortality rate of the patient, was 9/54 (16.6 %) which 3 of them were for lack of a clinical response. On the fourth visit, the adverse effects included: rash (11.10%), anemia (36.17%), nephrotoxicity (17.02%) and thrombocytopenia < 150000 (100%). Other side effects such as: leucopenia, severe thrombocytopenia (< 50000), pancytopenia and red man syndrome were not detected. CONCLUSIONS: Teicoplanin is suggestible for MRSA infections among severely poisoned patients according to its efficacy, safety, half life and tolerance.

Suicide epidemiology and characteristics among young Iranians at poison ward, Loghman-Hakim Hospital (1997-2007).

BACKGROUND: Suicide is a critical public health problem. In developing countries, the highest suicide rate is found in young adults with remarkable increasing rate. In this study, we have evaluated the epidemiology and characteristics of 8-16-year-old individuals who attempted suicideand were hospitalized in Loghman-Hakim Hospital, Tehran, Iran from 1997 to 2007. METHODS: A total of 6414 hospitalized patients, ages 8-16, who attempted suicide and were residents of Loghman-Hakim Hospital were investigated. We performed a retrospective chart review to study the characteristics of cases in a 10-year period by review of psychiatric and medical records. RESULTS: Out of 6414 patients, 22.6% were males, 5978 patients were 12-16 years old and the rest were aged 8-12 years. During the 10-year period, suicides showed a rising trend among adults, while in children no significant increase was detected. Communicative disorders were the most common underlying risk factors, particularly in females. One patient out of five cases had psychiatric disorders, of which adjustment disorders were the most predominant. A remarkable peak in suicides was observed in May and July, while winter had the highest suicide rate among seasons. CONCLUSIONS: Suicide due to drug overdose is higher in females than males in young population. This increasing trend is a psychiatric concern and should be resolved by improving mental and public health.

Temperature changes among organophosphate poisoned patients, Tehran- Iran.

BACKGROUND: Acute poisoning with organophosphorus compounds (OPs) is a major global clinical problem in the developing countries. There have been many animal studies and few human surveys on the effects of organophosphorus pesticide (OP) poisoning on thermoregulation. The aim of this prospective study was to document the pattern of tympanic temperature changes among OP poisoned patients throughout the length of their hospital stay. METHODS: 60 patients with diagnose of organophosphate poisoning were included in this study. Questioner was filled out by trained nurses including demographic, clinical and paraclinical data. Tympanic temperature and Pulse rate data of the cases were collected on five- occasions after admission. RESULTS: There were 41 (68.3%) male and 19 (31.7%) female, with a mean age of 34.4 ±19.4 years (range 13-89 years). Forty five patients had intentional poisoning for suicidal attempt. At the time of entry, the mean tympanic temperature, pulse rate, respiratory rate and blood pressure (systolic and diastolic) of the OP poisoned patients were respectively 37.1+/-0.6°C (36.0- 39.5), 91+/-18 (55-145), 18+/-5.6 (8-44), 116+/-20 mm Hg (70-170) and 75+/-11.6 mm Hg (40-110). 41.7% of the cases had serum butyryl cholinesterase activities (BChE) ≥ 50% normal (≥1600 mU/ml). Our patients had normal temperature at the time entry (mean = 37.1). Tympanic temperature decreasing below 36°C was not detected among the patients during the study period. A rise in mean tympanic temperature was found after atropine administration. CONCLUSION: Our study showed hypothermia was not considerable factor among organophosphate poisoned patients, although more studies with similar situations in tropical countries are needed.

A survey on microorganisms and their sensitivity by E-test in ventilator-associated pneumonia at Toxicological-Intensive Care Unit of Loghman-Hakim Hospital.

INTRODUCTION: Ventilator associated pneumonia (VAP) is the most common nosocomial infection at ICUs, with high mortality and morbidity. The diagnostic method for VAP is based on the combination of clinical, radiological, and microbiological criteria. Lower respiratory tract culture results are useful to confirm the etiology of VAP and adjusted antibiotics. Endotracheal aspiration (EA) is the simplest noninvasive technique for performing lower respiratory tract culture, with high sensitivity and moderately high specificity. The aim of this survey was to evaluate the quantitative cultures of endotracheal aspirates in VAP patients and the sensitivity patterns of microorganisms through E-test. METHOD: Among 582 ICU admitted patients who were under mechanical ventilation for more than 48 hours, 72 suspected patients of VAP were prospectively evaluated during a 10 month period. Evaluation of our ICU standards by APACHE III scoring, and GCS were carried out on the first day of admission in all patients. Quantitative cultures of EA were performed on all 72 patients. Antibiotic resistance pattern of isolated pathogens was defined by E-test. RESULTS: VAP was confirmed in 46 out of 72 cases (50, 69.4% males and 22, 30.6% females - mean age was 33 +/- 12 years) through quantitative cultures of EA samples. The probable incidence of VAP was 7.9% (per ventilated patients > or = 48 hours). The mean APACHE III score was 31.28 +/- 16. GCS in most of the patients was between 8 and 12. Staphylococcus aureus was the most frequently isolated organism (58.7%), with high sensitivity to Amikacin, Ciprofloxacin, and Teicoplanin (>92%); Pseudomonas aeruginosa was the second most frequent organism (17.4 percent); Acinetobacter isolates were potentially drug resistant, and only Amikacin was effective. CONCLUSION: Tracheal aspirates in combination with clinical findings show important roles in the management of VAP and decrease inappropriate antimicrobial therapy. S. aureus is the main agent leading to VAP in the TICU of the Loghman Hakim Hospital.

