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Supervía A, Caballero-Bermejo AF, Puiguriguer J, Córdoba F, Martínez-Baladrón A, Callado F, Lobo-Antuña V, Fuentes E, Molina-Samper V, Vert S, Ruíz-Ruíz F, Guijarro-Eguinoa FJ, Martín-Pérez B, Olmos S, Ruiz-Antorán B, Maza-Vera MT, Pallàs O, Climent B, Igartua-Astibia M, Gutiérrez E, Nogué S, Ferrer-Dufol A, Burillo-Putze G. Seven- and thirty-day mortality in digoxin poisoning: Results from the DIGITOX study. Am J Emerg Med 2024; 81:92-98. [PMID: 38713933 DOI: 10.1016/j.ajem.2024.04.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/08/2024] [Accepted: 04/26/2024] [Indexed: 05/09/2024] Open
Abstract
BACKGROUND Digoxin poisonings are relatively common and potentially fatal, requiring immediate therapeutic intervention, with special attention to the patient's hemodynamic status and the presence of electrocardiographic and electrolytic disturbances. OBJECTIVE To identify factors associated with seven-day and thirty-day mortality in digoxin poisoning. DESIGN, SETTINGS AND PARTICIPANTS A retrospective, observational, multicenter study was conducted across 15 Hospital Emergency Departments (HED) in Spain. All patients over 18 years of age who presented to participating HEDs from 2015 to 2021 were included. The inclusion criteria encompassed individuals meeting the criteria for digoxin poisoning, whether acute or chronic. OUTCOMES MEASURE AND ANALYSIS To identify independent factors associated with 7-day and 30-day mortality, a multivariate analysis was conducted. This analysis included variables of clinical significance, as well as those exhibiting a trend (p < 0.1) or significance in the bivariate analysis. MAIN FINDINGS A total of 658 cases of digoxin poisoning were identified. Mortality rates were 4.5% (30 patients) at seven days and 11.1% (73 patients) at thirty days. Regarding 7-day mortality, the mean age of deceased patients was comparable to survivors (84.7 (8.9) vs 83.9 (7.9) years; p = ns). The multivariate analysis revealed that factors independently associated with 7-day mortality encompassed the extent of dependence assessed by the Barthel Index (BI 60-89 OR 0.28; 95% CI 0.10-0.77; p = 0.014 and BI>90 OR 0.22; 95% CI 0.08-0.63; p = 0.005), the identification of ventricular arrhythmias (OR 1.34; 95% CI 1.34-25.21; p = 0.019), and the presence of circulatory (OR 2.84; 95% CI 1.19-6.27; p = 0.019) and neurological manifestations (OR 2.67; 95% CI 1.13-6.27; p = 0.025). Factors independently associated with 30-day mortality encompassed extent of dependence (BI 60-89 OR 0.37; 95% CI 0.20-0.71; p = 0.003 and BI>90 OR 0.18; 95% CI 0.09-0.39; p < 0.001) and the identification of circulatory (OR 2.13; 95% CI 1.10-4.15; p = 0.025) and neurological manifestations (OR 2.39; 95% CI 1.25-3.89; p = 0.006). CONCLUSIONS The study identifies the degree of dependency assessed by the Barthel Index and the presence of cardiovascular and neurological symptoms as independent predictors of both 7-day and 30-day mortality. Additionally, the detection of ventricular arrhythmia is also an independent factor for 7-day mortality.
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Affiliation(s)
- August Supervía
- Emergency Department, Hospital del Mar, Barcelona, Spain; Functional Clinical Toxicology Unit, Parc de Salut Mar, Barcelona, Spain; Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), Spain; Fundación Española de Toxicología Clínica, Spain
| | - Antonio F Caballero-Bermejo
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro, Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana, Madrid, Spain; Internal Medicine Department, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Jordi Puiguriguer
- Clinical Toxicology Unit, Emergency Department. Hospital Universitari Son Espases, Palma, Spain
| | - Francisca Córdoba
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), Spain; Fundación Española de Toxicología Clínica, Spain; Emergency Department, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, Spain
| | - Andrea Martínez-Baladrón
- Emergency Department, Complexo Hospitalario Universitario de Vigo, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Francisco Callado
- Emergency Department, Clinical Toxicology Unit. Hospital Universitario de Burgos, Burgos, Spain
| | - Victoria Lobo-Antuña
- Internal Medicine Department, Clinical Toxicology Unit, Consorci Hospital General Universitari, Valencia, Spain
| | - Elena Fuentes
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), Spain; Emergency Department, Hospital Universitari de Bellvitge, Barcelona, Spain
| | | | - Susana Vert
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), Spain; Emergency Department, Hospital de Viladecans, Barcelona, Spain
| | | | | | - Beatriz Martín-Pérez
- Emergency Department, Clinical Toxicology Unit, Hospital Universitario Río Ortega, Valladolid, Spain
| | - Samuel Olmos
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), Spain; Emergency Department, Consorci Hospitalari Parc Taulí de Sabadell, Barcelona, Spain
| | - Belén Ruiz-Antorán
- Clinical Pharmacology Department, Hospital Universitario Puerta de Hierro, Instituto de Investigación Sanitaria Puerta de Hierro - Segovia de Arana, Madrid, Spain
| | - María Teresa Maza-Vera
- Emergency Department, Complexo Hospitalario Universitario de Vigo, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Oriol Pallàs
- Emergency Department, Hospital del Mar, Barcelona, Spain; Functional Clinical Toxicology Unit, Parc de Salut Mar, Barcelona, Spain
| | - Benjamín Climent
- Internal Medicine Department, Clinical Toxicology Unit, Consorci Hospital General Universitari, Valencia, Spain
| | | | - Edith Gutiérrez
- Internal Medicine Department, Hospital Universitario Puerta de Hierro, Instituto de Investigación Sanitaria Segovia de Arana, Madrid, Spain; Emergency Department, Hospital Universitario de Torrejón, Madrid, Spain
| | - Santiago Nogué
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), Spain; Fundación Española de Toxicología Clínica, Spain
| | | | - Guillermo Burillo-Putze
- Fundación Española de Toxicología Clínica, Spain; Emergency Department, Hospital Universitario de Canarias, Tenerife, Spain; Department of Physical Medicine and Pharmacology, Universidad de La Laguna, Tenerife, Spain
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Supervía A, Martínez Baladrón A, Córdoba F, Callado F, Lobo Antuña V, Puiguriguer J, Fuentes E, Molina Samper V, Caballero-Bermejo AF, Vert S, Ruíz-Ruíz F, Guijarro Eguinoa FJ, Martín-Pérez B, Olmos S, Burillo-Putze G, Maza Vera MT, Pallàs O, Climent B, Igartua Astibia M, Gutiérrez E, Nogué S, Ferrer Dufol A. Characteristics of digoxin toxicity attended in Spanish emergency departments according to type of poisoning and administration of digoxin antibodies: the DIGITOX study. Emergencias 2023; 35:328-334. [PMID: 37801414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
OBJECTIVES Digoxin toxicity accounts for a small percentage of poisonings attended by emergency departments. This study aimed to describe differences between acute and chronic digoxin toxicity and assess the use of digoxin-specific antibody fragments (digoxin-Fab) as an antidote. MATERIAL AND METHODS Retrospective, observational, multicenter study in 15 hospital emergency departments in 8 Spanish autonomous communities in 7 years. We collected patient, clinical and treatment variables, and discharge destination. Patients were classified according to whether toxicity was acute or chronic and whether digoxin-Fab was administered or not. RESULTS Twenty-seven acute and 631 chronic digoxin poisonings were attended. The mean (SD) patient age was 83.9 (7.9) years, and 76.9% were women. Patients with acute toxicity were younger (80.0 [12] years) than those with chronic toxicity (84.1 [7.7] years) (P .038), and accidental poisoning was less common (in 85.2% vs 100% in chronic toxicity; P .001). Cases of acute toxicity were also more serious (Poison Severity Score (29.6% vs 12.5% in chronic toxicity; P .001). Thirty-four patients were treated with digoxin-Fab (5.4%). These patients were younger (78.7 [11.5] years vs 84.2 (7.6) years), their toxicity was more often acute (in 20.6% vs 3.2% in chronic toxicity), more had attempted suicide (8.8% vs 0.2% with chronic toxicity), and more had severe symptoms (50% vs 11.2%) (P .001, all comparisons). Hospital admission was required for 76.1%. Overall, mortality was 11.4%. CONCLUSION Chronic toxicity accounts for most digoxin poisoning cases, and most patients are women. Acute toxicity is more serious. Patients who required digoxin-Fab have more severe poisoning. Such patients usually have acute toxicity, and attempted suicide is more often the reason for the emergency.
