Accidental Aluminum Phosphide Intoxication Successfully Treated with Hyperbaric Oxygen Therapy: A Case Report

The most common pesticide agents are organophosphates and phosphides, aluminum phosphide (ALP) in particular. ALP is a major cause of suicidal poisoning in many countries. In other countries, the problem of accidental, mainly occupational-related, poisoning is also real and actual. Almost two thirds of individuals in poisoning cases have died. This case report describes a case of a patient with accidental ALP intoxication. The origin of the poisoning was the fumigation of stored grain in an agricultural building adjacent to the building in which patient was temporarily housed, while both buildings were connected by an underground corridor, through which the released poison gas penetrated. The case was originally presented by the rescuers as well as healthcare professionals of the local hospital as carbon monoxide intoxication, which has a similar symptomatology as ALP intoxication. The patient was treated comprehensively, including using the HBOT method, which is very unique in the case of phosphine intoxication in human medicine, with an excellent final clinical outcome. This was the first described case of HBOT for ALP intoxication in clinical medicine, although the HBOT indication itself became a coincidence in this case. Further studies must be undertaken to demonstrate the effectiveness of HBOT in treating patients with ALP poisoning.

Acute drug intoxication in childhood: a 10-year retrospective observational single-centre study and case reports

BACKGROUND

Medication poisoning in children is a severe condition that can endanger a child's life. Although drug intoxications are easily preventable, awareness of the proper handling of drugs and their safe storage out of the reach of children is not widespread among the general public. In this work, we investigated the demographic and clinical data of children admitted to the Department of Pediatrics of the University Hospital Olomouc for acute drug-induced intoxication. We also selected several case reports to illustrate the wide range of both presentations and outcomes in individual patients.

METHOD

Cases of drug-induced intoxications were selected from a group of patients under the age of 19 years admitted to the hospital for poisoning between January 1, 2010, and December 31, 2019. Medical records of these patients were prospectively evaluated, and overview tables and graphs of predefined research objectives were created.

RESULTS

During the given time period, 162 children with suspected drug intoxications were hospitalized at the Department of Pediatrics, University Hospital Olomouc. Of these, 108 cases were reported in girls and 54 in boys (66.7% vs. 33.3%). In 16 cases (9.9%), there was a severe intoxication requiring follow-up intensive care. There was also one case of fatal accidental intoxication. Most poisonings were seen in toddlers (65; 40.1%). Intoxication with suicidal ideation was found in 44 cases (27.2%), with a higher incidence of suicide attempts in girls (40 vs. 4). Repeated intoxication was recorded in nine cases. Analgesics were the most common drug group (61; 37.7%), with paracetamol (28; 17.3%) being the leading drug. In 154 cases (95.1%), the drugs were taken orally, most often in the form of tablets.

CONCLUSION

Accidental drug intoxications most frequently occurred in the age group from one to three years old. The second highest incidence was among adolescents most of which were suicide attempts. Analgesics and psychoactive agents accounted for the majority of cases. Medications should be kept in places where children cannot reach them.

Targeting the Aryl Hydrocarbon Receptor with Microbial Metabolite Mimics Alleviates Experimental Colitis in Mice

Targeting the aryl hydrocarbon receptor (AhR) is an emerging therapeutic strategy for multiple diseases (e.g., inflammatory bowel disease). Thermosporothrix hazakensis microbial metabolite 2-(1'H-indole-3'-carbonyl)-thiazole-4-carboxylic acid methyl ester (ITE) is a putative AhR endogenous ligand. To improve the chemical stability, we synthesized a series of ITE chemical mimics. Using a series of in vitro assays, we identified 2-(1H-indole-3-carbonyl)-N-methyl thiazole-4-carboxamide (ITE-CONHCH₃) as a highly potent (EC₅₀ = 1.6 nM) AhR agonist with high affinity (K_i = 88 nM). ITE-CONHCH₃ triggered AhR nuclear translocation and dimerization of AhR-ARNT, enhanced AhR binding in the CYP1A1 promoter, and induced AhR-regulated genes in an AhR-dependent manner. The metabolic stability of ITE-CONHCH₃ in a cell culture was 10 times higher than that of ITE. Finally, we observed protective effects of ITE-CONHCH₃ in mice with DSS-induced colitis. Overall, we demonstrate and validate a concept of microbial metabolite mimicry in the therapeutic targeting of AhR.

