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Wu Y, Zhou Z, Ai Z, Wang T, Cui L. Abnormal blood concentration changes in a 71-year-old female who survived a 10,000mg overdose of clozapine: a case report. BMC Psychiatry 2024; 24:123. [PMID: 38355481 PMCID: PMC10865518 DOI: 10.1186/s12888-024-05582-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/03/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clozapine is a highly effective second-generation antipsychotic with few extrapyramidal reactions, making it a preferred choice among clinicians. However, instances of acute clozapine poisoning resulting from suicide attempts and misuse have been reported. Through our review of existing literature, we identified that we believe to be the highest recorded overdose of clozapine in elderly patients, resulting in a nonfatal outcome. CASE PRESENTATION The case report involves a 71-year-old female with a history of depression who ingested a dose of 10,000 mg of clozapine. Approximately 6 h after the overdose, the clozapine level was 5,200 μg/L, significantly surpassing the recommended therapeutic concentration range of 350-600 μg/L. After gastric lavage and hemoperfusion, the blood level dropped to 1847.11 μg/L. Notably, during therapeutic drugs monitoring (TDM), we found a perplexing spike in the patient's blood level to 5554.15 μg/L after the second hemoperfusion. CONCLUSION In this case we mainly focused on the abnormal fluctuations in the concentration of clozapine. We conducted a comprehensive analysis of potential factors contributing to this abnormal phenomenon in terms of the patient's age, clinical symptoms, various laboratory test indexes, and the pharmacokinetics of clozapine. Our findings underscore the importance of timely TDM and the precision of results in managing elderly patients experiencing high-dose clozapine poisoning.
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Affiliation(s)
- Yonghua Wu
- Department of Laboratory Medicine, Peking University Third Hospital, No.49, North Garden Rd, Haidian District, Beijing, 100191, China.
| | - Ziyan Zhou
- Department of Laboratory Medicine, Peking University Third Hospital, No.49, North Garden Rd, Haidian District, Beijing, 100191, China
| | - Ziyi Ai
- Department of Laboratory Medicine, Peking University Third Hospital, No.49, North Garden Rd, Haidian District, Beijing, 100191, China
| | - Tiancheng Wang
- Department of Laboratory Medicine, Peking University Third Hospital, No.49, North Garden Rd, Haidian District, Beijing, 100191, China
| | - Liyan Cui
- Department of Laboratory Medicine, Peking University Third Hospital, No.49, North Garden Rd, Haidian District, Beijing, 100191, China
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Yu ZX, Pi Y, Chen MK, Dong DJ, Gu Q. Clozapine-Induced Severe Toxicity: Exploring the Pharmacokinetic Profile of Clozapine and Its Significance in Hemodynamic Instability - A Case Report. Int Med Case Rep J 2024; 17:111-120. [PMID: 38348428 PMCID: PMC10860498 DOI: 10.2147/imcrj.s444685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 02/01/2024] [Indexed: 02/15/2024] Open
Abstract
Hemodynamic instability in patients with clozapine intoxication can indirectly reflect the serum concentration of clozapine.We have described a case of a 32-year-old pregnant woman who developed life-threatening clozapine toxicity at 28 weeks of gestation. The levels of clozapine and norclozapine in the serum were high. We initiated hemoperfusion(HP) and other detoxification therapies to remove the drug. The patient had severely dilated peripheral blood vessels, which led to cardiac symptoms such as fatal hypotension and uncontrollable tachycardia, resulting in very high cardiac output and elevated Central venous oxygen saturation (ScvO2). Pharmacological intervention significantly improved the hemodynamics.In light of our observations in the ongoing case, we posit that evaluating hemodynamic parameters before and after blood detoxification could serve as a valuable means to gauge effectiveness and provide guidance for treatment.