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Affiliation(s)
- August Supervía
- Servicio de Urgencias, Hospìtal del Mar, Barcelona, España. Unitat Funcional de Toxicología del Parc de Salut Mar, Barcelona, España. Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), España. Fundación Española de Toxicología Clínica, España
| | | | - Francisca Córdoba
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), España. Fundación Española de Toxicología Clínica, España. Servicio de Urgencias, Hospital Moisès Broggi, Sant Joan Despí, Barcelona, España
| | - Francisco Callado
- Servicio de Urgencias, Unidad de Toxicología Clínica, Hospital Universitario de Burgos, Burgos, España
| | | | - Jordi Puiguriguer
- Fundación Española de Toxicología Clínica, España. Servicio de Urgencias, Hospital Son Espases, Mallorca, España
| | - Elena Fuentes
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), España. Servicio de Urgencias, Hospital Universitari de Bellvitge, Barcelona, España
| | | | | | - Susana Vert
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), España. Servicio de Urgencias, Hospital de Viladecans, Barcelona, España
| | | | | | - Beatriz Martín-Pérez
- Servicio de Urgencias y Unidad de Toxicología Clínica, Hospital Universitario Río Ortega, Valladolid, España
| | - Samuel Olmos
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), España. Servicio de Urgencias, Consorci Hospitalari Parc Taulí de Sabadell, Barcelona, España
| | - Guillermo Burillo-Putze
- Fundación Española de Toxicología Clínica, España. Universidad Europea de Canarias, Facultad de Ciencias de la Salud, Tenerife, España
| | | | - Oriol Pallàs
- Servicio de Urgencias, Hospìtal del Mar, Barcelona, España. Unitat Funcional de Toxicología del Parc de Salut Mar, Barcelona, España
| | | | | | | | - Santiago Nogué
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox), España. Fundación Española de Toxicología Clínica, España
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Supervía A, Salgado E, Córdoba F, García Gibert L, Martínez Sánchez L, Moreno A, Fuentes E, Galicia Paredes M, Martínez Millán D, Clemente C, Nogué S. Poisoning cases in Catalonia: characteristics according to age groups in the Intox.28 study. Emergencias 2021; 33:115-120. [PMID: 33750052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The Toxicology Working Group of the Catalan Society of Emergency Medicine (SoCMUETox) began the Intox-28 study in 2013. The aim was to identify differences in poisoning cases between 3 age groups. MATERIAL AND METHODS Descriptive observational study of poisoning cases managed in 8 hospital emergency departments on the 28th day of each month from 2013 to 2019. We gathered information on patient particulars, type of poison, clinical data, and discharge destination. The patient sample was distributed into 3 groups for comparison: minors under the age of 17 years, adults aged 17 to 65 years, and adults over the age of 65 years. RESULTS The hospitals registered 1088 cases: 132, 859, and 97 in each age group. In comparisons between the minors and the adults aged 65 years or younger, the minors had more females (58.3% vs 46.1%), fewer recreational poisonings (22% vs 46.1%) more poisonings inside the home (67.4% vs 51.1%), more medication poisonings (49.2% vs 31.1%), and less often received treatment (43.2% vs 73%) (P .001, all comparisons). The proportion of older adults receiving treatment (73.2%) was similar to that of the younger adults. CONCLUSION The characteristics of poisonings vary according to age. Differences lie in gender, intentionality, and type of poison.
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Affiliation(s)
- August Supervía
- Servicio de Urgencias, Hospital Universitario del Mar, Barcelona, España. Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox)
| | - Emilio Salgado
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Servicio de Urgencias, Hospital Clínic de Barcelona, España
| | - Francisca Córdoba
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Hospital Moises Broggi Sant Joan Despí, Barcelona, España
| | - Lidia García Gibert
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Servicio de Urgencias, Consorci Sanitari Parc Taulí Sabadell, Barcelona, España
| | - Lidia Martínez Sánchez
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Área de Urgencias, Hospital Sant Joan de Déu, Barcelona, España
| | - Albert Moreno
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Servicio de Urgencias, Hospital Joan XXIII, Tarragona, España
| | - Elena Fuentes
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Servicio de Urgencias, Hospital Universitario de Bellvitge, Barcelona, España
| | - Miguel Galicia Paredes
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Servicio de Urgencias, Hospital Clínic de Barcelona, España
| | - Daniel Martínez Millán
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Servei d'Emergències Mediques, Barcelona, España
| | - Carlos Clemente
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Centre Forum, Parc de Salut Mar, Barcelona, España
| | - Santiago Nogué
- Grup de Treball de Toxicologia de la SoCMUE (SoCMUETox). Servicio de Urgencias, Hospital Clínic de Barcelona, España
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Perelló R, Aused M, Saubí N, Quirós C, Blanco JL, Martínez-Rebollar M, Galicia M, Salgado E, Nogué S. Acute street drug poisoning in the patient with human immunodeficiency virus infection: the role of chemsex. Emergencias 2019; 30:405-407. [PMID: 30638344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To identify the drugs usually abused in cases of acute poisoning in human immunodeficiency virus (HIV) infected patients. MATERIAL AND METHODS Retrospective study of episodes of acute street drug poisoning in HIV-infected patients in our emergency department over a period of 1 year. Chemsex was defined as the use of methamphetamines, -hydroxybutyrate (GHB), -butyrolactone (GBL), and/or mephedrone in order to prolong sexual activity. RESULTS We included 101 patients, 93 (92%) of whom were men. The drug that caused the most cases of acute poisoning was cocaine, detected in 52 patients (51%). GHB and amphetamines were the next most frequently implicated street drugs. The prevalence of chemsex in this series was 87%. Mortality was 2%. Amphetamine poisoning was related to intensive care unit admission (odds ratio, 9,2 [95% CI, 1.6-52.2], P=.012). CONCLUSION Cocaine use was the main cause of acute poisoning in this series. The prevalence of chemsex was high.
