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Kraaijvanger N, Mieloo T. Neuroleptic malignant syndrome after overdose of haloperidol - A case report. Toxicol Rep 2024; 12:356-360. [PMID: 38560509 PMCID: PMC10981033 DOI: 10.1016/j.toxrep.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction The Neuroleptic Malignant Syndrome (NMS), alternatively referred to as the Antipsychotic Malignant Syndrome, is a potentially fatal condition that is infrequently observed and is linked to the administration of antipsychotic medications. This syndrome is characterized by a disturbance in consciousness, autonomic instability manifesting as hyperthermia, and muscular rigidity. The onset of this syndrome is typically within the initial month of treatment or following an escalation in the dosage of an antipsychotic medication. This case report delineates a case where NMS was precipitated by an excessive intake of haloperidol, a typical antipsychotic drug. Case description In the Emergency Department (ED), a 23-year-old male was admitted following an overdose of haloperidol, a typical antipsychotic drug. The patient exhibited symptoms of tachypnea and tachycardia, and initially presented with hypotension. His level of consciousness was variable, but maximal upon stimulation. Notably, there was a significant increase in muscle tension, characterized by cogwheel rigidity. His body temperature rose to 38.6 degrees Celsius. Laboratory findings revealed a substantial high anion gap metabolic acidosis, with a lactate level of 21.2 mmol/L. Additionally, his creatine kinase level was elevated, measuring 1347 U/L. The therapeutic approach encompassed the intravenous administration of midazolam (2.5 mg), lorazepam (2.5 mg), and biperiden (5 mg), in conjunction with resuscitation involving 2 liters of 0.9% NaCl. The patient demonstrated a positive response to this regimen, leading to his admission to the ward. Following a full recovery, he was discharged from the hospital the subsequent day. Discussion The patient in our case fulfilled all the diagnostic criteria for NMS as stipulated in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V). NMS is not contingent on the dosage, although an increased dosage does elevate the risk. A thorough review of existing literature did not yield any cases mirroring ours. Conclusion In conclusion, we present a case where NMS developed after an overdose of haloperidol.
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Affiliation(s)
- Nicole Kraaijvanger
- Emergency Department, Leiden University Medical Center, Leiden, the Netherlands
| | - Tim Mieloo
- Emergency Department, Leiden University Medical Center, Leiden, the Netherlands
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Dragonetti JD, Posada JG, Key RG, Kugler JL. Catatonia-related adverse outcomes after long-acting injectable antipsychotics: Case series. SAGE Open Med Case Rep 2024; 12:2050313X241229008. [PMID: 38304856 PMCID: PMC10832410 DOI: 10.1177/2050313x241229008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/11/2024] [Indexed: 02/03/2024] Open
Abstract
Due to a lack of controlled, prospective trials examining the pathophysiology and treatment of catatonia, current guidelines vary regarding how and when to best use antipsychotics in the presence of catatonia and what factors to consider in a thorough risk-benefit analysis. The literature is especially limited in describing the risks and benefits of using long-acting injectable antipsychotics in the presence of catatonia. We describe four cases where patients with preexisting catatonia received long-acting injectable first generation antipsychotics and experienced severe adverse effects (three experienced worsening of catatonia and one experienced neuroleptic malignant syndrome). The evidence base for managing comorbid catatonia and psychosis remains underdeveloped and inconsistent, but there are numerous known risk factors for adverse antipsychotic reactions, which we describe in relation to these cases. Finally, we present best practices to consider when managing comorbid psychosis and catatonia, especially when considering the use of long-acting injectable antipsychotics.
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Affiliation(s)
- Joseph D Dragonetti
- Department of Psychiatry & Behavioral Sciences, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Jacqueline G Posada
- Department of Psychiatry & Behavioral Sciences, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Richard Garrett Key
- Department of Psychiatry & Behavioral Sciences, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Joseph L Kugler
- Department of Psychiatry & Behavioral Sciences, The University of Texas at Austin Dell Medical School, Austin, TX, USA
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Penugonda AJ, Singh Y, Kattula D, Bhaskar M. Neuroleptic Malignant Syndrome in a 15-Month-Old Child: A Case Report. J Clin Psychopharmacol 2023; 43:455-456. [PMID: 37683235 DOI: 10.1097/jcp.0000000000001749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/19/2023]
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Abstract
ABSTRACT Each year, nearly one-fifth of adults in the United States are prescribed at least one psychotropic medication. An increased trend in psychiatric polypharmacy has heightened awareness of drug-drug interactions and the tracking of adverse drug reactions. This article describes a patient who developed concomitant neuroleptic malignant syndrome (NMS) and nephrogenic diabetes insipidus during cross-titration of his antipsychotics while on lithium. The patient's mild form of NMS in turn caused hypovolemia and acute kidney injury. This case study highlights the dangers of polypharmacy and how it can obscure the presentation of even classic adverse reactions.