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Affiliation(s)
- Zhu-Xi Yu
- Department of Critical Care Medicine, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, 21008, People’s Republic of China
| | - Yang Pi
- Department of Critical Care Medicine, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, 21008, People’s Republic of China
| | - Mei-Kai Chen
- Department of Critical Care Medicine, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, 21008, People’s Republic of China
| | - Dan-Jiang Dong
- Department of Critical Care Medicine, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, 21008, People’s Republic of China
| | - Qin Gu
- Department of Critical Care Medicine, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, Jiangsu, 21008, People’s Republic of China
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3
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Lashin HI, Sharif AF. Evaluation of various scoring systems as predictors of the need for intensive care unit admission and other adverse outcomes among patients with acute clozapine poisoning. Toxicol Res (Camb) 2023; 12:468-479. [PMID: 37397925 PMCID: PMC10311143 DOI: 10.1093/toxres/tfad029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/25/2023] [Accepted: 04/06/2023] [Indexed: 07/04/2023] Open
Abstract
Acute clozapine poisoning (ACP) is frequently reported worldwide. We evaluated the efficacy of the Poison Severity Score (PSS), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Rapid Emergency Medicine Score (REMS), and Modified Early Warning Score (MEWS) as predictors for intensive care unit (ICU) admission, mechanical ventilation (MV), mortality, and length of hospital stay in patients with ACP. A retrospective cohort study was conducted using records of patients diagnosed with ACP from January 2017 to June 2022 and admitted to an Egyptian poison control center. Analyzing 156 records showed that all assessed scores were significant predictors of the studied outcomes. The PSS and APACHE II score showed the highest area under the curve (AUC) as ICU admission predictors with insignificant variations. The APACHE II score showed the best discriminatory power in predicting MV and mortality. Nevertheless, MEWS exhibited the highest odds ratio (OR) as an ICU predictor (OR = 2.39, and 95% confidence interval = 1.86-3.27) and as a mortality predictor (OR = 1.98, and 95% confidence interval = 1.16-4.41). REMS and MEWS were better predictors of length of hospital stay compared with the APACHE II score. The simpler, lab-independent nature and the comparable discrimination but higher odds ratio of MEWS compared with APACHE II score justify MEWS' superior utility as an outcome predictor in ACP. We recommend using either the APACHE II score or MEWS, depending on the availability of laboratory investigations, resources, and the case's urgency. Otherwise, the MEWS is a substantially feasible, economical, and bedside alternative outcome predictor in ACP.
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Affiliation(s)
- Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Asmaa F Sharif
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Le Marois M, Sanson C, Maizières MA, Partiseti M, Bohme GA. The atypic antipsychotic clozapine inhibits multiple cardiac ion channels. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:161-166. [PMID: 36308551 DOI: 10.1007/s00210-022-02314-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/17/2022] [Indexed: 01/29/2023]
Abstract
Clozapine is an atypical neuroleptic used to manage treatment-resistant schizophrenia which is known to inhibit cardiac hERG/KV11.1 potassium channels, a pharmacological property associated with increased risk of potentially fatal Torsades de Pointes (TdP) and sudden cardiac death (SCD). Yet, the long-standing clinical practice of clozapine does not show a consistent association with increased incidence of TdP, although SCD is considerably higher among schizophrenic patients than in the general population. Here, we have established the inhibitory profile of clozapine at the seven cardiac ion currents proposed by the ongoing comprehensive in vitro pro-arrhythmia (CiPA) initiative to better predict new drug cardio-safety risk. We found that clozapine inhibited all CiPA currents tested with the following rank order of potency: KV11.1 > NaV1.5 (late current) ≈ CaV1.2 ≈ NaV1.5 (peak current) ≈ KV7.1 > KV4.3 > Kir2.1 (outward current). Half-maximal inhibitory concentrations (IC50) at the repolarizing KV11.1 and KV7.1 channels, and at the depolarizing CaV1.2 and NaV1.5 channels fell within a narrow half-log 3-10 µM concentration range, suggesting that mutual compensation could explain the satisfactory arrhythmogenic cardio-safety profile of clozapine. Although the IC50 values determined herein using an automated patch-clamp (APC) technique are at the higher end of clozapine plasmatic concentrations at target therapeutic doses, this effective antipsychotic appears prone to distribute preferentially into the cardiac tissue, which supports the clinical relevance of our in vitro pharmacological findings.
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Affiliation(s)
- Marguerite Le Marois
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France
| | - Camille Sanson
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France
| | - Magali-Anne Maizières
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France
| | - Michel Partiseti
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France
| | - G Andrees Bohme
- High Content Biology, Integrated Drug Discovery, Sanofi-Aventis R&D, 13 quai Jules Guesde, 94403, Vitry-sur-Seine, France.