Dose-independent occurrence of seizure with tramadol.

INTRODUCTION: Tramadol, as a centrally-acting, opioid-like analgesic with serotonin reuptake inhibition property, is one of the most prescribed analgesics in the world. We assessed the incidence of seizure, as it is one of the most important adverse effects. METHODS: In a cross-sectional study, 215 cases of tramadol users or abusers who were admitted to Loghman-Hakim Hospital Poisoning Center (LHHPC) in Tehran during a 5-month period, from April 2007 to September 2007, were assessed to evaluate the occurrence of seizure. Patients with positive history of co-ingestion of other drugs, addiction, convulsive disorders, renal diseases, or head trauma with abnormal electroencephalography (EEG) or computerized tomography (CT) scan of the brain were excluded, thus 132 patients were included in the study. For patients who had seizure, CT scan of the brain and EEG were performed, and frequency and type of seizure were identified. Mean tramadol dose was compared between patients with and without seizure. RESULTS: Among the patients, 97 (73.5%) were male. Seizure occurred in 61 patients (46.2%) within 24 hours after tramadol ingestion. The majority of patients who had seizure were male (male, 83.6% vs. female, 16.4%). Mean tramadol dose was lower among females than males (males, 2413 mg vs. females, 1706 mg), but the difference was not statistically significant. Of 35 patients with documented seizure type, all showed generalized tonic-clonic seizure and 12 patients had abnormal EEG (35.3%). No statistically significant difference was observed in mean tramadol intake between patients with or without seizure. Analysis of patients with seizure, according to tramadol intake, indicated that most patients used tramadol in the dose range of 500-1000 mg followed in occurrence by 1500-2000 mg, then 100-500 mg, 2500-3000 mg, and 3500-4000 mg. CONCLUSIONS: Mean tramadol intake does not differ between patients with and without seizure, and the most common dose range in those with seizure is 500-1000 mg. We thus conclude that the incidence of seizure with tramadol is not dose dependent.

Cefepime/clindamycin vs. ceftriaxone/clindamycin for the empiric treatment of poisoned patients with aspiration pneumonia.

Different antimicrobial treatments have proved to be effective in patients with aspiration pneumonia. However, resistant bacterial strains are commonly observed in hospital settings challenging the empirical treatment of these patients. In this study, we aimed to compare the efficacy of cefepime/clindamycin and ceftriaxone/clindamycin for empiric therapy of poisoned patients with aspiration pneumonia. In an open, randomized, prospective design, 140 consecutive patients aged more than 13 years, with radiographic signs of infiltration in chest radiography and dullness on percussion or pulmonary rales or ronchi in combination with at least two of the following clinical criteria were considered as eligible: fever > or = 37 degrees C (axillary), or hypothermia < 35 degrees C (axillary) and leukocytosis (> 10 cells/mm3), or leukopenia (< 3,000 cells/mm3), a left-shift of > 10%, or purulent sputum or secretion from trachea or bronchi. Participants received intravenously either ceftriaxone 1 g q12 h and clindamycin 900 mg q8 h (group 1) or cefepime 1 g q12 h and clindamycin 900 mg q8 h (group 2). On day 5 of treatment, the number of improved/cured patients was not different between groups (OR 0.86; 95% CI 0.24 to 2.90) nor at 14 days of the study (OR 0.66; 95% CI 0.12 to 3.29). Six patients died in group 1 and 5 in group 2 (RR 0.83; 95% CI 0.28 to 2.46). In conclusion, efficacy of empiric treatment of poisoned patients with aspiration pneumonia with ceftriaxone/clindamycin was comparable to treatment with cefepime/clindamycin.

Gastrointestinal and urinary tract bleeding in methanol toxicity.

Methanol is a clear, colourless liquid with a smell and taste similar to ethanol. Intoxications with methanol are still frequent in large parts of the developing world. Haemodialysis should be done in cases of severe toxicity to eliminate toxic metabolites. In this case report, we describe a 37-year-old chronic alcohol abuser with methanol poisoning, who developed haematuria and upper gastrointestinal (GI) bleeding after haemodialysis. The upper GI endoscopic findings showed only low grade oesophageal ulceration. Haematuria and upper GI bleeding in our patient might also have cause by the effect of heparinisation during haemodialysis.