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Affiliation(s)
- Carlee Zaki
- At Bellevue Hospital in New York City, Carlee Zaki, Meredith Ugell, Trang Vo , and Steven Liu practice in the Department of Medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise
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Savvidou A, Jennions E, Wikström S, Olsson-Engman M, Sofou K, Darin N. Drug-induced hyperthermia with rhabdomyolysis in CLN3 disease. Eur J Paediatr Neurol 2022; 39:74-78. [PMID: 35716526 DOI: 10.1016/j.ejpn.2022.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 05/31/2022] [Accepted: 06/08/2022] [Indexed: 11/16/2022]
Abstract
CLN3 disease (MIM# 204200), the most prevalent of the neuronal ceroid lipofuscinoses (NCL), is an autosomal recessive disorder with juvenile onset characterized by blindness, epilepsy, dementia, psychiatric manifestations, and motor deterioration. Problems related to behavior, emotions and thought are among the main features. Antidepressant and antipsychotic drugs have been employed with variable results. Neuroleptic malignant syndrome (NMS) has previously been described in two patients with NCL, one with CLN3 disease and one with adult onset NCL of unclear genetic origin. Our aims were to describe the occurrence of drug-induced hyperthermia in pediatric patients with CLN3 disease from West and South Sweden and to delineate the range of associated clinical features. Our study identified four patients presenting with seven episodes of severe drug-induced hyperthermia and either NMS-like or Serotonin syndrome (SS)-like features. Possibly provoking drugs were risperidone, clozapine, olanzapine, haloperidol, quetiapine, and sertraline. The course was atypical, frequently prolonged, associated with rhabdomyolysis and status dystonicus, and resulted in the death of three of the patients. Our study points to a vulnerability to drug-induced hyperthermia in patients with CLN3 disease which we believe could be underreported. Interestingly the proposed pathophysiological mechanisms behind NMS and SS on one hand and CLN3 on the other hand seem to converge in a common mechanism involving dysregulation of the sympathetic nervous system.
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Affiliation(s)
- A Savvidou
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Pediatrics, Gothenburg, Sweden
| | - E Jennions
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Pediatrics, Gothenburg, Sweden
| | - S Wikström
- Centre for Clinical Research and Education, County Council of Värmland, Sweden; School of Medical Sciences, Örebro University, Sweden
| | | | - K Sofou
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Pediatrics, Gothenburg, Sweden
| | - N Darin
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Pediatrics, Gothenburg, Sweden.
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6
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Touzani S, Hamdouni M, Houari N, Khbiza YY, Elbouazzaoui A, Boukatta B, Kanjaa N. Neuroleptic malignant syndrome cases in a Moroccan intensive care unit: a retrospective analysis and literature review. JOURNAL OF NEUROCRITICAL CARE 2021. [DOI: 10.18700/jnc.210019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: Neuroleptic malignant syndrome (NMS) is a rare but potentially life-threatening neuropsychiatric emergency. The aim of our study was to update our bedside procedures by investigating NMS cases managed in the intensive care unit (ICU).Methods: This retrospective study included all NMS patients admitted to our hospital between January 2012 and December 2019. The variables analyzed included demographics, diagnosis, therapeutics, and outcomes.Results: This study included 20 patients, with an average age of 36.6 years. The male to female ratio was 1:4. No patient had a history of NMS, and 60% of the patients had schizophrenia. First-generation neuroleptics (NLs) were the most commonly prescribed drugs (80%). The mean time between the introduction of NLs and onset of symptoms was 7.6 days. Rigidity was observed in 90% of the patients, hyperthermia and neuropsychic syndrome in 65%, and dysautonomia in 50%. The creatine phosphokinase level in all patients was four times the normal value. Mechanical ventilation was required in 20% of the patients and hemodialysis in one patient. None of the patients received specific therapy. The mean duration of ICU stay was 10 days. The mortality rate was 10%,, mainly associated with renal failure. The analysis of the predictors of mortality was limited by the size of our cohort.Conclusion: NMS is a rare condition requiring multidisciplinary implementation of contextualized and updated procedures. Early detection and supportive treatment could improve the prognosis in resource-limited settings, where specific treatments are not available. Predictive risk factors should be investigated in larger multicenter cohorts.