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5
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Sharif AF, Aouissi HA, Kasemy ZA, Byeon H, Lashin HI. Development and validation of a risk prediction nomogram for disposition of acute clozapine intoxicated patients to intensive care unit. Hum Exp Toxicol 2023; 42:9603271231186154. [PMID: 37379491 DOI: 10.1177/09603271231186154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND Clozapine is an atypical antipsychotic drug used for the treatment of refractory schizophrenia. It is reported as the most toxic in its class. Using serum clozapine level as a severity indicator is doubtful and unfeasible, particularly in low resourced countries. METHODS This is an extended two-phase retrospective study that utilized medical records of patients diagnosed with acute clozapine intoxication and admitted to Tanta University Poison Control Center, Egypt during the past 6 years. Two hundred and eight medical records were used to establish and validate a nomogram for predicting the need for intensive care unit (ICU) admission in acute clozapine intoxicated patients. RESULTS A reliable simple bedside nomogram was developed and proved its significant ability to predict the need for ICU admission, with an area under the curve (AUC) of 83.9% and 80.8% accuracy. It encompassed the age of admitted patients (AUC = 64.8%, p = .003), respiratory rate (AUC = 74.7%, p < .001), O2 saturation (AUC = 71.7%, p < .001), and random blood glucose level upon admission (AUC = 70.5%, p < .001). External validation of the proposed nomogram showed a high AUC (99.2%) with an overall accuracy of 96.2%. CONCLUSION There is a need to develop a reliable objective tool predicting the severity and need for ICU admission in acute clozapine intoxication. The proposed nomogram is a substantially valuable tool to estimate ICU admission probabilities among patients with acute clozapine intoxication and will help clinical toxicologists make rapid decisions for ICU admission, especially in countries with low resources.
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Affiliation(s)
- Asmaa F Sharif
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
- Department of Clinical Medical Sciences, College of Medicine, Dar Al-Uloom University, Riyadh, Saudi Arabia
| | - H A Aouissi
- Scientific and Technical Research Center on Arid Regions (CRSTRA), Biskra, Algeria
- Laboratoire de Recherche et d'Etude en Aménagement et Urbanisme (LREAU), Université des Sciences et de la Technologie (USTHB), Algiers, Algeria
- Environmental Research Center (CRE), Badji-Mokhtar Annaba University, Annaba, Algeria
| | - Zeinab A Kasemy
- Public Health and Community Medicine Department, Faculty of Medicine, Menoufia University, Shebin El Kom, Egypt
| | - H Byeon
- Department of Digital Anti-Aging Healthcare (BK21), Inje University, Gimhae, Republic of Korea
| | - Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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6
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Dawson JL, Sluggett JK, Schumann JL, Procter NG, Bell JS. Fatal poisonings involving clozapine: A 16-year review of Australian coronial investigations. Aust N Z J Psychiatry 2022; 56:50-58. [PMID: 33736477 DOI: 10.1177/0004867421998788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Concerns about intentional and unintentional poisoning present a barrier to wider use of clozapine in treatment-resistant schizophrenia. The objective of this study was to investigate decedent demographics and trends in fatal poisonings in Australia involving clozapine. METHODS This was a retrospective case series of all fatal drug toxicity reported to an Australian coroner between 1 May 2000 and 31 December 2016 where toxicological analysis detected clozapine. Cases were identified using the National Coronial Information System. Demographics extracted included age and gender of the decedent, year and location of death, cause and manner of death and drugs detected in post-mortem samples. RESULTS There were 278 poisoning deaths where clozapine was detected in toxicological analyses. Three-quarters of all cases (n = 207) involved men and the median age at death was 38.5 years (interquartile range: 16 years). Three-quarters of the deaths occurred in the home. Overall, 15.8% of deaths were deemed intentional, 57.5% unintentional and 24.5% of unknown intent. While the annual number of intentional self-poisonings remained constant with <5 per year, the overall number of fatalities increased due to an increase in unintentional poisonings. Multiple drug toxicity was reported in 55.0% of cases and clozapine alone in 45.0% of cases. The most common co-reported medications were antidepressants, benzodiazepines and opioids detected in 47.1%, 44.4% and 41.2% of multiple drug toxicities, respectively. CONCLUSION This was the first Australia-wide review of all fatal drug poisonings reported to a coroner involving clozapine. Fatalities were most common in men and occurred at home. Multiple drug toxicity generally involved psychotropic, sedative or opioid analgesic medications. Despite increasing clozapine use, rates of intentional poisoning have remained constant and low. Developing a better knowledge of unintentional fatalities presents an opportunity to minimise harm.
