Comparing Sequential Organ Failure Assessment Score, Acute Physiology and Chronic Health Evaluation II, Modified Acute Physiology and Chronic Health Evaluation II, Simplified Acute Physiology Score II and Poisoning Severity Score for Outcome Prediction of Pesticide Poisoned Patients Admitted to the Intensive Care Unit.

Objective: This study aimed to assess the severity of poisoning, various scoring systems, including Sequential Organ Failure Assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE II), Simplified Acute Physiology Score (SAPS II), Modified APACHE II, and poisoning severity score (PSS) were used. In this study, we compared the predictive value of these scoring systems on the outcome of pesticide-poisoned patients. Methods: This is a cross-sectional study of pesticide-poisoned patients (140 patients) who were admitted to the intensive care unit (ICU) of Khorshid Hospital, Isfahan, Iran, between January 2015 and 2019. The area under the receiver operating characteristic (AUC) curve and the predictive value of scoring systems were compared. Findings: Poisoning was higher in the male population (72.8%). The causes of poisoning were paraquat, (38.6%), aluminum phosphide, (32.1%), and organophosphate, (29.3%). The mean age of the patients was 33.9 years. Most patients (79.3%) attempted suicide. The mortality rate was 46.43%. The mean of "SOFA score," "APACHE II," "SAPS II," "Modified APACHE II," and "PSS" was 5.9; 15.7; 30.02; 15.8; and 1.9, respectively. There was a significant difference in the mean of all scoring systems for outcome prediction. Among all scoring systems, the SAPS II score with the cutoff point (16.5) had the best criteria for outcome prediction (AUC (0.831 ± 0.037), sensitivity (83.1%, 95% confidence interval [CI]: [71.7-91.2]), specificity (75.7%, 95% CI: [64.3-84.9]), positive predictive values (75.0%, 95% CI: [66.4-82.0]), negative predictive values (83.6%, 95% CI: [74.5-89.9]). Conclusion: The SAPS II scoring system may be a suitable indicator for outcome predictions in pesticide-poisoned patients in the ICU.

Uncommon manifestation of poisoning with a mixture of pesticides.

The ingestion of pesticides for suicide commitment purposes is common in developing countries. We present a case of suicide with ingestion of mixed pesticides. The autopsy findings showed the presence of diazinon, chlorpyrifos, trifluralin, fenpropathrin, pyriproxyfen, and cypermethrin in his body. Clinicians managing poisoning cases need to be aware of poisoning with mixture of pesticides as a rare but highly fatal outcome.

Efficacy of the Combination of Indomethacin and Methocarbamol versus Indomethacin Alone in Patients with Acute Low Back Pain: A Double-Blind, Randomized Placebo-Controlled Clinical Trial.

OBJECTIVE: Acute low back pain is a common ailment and causes pain and disability. Physicians often prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to treat acute low back pain; however, due attention has recently been drawn to muscle relaxants to reduce the severity of patients' daily physical dysfunction. Therefore, this study aimed to evaluate the therapeutic effect of the administration of indomethacin alone compared with methocarbamolas a muscle relaxant and indomethacin as an NSAID on the treatment of acute low back pain. METHODS: The present double-blind clinical trial was performed on 64 patients with acute low back pain. The patients were categorized into two groups and received the treatments as follows. Indomethacin capsules of 25 mg every 8 h and placebo tablets every 8 h were administered in the first group (Group I). Indomethacin capsules of 25 mg every 8 h and methocarbamol tablets of 500 mg every 8 h were administered in the second group (Group I + M). Patient pain intensity and physical function based on Back Pain Function Scale (BPFS) were recorded before and 1 week after the intervention. FINDINGS: The present study results revealed that the mean pain reduction of patients in Group I + M was significantly higher than that of Group I (3.66 ± 3.17 vs. 1.84 ± 1.53; P < 0.001). Moreover, the mean BPFS increase in Group I + M was significantly higher than that of Group I (19.44 ± 8.66 vs. 4.75 ± 4.35; P < 0.001). CONCLUSION: According to the results of the present study, concomitant administration of indomethacin and methocarbamol can be more effective in reducing pain intensity and improving the patient's physical function (or performance).

Plasmapheresis for the management of acute cyanide poisoning: A case report and review of literature.

In case of mild to moderate cyanide poisoning, especially when standard antidote kits are not readily available, plasmapheresis can be utilized as an alternative option alongside supportive measures.

Myocardial infarction without coronary artery occlusion following mental stress.

Myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) is syndrome with clinical evidence of acute MI (AMI) with normal coronary arteries. This study reports the case of a 23-year-old single woman referring to the hospital with clinical manifestations of MI, with electrocardiography findings of slow ventricular tachycardia or accelerated idioventricular rhythm and atrioventricular dissociation, and high troponin levels, which was admitted with the diagnosis of MINOCA due to mental stress (grief) and was discharged after 4 days of monitoring and following stabilization of conditions and absence of symptoms. Other causes of MINOCA ruled out through imaging studies. Mental stress can lead to MINOCA.

Investigating the Outcomes of Aluminum Phosphide Poisoning in Khorshid Referral Hospital, Isfahan, Iran: A Retrospective Study.