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Guinart D, Misawa F, Rubio JM, Pereira J, de Filippis R, Gastaldon C, Kane JM, Correll CU. A systematic review and pooled, patient-level analysis of predictors of mortality in neuroleptic malignant syndrome. Acta Psychiatr Scand 2021; 144:329-341. [PMID: 34358327 DOI: 10.1111/acps.13359] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 07/12/2021] [Accepted: 08/04/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Neuroleptic malignant syndrome (NMS) is a potentially fatal, idiosyncratic reaction to antipsychotics. Due to low incidence of NMS, research on risk factors of mortality associated with NMS is limited. METHODS Two authors independently searched Medline/Embase/Cochrane/CINAHL/PsychINFO databases for case reports with author-defined NMS published in English until 05/30/2020. Demographic, clinical, treatment, and outcome data were independently extracted following PRISMA guidelines. NMS severity was rated using the Francis-Yacoub scale. Mortality risk factors were identified using a multivariable regression analysis including all characteristics that were significantly different between NMS cases resulting vs. not resulting in death. RESULTS 683 cases with NMS were analyzed (median age = 36 years, males = 62.1%). In a multivariable model, independent predictors of NMS mortality were lack of antipsychotic discontinuation (odds ratio (OR) = 4.39 95% confidence interval (CI) = 2.14-8.99; p < 0.0001), respiratory problems (OR = 3.54 95%CI = 1.71-7.32; p = 0.0004), severity of hyperthermia (Unit-OR = 1.30, 95%CI = 1.16-1.46; p < 0.0001), and older age (Unit-OR = 1.05, 95%CI = 1.02-1.07; p = 0.0014). Even in univariate, patient-level analyses, antipsychotic formulation was not related to death (oral antipsychotic (OAP): n = 39/554 (7.0%) vs. long-acting injectable (LAI): n = 13/129 (10.1%); p = 0.2413). Similarly, death with NMS was not related to antipsychotic class (first-generation antipsychotic: n = 38/433 (8.8%) vs. second-generation antipsychotic: n = 8/180 (4.4%); p = 0.0638). Non-antipsychotic co-treatments were not associated with NMS mortality. CONCLUSION Despite reliance on case reports, these findings indicate that presence of respiratory alterations, severity of hyperthermia, and older age should alert clinicians to a higher NMS mortality risk, and that antipsychotics should be stopped to reduce mortality, yet when NMS arises on LAIs, mortality is not increased vs. OAPs.
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Affiliation(s)
- Daniel Guinart
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.,Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Institut de Neuropsiquiatria i Addiccions (INAD), Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Departament de Psiquiatria, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Jose M Rubio
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | - Justin Pereira
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA
| | - Renato de Filippis
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Chiara Gastaldon
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Department of Neuroscience, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - John M Kane
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA
| | - Christoph U Correll
- Division of Psychiatry Research, The Zucker Hillside Hospital, Northwell Health, New York, NY, USA.,Center for Psychiatric Neuroscience, Feinstein Institutes for Medical Research, Manhasset, NY, USA.,Department of Psychiatry, Donald and Barbara Zucker School of Medicine at Northwell/Hofstra, Hempstead, NY, USA.,Department of Child and Adolescent Psychiatry, Charité-Universitätsmedizin Berlin, Berlin, Germany
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9
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Abstract
Introduction: Many drugs are known to induce malignant syndromes. The most common malignant syndromes are induced by the use of antipsychotics and anesthetics and the withdrawal of anti-Parkinson drugs. As the clinical manifestations of antipsychotic malignant syndrome, Parkinson's disease hyperpyrexia syndrome and anesthetic-induced malignant syndrome are very similar, they are easily confused in the clinic.Areas covered: We reviewed articles published between 1960 and April 2021 describing malignant syndromes. This paper provides a detailed literature review of malignant syndromes and important guidance for the diagnosis and treatment of malignant syndromes to clinicians.Expert opinion: Although malignant syndromes are rare conditions with a low incidence, these conditions usually progress rapidly and can endanger patients' lives, meriting attention from clinicians. The typical clinical manifestations of malignant syndromes are hyperpyrexia, muscular rigidity, an altered mental status and increased levels of creatine kinase; however, the pathophysiology, treatment and prognosis of different malignant syndromes are quite different. Prompt diagnosis and treatment may significantly improve the prognosis of patients with malignant syndromes.