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Affiliation(s)
- Jessica L Dawson
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.,SA Pharmacy, Flinders Medical Centre, Bedford Park, SA, Australia
| | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia.,UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA, Australia
| | - Jennifer L Schumann
- Department of Forensic Medicine, Monash University, Southbank, VIC, Australia.,Victorian Institute of Forensic Medicine, Southbank, VIC, Australia
| | - Nicholas G Procter
- UniSA Clinical & Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, VIC, Australia
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7
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A Real-World Study of Risk Factors for QTc Prolongation in Schizophrenia Patients Receiving Atypical Antipsychotics. J Clin Psychopharmacol 2022; 42:71-74. [PMID: 34928562 DOI: 10.1097/jcp.0000000000001501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The risk of sudden cardiac death in patients receiving atypical antipsychotics may be related to QTc prolongation. The aim of this study was to investigate the risk factors for QTc prolongation to prevent QTc prolongation and guide clinical practice. METHODS All electrocardiogram recordings of 913 schizophrenia patients who were receiving atypical antipsychotics were reviewed for prolonged QTc and associated conditions. Binary logistic regression analysis was used to investigate risk factors for QTc prolongation. RESULTS Logistic regression analysis demonstrated that sex (odds ratio [OR], 0.386; P = 0.010), age (OR, 1.047; P = 0.000), high-density lipoprotein (OR, 0.257; P = 0.014), and antipsychotics dose (OR, 1.040; P = 0.036) were significantly associated with QTc prolongation. CONCLUSIONS In patients with male sex, elder age, low high-density lipoprotein, or large antipsychotics dose, QTc should be monitored more frequently.
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8
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Khan Z, Miller EA, Pervaiz AM. Clozapine Intoxication in a Patient on Chronic Use With a Short-Term Noncompliance. Cureus 2021; 13:e16578. [PMID: 34430174 PMCID: PMC8378287 DOI: 10.7759/cureus.16578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2021] [Indexed: 11/10/2022] Open
Abstract
Clozapine has been associated with various adverse effects at both subtherapeutic and standard doses. These adverse effects are most commonly seen during the initiation of therapy in treatment-naïve patients. However, reports of intoxication in patients with long-term use of clozapine are yet to be documented. We highlight the case of a 42-year-old gentleman who had been on long-term clozapine use and presented with an altered mental status after being resumed on full standard doses without careful titration of clozapine after a short period of medication noncompliance. His workup in the hospital was largely unremarkable, and his presentation was attributed to the resumption of clozapine without medication titration. This is the first case to demonstrate the necessity of careful titration regardless of previous treatment history and highlights that patients should be started on clozapine at low levels to avoid the possibility of acute intoxication.
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Affiliation(s)
- Zoha Khan
- Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield, USA
| | - Emily A Miller
- Internal Medicine, Tufts University School of Medicine, Boston, USA
| | - Abdullah M Pervaiz
- Internal Medicine, University of Massachusetts Medical School - Baystate, Springfield, USA
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Seifert J, Heck J, Eckermann G, Singer M, Bleich S, Grohmann R, Toto S. [Vaccination Against COVID-19 in Patients Treated with Psychotropic Drugs]. PSYCHIATRISCHE PRAXIS 2021; 48:399-403. [PMID: 34344044 PMCID: PMC8570910 DOI: 10.1055/a-1531-4460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Vaccines against SARS-CoV-2 have been available in the European Union since December 2020. Persons suffering from mental illness have an increased risk of a severe or fatal course following an infection with SARS-CoV-2. Thus, the question arises to what extent interactions between the newly approved vaccines and psychotropic drugs may be expected. Data on the tolerability and efficacy of vaccines against SARS-CoV-2 under treatment with psychotropic drugs are not available to date - however, potential interactions can be derived from previous investigations on vaccines against other pathogens, such as a reduced immune response with lower clinical efficacy and an increase in drug plasma levels due to the indirect vaccine-mediated inhibition of metabolizing enzymes. On the other hand, depressed patients treated with antidepressant medication show a better immune response.