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Affiliation(s)
| | - Mónica Aused
- Área de Urgencias, Hospital Clínic, Barcelona, España
| | - Narcís Saubí
- Servicio de Infecciones, Hospital Clínic, Barcelona, España
| | - Carmen Quirós
- Área de Urgencias, Hospital Clínic, Barcelona, España
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Escoda O, Reverter E, To-Figueras J, Casals G, Fernández J, Nogué S. Potential value of urinary amatoxin quantification in patients with hepatotoxic mushroom poisoning. Liver Int 2019; 39:1128-1135. [PMID: 30565383 DOI: 10.1111/liv.14028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 02/13/2023]
Abstract
BACKGORUND & AIMS Mushroom poisoning with Amanita phalloides or similar species can lead to liver failure with 10-30% mortality rates. We aimed at defining the prognostic value of urinary amatoxin quantification in patients with hepatotoxic mushroom poisoning. METHODS Data from 32 patients with hepatotoxic mushroom poisoning (Hospital Clínic Barcelona, 2002-16) in whom urinary amatoxins were determined (ELISA) were retrospectively reviewed. Correlations between urinary amatoxin and collected baseline variables with outcomes including hepatotoxicity (ALT>1000 U/L), severe acute liver injury (ALI, prothrombin <50%), acute liver failure (ALF, ALI and encephalopathy), transplantation/death and hospital length-of-stay, were evaluated. RESULTS 12/32 patients developed increased aminotransferase activity. Among the 13/32 amatoxin negative patients, 1 developed ALI and 12/13 no hepatotoxicity. Among the 19/32 amatoxin positive patients, 8/19 (42%) developed hepatotoxicity, including 5 who progressed to severe ALI, of whom 3 developed ALF (2 deaths, 1 transplantation). Urinary amatoxin and prothrombin were independent predictors of hepatotoxicity, ALT peak values (along with age) and hospital length-of-stay. In positive amatoxins patients, urinary concentrations > 55 ng/ml (or a baseline prothrombin ≤ 83%), were associated to hepatotoxicity (presented by 8/9 patients with ALT>1000 U/L). Among 5 patients with urinary amatoxin ≥ 70 ng/ml, 4 developed severe ALI. CONCLUSIONS In patients with hepatotoxic mushroom poisoning, a negative urinary amatoxin quantification within 72h of intake ruled out the risk of hepatotoxicity in 92% of patients, whereas positive urinary amatoxins were associated with hepatotoxicity and severe ALI. Concentrations >55 ng/ml and ≥ 70 ng/ml were predictive of hepatotoxicity and severe ALI, respectively.
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Affiliation(s)
- Ona Escoda
- Emergency Department, Hospital Clínic, Barcelona, Spain
| | - Enric Reverter
- Liver and Digestive ICU, Liver Unit, Hospital Clínic, Barcelona, Spain
| | | | - Gregori Casals
- Toxicology Laboratory, Hospital Clínic, Barcelona, Spain
| | - Javier Fernández
- Liver and Digestive ICU, Liver Unit, Hospital Clínic, Barcelona, Spain.,European Foundation for the Study of Chronic Liver Failure; EF CLIF, Barcelona, Spain
| | - Santiago Nogué
- Toxicology Unit, Emergency Department, Hospital Clínic, Barcelona, Spain.,Research Group "Urgencias: Procesos y Patologías", IDIBAPS, Barcelona, Spain
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Giavedoni P, Velasco V, Morgado-Carrasco D, Nogué S, Mascaró Galy JM. Delayed Allergic Reactions to Jellyfish Stings: Usefulness of Ultrasonographic Evaluation. J Ultrasound Med 2018; 37:2721-2724. [PMID: 29603311 DOI: 10.1002/jum.14604] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 01/10/2018] [Accepted: 01/17/2018] [Indexed: 06/08/2023]
Abstract
Jellyfish stings often cause immediate local skin reactions, and, less frequently, the affected individuals may develop delayed allergic reactions days or months after the sting. Here, we present 4 such cases. In all cases, color Doppler ultrasonography was performed at the time of diagnosis, and in 3 of the cases, clinical follow-ups with ultrasonographic evaluations were performed. Ultrasonography initially showed dermal thickening with decreased echogenicity that progressively normalized during follow-up. Ultrasonography was useful in quantifying inflammation by measuring the thickness of the dermis and was more precise than standard clinical follow-up of cutaneous lesions in these cases.
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Affiliation(s)
- Priscila Giavedoni
- Department of Dermatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Verónica Velasco
- Department of Toxicology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Daniel Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Santiago Nogué
- Department of Toxicology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Jose Manuel Mascaró Galy
- Department of Dermatology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
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Blanco-Hinojo L, Pujol J, Harrison BJ, Macià D, Batalla A, Nogué S, Torrens M, Farré M, Deus J, Martín-Santos R. Attenuated frontal and sensory inputs to the basal ganglia in cannabis users. Addict Biol 2017; 22:1036-1047. [PMID: 26934839 DOI: 10.1111/adb.12370] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/30/2015] [Accepted: 01/07/2016] [Indexed: 12/18/2022]
Abstract
Heavy cannabis use is associated with reduced motivation. The basal ganglia, central in the motivation system, have the brain's highest cannabinoid receptor density. The frontal lobe is functionally coupled to the basal ganglia via segregated frontal-subcortical circuits conveying information from internal, self-generated activity. The basal ganglia, however, receive additional influence from the sensory system to further modulate purposeful behaviors according to the context. We postulated that cannabis use would impact functional connectivity between the basal ganglia and both internal (frontal cortex) and external (sensory cortices) sources of influence. Resting-state functional connectivity was measured in 28 chronic cannabis users and 29 controls. Selected behavioral tests included reaction time, verbal fluency and exposition to affective pictures. Assessments were repeated after one month of abstinence. Cannabis exposure was associated with (1) attenuation of the positive correlation between the striatum and areas pertaining to the 'limbic' frontal-basal ganglia circuit, and (2) attenuation of the negative correlation between the striatum and the fusiform gyrus, which is critical in recognizing significant visual features. Connectivity alterations were associated with lower arousal in response to affective pictures. Functional connectivity changes had a tendency to normalize after abstinence. The results overall indicate that frontal and sensory inputs to the basal ganglia are attenuated after chronic exposure to cannabis. This effect is consistent with the common behavioral consequences of chronic cannabis use concerning diminished responsiveness to both internal and external motivation signals. Such an impairment of the fine-tuning in the motivation system notably reverts after abstinence.