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Affiliation(s)
- Minghua Tao
- Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Jiyuan Li
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, Shanxi Province, China
| | - Xuefeng Wang
- Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
| | - Xin Tian
- Department of Neurology, First Affiliated Hospital of Chongqing Medical University, Chongqing Key Laboratory of Neurology, Chongqing, China
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Lao KSJ, Zhao J, Blais JE, Lam L, Wong ICK, Besag FMC, Chang WC, Castle DJ, Chan EW. Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study. CNS Drugs 2020; 34:1165-1175. [PMID: 33010024 DOI: 10.1007/s40263-020-00767-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a rare and acute adverse drug reaction associated with antipsychotic therapy. However, few data on the risk and epidemiology of NMS are available. OBJECTIVES The aim of this study was to ascertain the incidence risk and all-cause mortality of NMS associated with antipsychotic use, and to assess the association of recent antipsychotic exposure and NMS. METHODS We did a population-based study using data from the Hong Kong Hospital Authority's Clinical Data Analysis and Reporting System database. Cases had a first diagnosis of NMS between 1 January 2004 and 30 November 2017. A case-crossover analysis was used to compare antipsychotic exposure 30 days before the diagnosis of NMS (index date) and a reference period 91-120 days before the index date. To adjust for potential time trends in antipsychotic exposure, we sampled from cases to match current cases and future cases, and further adjusted for select medications and acute medical conditions. RESULTS 297,647 patients were prescribed antipsychotics, and the incidence risk of NMS was 0.11%. Of the 336 cases included in the case-crossover analysis, 20 (6%) died within 30 days after the index date; only one case had NMS recorded as the primary cause of death. When compared with the reference period, cases were more frequently prescribed multiple antipsychotics (15.8% vs 26.8%; standardized mean difference [SMD] 0.27) and short-acting injectable antipsychotics (3.6% vs 13.7%; SMD 0.37) during the 30 days prior to the diagnosis of NMS. Odds ratios for antipsychotic exposure in the case-crossover, case-crossover adjusted for time trend, and case-crossover adjusted for time trend and potential confounders analysis were 8.00 (95% confidence interval 3.42-18.69), 5.88 (2.46-14.04), and 4.77 (1.95-11.66). CONCLUSIONS Our results suggest that recent use of antipsychotics is associated with NMS. Although a case-only design inherently controls for confounding by time-invariant factors, residual confounding by acute medical conditions with similar presentations to NMS cannot be fully excluded.
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Affiliation(s)
- Kim S J Lao
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China.,Global Medical Affairs, Merck Research Laboratories, Shanghai, China
| | - Jiaxi Zhao
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Joseph Edgar Blais
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Lam Lam
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China.,Research Department of Practice and Policy, UCL School of Pharmacy, London, UK
| | - Frank M C Besag
- Research Department of Practice and Policy, UCL School of Pharmacy, London, UK.,East London NHS Foundation Trust, Bedford, Bedfordshire, UK.,Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Wing Chung Chang
- Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.,State Key Laboratory of Brain & Cognitive Sciences, The University of Hong Kong, Hong Kong SAR, China
| | - David J Castle
- St Vincent's Hospital, Melbourne, Vic, Australia.,Department of Psychiatry, University of Melbourne, Melbourne, Vic, Australia
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Centre for Safe Medication Practice and Research, The University of Hong Kong, Office 02-08, 2/F Laboratory Block, 21 Sassoon Road, Pokfulam, Hong Kong SAR, China. .,Department of Psychiatry, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong SAR, China.
