Victorita Sorodoc

Is MARS system enough for A.phalloides-induced liver failure treatment?

Patients with Amanita phalloides-induced liver failure (LF) have a high mortality, despite significant advances in intensive care managemet. Our study evaluated the effect of Molecular Absorbents Recirculating System (MARS) comparative with optimal intensive care (OIC) in adults with this condition, in the absence of liver transplantation (LT). Six consecutive patients (women, range 16—61 years) affected by A.phalloides-induced LF were treated with OIC (3 patients) and MARS (3 patients). Laboratory parameters and hepeatic encephalopaty were evaluated 15 min before and 24 hours following each MARS treatment. Three 6-hour sessions per patient were performed in MARS group, with a statistically significant decrease in ammonia (p value 0.011), alaninaminotransferase (ALT) and prothrombin time (PT) (p value 0.004). Two patients had a significant rebound in bilirubin (+116%; p value 0. 04) 24 hours following MARS. Mortality in MARS group was 66.7%. Survival rate in OIC was 0%. Negative prognostic markers: lack of PT and hepatic encephalopaty improvement, rebound in bilirubin, and delay of MARS therapy initiation. No significant adverse reactions occurred during MARS. MARS is an effective depurative therapy in adults with A.phalloides-induced LF, but alone is not enough. Survival is predicted by the results of the initial MARS, amount of mushroom consumed, and time from toxin exposure.

Epidemiology of acute drug poisoning in a tertiary center from Iasi County, Romania

The aim of this retrospective epidemiological study was to investigate the demographical, etiological and clinical characteristics of acute drug poisonings in Iasi County, Romania. All patients were referred and admitted in the Toxicology Clinic of “Sf. Ioan” Emergency Clinic Hospital Iasi, Romania. Between 2003 and 2009, 811 cases of acute drug poisonings were recorded, counting for 28.43% from the total number of poisonings. The majority of these poisonings resulted in mild (51.94%) and medium (28.35%) clinical forms, while 19.71% were coma situations. In all, 63.51% of patients originated from urban areas, 39.94% were unemployed and the patients were predominantly women (66.46%). A high percentage (97.27%) were suicide attempts, using only one type of drug (65.88%) and the 21–30 years group (29.8%) records the highest incidence, for both women and men. The most frequently involved drugs were benzodiazepines 13.69%, anticonvulsive drugs 8.63%, barbiturates 8.51% and cardiovascular drugs 5.92%. Drugs combinations were recorded in 32.92% of cases and 1.2% were combinations between drugs and other substances. Mortality was the outcome in 0.3% of the total registered number of acute drug poisonings. This study underlines that in order to provide a proper management of these situations, a Regional Poison Information Center is absolutely necessary.

Cardiac Troponin T and NT-proBNP as Biomarkers of Early Myocardial Damage in Amitriptyline-Induced Cardiovascular Toxicity in Rats:

The main objective of this study was to investigate whether cardiac troponin (cTn) and N-terminal, protein B-type natriuretic peptide (NT-proBNP) can be useful as indicators for amitriptyline cardiotoxicity which is a known drug having sublethal toxic cardiac effects. At the same time, this study looked at detecting potential histopathological changes specific to irreversible cardiac injuries in a rat model of amitriptyline cardiotoxicity. Male Wistar rats were randomly divided into 2 groups, control (saline) group and amitriptyline group (100 mg/kg body weight intraperitoneally, equivalent for lethal dose at 50%). Blood was collected 30 minutes after the administration. The cTn was measured using 3 different methods (2 methods designed for human use and a sandwich enzyme immunoassay specific for rat cTnT). The brain natriuretic peptide was measured by 2 different methods (1 for human and 1 specific for rats). Electrocardiography showed that the QRS complex (P < .0001) and the QT interval (P = .002) were significantly prolonged for amitriptyline-treated animals. Troponin T and NT-proBNP had significantly increased levels in all the rats but showed positive results only when using rat-specific quantitative measurement. In certain rats, the histopathological examination identified a few small foci of acute myocardial necrosis. In conclusion, elevation of cTnT and NT-proBNP are early indicators of cardiotoxicity, yet the significance of irreversible myocardial damage in amitriptyline cardiotoxicity needs to be further understood.