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Affiliation(s)
| | - Jesus Pujol
- MRI Research Unit; Hospital del Mar; Barcelona Spain
- Centro Investigación Biomédica en Red de Salud Mental; CIBERSAM G21; Barcelona Spain
| | - Ben J Harrison
- Melbourne Neuropsychiatry Centre, Department of Psychiatry; The University of Melbourne; Melbourne Australia
| | - Dídac Macià
- MRI Research Unit; Hospital del Mar; Barcelona Spain
| | - Albert Batalla
- Department of Psychiatry and Psychology; Hospital Clínic, Institut d'Investigació Biomédica August Pi I Sunyer (IDIBAPS), CIBERSAM G25; Barcelona Spain
- Nijmegen Institute for Scientist-Practitioners in Addiction; Nijmegen Netherlands
| | - Santiago Nogué
- Section of Clinical Toxicology, Emergency Service, Hospital Clínic, IDIBAPS; University of Barcelona; Barcelona Spain
| | - Marta Torrens
- Human Pharmacology and Clinical Neurosciences; Institute of Neuropsychiatry and Addiction, Hospital del Mar Medical Research Institute; Barcelona Spain
- School of Medicine, Autonomous University of Barcelona; Red de Trastornos Adictivos (RETIC); Barcelona Spain
| | - Magí Farré
- Human Pharmacology and Clinical Neurosciences; Institute of Neuropsychiatry and Addiction, Hospital del Mar Medical Research Institute; Barcelona Spain
- School of Medicine, Autonomous University of Barcelona; Red de Trastornos Adictivos (RETIC); Barcelona Spain
| | - Joan Deus
- MRI Research Unit; Hospital del Mar; Barcelona Spain
- Department of Clinical and Health Psychology; Autonomous University of Barcelona; Barcelona Spain
| | - Rocío Martín-Santos
- Department of Psychiatry and Psychology; Hospital Clínic, Institut d'Investigació Biomédica August Pi I Sunyer (IDIBAPS), CIBERSAM G25; Barcelona Spain
- Department of Psychiatry and Clinical Psychobiology; University of Barcelona; Barcelona Spain
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Amigó M, Fernández F, Velasco V, Nogué S. [Injuries from pepper spray used for self defense: analysis of 15 cases managed in an emergency chemical decontamination area]. Emergencias 2016; 28:349-352. [PMID: 29106107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
We analyzed epidemiologic and clinical characteristics, treatment received, and clinical course in cases of pepper spray injury treated in the chemical decontamination area of an emergency department over a 5-year period. A total of 15 patients with a mean (SD) age of 25 (8.3) years were included. Thirteen were men and 53% were foreign-born. All uses of pepper spray occurred during muggings that to place mainly in the early hours of the morning (66.7% between 4:30 and 6:30 AM). Two or more attackers were injured in 60% of the events. Seventy-three percent of the attacks took place on the street and the median delay in reaching the emergency department was 30 minutes. The face and eyes were usually injured, and symptoms included itching, irritation, burning, and pain. On arrival, the patients were treated immediately (mean delay, 3 minutes) with hypertonic saline, an amphoteric surfactant, and a chelating agent in 80% of the cases, in which improvement was substantial as mean pain scale scores changed from 7.2 on admission to 3 on discharge (P=.009). Patients spent an average of 40 minutes in the treatment area. Eleven patients required further care from an ophthalmologist and topical medication for symptoms. Outcomes were good and there were no complications in any of the cases. We conclude that pepper sprays are being used as an aid to self defense in muggings in our community. Decontamination measures have priority as they alleviate symptoms and prevent long-lasting effects.
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Affiliation(s)
- Montserrat Amigó
- Área de Urgencias, Hospital Clínic, Barcelona, España. Grupo de investigación: Urgencias: Procesos y Patologías. IDIBAPS, Barcelona, España
| | | | | | - Santiago Nogué
- Grupo de investigación: Urgencias: Procesos y Patologías. IDIBAPS, Barcelona, España. Sección de Toxicología Clínica. Hospital Clínic, Barcelona, España
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10
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Nogué S, Galicia M, Parra M, To-Figueras J. [Methoxetamine-associated emergencies. First Spanish descriptions of this new drug]. Med Clin (Barc) 2015; 145:416-7. [PMID: 25817453 DOI: 10.1016/j.medcli.2015.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 01/08/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Santiago Nogué
- Sección de Toxicología Clínica, Servicio de Urgencias, Hospital Clínic, Facultad de Medicina, Universidad de Barcelona, Barcelona, España; Grupo de investigación Urgencias: procesos y patologías, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España.
| | - Miguel Galicia
- Sección de Toxicología Clínica, Servicio de Urgencias, Hospital Clínic, Facultad de Medicina, Universidad de Barcelona, Barcelona, España; Grupo de investigación Urgencias: procesos y patologías, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | - Marina Parra
- Laboratorio de Toxicología, Centro de Diagnóstico Biomédico, Hospital Clínic, Barcelona, España
| | - Jordi To-Figueras
- Laboratorio de Toxicología, Centro de Diagnóstico Biomédico, Hospital Clínic, Barcelona, España
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Galicia M, Nogué S, Miró Ò. MARRIED-cocaine score: validating a tool for detecting the risk of ED revisit in cocaine users. Emerg Med J 2015; 33:218-23. [DOI: 10.1136/emermed-2014-203683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 09/16/2015] [Indexed: 11/03/2022]
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12
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Galícia M, Nogué S, Burillo-Putze G. Respuesta. Med Clin (Barc) 2015; 145:228-9. [DOI: 10.1016/j.medcli.2015.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 01/18/2015] [Accepted: 01/22/2015] [Indexed: 10/23/2022]
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13
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Nogué S, Miró O, Aguilar R. Antídotos y servicios de urgencias. An Pediatr (Barc) 2015; 82:e260-1. [DOI: 10.1016/j.anpedi.2014.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 11/07/2014] [Indexed: 11/30/2022] Open
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14
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Nogué S, Miró O. Núcleos y ámbitos de investigación sobre adicciones: necesidad de una visión más amplia. Adicciones 2015. [DOI: 10.20882/adicciones.195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Nogué S, Miró O. Core research areas on addiction: the need for a broader view. Adicciones 2015; 27:75-76. [PMID: 25879479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Santiago Nogué
- ección de Toxicología Clínica. Hospital Clínic. Barcelona. España. Línea de investigación: Urgencias, procesos y patologías. IDIBAPS. Barcelona. España..
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16
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Fernández S, Pollio GA, Domínguez V, Nogué S, Torra M, Cardellach F. [Outbreak of lead poisoning associated with Ayurvedic medicine]. Med Clin (Barc) 2015; 144:166-9. [PMID: 24559541 DOI: 10.1016/j.medcli.2013.09.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 09/12/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Lead poisoning is normally caused by repeated occupational inhalation of lead. However, lead may also be absorbed through the digestive route. Some alternative medical treatments, such as Ayurvedic medicine, can also contain lead and may result in poisoning. PATIENTS AND METHOD We collected cases of lead poisoning related to Ayurvedic treatments attended at the Hospital Clinic of Barcelona. RESULTS Two female patients, aged 45 and 57 years, respectively, who initiated Ayurvedic treatments which involved the ingestion of various medicaments, were included. The first patient presented with anemia and abdominal pain. The lead level was 74μg/dL and free erythrocyte protoporphyrin was 163μg/dL. She was treated with intravenous calcium disodium ethylenediaminetetraacetic acid (CaNa2EDTA) and later with oral dimercaptosuccinic acid (DMSA) with a good evolution. The second patient presented with abdominal pain and a Burton's line. The lead level was 52μg/dL and free erythrocyte protoporphyrin was 262μg/dL. She was treated with oral DMSA and evolved favorably. Lead concentrations in some of the tablets supplied to the patients reached 2,003 and 19,650μg/g of tablet. CONCLUSIONS Lead poisoning may result from treatments based on Ayurvedic medicine and may reach epidemic proportions. Health control of alternative medicines is necessary.