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HyperCKemia and rhabdomyolysis in the neuroleptic malignant and serotonin syndromes: A literature review. Neuromuscul Disord 2020; 30:949-958. [PMID: 33250373 DOI: 10.1016/j.nmd.2020.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/23/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022]
Abstract
Neuroleptic malignant syndrome and serotonin syndrome are two syndromes whose molecular bases remain poorly understood. The phenotypes of both syndromes overlap with other syndromes that have a clear genetic background, in particular RYR1-related malignant hyperthermia. Through a literature review, performed according to the PRISMA guidelines, we aimed to report the clinical features of both syndromes, and the results of genetic testing performed. 10 case series and 99 case reports were included, comprising 134 patients. A male predominance of 58% was found. The median age was 35 (range 4-84) years. Eight patients experienced recurrent episodes of rhabdomyolysis. Genetic analysis was performed in eleven patients (8%), revealing four RYR1 variants, three likely benign (p.Asp849Asn, p.Arg4645Gln, p.Arg4645Gln) and one variant of uncertain significance (p.Ala612Thr). This review underlines that a subset of patients with neuroleptic malignant syndrome and serotonin syndrome develop recurrent episodes of rhabdomyolysis. This recurrent pattern suggests a possible underlying (genetic) susceptibility. However, the genetic background of neuroleptic malignant syndrome and serotonin syndrome has only been investigated to a very limited degree so far. The increasing availability of next generation sequencing offers an opportunity to identify potentially associated genetic backgrounds, especially in patients with recurrent episodes or a positive family history.
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Abstract
Electroconvulsive therapy (ECT) is an increasingly popular treatment for drug-resistant depression that may have utility for some patients with neuroleptic malignant syndrome (NMS) who are unresponsive to pharmacotherapy. Using a case study as an example, this article discusses the diagnosis of a patient with NMS, the use of ECT as a treatment for NMS, and the importance of nursing care for these patients.
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Affiliation(s)
- Lisa A Ruth-Sahd
- Lisa A. Ruth-Sahd is a professor at the York College of Pennsylvania in York, Pa., and Georgetown University in Washington, D.C. Darris Rodrigues is a nurse at St. Luke's University Health Network in Fountain Hill, Pa. Elizabeth Shreve is a nursing student at York College of Pennsylvania
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Schneider M, Regente J, Greiner T, Lensky S, Bleich S, Toto S, Grohmann R, Stübner S, Heinze M. Neuroleptic malignant syndrome: evaluation of drug safety data from the AMSP program during 1993-2015. Eur Arch Psychiatry Clin Neurosci 2020; 270:23-33. [PMID: 30506147 DOI: 10.1007/s00406-018-0959-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 11/21/2018] [Indexed: 02/02/2023]
Abstract
Neuroleptic malignant syndrome (NMS) is a rare, but severe adverse drug reaction of drugs with anti-dopaminergic properties. The main symptoms are fever and rigor. In addition, other symptoms such as creatine kinase elevation, alteration of consciousness and various neurological symptoms may occur. A total of 52 NMS cases have been documented in the drug safety program 'Arzneimittelsicherheit in der Psychiatrie' from 1993 to 2015. We calculated incidences and analyzed imputed substances and additional risk factors to study the impact of changing therapy regimes. The overall incidence was 0.16‰. High-potency first-generation antipsychotics (FGAs) had the highest incidences, e.g. flupentixol with 0.61‰. Second-generation antipsychotics (SGAs) had lower incidences. Low-potency FGAs had very low incidences, comparable to SGAs, but in contrast to SGAs, had not been imputed alone in any case of NMS. Preexisting organic pathologies of the central nervous system, lithium treatment, infection/exsiccosis and the withdrawal of medication with anticholinergic properties or alcohol were found to be additional risk factors. With the increasing use of SGAs, one should always be aware of the risk of NMS. Better suited diagnostic criteria for 'atypical NMS' would lead to a better understanding and, therefore, to improved treatment possibilities.
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Affiliation(s)
- Michael Schneider
- University Clinic for Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf bei Berlin, Germany.
| | - Johannes Regente
- University Clinic for Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf bei Berlin, Germany.,Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Timo Greiner
- University Clinic for Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf bei Berlin, Germany
| | - Stephanie Lensky
- University Clinic for Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf bei Berlin, Germany
| | - Stefan Bleich
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Sermin Toto
- Department of Psychiatry, Social Psychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Renate Grohmann
- Department of Psychiatry, Ludwig-Maximilians-University, Munich, Germany
| | - Susanne Stübner
- Department of Psychiatry, Kbo-IAK, Academic Teaching Hospital of the Ludwig-Maximilians University, Haar, Munich, Germany
| | - Martin Heinze
- University Clinic for Psychiatry and Psychotherapy, Brandenburg Medical School, Immanuel Klinik Rüdersdorf, Seebad 82/83, 15562, Rüdersdorf bei Berlin, Germany
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Barnes TR, Drake R, Paton C, Cooper SJ, Deakin B, Ferrier IN, Gregory CJ, Haddad PM, Howes OD, Jones I, Joyce EM, Lewis S, Lingford-Hughes A, MacCabe JH, Owens DC, Patel MX, Sinclair JM, Stone JM, Talbot PS, Upthegrove R, Wieck A, Yung AR. Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2020; 34:3-78. [PMID: 31829775 DOI: 10.1177/0269881119889296] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.