Biomarkers, lactate, and clinical scores as outcome predictors in systemic poisons exposures

Acute exposure to systemic poisons represents an important challenge in clinical toxicology. We aimed to analyze the potential role of cardiac biomarkers, routine laboratory tests, and clinical scores as morbidity and in-hospital mortality predictors in patients intoxicated with various systemic poisons. We conducted a prospective study on adults acutely exposed to systemic poisons. We determined the PSS, Glasgow Coma Scale (GCS), and we performed electrocardiogram, laboratory tests, lactate and cardiac biomarkers (which were reassessed 4 h, respectively 6 h later). Of 120 patients included, 45% developed complications, 19.2% had a poor outcome, and 5% died. Multivariate logistic regression sustained lactate (odds ratio (OR) 1.58; confidence interval (CI) 95%: 0.97–2.59; p 0.066), MB isoenzyme of creatine kinase (6h-CKMB; OR 1.08; CI 95%: 1.02–1.16; p 0.018) as predictors for a poor outcome. A GCS < 10 (OR 0.113; CI 95%: 0.019–0.658; p 0.015) and 4h-lactate (OR 4.87; CI 95%: 0.79–29.82; p 0.087) predicted mortality after systemic poisons exposure. Receiver operating characteristic analysis showed that brain natriuretic peptide (area under the curve (AUC), 0.96; CI 95%: 0.92–0.99; p < 0.001), lactate (AUC, 0.91; CI 95%: 0.85–0.97; p < 0.001), and 6h-CKMB have good discriminatory capacity for predicting a poor outcome. In conclusion, these biomarkers, lactate, and GCS can be used to predict morbidity and mortality after systemic poisons exposure.

Acute pancreatitis after nifedipine and acetaminophen poisoning — case report

The incidence of drug-induced pancreatitis is rare. There have been several reports of acute pancreatitis as a complication in acute poisoning with drugs or toxins. We present a case of a young woman with acute pancreatitis secondary to an overdose of nifedipine and acetaminophen in a suicide attempt. We excluded other causes of acute pancreatitis by clinical history, serum toxicology, serology, and abdominal imaging. The most likely underlying pathophysiological mechanism was ischemic injury of the pancreas secondary to severe collapse induced by nifedipine and possible acetaminophen-induced direct pancreatotoxicity. The pancreatitis resolved with treatment that included continuous veno-venous haemofiltration in an intensive care unit. Emergency and intensive care units should be aware of this unusual complication of such poisoning. To our knowledge, this is the first reported association between massive nifedipine overdose and acute pancreatitis.

Development and validation of a risk-prediction nomogram for in-hospital mortality in adults poisoned with drugs and nonpharmaceutical agents: An observational study

Abstract Acute poisoning with drugs and nonpharmaceutical agents represents an important challenge in the emergency department (ED). The objective is to create and validate a risk-prediction nomogram for use in the ED to predict the risk of in-hospital mortality in adults from acute poisoning with drugs and nonpharmaceutical agents. This was a prospective cohort study involving adults with acute poisoning from drugs and nonpharmaceutical agents admitted to a tertiary referral center for toxicology between January and December 2015 (derivation cohort) and between January and June 2016 (validation cohort). We used a program to generate nomograms based on binary logistic regression predictive models. We included variables that had significant associations with death. Using regression coefficients, we calculated scores for each variable, and estimated the event probability. Model validation was performed using bootstrap to quantify our modeling strategy and using receiver operator characteristic (ROC) analysis. The nomogram was tested on a separate validation cohort using ROC analysis and goodness-of-fit tests. Data from 315 patients aged 18 to 91 years were analyzed (n = 180 in the derivation cohort; n = 135 in the validation cohort). In the final model, the following variables were significantly associated with mortality: age, laboratory test results (lactate, potassium, MB isoenzyme of creatine kinase), electrocardiogram parameters (QTc interval), and echocardiography findings (E wave velocity deceleration time). Sex was also included to use the same model for men and women. The resulting nomogram showed excellent survival/mortality discrimination (area under the curve [AUC] 0.976, 95% confidence interval [CI] 0.954–0.998, P < 0.0001 for the derivation cohort; AUC 0.957, 95% CI 0.892–1, P < 0.0001 for the validation cohort). This nomogram provides more precise, rapid, and simple risk-analysis information for individual patients acutely exposed to drugs and nonpharmaceutical agents, and accurately estimates the probability of in-hospital death, exclusively using the results of objective tests available in the ED.