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Affiliation(s)
- Sara Fernández
- Servicio de Medicina Interna, Hospital Clínic, Barcelona, España
| | | | | | - Santiago Nogué
- Sección de Toxicología Clínica, Hospital Clínic, Barcelona, España.
| | - Mercè Torra
- Sección de Toxicología Analítica, Hospital Clínic, Barcelona, España
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Martín C, Nogué S. Novedades en el envenenamiento por mordedura de víbora. Med Clin (Barc) 2015; 144:132-6. [DOI: 10.1016/j.medcli.2014.06.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Revised: 06/06/2014] [Accepted: 06/12/2014] [Indexed: 10/24/2022]
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18
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Monforte S, Ríos J, Nogué S. [Hospital activation of the CODITOX protocol for severe acute poisoning]. Emergencias 2015; 27:95-102. [PMID: 29077350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Clinical care protocols, such as CODITOX for severe acute poisonings, attempt to codify and coordinate care processes to prevent delays in situations where timing is a key factor. This study aimed to measure the degree of adherence to CODITOX and compare patterns of activation of the protocol over time. MATERIAL AND METHODS Noninterventional, retrospective, analytical study of CODITOX activations in 2012. We compared poisonings attended according to the CODITOX protocol to those attended without CODITOX activation in the emergency department's resuscitation unit. RESULTS Out of 90 poisoning cases, 12 were attended following the CODITOX (group A). In 36 cases (group B), patients were not attended according to protocol even though they presented with criteria that should have activated it; in the remaining 42 cases, criteria for activating the protocol were not present and it was not used. Complications developed in 75% of group-A cases and 28% of group-B cases (P=.006). In group A, 41.7% of the patients were admitted to the intensive care unit (25% in group B); mortality was 4.4% and there were no significant between-group differences. The times between arrival and administration of charcoal and between arrival and administration of an antidote tended to be shorter in group A, but again the between-group differences were not statistically significant and did not affect duration of hospital stay. CONCLUSION The CODITOX protocol is not used in all cases that meet the activation criteria. Although the cases treated according to protocol were more serious, no clinical, therapeutic, or outcome differences could be identified between patients treated or not treated according to the CODITOX. The protocol-treated patients developed more complications, however.
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Affiliation(s)
- Sandra Monforte
- Enfermería de Urgencias, Área de Urgencias, Hospital Clínic, Barcelona, España
| | - José Ríos
- Unidad de Estadística, IDIBAPS, Barcelona, España
| | - Santiago Nogué
- Sección de Toxicología Clínica, Área de Urgencias, Hospital Clínic, Barcelona, España
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Bordehore C, Nogué S, Gili JM, Acevedo MJ, Fuentes VL. Carybdea marsupialis (Cubozoa) in the Mediterranean Sea: the first case of a sting causing cutaneous and systemic manifestations. J Travel Med 2015; 22:61-3. [PMID: 25163356 DOI: 10.1111/jtm.12153] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 04/24/2014] [Accepted: 04/28/2014] [Indexed: 11/30/2022]
Abstract
A woman stung by the box jellyfish Carybdea marsupialis (Cnidaria, Cubozoa) at a Spanish Mediterranean beach showed systemic manifestations over several months [pain far from the inoculation point, arthralgia, paresthesia, hyperesthesia, increase in eosinophils and immunoglobulin E (IgE)] in addition to the skin condition.
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Affiliation(s)
- Cesar Bordehore
- Department of Ecology, Ramon Margalef Research Institute, University of Alicante, Alicante, Spain
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Nogué S, Amigó M, Puiguriguer J. Indicadores de calidad en la asistencia toxicológica. An Pediatr (Barc) 2015; 82:51-2. [DOI: 10.1016/j.anpedi.2014.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 01/22/2014] [Accepted: 01/27/2014] [Indexed: 10/25/2022] Open
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21
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Galicia M, Nogué S, Burillo-Putze G. Diez años de asistencias urgentes a consumidores de cocaína en España. Med Clin (Barc) 2014; 143:322-6. [DOI: 10.1016/j.medcli.2013.11.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 11/12/2013] [Accepted: 11/14/2013] [Indexed: 11/16/2022]
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22
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Batalla A, Soriano-Mas C, López-Solà M, Torrens M, Crippa JA, Bhattacharyya S, Blanco-Hinojo L, Fagundo AB, Harrison BJ, Nogué S, de la Torre R, Farré M, Pujol J, Martín-Santos R. Modulation of brain structure by catechol-O-methyltransferase Val(158) Met polymorphism in chronic cannabis users. Addict Biol 2014; 19:722-32. [PMID: 23311613 DOI: 10.1111/adb.12027] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Neuroimaging studies have shown that chronic consumption of cannabis may result in alterations in brain morphology. Recent work focusing on the relationship between brain structure and the catechol-O-methyltransferase (COMT) gene polymorphism suggests that functional COMT variants may affect brain volume in healthy individuals and in schizophrenia patients. We measured the influence of COMT genotype on the volume of four key regions: the prefrontal cortex, neostriatum (caudate-putamen), anterior cingulate cortex and hippocampus-amygdala complex, in chronic early-onset cannabis users and healthy control subjects. We selected 29 chronic cannabis users who began using cannabis before 16 years of age and matched them to 28 healthy volunteers in terms of age, educational level and IQ. Participants were male, Caucasians aged between 18 and 30 years. All were assessed by a structured psychiatric interview (PRISM) to exclude any lifetime Axis-I disorder according to Diagnostic and Statistical Manual for Mental Disorders-Fourth Edition. COMT genotyping was performed and structural magnetic resonance imaging data was analyzed by voxel-based morphometry. The results showed that the COMT polymorphism influenced the volume of the bilateral ventral caudate nucleus in both groups, but in an opposite direction: more copies of val allele led to lesser volume in chronic cannabis users and more volume in controls. The opposite pattern was found in left amygdala. There were no effects of COMT genotype on volumes of the whole brain or the other selected regions. Our findings support recent reports of neuroanatomical changes associated with cannabis use and, for the first time, reveal that these changes may be influenced by the COMT genotype.
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Affiliation(s)
- Albert Batalla
- Department of Psychiatry; Clinical Institute of Neuroscience; Hospital Clínic, IDIBAPS, CIBERSAM; Spain
- Department of Psychiatry and Clinical Psychobiology; University of Barcelona; Spain
| | - Carles Soriano-Mas
- CRC Mar; Hospital del Mar; Spain
- Department of Psychiatry; Bellvitge University Hospital-IDIBELL, CIBERSAM; Spain
| | | | - Marta Torrens
- Neuroscience Program; IMIM (Hospital del Mar Medical Research Institute)-INAD-Parc de Salut Mar, Autonomous University of Barcelona and Pompeu Fabra University; Spain
- Red de Trastornos Adictivos (RETIC); IMIM-INAD-Parc de Salut Mar; Spain
| | - José A. Crippa
- Neuroscience and Cognitive Behavior Department; University of Sao Paulo; Brazil
- INCT Translational Medicine (INCT-TM, CNPq); Brazil
| | - Sagnik Bhattacharyya
- Department of Psychosis Studies; King's College London, Institute of Psychiatry; UK
| | | | - Ana B. Fagundo
- Neuroscience Program; IMIM (Hospital del Mar Medical Research Institute)-INAD-Parc de Salut Mar, Autonomous University of Barcelona and Pompeu Fabra University; Spain
| | - Ben J. Harrison
- CRC Mar; Hospital del Mar; Spain
- Melbourne Neuropsychiatry Centre; Department of Psychiatry; The University of Melbourne & Melbourne Health; Australia
| | - Santiago Nogué
- Clinical Toxicology Unit; Emergency Department; Hospital Clínic, IDIBAPS, University of Barcelona; Spain
| | - Rafael de la Torre
- Neuroscience Program; IMIM (Hospital del Mar Medical Research Institute)-INAD-Parc de Salut Mar, Autonomous University of Barcelona and Pompeu Fabra University; Spain