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Affiliation(s)
- Thomas Re Barnes
- Emeritus Professor of Clinical Psychiatry, Division of Psychiatry, Imperial College London, and Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Richard Drake
- Clinical Lead for Mental Health in Working Age Adults, Health Innovation Manchester, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Carol Paton
- Joint-head of the Prescribing Observatory for Mental Health, Centre for Quality Improvement, Royal College of Psychiatrists, London, UK
| | - Stephen J Cooper
- Emeritus Professor of Psychiatry, School of Medicine, Queen's University Belfast, Belfast, UK
| | - Bill Deakin
- Professor of Psychiatry, Neuroscience & Psychiatry Unit, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - I Nicol Ferrier
- Emeritus Professor of Psychiatry, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine J Gregory
- Honorary Clinical Research Fellow, University of Manchester and Higher Trainee in Child and Adolescent Psychiatry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Peter M Haddad
- Honorary Professor of Psychiatry, Division of Psychology and Mental Health, University of Manchester, UK and Senior Consultant Psychiatrist, Department of Psychiatry, Hamad Medical Corporation, Doha, Qatar
| | - Oliver D Howes
- Professor of Molecular Psychiatry, Imperial College London and Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ian Jones
- Professor of Psychiatry and Director, National Centre of Mental Health, Cardiff University, Cardiff, UK
| | - Eileen M Joyce
- Professor of Neuropsychiatry, UCL Queen Square Institute of Neurology, London, UK
| | - Shôn Lewis
- Professor of Adult Psychiatry, Faculty of Biology, Medicine and Health, The University of Manchester, UK, and Mental Health Academic Lead, Health Innovation Manchester, Manchester, UK
| | - Anne Lingford-Hughes
- Professor of Addiction Biology and Honorary Consultant Psychiatrist, Imperial College London and Central North West London NHS Foundation Trust, London, UK
| | - James H MacCabe
- Professor of Epidemiology and Therapeutics, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, and Honorary Consultant Psychiatrist, National Psychosis Service, South London and Maudsley NHS Foundation Trust, Beckenham, UK
| | - David Cunningham Owens
- Professor of Clinical Psychiatry, University of Edinburgh. Honorary Consultant Psychiatrist, Royal Edinburgh Hospital, Edinburgh, UK
| | - Maxine X Patel
- Honorary Clinical Senior Lecturer, King's College London, Institute of Psychiatry, Psychology and Neuroscience and Consultant Psychiatrist, Oxleas NHS Foundation Trust, London, UK
| | - Julia Ma Sinclair
- Professor of Addiction Psychiatry, Faculty of Medicine, University of Southampton, Southampton, UK
| | - James M Stone
- Clinical Senior Lecturer and Honorary Consultant Psychiatrist, King's College London, Institute of Psychiatry, Psychology and Neuroscience and South London and Maudsley NHS Trust, London, UK
| | - Peter S Talbot
- Senior Lecturer and Honorary Consultant Psychiatrist, University of Manchester and Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Upthegrove
- Professor of Psychiatry and Youth Mental Health, University of Birmingham and Consultant Psychiatrist, Birmingham Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Angelika Wieck
- Honorary Consultant in Perinatal Psychiatry, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Alison R Yung
- Professor of Psychiatry, University of Manchester, School of Health Sciences, Manchester, UK and Centre for Youth Mental Health, University of Melbourne, Australia, and Honorary Consultant Psychiatrist, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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15
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Atypical neuroleptic malignant syndrome: A systematic review of case reports. Gen Hosp Psychiatry 2019; 60:12-19. [PMID: 31299470 DOI: 10.1016/j.genhosppsych.2019.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/19/2019] [Accepted: 06/19/2019] [Indexed: 12/18/2022]
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16
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Karamustafalioglu N, Kalelioglu T, Celikel G, Genc A, Emul M. Clinical utility of neutrophil-lymphocyte ratio in the diagnosis of neuroleptic malignant syndrome. Nord J Psychiatry 2019; 73:288-292. [PMID: 31164025 DOI: 10.1080/08039488.2019.1623315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Neuroleptic malignant syndrome (NMS) is a life-threatening side effect of antipsychotic medication. In this study, we aimed to investigate the hypothesis of inflammation via neutrophil-lymphocyte ratio (NLR) in the etiology of NMS. Methods: In this retrospective case-control study, data were collected using digital database of Bakırköy Mental Health Research and Training State Hospital by screening NMS diagnosis according to 'International Classification of Diseases (ICD-10) code: G21.0' between the years of 2007 and 2017. We included 32 hospitalizations with the diagnosis of NMS and 31 other acute psychiatric hospitalizations without NMS of same patients. NLR was calculated as proportion of absolute neutrophil count to absolute lymphocyte count. Significance level was accepted as p < .05. Results: The mean NLR value of NMS group was 9.55 ± 5.13 and control group was 2.06 ± 0.71 (p < .001). According to ROC analysis in our study group, we found a mean NLR cutoff value ≥4 and lymphocyte percent cutoff of ≤18.4% have the probability of correctly identifying patients with NMS with the 100% sensitivity and 100% specificity. Conclusions: In this retrospective study, we considered that higher NLR value in NMS episode might be a resemblance of systemic inflammatory state. In addition, our results suggest that both NLR and lymphocyte percentage may be alternative minor criteria which are more sensitive and specific than leukocyte levels and CPK.