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Affiliation(s)
- Johanna Seifert
- Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hochschule Hannover, Hannover
| | - Johannes Heck
- Institut für Klinische Pharmakologie, Medizinische Hochschule Hannover, Hannover
| | - Gabriel Eckermann
- Klinik für Forensische Psychiatrie und Psychotherapie, Bezirkskrankenhaus Kaufbeuren, Kaufbeuren
| | - Monika Singer
- kbo-Lech-Mangfall-Klinik Agatharied, Fachklinik für Psychiatrie, Psychotherapie und Psychosomatik, Hausham
| | - Stefan Bleich
- Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hochschule Hannover, Hannover
| | - Renate Grohmann
- Klinik für Psychiatrie und Psychotherapie, Ludwig-Maximilians-Universität München, München
| | - Sermin Toto
- Klinik für Psychiatrie, Sozialpsychiatrie und Psychotherapie, Medizinische Hochschule Hannover, Hannover
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Elgazzar FM, Elgohary MS, Basiouny SM, Lashin HI. Intravenous lipid emulsion as an adjuvant therapy of acute clozapine poisoning. Hum Exp Toxicol 2021; 40:1053-1063. [DOI: 10.1177/0960327120983873] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Clozapine is a frequently prescribed atypical antipsychotic drug. Various case reports documented the successful recovery of acute antipsychotics toxicity in association with the administration of intralipid emulsion (ILE). Aim: This study aimed to assess the adjuvant therapeutic role of SMOF Lipid administration on the outcomes of acute clozapine poisoning. Methods: Forty patients with acute clozapine poisoning were randomly allocated into two equal groups. The control group received the standard supportive treatment only, whereas the intervention group received the standard supportive treatment plus SMOF Lipid 20% infusion. All patients were subjected to history taking, full clinical examination, and laboratory investigations. The study outcomes were evaluated. Results: The mean Glasgow Coma Scale (GCS) at 6 hours (13.1 ± 2.3 vs 9.2 ± 2, p < 0.001) and 12 hours (14.3 ± 1.5 vs 9.6 ± 2, p < 0.001) after admission was significantly higher in the intervention group compared to the control group. The intervention group showed a significantly lower frequency of prolonged QTc interval 12 hours after admission (p = 0.003), as well as a significantly shorter hospital stay (p < 0.001). Conclusions: SMOF Lipid infusion seemed to have improved GCS, the prolonged QTc interval, and shortened the length of hospital stay. Furthermore, there were no adverse effects related to its administration.
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Affiliation(s)
- Fatma M Elgazzar
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Mona S Elgohary
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Sara M Basiouny
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Heba I Lashin
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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11
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Zhang Y, Qiu S, Orlova E. The systemic inflammatory response syndrome in acute antipsychotic poisoning. J Biochem Mol Toxicol 2020; 34:e22546. [PMID: 32583942 DOI: 10.1002/jbt.22546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/06/2020] [Accepted: 06/05/2020] [Indexed: 11/10/2022]
Abstract
The purpose of this study was to investigate the mutual effect of systemic inflammatory response syndrome (SIRS) accompanied with fibrinolysis, endotoxemia, and coagulation in severe cases of antipsychotic poisoning. A total of 199 patients were examined, of which 71 were men and 128 were women. The age of the patients was from 22 to 63 years, (45.3 ± 6.1 years on average). According to the results of the course of therapy, the patients were divided into two groups. In the blood plasma, the content of C-reactive protein, fibrinogen and its proteolysis products (oligopeptides, D-dimers), interleukin-6 were determined. In the first 1 to 3 days, in group 1, the level of interleukin-6 decreased and approached the normal level (P ≤ .05). The opposite trend continued throughout the observation of patients from group 2-their levels of interleukin-6 increased day by day (P ≤ .05). The concentration of D-dimer already in 1 day after admission to intensive care in patients from group 2 exceeded the norm by 14 times (P ≤ .05). The level of D-dimer correlated with the level of oligopeptides in blood plasma upon admission, as well as for 3 and 5 days after admission to intensive care: 0.36, 0.76 at P ≤ .05, 0.94 at P ≤ .01, respectively. Similar correlations were obtained for the content of oligopeptides in urine and the level of D-dimer: 0.55, 0.85 at P ≤ .05, 0.93 at P ≤ .01. In this regard, the most pronounced correlation is that between the SIRS score, plasma D-dimer level, and the plasma level of the D-dimer derivatives, oligopeptides.
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Affiliation(s)
- Yaqun Zhang
- Tomsk State University, Tomsk, Russian Federation
- Shenyang Normal University, Shenyang, China
| | - Shengnu Qiu
- University College London, London, United Kingdom
| | - Ekaterina Orlova
- I. M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
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Chiappini S, Schifano F, Corkery JM, Guirguis A. Focus on Clozapine Withdrawal- and Misuse-Related Cases as Reported to the European Medicines Agency (EMA) Pharmacovigilance Database. Brain Sci 2020; 10:E105. [PMID: 32079135 PMCID: PMC7071448 DOI: 10.3390/brainsci10020105] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Clozapine is of high clinical relevance for the management of both treatment-resistant schizophrenia and psychotic disturbances with concurrent drug misuse. Although the molecule presents with a range of well-known side-effects, its discontinuation/withdrawal syndrome has been only anecdotally described. AIMS the 2005-2018 European Medicines Agency (EMA) dataset of Adverse Drug Reactions (ADRs) was analyzed to identify and describe possible clozapine withdrawal- and misuse-/abuse-/dependence-related issues. METHOD A descriptive analysis of clozapine-related ADRs was performed when available, data on ADRs' outcome, dosage, and possible concomitant drug(s) were considered. RESULTS Out of 11,847 clozapine-related ADRs, some 599 (5.05%) were related to misuse/abuse/dependence/withdrawal issues, including 258 withdrawal-related (43.1%); 241 abuse-related (40.2%); and 80 intentional product misuse-related (13.3%) ADRs. A small number of overdose- and suicide-related ADRs were reported as well. Clozapine was typically (69.2%) identified alone, and most (84.7%) fatalities/high-dosage intake instances were reported in association with a history of substance abuse. CONCLUSIONS Previous suggestions about the possibility of a clozapine discontinuation/withdrawal occurrence are here supported, but further studies are needed. However, the misuse/abuse cases here identified might be difficult to interpret, given the lack of studies highlighting the possible recreational use of clozapine. The high-dosage intake, fatal outcomes and clozapine/polydrug abuse issues reported here may, however, be a reason for concern.