A synergy of liquid chromatography with high-resolution mass spectrometry and coagulation test for determination of direct oral anticoagulants for clinical and toxicological purposes

Direct oral anticoagulants are an alternative to anticoagulants based on vitamin K antagonists. Monitoring of direct oral anticoagulant concentration levels is necessary in specific cases (e.g. in emergency conditions, for determination of the cause of bleeding, adverse effects, risk of drug-direct oral anticoagulants interaction); therefore, a sensitive and specific method is needed. A methanol protein precipitation method followed by liquid chromatography with high-resolution mass spectrometry was developed for simultaneous separation and determination of apixaban, betrixaban, edoxaban, dabigatran, rivaroxaban and ximelagatran. The proposed method was fully validated in terms of linearity, the limits of detection and quantification, intra- and inter-day trueness and precision, recovery, matrix effect, process efficiency and stability. The method shows a strong correlation (Pearson's correlation coefficients > 0.92) with coagulation assays of apixaban, dabigatran and rivaroxaban (dilute thrombin time for gatrans and anti Xa factor (anti-Xa) activity for xabans). In addition, the developed method was applied for the identification and determination of apixaban and dabigatran in post-mortem serum samples. The developed method is a good alternative to coagulation tests which may show various interferences.

Acute medication poisoning causing hospital admissions in childhood: a 3-year prospective observational single-center study

Although the risks of medication poisoning in children are often reported, there is a lack of studies addressing this issue. The majority of papers deal with a wide range of xenobiotics poisoning and, in particular, alcohol intoxications. All hospital admissions during three years were prospectively recorded. Patients younger than 19 years of age admitted for acute drug intoxications were further evaluated. A total of 15,069 children were admitted. Of them, 55 were hospitalized for acute medication poisoning. The condition was more common in girls (72.7 % vs. 27.3 %, p<0.01). Toddlers were the largest patient group (36.4 %). Non-steroidal anti-inflammatory drugs (NSAIDs) were the most frequently used agents, with ibuprofen being the leading drug (20 % of all cases). The route of intoxication was almost exclusively oral. Solid drug forms were involved in 40 (72.7 %) cases. There was one fatal accidental poisoning. The highest occurrence of accidental drug intoxications was in the age group from one to three years. Attempted suicides were most frequent among adolescents. We are currently actively dealing with the issue. The cohort has been expanded to include a period of ten years and is being analyzed.

Manner of Death of Older People with Regard to Blood Alcohol Concentration

OBJECTIVE

Alcohol abuse is related to a wide variety of negative health outcomes including mortality in older people. Alcohol abuse in older people is characterised by certain specific features uncommon in general adult population. The main objective of this study was to analyse the autopsy protocols of deceased older people in relation to blood alcohol concentration (BAC), sex, age, and manner of death. As a positive BAC, >0.20 g/kg was accepted.

METHODS

The sample consists of 1,012 deceased older people (i.e. aged 65 years and over) selected out of 2,377 autopsied subjects in the period from 2003–2013. Subjects included into the sample were chosen via the proportional sampling method. Data (BAC, sex, age, and manner of death) was recorded in a single structured protocol. Data was evaluated statistically (Kolmogorov-Smirnov two-sample test, Wilcoxon two-sample test, risk ratio).

RESULTS

Among older people, there has been a statistically significant correlation of natural death with sex (men died earlier) and with increased BAC (people with positive BAC died earlier). In case of violent death there is a difference in the types of accidents in older people with positive BAC (>0.2 g/kg) and with negative BAC (≤0.2 g/kg). Drowning is more common in older people with positive BAC.

CONCLUSIONS

Health campaigns in Europe and the Czech Republic aimed at reducing alcohol consumption mainly deal with young people. Alcohol abuse has an impact on premature mortality even in older people. As shown by this study, older people with positive BAC die significantly earlier.

Heart rate is a useful marker of adherence to beta-blocker treatment in hypertension

OBJECTIVES

Suboptimal medication adherence is common among patients with hypertension. Measurements of plasma or urinary levels of antihypertensive drugs are useful, but not widely available. The aim of our study was to investigate the relation of patients' heart rates to their serum beta-blocker levels.

METHODS

We correlated 220 measurements of serum beta-blocker levels in 106 patients with apparently resistant hypertension to their corresponding office heart rate. A significant proportion, 44.6% of patients, were non-adherent to beta-blocker treatment according to serum level measurement. Non-adherent patients had significantly higher heart rates (80.9 vs. 66.6 bpm, p < .001), systolic (157.4 vs. 147.0 mm Hg, p = .002) and diastolic blood pressure (91.1 vs. 87.2 mm Hg, p = .041) in comparison to adherent patients.