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Affiliation(s)
- Nesrin Karamustafalioglu
- a Department of Psychiatry , Bakırköy Mental Health Research and Training State Hospital , Istanbul , Turkey
| | - Tevfik Kalelioglu
- a Department of Psychiatry , Bakırköy Mental Health Research and Training State Hospital , Istanbul , Turkey
| | - Guler Celikel
- a Department of Psychiatry , Bakırköy Mental Health Research and Training State Hospital , Istanbul , Turkey
| | - Abdullah Genc
- b Department of Psychiatry , Şişli Hamidiye Etfal Research and Training State Hospital , Istanbul , Turkey
| | - Murat Emul
- c Private Psychiatry Center , Istanbul , Turkey
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17
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Sienaert P, van Harten P, Rhebergen D. The psychopharmacology of catatonia, neuroleptic malignant syndrome, akathisia, tardive dyskinesia, and dystonia. HANDBOOK OF CLINICAL NEUROLOGY 2019; 165:415-428. [PMID: 31727227 DOI: 10.1016/b978-0-444-64012-3.00025-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Although highly prevalent, motor syndromes in psychiatry and motor side effects of psychopharmacologic agents remain understudied. Catatonia is a syndrome with specific motor abnormalities that can be seen in the context of a variety of psychiatric and somatic conditions. The neuroleptic malignant syndrome is a lethal variant, induced by antipsychotic drugs. Therefore, antipsychotics should be used with caution in the presence of catatonic signs. Antipsychotics and other dopamine-antagonist drugs can also cause motor side effects such as akathisia, (tardive) dyskinesia, and dystonia. These syndromes share a debilitating impact on the functioning and well-being of patients. To reduce the risk of inducing these side effects, a balanced and well-advised prescription of antipsychotics is of utmost importance. Clinicians should be able to recognize motor side effects and be knowledgeable of the different treatment modalities.
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Affiliation(s)
- Pascal Sienaert
- Academic Center for ECT and Neuromodulation (AcCENT), University Psychiatric Center KU Leuven, Kortenberg, Belgium.
| | - Peter van Harten
- Research Department, GGz Centraal Innova, Amersfoort, and Department of Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, University of Maastricht, Maastricht, The Netherlands
| | - Didi Rhebergen
- Department of Psychiatry and Institute for Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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18
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Abstract
BACKGROUND Neuroleptic malignant syndrome (NMS) is a rare but severe undesired complication of psychopharmacological treatment. The mortality has shown a significant decrease since its first description. Knowledge of NMS is important for every clinician because of the need for rapid diagnosis and treatment. OBJECTIVE This article presents a review and critical appraisal of the current study situation for NMS. Recommendations for diagnostics, differential diagnostics and treatment are presented particularly from a clinical perspective. MATERIAL AND METHODS A literature review with the keywords "neuroleptic malignant syndrome", "Malignes neuroleptisches Syndrom" and various psychotropic drugs was performed in PubMed. The database of the Working Group for Pharmaceutical Treatment of Psychiatric Diseases (Arbeitsgemeinschaft für Arzneimitteltherapie bei psychiatrischen Erkrankungen, AGATE) was analyzed with respect to registered cases of the undesired side effect NMS. RESULTS In contrast to the first description, which also led to the name, there are now case reports of clinical conditions similar to NMS, which were obviously triggered by several groups of psychotropic drugs not just antipsychotic agents (German: Neuroleptika). Treatment recommendations exist whereby the effectiveness cannot always be scientifically substantiated; however, it is still undisputed that a rapid initiation of treatment is of great importance. DISCUSSION The psychiatrist must be familiar with the symptoms of NMS, its differential diagnosis and the therapeutic options for a rapid and effective treatment. Further studies are urgently needed for scientific substantiation of the pathophysiology of NMS and to develop evidence-based guidelines for treatment.