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Affiliation(s)
- Stefania Chiappini
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK; (S.C.); (J.M.C.)
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK; (S.C.); (J.M.C.)
| | - John Martin Corkery
- Psychopharmacology, Drug Misuse, and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire AL10 9AB, UK; (S.C.); (J.M.C.)
| | - Amira Guirguis
- Swansea University Medical School, Institute of Life Sciences 2, Swansea University, Singleton Park, Swansea SA2 8PP, UK;
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Delayed complications after severe clozapine intoxication: a case report. The pharmacokinetic profile of clozapine and it's important role in the course of symptoms. Int Clin Psychopharmacol 2019; 34:269-272. [PMID: 31107832 DOI: 10.1097/yic.0000000000000272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Clozapine intoxications have a varied clinical presentation and may have severe complications. Management and treatment guidelines rarely highlight the risks of delayed clinical presentations. We present the case of a 50-year-old man showing severe complications 15 hours after intoxication with 4200 mg clozapine. Treatment consisted of strict monitoring, including vital support and regular clozapine blood levels. Clinical presentations may be delayed up to 5 days after intoxication, for which strict monitoring of clinical symptoms and vital functions during this period is of major importance. We discuss the clinical course of clozapine intoxication, the value of sampling clozapine blood levels and provide an overview of the current treatment guidelines, which we suggest to update to include the management of delayed complications.
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Pawełczyk A, Kotlicka-Antczak M, Łojek E, Pawełczyk T. Preliminary study of higher-order language and extralinguistic impairments in individuals with high clinical risk of psychosis and first episode of schizophrenia. Early Interv Psychiatry 2019; 13:369-378. [PMID: 28857488 DOI: 10.1111/eip.12482] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 06/09/2017] [Accepted: 07/17/2017] [Indexed: 11/26/2022]
Abstract
AIM Higher-order language functions are associated with understanding indirect speech acts, lexical-semantic processes, the understanding and production of prosody, discourse production and comprehension. Only a few studies imply that language abnormalities may be present in individuals at ultra-high risk for psychosis (UHR) and first-episode of schizophrenia (FE). The purpose of this study was to test the presence of higher-order language dysfunctions in UHR and FE subjects using a standardized comprehensive test battery. METHODS Twenty patients experiencing FE schizophrenia, 33 UHR individuals and 20 healthy controls (HC) took part in the study. Higher-order language and extralinguistic abilities were evaluated using the Right Hemisphere Language Battery (RHLB-PL). The battery consisted of tests covering the comprehension of implicit information, lexico-semantic processing, understanding humour, making inappropriate remarks and comments, understanding and explaining metaphors, understanding prosody and appropriateness of behaviour in communication settings. RESULTS The UHR patients scored lower than HC when comprehending implicit information, discourse and in areas associated with the effectiveness of interpersonal communication; however, they scored higher than the FE participants in explanation of metaphors and processing language information in the context of general knowledge. The FE participants scored lower than healthy controls in comprehension of implicit information, explanation of metaphors, discourse understanding, processing language information in the context of general knowledge and effectiveness of interpersonal communication. CONCLUSIONS The higher-order language dysfunctions mediated by the right hemisphere appear to be present in subjects at UHR of schizophrenia and those experiencing their FE. The results may play a crucial role in diagnostic processes.