On the mechanisms underlying poisoning-induced rhabdomyolysis and acute renal failure.

ABSTRACT The clinical syndrome of rhabdomyolysis is caused by injury of skeletal muscles resulting in release of intracellular muscle constituents. Drug poisoning is one of the causes of severe rhabdomyolysis. Severe electrolyte disorders and acute renal failure may occur in rhabdomyolysis, leading to life-threatening situations. Early initiation of renal replacement therapy can help improve outcome. In the present retrospective study, medical records of 181 patients suspected of rhabdomyolysis from Loghman-Hakim Hospital in the period of 2004 to 2005 were reviewed. A creatinine phosphokinase (CPK) value of greater than five times normal (>/=975 IU/L) was the basis for confirmation of a rhabdomyolysis diagnosis. An increased serum creatinine level of more than 30% was the basis for acute renal failure diagnosis. Out of 156 patients, 100 were male with an age range of 13 to 78 years. One hundred and two (92%) patients had CPK >975 U/L, and 36 patients (28.6%) had a 30% or more increase in their creatinine level during their admission days. Mean fluid intake was the same in patients with renal failure and those without renal failure. In 8.3% of the cases, multiple drug poisoning was observed. The most common compound overdose associated with rhabdomyolysis was opium. It is concluded that fluid therapy alone is not adequate in the management of acute renal failure in rhabdomyolysis. Therefore, other etiological factors are involved that remain to be elucidated by further studies.

A case report of opium body packer; review of the treatment protocols and mechanisms of poisoning.

ABSTRACT Body packers are people who illegally carry drugs, mostly cocaine as well as opium and/or heroin, concealed within their bodies. The packets are inserted in the mouth, rectum, or vagina in order to get across borders without being detected. In this presentation we report a case of an opium body packer and review the available scientific literature by focusing on mechanisms of toxicity and treatment approach. The patient was a 35-year-old man who had lethargy, respiratory depression, tachycardia, normal blood pressure, hyperthermia, and pinpoint pupils on presentation. No past medical history was obtained and the only positive history was his travel from Afghanistan 2 days earlier, which he had given to emergency personnel before arriving at our hospital. Complete blood cells and kidney and liver tests were all in normal range. In the emergency department, the patient was treated with oxygen, naloxone, and hypertonic glucose. One dose of activated charcoal (1 g/kg) was administered orally. After intravenous injection of naloxone (4 mg), the lethargy, respiratory depression, and miosis were resolved. The patient was admitted to the intensive care unit and 90 min after admission, the patient redeveloped respiratory distress and lost consciousness. He was intubated and mechanically ventilated due to the suspicious of body packing. Plain abdominal x-ray showed multiple packets throughout the gastrointestinal tract; 81 packets were removed by surgery and three of them were left due to leaking. After removing the packets, the patient was treated conservatively. He suffered a pulmonary infection (aspiration pneumonia) and he regained consciousness after 4 days. Upon recovery the patient was seen by a psychiatrist prior to going to prison. Surgery is recommended for body packers who have significant signs or symptoms.

Randomized trial of a single, double and triple dose of 10 mg/kg of a human formulation of triclabendazole in patients with fascioliasis.

1. A study performed > 10 years ago and case reports published recently suggest that triclabendazole is effective for the treatment of patients with fascioliasis. 2. To confirm the efficacy of a human formulation of triclabendazole, we enrolled 165 patients into the present study and divided the subjects into two groups: (i) those who had fascioliasis, as evidenced by the presence of ova in their stools; and (ii) patients with clinical and laboratory data suggesting fascioliasis. 3. Patients were randomly allocated to receive 10 mg/kg, p.o., triclabendazole for 1, 2 or 3 days (single-, double- and triple-dose groups, respectively). Medical history and physical and laboratory examinations were performed at baseline and at 7, 14, 30 and 60 days after treatment. Results were based on 152 patients who completed the study. 4. A sharp decrease in the proportion of clinical signs and symptoms was observed in all groups immediately after treatment. Ova disappeared from the stools of all patients in the single- and double-dose groups. Thirty days after treatment, ova were identified in the stools of two patients in the triple-dose group who received a second course of triclabendazole. 5. All cases were cured on day 60. However, the cure rate was lower when the patients with suggestive fascioliasis were included in the analysis. The cure rate was not significantly different (P > 0.05) among the three dose groups. No cases of toxic hepatitis were observed. 6. In conclusion, oral administration of 10 mg/kg of the human pharmaceutical preparation of triclabendazole for 1-3 days is safe and effective in the treatment of human fascioliasis.

Antiretroviral treatment of maternal HIV infection.

QUESTION: One of my pregnant patients tested positive for human immunodeficiency virus. Will HIV therapy put her pregnancy outcome at risk? ANSWER: The biggest risk is vertical transmission of HIV to her baby. She should be treated with combination therapy; triple therapy is required to reduce vertical transmission. Zidovudine is not teratogenic in humans, but information on other antiretroviral drugs is incomplete.