Profile of adult acute cholinesterase inhibitors substances poisoning – a 30 years analysis

Abstract Objectives: The objective of this study was to assess the pattern and outcome of acute cholinesterase inhibitors substances (CIS) poisoning cases, in a cohort from a regional tertiary care hospital. Methods: cases admitted in the Toxicology Clinic of “Sf. Spiridon” Emergency Clinic Hospital Iasi, Romania between 1983 and 2013 were studied. Results: a total number of 606 patients were included. The reason for exposures was intentional in 70% of cases and the commonest route of poisoning was oral in 92.2%. The highest percent of cases was females (56.4), the age group 20-29 (25.4%) and the majority (66.7%) coming from rural areas, 28.2% being agricultural workers. 36.6% of cases were severe clinical forms. Overall mortality rates were 3.8%, more than half of the death patients (65.2%) had concomitant alcohol intake. It was a significant statistical association between decrease level of serum cholinesterase on admittance and severe forms (p 0.000) and between survival and deaths groups (p 0.000). The pattern of poisoning described by our retrospective study suggests that CIS poisoning are mainly preventable. The main effective goals for prevention are restriction in free accessibility to toxic pesticides, together with sustained efforts in education concerning the life-threatening danger of pesticide poisoning.

Repeated Bronchoscopy - Treatment of Severe Respiratory Failure in a Fire Victim

Abstract A case of respiratory failure in a domestic fire victim presenting with 1-3-degree skin burns on 10% of the total body surface, is reported. Forty-eight hours after admission to hospital, the patient developed severe respiratory failure that did not respond to mechanical ventilation. Severe obstruction of the airway had resulted from secretions and deposits of soot forming bronchial casts. The patient required repeated bronchoscopies to separate and remove the bronchial secretions and soot deposits. An emergency bronchial endoscopic exam was crucial in the patient’s survival and management. The patient was discharged from the hospital after twenty-four days.

Usefulness of transthoracic echocardiography parameters and brain natriuretic peptide as mortality predictors in hospitalized, acutely poisoned patients: a prospective observational study

Acute poisonings represent a common cause of morbidity and mortality worldwide. The prognostic utility of the transthoracic echocardiography (TTE) parameters combined with brain natriuretic peptide (BNP) in acute poisoning with different xenobiotics, upon admission in the hospital, was not evaluated. This prospective observational cohort study included 229 acutely poisoned non‐diabetic adults, with a median age of 44 years (range 18–90 years), 50.7% women, with an in‐hospital mortality rate of 8.7%. Univariate logistic regression analysis showed that age, the left ventricle kinetic abnormalities, the E‐wave deceleration time (EDT) and BNP correlated significantly with mortality in acutely poisoned patients. Multivariate logistic regression showed that only EDT [odds ratio (OR) 3.44, 95% confidence interval (CI) 1.54–7.69, p 0.003], BNP (OR 1.61, 95% CI: 1.02–2.55, p 0.04) and age (OR 2.66, 95% CI: 1.23–5.76, p 0.013) are predictive for mortality. The receiver‐operating characteristic (ROC) analysis proved EDT [area under the ROC curve (AUC), 0.85; CI: 0.76–0.94; p 0.001], BNP (AUC, 0.83; CI: 0.75–0.91; p 0.001) and age (AUC, 0.82; CI: 0.74–0.90; p 0.001) as indicators for fatalities. In hospitalized patients acutely intoxicated with undifferentiated poisons, EDT as a parameter of left ventricle diastolic function and BNP are useful to early predict mortality.