RESULTS

Heart rate above 75.5 beats per minute predicted non-adherence to beta-blocker treatment with a sensitivity of 62.5%, specificity 86.8% and AUC ROC 0.802 (p < .001). Higher heart rate cutoff might be applicable for nebivolol but was not determined due to the low number of patients treated with nebivolol.

CONCLUSIONS

We concluded that heart rate was shown to be a good predictor of non-adherence to beta-blocker treatment, and might become a quick and easy measure to determine patient adherence in hypertensive patients.

Copper nanowire coated carbon fibers as efficient substrates for detecting designer drugs using SERS

Miniature Surface Enhanced Raman Scattering (SERS) sensors were fabricated by coating the carbon fiber microelectrodes with copper nanowires. The coating procedure, based on anodizing the copper wire in ultrapure water followed by cathodic deposition of the anode-derived material onto carbon fiber electrodes, provides a "clean" copper nanowire network. The developed miniature (10µm in diameter and 2mm in length) and nanoscopically rough SERS substrates are applicable in drug sensing, as shown by the detection and resolving of a range of seized designer drugs in trace amounts (microliter volumes of 10^-10-10^-12M solutions). The copper nanowire modified carbon microfiber substrates could also find further applications in biomedical and environmental sensing.

Multi-drug intoxication fatality involving atorvastatin: A case report

Mixed antihypertensive drug intoxication poses a significant risk for patient mortality. In tandem to antihypertensives, hypolipidemic medicines (especially statins) are often prescribed. Among their well-known adverse effects belongs rhabdomyolysis. We report a case of fatal multi-drug overdose in a 65-year-old female alcoholic. The patient was unconscious at admission. Empty blister packs indicated the abuse of 250 tablets of urapidil, 42 tablets of verapamil/trandolapril, 50 tablets of moxonidin, 80 tablets of atorvastatin and 80 tablets of diacerein. Standard measures (gastric lavage, activated charcoal, mechanical ventilation, massive doses of vasopressors, volume expansion, diuretics and alkalinization) failed to provide sufficient drug elimination and hemodynamic support and the sufferer deceased on the fourth day. Dramatic elevations of serum myoglobin (34,020 μg/L) and creatine kinase (219 μkat/L) were accompanied by rise in cardiac troponin I and creatinine. Gas chromatography revealed ethanol 1.17 g/kg (blood) and 2.81 g/kg (urine). Thin layer chromatography and gas chromatography of gastric content and urine verified verapamil, moxonidin and urapidil fragment (diacerein method was unavailable). Atorvastatin and trandolapril concentrations (LC-MS(n)) equaled 277.7 μg/L and 57.5 μg/L, resp. (serum) and 8.15 μg/L and 602.3 μg/L, resp. (urine). Histology confirmed precipitates of myoglobin with acute necrosis of proximal renal tubules in association with striated muscle rhabdomyolysis and myocardial dystrophy. Cardiogenic-distributive shock in conjunction with acute renal failure due to the combined self-poisoning with vasoactive agents and atorvastatin were determined to be this decedent's immediate cause of death. The manner of death was assigned to be suicidal.

Determination and identification of synthetic cannabinoids and their metabolites in different matrices by modern analytical techniques - a review

Synthetic cannabinoids have gained popularity due to their easy accessibility and psychoactive effects. Furthermore, they cannot be detected in urine by routine drug monitoring. The wide range of active ingredients in analyzed matrices hinders the development of a standard analytical method for their determination. Moreover, their possible side effects are not well known which increases the danger. This review is focused on the sample preparation and the determination of synthetic cannabinoids in different matrices (serum, urine, herbal blends, oral fluid, hair) published since 2004. The review includes separation and identification techniques, such as thin layer chromatography, gas and liquid chromatography and capillary electrophoresis, mostly coupled with mass spectrometry. The review also includes results by spectral methods like infrared spectroscopy, nuclear magnetic resonance or direct-injection mass spectrometry.

[Gastric lavage after peroral intoxication--controversial views]

Gastric lavage after ingestion of excessive amounts of a drug/poison--yes or no? If yes, at what time intervals from ingestion? On one side stand some authors who emphasize the complications, contraindications, and low yield of this procedure. These authors recommended that gastric lavage should be performed only within 30-60 minutes after ingestion of toxic doses of a drug/poison. Later lavage usually has no clinical benefit. On the other side stand some other authors who recommend gastric lavage in patients as late as 6 hours after intoxication. In some cases, when the ingested substance slows gastric emptying, they even recommend lavage until 24 hours after intoxication. Based on our experience, it is necessary to support strongly the second group of the authors and recommend the extension of the time interval when to perform gastric lavage in intoxication.