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Affiliation(s)
- Agnieszka Pawełczyk
- Chair of Psychiatry, Department of Affective and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Magdalena Kotlicka-Antczak
- Chair of Psychiatry, Department of Affective and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
| | - Emila Łojek
- Chair of Neuropsychology, Department of Cognitive Neuropsychology, University of Warsaw, Warsaw, Poland
| | - Tomasz Pawełczyk
- Chair of Psychiatry, Department of Affective and Psychotic Disorders, Medical University of Lodz, Lodz, Poland
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Lebin JA, Villarreal JD, Chen BC, Hall MK. Clozapine Intoxication Mimicking Acute Stroke. Clin Pract Cases Emerg Med 2018; 2:155-157. [PMID: 29849223 PMCID: PMC5965117 DOI: 10.5811/cpcem.2018.1.36734] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 12/31/2017] [Accepted: 01/19/2018] [Indexed: 11/28/2022] Open
Abstract
Clozapine is an atypical antipsychotic drug prescribed for treatment-resistant schizophrenia. The risk of adverse hematologic, cardiovascular, and neurologic effects has tempered its use, and reports of overdoses remain rare. We report a case of accidental acute clozapine intoxication in a clozapine-naïve patient, who presented with symptoms mimicking acute stroke and later developed status epilepticus. Clozapine intoxication is a rare presentation in the emergency department with potential for iatrogenic harm if not correctly identified.
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Affiliation(s)
- Jacob A Lebin
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | | | - Betty C Chen
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - M Kennedy Hall
- University of Washington, Department of Emergency Medicine, Seattle, Washington
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Zhu Q, Yu X, Wu Z, Lu F, Yuan Y. Antipsychotic drug poisoning monitoring of clozapine in urine by using coffee ring effect based surface-enhanced Raman spectroscopy. Anal Chim Acta 2018. [PMID: 29523253 DOI: 10.1016/j.aca.2018.02.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Antipsychotics are the drugs most often involved in drug poisoning cases, and therefore, therapeutic drug monitoring (TDM) is necessary for safe and effective medication administration of these drugs. In this study, a coffee ring effect-based surface-enhanced Raman spectroscopy (CRE-SERS) method was developed and successfully used to monitor antipsychotic poisoning by using urine samples for the first time. The established method exhibited excellent SERS performance since more hot spots were obtained in the "coffee ring". Using the optimized CRE-SERS method, the sensitivity was improved one order more than that of the conventional method with reasonable reproducibility. The antipsychotic drug clozapine (CLO) spiked into urine samples at 0.5-50 μg mL-1 was quantitatively detected, at concentrations above the thresholds for toxicity. The CRE-SERS method allowed CLO and its metabolites to be ultimately distinguished from real poisoning urine samples. The coffee-ring effect would provide more opportunities for practical applications of the SERS-based method. The frequent occurrence of drug poisoning may have created a new area for the application of the CRE-SERS method. It is anticipated that the developed method will also have great potential for other drug poisoning monitoring.
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Affiliation(s)
- Qingxia Zhu
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 201999, China
| | - Xiaoyan Yu
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 201999, China
| | - Zebing Wu
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 201999, China
| | - Feng Lu
- Department of Pharmaceutical Analysis, School of Pharmacy, Second Military Medical University, Shanghai, 200433, China
| | - Yongfang Yuan
- Department of Pharmacy, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, 201999, China.
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Cairns R, Buckley NA. The Poisoning Severity Score: If It Did Not Exist, We Would Have To Invent It. J Med Toxicol 2017; 13:131-134. [PMID: 28516408 PMCID: PMC5440327 DOI: 10.1007/s13181-017-0614-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Rose Cairns
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia
- Discipline of Pharmacology, School of Medical Sciences, Sydney Medical School, The University of Sydney, Camperdown, Australia
| | - Nicholas A Buckley
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, NSW, 2145, Australia.
- Discipline of Pharmacology, School of Medical Sciences, Sydney Medical School, The University of Sydney, Camperdown, Australia.