- CIBEROBN; Spain
| | - Magí Farré
- Neuroscience Program; IMIM (Hospital del Mar Medical Research Institute)-INAD-Parc de Salut Mar, Autonomous University of Barcelona and Pompeu Fabra University; Spain
- Red de Trastornos Adictivos (RETIC); IMIM-INAD-Parc de Salut Mar; Spain
| | | | - Rocío Martín-Santos
- Department of Psychiatry; Clinical Institute of Neuroscience; Hospital Clínic, IDIBAPS, CIBERSAM; Spain
- Department of Psychiatry and Clinical Psychobiology; University of Barcelona; Spain
- Neuroscience Program; IMIM (Hospital del Mar Medical Research Institute)-INAD-Parc de Salut Mar, Autonomous University of Barcelona and Pompeu Fabra University; Spain
- Neuroscience and Cognitive Behavior Department; University of Sao Paulo; Brazil
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23
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Escobar JJ, Sanz-Gallen P, Nogué S, Uña-Gorospe M. Maculopatía crónica bilateral en un soldador. Med segur trab 2014. [DOI: 10.4321/s0465-546x2014000200015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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24
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Nogué S, Amigó M, Galicia M. Raves, consumo de drogas y asistencia en urgencias. Adicciones 2014. [DOI: 10.20882/adicciones.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Pujol J, Blanco-Hinojo L, Batalla A, López-Solà M, Harrison BJ, Soriano-Mas C, Crippa JA, Fagundo AB, Deus J, de la Torre R, Nogué S, Farré M, Torrens M, Martín-Santos R. Functional connectivity alterations in brain networks relevant to self-awareness in chronic cannabis users. J Psychiatr Res 2014; 51:68-78. [PMID: 24411594 DOI: 10.1016/j.jpsychires.2013.12.008] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 11/15/2013] [Accepted: 12/17/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Recreational drugs are generally used to intentionally alter conscious experience. Long-lasting cannabis users frequently seek this effect as a means to relieve negative affect states. As with conventional anxiolytic drugs, however, changes in subjective feelings may be associated with memory impairment. We have tested whether the use of cannabis, as a psychoactive compound, is associated with alterations in spontaneous activity in brain networks relevant to self-awareness, and whether such potential changes are related to perceived anxiety and memory performance. METHODS Functional connectivity was assessed in the Default and Insula networks during resting state using fMRI in 28 heavy cannabis users and 29 control subjects. Imaging assessments were conducted during cannabis use in the unintoxicated state and repeated after one month of controlled abstinence. RESULTS Cannabis users showed increased functional connectivity in the core of the Default and Insula networks and selective enhancement of functional anticorrelation between both. Reduced functional connectivity was observed in areas overlapping with other brain networks. Observed alterations were associated with behavioral measurements in a direction suggesting anxiety score reduction and interference with memory performance. Alterations were also related to the amount of cannabis used and partially persisted after one month of abstinence. CONCLUSIONS Chronic cannabis use was associated with significant effects on the tuning and coupling of brain networks relevant to self-awareness, which in turn are integrated into brain systems supporting the storage of personal experience and motivated behavior. The results suggest potential mechanisms for recreational drugs to interfere with higher-order network interactions generating conscious experience.
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Affiliation(s)
- Jesus Pujol
- MRI Research Unit, CRC Mar, Hospital del Mar, Barcelona, Spain.
| | - Laura Blanco-Hinojo
- MRI Research Unit, CRC Mar, Hospital del Mar, Barcelona, Spain; Human Pharmacology and Neurosciences, Institute of Neuropsychiatry and Addiction, Hospital del Mar Research Institute, Barcelona, Spain
| | - Albert Batalla
- Clinical Institute of Neuroscience, Hospital Clínic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain; Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain
| | - Marina López-Solà
- MRI Research Unit, CRC Mar, Hospital del Mar, Barcelona, Spain; Department of Psychology and Neuroscience, University of Colorado, Boulder, CO, USA
| | - Ben J Harrison
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne, Melbourne, Australia
| | - Carles Soriano-Mas
- Department of Psychiatry, Bellvitge University Hospital-IDIBELL, Barcelona, Spain; Carlos III Health Institute, Ministry of Science and Innovation, CIBERSAM, Spain
| | - Jose A Crippa
- Department of Neuroscience and Behavior, RibeirãoPreto Medical School, University of São Paulo, Brazil; INCT Translational Medicine (CNPq), Brazil
| | - Ana B Fagundo
- Human Pharmacology and Neurosciences, Institute of Neuropsychiatry and Addiction, Hospital del Mar Research Institute, Barcelona, Spain
| | - Joan Deus
- MRI Research Unit, CRC Mar, Hospital del Mar, Barcelona, Spain; Department of Clinical and Health Psychology, Autonomous University of Barcelona, Spain
| | - Rafael de la Torre
- Human Pharmacology and Neurosciences, Institute of Neuropsychiatry and Addiction, Hospital del Mar Research Institute, Barcelona, Spain; Red-Fisiopatología de la Obesidad y Nutrición (CIBERobn), Santiago de Compostela, Spain
| | - Santiago Nogué
- Section of Clinical Toxicology, Emergency Service, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Magí Farré
- Human Pharmacology and Neurosciences, Institute of Neuropsychiatry and Addiction, Hospital del Mar Research Institute, Barcelona, Spain; School of Medicine, Autonomous University of Barcelona, Red de Trastornos Adictivos (RETIC), Barcelona, Spain
| | - Marta Torrens
- Human Pharmacology and Neurosciences, Institute of Neuropsychiatry and Addiction, Hospital del Mar Research Institute, Barcelona, Spain; School of Medicine, Autonomous University of Barcelona, Red de Trastornos Adictivos (RETIC), Barcelona, Spain
| | - Rocío Martín-Santos
- Clinical Institute of Neuroscience, Hospital Clínic, IDIBAPS, CIBERSAM, University of Barcelona, Barcelona, Spain; Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain; INCT Translational Medicine (CNPq), Brazil
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Alobid I, Nogué S, Izquierdo-Dominguez A, Centellas S, Bernal-Sprekelsen M, Mullol J. Multiple chemical sensitivity worsens quality of life and cognitive and sensorial features of sense of smell. Eur Arch Otorhinolaryngol 2014; 271:3203-8. [PMID: 24687801 DOI: 10.1007/s00405-014-3015-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 03/17/2014] [Indexed: 11/25/2022]
Abstract
Multiple chemical sensitivity (MCS) is characterized by a loss of tolerance to a variety of environmental chemicals. Multiple chemical sensitivity is frequently triggered by exposure to chemical agents, especially insecticides. The aim of the study was to measure the sense of smell and quality of life in patients with MCS compared to the control group. We studied the sense of smell, both sensitive and sensorial characteristics, in female patients with MCS (n = 58, mean 50.5 ± 8.5 years) and healthy female volunteers without rhinosinusal pathologies (n = 60, mean age 46 ± 10.2 years). Olfactometry (Barcelona Smell Test 24/BAST-24), sinonasal symptoms (visual analogue scale/VAS 0-100 mm), and quality of life (Quick Environmental Exposure and Sensitivity Inventory/QEESI) were assessed. Multiple chemical sensitivity patients showed a significant impairment in smell identification (19 ± 12 %; p > 0.05) and forced choice (62 ± 18 %; p > 0.05), but not in smell detection (96 ± 4 %) compared to the control group. Multiple chemical sensitivity patients reported more odours as being intense and irritating and less fresh and pleasant when compared with the control group. Patients scored a high level (40-100) on QEESI questionnaire (symptom severity, chemical intolerances, other intolerances, life impact). In MCS patients, total symptom intensity (VAS/0-700 mm) score was 202 ± 135, while disease severity score was 80 ± 23. The most frequent symptoms were itching and posterior rhinorrhea. Multiple chemical sensitivity patients have an impairment in smell cognitive abilities (odour identification and forced choice, but not for detection) with increased smell hypersensitivity and poor quality of life.