[The correlation of results of breath analysers and laboratory blood examinations of blood-ethanol concentration (Czech and Slovak study)]

The target of this study was to compare the results of breath analysers and "lege artis" laboratory blood examinations when determining alcohol levels. This was then used to determine whether any differences exist between the two methods, and how large these differences are. 610 cases from 11 workplaces in the Czech Republic and Slovakia were analysed. The type of breath analyser was not taken into consideration. All cases had to be in the elimination phase. Difference of time between breath test and blood test were rectified through the use of reverse recomputation. It was detected that only 20.8% of the results of respiratory analyser tests correspond to the detected real alcohol level in blood. The maximum difference when a respiratory analyser measured more than a blood test was 1.34 g x kg(-1). and the maximum difference when the analyse measured less was 1.86 g x kg(-1).

Isolation and identification of the Amanita muscaria and Amanita pantherina toxins in human urine

OBJECTIVES

Ibotenic acid, muscimol and muscarine were recognized as responsible for psychotropic effects of A. muscaria and A. pantherina. Demand for their specific and sensitive identification and quantitation in biological material lead to effort to develop reliable analytical method, but satisfactory solution is still lacking. Presented article describes liquid chromatography-mass spectrometry method suitable for isolation and identification of principal toxins of A. muscaria and A. pantherina in urine.

METHODS AND RESULTS

Dedicated liquid chromatography-mass spectrometry method is reported. Technique consists of an extraction of analytes on Strata X-CW and Discovery SCX SPE cartridges and separation is achieved using a Gemini C18 column (150 mm x 2.0 mm, 5 micron) and 8 mM heptafluorobutyric acid as mobile phase. Detection at m/z 159 for ibotenic acid, m/z 115 for muscimol and m/z 174 for muscarine was used. Retention times and LODs are 2.6 min and 50 ng.ml-1 for ibotenic acid, 4.6 min and 40 ng.ml-1 for muscimol and 14.2 min and 3 ng.ml-1 for muscarine.

CONCLUSION

A sensitive and specific liquid chromatography-mass spectrometry assay was developed for analysis of principal toxins of A. muscaria and A. pantherina in urine. Method was found to be sufficiently sensitive and specific for analysis of urine of intoxicated patients.

Detection and determination of abused hallucinogens in biological material

OBJECTIVES

Until recently, routine toxicological analysis of some hallucinogens in biological material posed problems which were only resolved after the introduction of modern analytic systems into toxicological laboratories. The most frequent hallucinogens in clinical and forensic toxicology can be grouped as: cannabinoids, tropane alkaloids, N,N-dimethyltryptamine derivatives and synthetic or semisynthetic hallucinogens.

METHODS & RESULTS

There are several methods currently used for their analysis. Immunoassay analysis of abused hallucinogens is limited to the cannabinoids. Thin layer chromatography (TLC) is able to detect higher concentrations of 1-nor-delta- 9-tetrahydrocannabinol-9-carboxylic acid (THC-COOH), tropane alkaloids (atropine and scopolamine) and ketamine (synthetic hallucinogen) in urine but for lower concentrations and for some other substances it lacks sensitivity. A reliable solution to the demand for specific and sensitive analysis of hallucinogens in biological material is gas chromatography - mass spectrometry (GC-MS). Thus, at present, analysis of cannabinoids, tropane alkaloids, ketamine as well as psilocin (N,N-dimethyltryptamine derivative) is well-managed.

CONCLUSIONS

The introduction of GC-MS systems appears to be indispensable for satisfactory qualitative and quantitative analysis of drugs of abuse, particularly hallucinogens in biological material.

Possibilities and problems with identification and determination of "new" hypnotics

Authors discuss problems with identification and determination of flunitrazepam and zolpidem in biological material (BM). Over the recent years, these two structurally different substances have become the most frequently used as well as abused hypnotic drugs. This study presents applicability of immunochemical methods in the screening of flunitrazepam, one of the most commonly prescribed drugs among the benzodiazepines. Herein described techniques, a liquid-liquid (L-L) extraction, solid phase extraction (SPE) and the so-called "freeze out" method are used for isolation of the above mentioned compounds from BM. Besides the thin layer chromatography (TLC) and gas chromatography - mass spectrometry (GC-MS) applied in qualitative analysis, the study also describes a gas chromatography with electron capture detector (GC-ECD) and gas chromatography with nitrogen phosphorus detector (GC-NPD) optimized for the determination of flunitrazepam and zolpidem in blood (serum). Successful analyses of these two substances are of major importance, especially in interpreting the results of forensic toxicological examinations.