Objective: Aluminum phosphide (ALP) (rice-tablet) is a common cause of adult poisoning in Iran, including Isfahan. So far, no effective treatment has been identified for this poisoning. We aimed to investigate the outcome of ALP poisoned patients admitted to the clinical toxicology ward of Khorshid Hospital in Isfahan from 2017 to 2019. Methods: This chart-review study was performed on the population of ALP poisoned patients admitted to the clinical toxicology ward of Khorshid University Hospital from 2017 to 2019 treated with the hospital's new treatment protocol, using the complete enumeration approach. The outcomes were determined by reviewing and abstracting medical charts of ALP poisoned patients from the hospital archive. Findings: The most common complaints at admission were depressed consciousness (41.9%) and vomiting (32.2%). There was no significant change in blood sugar, pH, base excess (BE), and venous blood bicarbonate throughout their hospitalization (P > 0.05). Treatment outcomes had a significant relationship with blood pH 2 h and 6 h after admission and the BE 6 h after admission (P < 0.05). There was also a significant relationship between the outcome and the length of stay, initial ejection fraction (EF), and EF in predischarge echocardiography (P < 0.05). Out of 31 patients, 24 (77.4%) died within 72 h, 5 (16.1%) recovered without any complication, and 2 (6.5%) recovered with some complications. Conclusion: The mortality rate of ALP poisoned patients was reasonably high and can be attributed to the poor efficacy of the new treatment protocol or the long time it takes for patients to reach the hospital and start receiving treatments.

Sudden Death Following Suicide with Colchicine and Chloroquine.

Poisoning with any of the colchicine or chloroquine drugs is rare. These drugs exert therapeutic and toxic effects on tissues by different mechanisms. Colchicine is used to treat a number of rheumatologic diseases and heart problems. In addition, chloroquine is used to treat malaria and some inflammatory diseases. There is a small gap between the therapeutic and toxic doses of these drugs. Gastrointestinal symptoms are the initial causes of poisoning with these drugs and then widespread organ failure in later stages can lead to sudden cardiac death. We introduce a case of concurrent poisoning with both drugs, in which the patient presented with a headache, nausea, and vomiting several hours after suicide. On the 1st day, the patient's status was stable, but on the 2nd day, the patient suddenly becomes ill and died even though the patient received supportive therapy. Concurrent poisoning with chloroquine and colchicine is extremely lethal, and early aggressive management is recommended even in an apparently stable patient.

An Unusual Acute Cyanide Intoxication.

Suicide with cyanides is relatively rare but highly lethal. The lethal oral dose of cyanide salts is 200 mg, and concentrations >3 mg/L may be potentially lethal. The symptoms of poisoning are predominating in the central nervous system and cardiovascular system. We report the case of a 43-year-old goldsmith man who presented with self-poisoning by cyanide salt ingestion. Patient's symptoms included confusion, cardiac arrhythmias, hyperkalemia, leukocytosis, metabolic acidosis with high anion gap, hypotension, and then hypertension. The cause of the patients poisoning was not initially diagnosed. Intensive supportive treatment was performed. The patient died on the 3rd day of admission following cardiac arrest. At autopsy, hemorrhagic gastritis and cherry-red discoloration of the chest muscles were observed. Forensic toxicology showed cyanide in the blood and tissues. Cyanide poisoning could appear in different forms, and like our case, the symptoms can last for several days with nonspecific symptoms.

Serotonin Toxicity Following Suicide with Citalopram and Lamotrigine: A Rare Case Report and Literature Review.

Serotonin toxicity is a common but often unrecognized toxicological condition. In most cases, a combination of two or more serotonergic drugs can cause serotonin syndrome. We describe a case of serotonin toxicity in a 17-year-old woman, secondary to suicidal ingestion of 1000 mg lamotrigine and 400 mg citalopram, which has been rarely reported. Our patient had a medical history of depression and was treated with lamotrigine and citalopram. She was brought to the emergency room with nausea, diaphoresis, agitation, shivering, tremor, vertigo, ataxia, mydriasis, nystagmus, hyperreflexia, myoclonus, tachycardia, tachypnea, and mild fever. The symptoms and signs were resolved within 3 days following hydration, sedation, and cyproheptadine. Minor cardiovascular symptoms are probably due to the less toxic dose of citalopram. Lamotrigine, especially in combination with other serotonergic drugs, should be considered a cause of serotonin toxicity.

Massive Citalopram Overdose Associated with Recurrent Seizures and Bilateral Shoulder Dislocations.

Selective serotonin reuptake inhibitors (SSRIs) are widely used in the treatment of many types of mental disorders. Citalopram is commonly used as a new generation of SSRIs in this regard; however, unfortunately, its overdose is associated with seizure and heart disorders. The reported case in the present study indicated recurrent seizures, nonspecific ST-T changes, and prolonged QT interval due to the overuse of citalopram. The patient had bilateral anterior shoulder dislocation along with right proximal humerus fracture that was occurred during the seizure. The dislocation was initially reduced and then fixed. Moreover, the seizure was controlled with diazepam without any problems, and cardiac monitoring continued for 2 days. Massive citalopram overdose may be associated with recurrent seizures and QT prolongation. Complications postseizures, such as shoulder dislocations, should be examined for and managed appropriately.

Unstable Angina: A Rare Presentation of Minoxidil Intoxication: A Case Report and Literature Review.

Minoxidil is an antihypertensive direct vasodilator that can cause severe toxicity when sufficiently ingested. We report a case of accidental ingestion of 5 ml topical minoxidil solution 5% presented with chest pain and new-onset ST depressions. After giving IV saline and performing echocardiography/angiography, the patient fully recovered without any pharmacotherapy such as vasopressors and discharged 4 days after admission. The clinical toxicology, treatment, and previous case reports of minoxidil poisoning have been reviewed.