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Affiliation(s)
- Isam Alobid
- Rhinology Unit and Smell Clinic, Department of Otorhinolaryngology, Hospital Clinic, Universitat de Barcelona, c/Villarroel, 170, Barcelona, 08036, Spain,
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Amigó M, Nogué S. La tierra de Fuller y otras medidas de descontaminación digestiva en el tratamiento de las intoxicaciones. Med Clin (Barc) 2014; 142:135. [DOI: 10.1016/j.medcli.2013.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 09/05/2013] [Indexed: 11/24/2022]
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Affiliation(s)
- Sara Fernández
- Área de Vigilancia Intensiva, Hospital Clínic, Barcelona, España.
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Burillo-Putze G, Aldea-Perona A, Rodríguez-Jiménez C, García-Sáiz MM, Climent B, Dueñas A, Munné P, Nogué S, Hoffman RS. [Emergent drugs (II): the Pharming phenomenon]. An Sist Sanit Navar 2013; 36:99-114. [PMID: 23648497 DOI: 10.4321/s1137-66272013000100010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The use of medicines, with or without medical prescription, for recreational ends by the young population has received little attention from doctors. In the USA, one in five adolescents has used medicines for recreational purposes, and consultations in Emergency Departments for medicine abuse have exceeded those for illegal drugs. Although few data are available in Spain, such consumption is situated between 3.1 and 8.6% according to surveys. The medicines most used are dextromethorphan and methylphenidate. The former, on sale without prescription, presents a varied symptomatology, dosage and dependent metabolic action, ranging from euphoria to hallucinations. Methylphenidate, taken orally, nasally or intravenously, is used as a stimulant in substitution for cocaine and is one of the medicines most diverted onto the illicit market at the world level. In principle, other substances like modafinil and propofol present a limited incidence of non-medical use, but they have a probable abuse potential that should be borne in mind, above all in the health context. Finally, opiates like fentanyl, oxycodone and buprenorphine, with new pharmaceutical presentations, have recently become generalized in the therapeutic arsenal of many medical specialities; they are giving rise to phenomena of abuse, dependence and diversion towards the illicit market. Demands for detoxification treatment, their mixture with illegal substances, and cases of death should alert us to the abuse of these medicines.
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Affiliation(s)
- G Burillo-Putze
- Universidad Europea de Canarias, Facultad de Ciencias de Salud, Servicio de Urgencias, Hospital Universitario de Canarias, Tenerife, España.
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Batalla A, Bhattacharyya S, Yücel M, Fusar-Poli P, Crippa JA, Nogué S, Torrens M, Pujol J, Farré M, Martin-Santos R. Structural and functional imaging studies in chronic cannabis users: a systematic review of adolescent and adult findings. PLoS One 2013; 8:e55821. [PMID: 23390554 PMCID: PMC3563634 DOI: 10.1371/journal.pone.0055821] [Citation(s) in RCA: 264] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 01/02/2013] [Indexed: 12/18/2022] Open
Abstract
Background The growing concern about cannabis use, the most commonly used illicit drug worldwide, has led to a significant increase in the number of human studies using neuroimaging techniques to determine the effect of cannabis on brain structure and function. We conducted a systematic review to assess the evidence of the impact of chronic cannabis use on brain structure and function in adults and adolescents. Methods Papers published until August 2012 were included from EMBASE, Medline, PubMed and LILACS databases following a comprehensive search strategy and pre-determined set of criteria for article selection. Only neuroimaging studies involving chronic cannabis users with a matched control group were considered. Results One hundred and forty-two studies were identified, of which 43 met the established criteria. Eight studies were in adolescent population. Neuroimaging studies provide evidence of morphological brain alterations in both population groups, particularly in the medial temporal and frontal cortices, as well as the cerebellum. These effects may be related to the amount of cannabis exposure. Functional neuroimaging studies suggest different patterns of resting global and brain activity during the performance of several cognitive tasks both in adolescents and adults, which may indicate compensatory effects in response to chronic cannabis exposure. Limitations However, the results pointed out methodological limitations of the work conducted to date and considerable heterogeneity in the findings. Conclusion Chronic cannabis use may alter brain structure and function in adult and adolescent population. Further studies should consider the use of convergent methodology, prospective large samples involving adolescent to adulthood subjects, and data-sharing initiatives.
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Affiliation(s)
- Albert Batalla
- Psychiatry, Institute of Neurosciences, Hospital Clínic, IDIBAPS, CIBERSAM, Barcelona, Spain
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain
- Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sagnik Bhattacharyya
- Department of Psychosis Studies, King’s College London, Institute of Psychiatry, London, United Kingdom
| | - Murat Yücel
- Melbourne Neuropsychiatry Centre, The University of Melbourne, Melbourne, Victoria, Australia
| | - Paolo Fusar-Poli
- Department of Psychosis Studies, King’s College London, Institute of Psychiatry, London, United Kingdom
| | - Jose Alexandre Crippa
- Neuroscience and Cognitive Behavior Department, University of Sao Paulo, Ribeirao Preto, Brazil
- National Science and Technology Institute for Translational Medicine (INCT-TM, CNPq), Ribeirao Preto, Brazil
| | - Santiago Nogué
- Clinical Toxicology Unit, Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Marta Torrens
- Neuroscience Program, Pharmacology Unit and Drug Addiction Unit, IMIM-INAD-Parc de Salut Mar, Autonomous University of Barcelona, Barcelona, Spain
- Red de Trastornos Adictivos (RETIC), IMIM-INAD-Parc de Salut Mar, Barcelona, Spain
| | - Jesús Pujol
- Institut d’Alta Tecnologia-PRBB, CRC Mar, Hospital del Mar, Barcelona, Spain
| | - Magí Farré
- Neuroscience Program, Pharmacology Unit and Drug Addiction Unit, IMIM-INAD-Parc de Salut Mar, Autonomous University of Barcelona, Barcelona, Spain
- Red de Trastornos Adictivos (RETIC), IMIM-INAD-Parc de Salut Mar, Barcelona, Spain
| | - Rocio Martin-Santos
- Psychiatry, Institute of Neurosciences, Hospital Clínic, IDIBAPS, CIBERSAM, Barcelona, Spain
- Department of Psychiatry and Clinical Psychobiology, University of Barcelona, Barcelona, Spain
- National Science and Technology Institute for Translational Medicine (INCT-TM, CNPq), Ribeirao Preto, Brazil
- * E-mail:
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Nogué S, Cino J, Corominas N, Soy D. Intoxicación por flecainida. Med Clin (Barc) 2013; 140:46. [DOI: 10.1016/j.medcli.2012.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Accepted: 05/31/2012] [Indexed: 10/27/2022]
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Batalla A, Bhattachayyria S, Yucel M, Fusar-Poli P, Crippa J, Nogué S, Torrens M, Pujol J, Farré M, Martín-Santos R. 1301 – Structural and functional imaging studies in chronic cannabis users: a systematic review of adolescent and adult findings. Eur Psychiatry 2013. [DOI: 10.1016/s0924-9338(13)76359-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Nogué S, Miró Ò. Sumisión química y atención en los servicios de Urgencias. Med Clin (Barc) 2012; 139:461; author reply 462. [DOI: 10.1016/j.medcli.2012.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
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Abstract
INTRODUCTION Internal transport of cocaine in liquid form by body packers has been reported by the media, but there are no scientific publications on the clinical aspects of this practice. CASE REPORTS We describe two cases of body packers bearing 36 and 4 packs containing liquid cocaine in the colon and rectum, respectively. Abdominal X-ray in both cases showed radiological characteristics that differed from those commonly found in body packers transporting solid-state cocaine, heroin, or cannabis (packs with lower radiological density, diffuse borders, elongated and resembling feces). Both patients were asymptomatic and were discharged from the emergency department 6 hours after admission. DISCUSSION Expulsion time after laxative administration was shorter compared to "solid" drug body packers. The diagnostic sensitivity of different imaging techniques remains to be established for internally concealed liquid drugs. There have been press reports of internal pack rupture resulting in death, so caution is required. The lower radiographic density of liquid cocaine condom packs and their adaptability to intestinal anatomy make them difficult to detect using plain abdominal radiography. Physicians should be aware of the possibility of false negative radiological findings in these cases.