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QTc interval prolongation and torsade de pointes associated with second-generation antipsychotics and antidepressants: a comprehensive review. CNS Drugs 2014; 28:887-920. [PMID: 25168784 DOI: 10.1007/s40263-014-0196-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
We comprehensively reviewed published literature to determine whether it supported the link between corrected QT (QTc) interval prolongation and torsade de pointes (TdP) for the 11 second-generation antipsychotics and seven second-generation antidepressants commonly implicated in these complications. Using PubMed and EMBASE, we identified four thorough QT studies (one each for iloperidone, ziprasidone, citalopram, and escitalopram), 40 studies specifically designed to assess QTc interval prolongation or TdP, 58 publications based on data from efficacy and safety trials, 18 toxicology studies, and 102 case reports. Thorough QT studies, QTc prolongation-specific studies, and studies based on efficacy and safety trials did not link drug-associated QTc interval prolongation with TdP. They only showed that the drugs reviewed caused varying degrees of QTc interval prolongation, and even that information was not clear and consistent enough to stratify individual drugs for this risk. The few toxicology studies provided valuable information but their findings are pertinent only to situations of drug overdose. Case reports were most informative about the drug-QTc interval prolongation-TdP link. At least one additional well established risk factor for QTc prolongation was present in 92.2 % of case reports. Of the 28 cases of TdP, six (21.4 %) experienced it with QTc interval <500 ms; 75 % of TdP cases occurred at therapeutic doses. There is little evidence that drug-associated QTc interval prolongation by itself is sufficient to predict TdP. Future research needs to improve its precision and broaden its scope to better understand the factors that facilitate or attenuate progression of drug-associated QTc interval prolongation to TdP.
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West S, Jeffery-Smith A, Brownlee W, Kenedi C. Covert clozapine overdose: Clozapine toxicity in a naive patient. Aust N Z J Psychiatry 2013; 47:1208-9. [PMID: 23817859 DOI: 10.1177/0004867413495926] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen West
- 1Department of General Medicine, Auckland City Hospital, Grafton, Auckland, New Zealand
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XXXIII International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 28–31 May 2013, Copenhagen, Denmark. Clin Toxicol (Phila) 2013. [DOI: 10.3109/15563650.2013.785188] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Heppner HJ, Christ M, Gosch M, Mühlberg W, Bahrmann P, Bertsch T, Sieber C, Singler K. Polypharmacy in the elderly from the clinical toxicologist perspective. Z Gerontol Geriatr 2013; 45:473-8. [PMID: 22915001 DOI: 10.1007/s00391-012-0383-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Polypharmacy is closely associated with multimorbidity in the elderly and can lead to problems and drug interactions. AIM This study assessed polypharmacy in the elderly, tracking inquiries to the Poison Information Centre Nuremberg (PICN) and patients needing toxicological intensive care therapy. METHODS From 2006-2009, all PICN inquiries involving individuals > 70 years were tracked, as were cases at the Toxicological Intensive Care Unit (T-ICU) regarding adverse drug reactions (ADRs) and drug poisoning. RESULTS Of 11,683 PICN calls about pharmaceuticals, 175 (1.5%) were from people > 70 years; 156 (4.8%) of 3,272 T-ICU patients were > 70 years. Calls about psychopharmaceuticals (46.9%) and analgesics (25.7%) were most frequent. Among the T-ICU patients, psychopharmaceuticals like sedatives and hypnotics were frequently involved (20.5%), as were tricyclic antidepressants (17.9%) and analgesics (29.5%). Ethanol was co-ingested by 18.3%. CONCLUSION Population-specific poison prevention strategies are needed to reduce toxic exposures. Such strategies could include pharmacist intervention, improved prescriber communication and education regarding the geriatric population, and computerized drug databases.
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Affiliation(s)
- H J Heppner
- Department of Emergency and Intensive Care Medicine, Klinikum Nuremberg, Prof.-E.-Nathan-Str. 1, 90419, Nuremberg, Germany.
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Abstract
OBJECTIVE Clozapine treatment remains the gold standard for treatment-resistant schizophrenia, but treatment with clozapine is associated with several side-effects that complicate the use of the drug. This clinical overview aims to provide psychiatrists with knowledge about how to optimize clozapine treatment. Relevant strategies for reducing side-effects and increasing the likelihood of response are discussed. METHOD Studies of clozapine available in MEDLINE were reviewed. RESULTS A slow up-titration of clozapine is recommended in order to reach the optimal dosage of clozapine and diminish the risk of dose-dependent side-effects. Particularly, in case of partial response or non-response, the use of therapeutic drug monitoring of clozapine is recommended. Plasma levels above the therapeutic threshold of 350-420 ng/ml are necessary to determine non-response to clozapine. To ease the burden of dose-dependent side-effects, dose reduction of clozapine should be tried and combination with another antipsychotic drug may facilitate further dose reduction. For most side-effects, counteracting medication exists. Augmentation with lamotrigine, antipsychotics, or electroconvulsive therapy may be beneficial in case of partial response to clozapine. CONCLUSION Treatment with clozapine should be optimized in order to increase the rate of response and to minimize side-effects, thus diminishing the risk of discontinuation and psychotic relapse.
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Affiliation(s)
- J Nielsen
- Unit for Psychiatric Research, Aalborg Psychiatric Hospital, Aarhus University Hospital, Denmark.
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