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Affiliation(s)
- R Knorr
- Klinik für Psychiatrie und Psychotherapie, Zentrum für Psychiatrie Reichenau, Feursteinstraße 55, 78479, Reichenau, Deutschland.
- Institut AGATE gGmbH, Pentling, Deutschland.
| | - J Schöllkopf
- Klinische Pharmakologie am Lehrstuhl für Pharmakologie und Toxikologie, Universität Regensburg, Regensburg, Deutschland
| | - E Haen
- Klinische Pharmakologie am Lehrstuhl für Pharmakologie und Toxikologie, Universität Regensburg, Regensburg, Deutschland
- Klinische Pharmakologie am Lehrstuhl für Psychiatrie, Universität Regensburg, Regensburg, Deutschland
- Institut AGATE gGmbH, Pentling, Deutschland
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19
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Sahin A, Cicek M, Gonenc Cekic O, Gunaydin M, Aykut DS, Tatli O, Karaca Y, Arici MA. A retrospective analysis of cases with neuroleptic malignant syndrome and an evaluation of risk factors for mortality. Turk J Emerg Med 2017; 17:141-145. [PMID: 29464217 PMCID: PMC5812912 DOI: 10.1016/j.tjem.2017.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/26/2017] [Accepted: 10/05/2017] [Indexed: 11/18/2022] Open
Abstract
Objective Neuroleptic malignant syndrome (NMS) is a neurological emergency rarely encountered in clinical practice but with a high mortality rate. Cases associated with atypical antipsychotic use or termination of dopamine agonists have been seen in recent years. The purpose of this study was to assess the presence of risk factors for mortality by investigating all clinical and laboratory characteristics of cases with NMS. Material and methods This descriptive, cross-sectional study retrospectively investigated all clinical and laboratory characteristics by scanning the ICD-10 codes of patients presenting to the XXXX Faculty of Medicine Emergency Department and diagnosed with NMS between 2006 and 2016. Patients were divided into surviving and non-surviving groups, and the data elicited were subjected to statistical comparisons. Results The mean age of the 18 patients diagnosed with NMS was 46.9 ± 4.8 years, and 50% were women. In addition to antipsychotics among the drugs leading to NMS, the syndrome also developed as a result of levodopa withdrawal in three patients and metoclopramide use in one patient. Statistically significant differences were determined between the surviving and non-surviving patients in terms of blood pressure, blood urea nitrogen (BUN), creatine kinase (CK) and mean platelet volume (MPV) values (p ≤ 0.05). Conclusion In this study the most common agent that cause NMS was atypical antipsychotics. Also advanced age, increased blood pressure and serum CK, BUN and MPV values were identified as potential risk factors for mortality in NMS.
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Affiliation(s)
- Aynur Sahin
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
- Corresponding author. Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, 61080, Trabzon, Turkey.Karadeniz Technical UniversityFaculty of MedicineDepartment of Emergency MedicineTrabzon61080Turkey
| | - Mustafa Cicek
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Ozgen Gonenc Cekic
- Fatih Public Hospital, Department of Emergency Medicine, Trabzon, Turkey
| | - Mucahit Gunaydin
- Giresun University, Faculty of Medicine, Department of Emergency Medicine, Giresun, Turkey
| | - Demet Saglam Aykut
- Karadeniz Technical University, Faculty of Medicine, Department of Psychiatry, Trabzon, Turkey
| | - Ozgur Tatli
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Yunus Karaca
- Karadeniz Technical University, Faculty of Medicine, Department of Emergency Medicine, Trabzon, Turkey
| | - Mualla Aylin Arici
- Dokuz Eylül University, Faculty of Medicine, Department of Pharmacology, İzmir, Turkey
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