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Affiliation(s)
- Guillermo Burillo-Putze
- Área de Toxicología Clínica, Servicio de Urgencias, Hospital Universitario de Canarias, Tenerife, España.
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Galicia M, Nogué S, Casañas X, Iglesias M, Puiguriguer J, Supervía A, Aguirre A, Clemente C, Puente I, Echarte JL, García-Pérez C, Burillo-Putze G, Bernal A, Busca P, Gil E, Mirò Ò. Multicenter assessment of the revisit risk for a further drug-related problem in the emergency department in cocaine users (MARRIED-cocaine study). Clin Toxicol (Phila) 2012; 50:176-82. [DOI: 10.3109/15563650.2012.658917] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Rull V, Montoya E, Nogué S, Huber O. Preliminary palynological analysis of a Holocene peat bog from Apakará-tepui (Chimantá Massif, Venezuelan Guayana). Collect Bot 2011. [DOI: 10.3989/collectbot.2011.v30.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Ribas-Deix O, Sanz-Gallén P, Nogué S. Osteonecrosis de la mandíbula asociada al tratamiento oral con ibandronato. An Sist Sanit Navar 2011; 34:489-91. [DOI: 10.4321/s1137-66272011000300016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Affiliation(s)
- Pere Sanz-Gallén
- Clinical Toxicology Unit, Hospital Clínic, 08036 Barcelona, Spain.
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Fernández J, Colomé JF, Sanz-Gallén P, Sanz-Gallén P, Nogué S, Xarau SN. [Follow-up of two patients with mesangial IgA glomerulonephritis exposed to cadmium and organic solvents]. An Sist Sanit Navar 2011; 33:309-13. [PMID: 21233866 DOI: 10.4321/s1137-66272010000400007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
For several years we carried out a follow-up of two patients with IgA mesangial glomerulonephritis with antecedents of exposure to toxic substances (cadmium and organic solvents). The first case involved a 47 year old male who was diagnosed with mesangial IgA glomerulonephritis eight years ago; he had been working for twelve years as a solderer. He had used metal bars containing 25% cadmium as part of the soldering material. Very high levels of cadmium were detected in his blood and urine. The second case involved a 50 year male who was exposed to a wide number of organic dissolvents for 23 years. Three years ago he was diagnosed with a proliferative diffuse mesangial glomerulonephritis with IgA deposits; in spite of that, the patient continued working until one year ago, when was found to have a chronic stage 3 renal disease secondary to IgA nephropathy. Patients diagnosed with mesangial IgA glomerulonephritis should be kept apart from exposure to nephrotoxic substances.
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Rull V, López-Martínez C, Lara A, Campbell L, Nogué S. Additions to the Pantepui pollen flora (Venezuelan Guayana): the Maguire Collection. Collect Bot 2011. [DOI: 10.3989/collectbot.2010.v29.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Galicia M, Nogué S, Sanjurjo E, Miró O. Consultas urgentes derivadas del consumo de éxtasis (3,4-metilenodioximetanfetamina) y derivados anfetamínicos: perfil epidemiológico, clínico y evolutivo. Rev Clin Esp 2010; 210:371-8. [DOI: 10.1016/j.rce.2010.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 12/14/2009] [Accepted: 01/04/2010] [Indexed: 11/17/2022]
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Bosch X, Loma-Osorio P, Guasch E, Nogué S, Ortiz JT, Sánchez M. Prevalence, clinical characteristics and risk of myocardial infarction in patients with cocaine-related chest pain. Rev Esp Cardiol 2010; 63:1028-1034. [PMID: 20804698 DOI: 10.1016/s1885-5857(10)70206-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
INTRODUCTION AND OBJECTIVES To investigate the frequency of recent cocaine use in patients attending an emergency department for acute chest pain, to describe the clinical characteristics of these patients, and to estimate the incidence of acute coronary syndrome in this population. METHODS Observational cohort study using a standard questionnaire that includes items on recent cocaine consumption. RESULTS During a 1-year period, 1240 patients aged under 55 years presented with chest pain. Of these, 63 (5%) had cocaine-related chest pain (7% of men and 1.8% of women). These patients were younger (35+/-10 years vs. 39+/-10 years; P=.002), were more frequently male (87% vs. 62%; P< .001), and were more frequently smokers (59% vs. 35%; P< .001). Patients who had used cocaine recently had a higher incidence of acute myocardial infarction (16 vs. 4%; P< .001), especially ST-segment-elevation myocardial infarction (11.1% vs. 1.6%; P< .01). After adjusting for coronary risk factors, history of cardiovascular disease and previous treatment, the odds ratio for myocardial infarction with recent cocaine consumption was 4.3 (95% confidence interval, 2-9.4). CONCLUSIONS Cocaine-related chest pain is often encountered in emergency departments, especially in men aged under 55 years. It is associated with a four-fold increase in the risk of acute myocardial infarction. All male patients aged under 55 years with acute chest pain should be asked about cocaine use.
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Affiliation(s)
- Xavier Bosch
- Servicio de Cardiología, Institut del Tórax, Hospital Clínic e Institut d'Investigacions Biomèdiques August Pi i Sunyer, Departamento de Medicina, Universidad de Barcelona, Barcelona, España.
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Rodríguez M, Uroz V, Nogué S, Climent B, Puiguriguer J, Dorado M, Mateo S, Nieto Á, Anadón M. Gender analysis in occupational poisonings in Spain. Toxicol Lett 2010. [DOI: 10.1016/j.toxlet.2010.03.291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Amigó M, Nogué S, Miró Ò. Carbón activado en 575 casos de intoxicaciones agudas. Seguridad y factores asociados a las reacciones adversas. Med Clin (Barc) 2010; 135:243-9. [DOI: 10.1016/j.medcli.2009.10.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Revised: 10/04/2009] [Accepted: 10/06/2009] [Indexed: 10/19/2022]
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Garrabou G, Morén C, Nicolàs M, Trullàs J, Mondón S, Navarro V, Jou J, Nogué S, Miró Ò, Casademont J, Cardellach F. 18 Methylene chloride effects on mitochondria. Mitochondrion 2010. [DOI: 10.1016/j.mito.2009.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Sanz P, Nogué S, Farrús X, María Molina J. [Semicircular lipoatrophy in office workers]. Med Clin (Barc) 2010; 134:135-6. [PMID: 19427654 DOI: 10.1016/j.medcli.2009.02.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 02/05/2009] [Indexed: 11/25/2022]
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Ruiz MT, Nogué S, Zavala E, Cirera A. [Does a history of substance abuse influence sedation requirements in critically-ill patients?]. Med Intensiva 2009; 34:433-4. [PMID: 20031279 DOI: 10.1016/j.medin.2009.11.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/15/2009] [Accepted: 11/10/2009] [Indexed: 11/19/2022]
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Montoya E, Rull V, Nogué S, Díaz WA. Paleoecología del Holoceno en la Gran Sabana, SE Venezuela: Análisis preliminar de polen y microcarbones en la Laguna Encantada. Collect Bot 2009. [DOI: 10.3989/collectbot.2008.v28.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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