CREATINE KINASE IN PATIENTS WITH RHABDOMYOLYSIS ACUTELY INTOXICATED WITH PSYCHOTROPIC AND CHEMICAL SUBSTANCES.

The aim of this study was to determine the CK activity and its association with the length of hospital stay in acutely intoxicated patients with psychotropic and chemical substances. Rhabdomyolysis is defined as a creatine kinase (CK) > 250 U/L. We included adult patients ≥ 18 years of age, with rhabdomyolysis acutely intoxicated with psychotropic and chemical substances in the first 48 hours. We excluded patients with rhabdomyolysis in muscle trauma as a result of a traumatic accident, myocardial infarction, cerebral vascular infarction, cerebral hemorrhage, and chronic hepatic and renal disease. In all patients with rhabdomyolysis, the mean CK on the first, third and fifth day was consequently 5715.9±16088.8 U/L with a maximum value of 129077 U/L vs. 5548.5±9851.5 U/L with a maximum value of 63947U/L vs. 2970.42±7161.68 U/L with a maximum value of 53672 U/L. The comparison for the whole sample in the three measurement times, for p <0.05, showed a significant difference (Friedman Test: N = 62; Chi-Square = 34.935; df = 2; p = 0.00001). For the whole sample of patients with rhabdomyolysis, as well as in the group of psychotropic intoxications, for p < 0.05, the level of CK on the first day was confirmed as an independent predictor that significantly affected the variability of the length of hospitalization by 5.2% (R2 = 0.052) vs. 20% (R2=0.200). In rhabdomyolysis, as a result of acute intoxication with psychotropic and chemical substances it is important to examine the creatine kinase. Creatine kinase levels were higher in rhabdomyolysis in acutely intoxicated patients with psychoactive compared to chemical substances. In the group intoxicated with psychoactive substances creatine kinase as an independent predictor significantly affected the length of hospitalization.

FATAL ACUTE ALIMINIUM PHOSPHIDE POISONING - CASE REPORT AND LITERATURE REVIEW WITH REFERENCE TO CURRENT TREATMENT PROTOCOLS AND OUTCOME.

Aluminum phosphide (AlP) has been known for more than 80 years as an effective pesticide for grain protection, but also as a suicidal agent used for human self-poisoning. Phosphine gas released in contact with stomach acid after oral ingestion of AlP is responsible for its toxicity. The poison affects all systems, so the mortality rate is quite high, especially after deliberate ingestions. We report the first case of severe AlP poisoning seen in our institution with a fatal outcome and furthermore, we present literature review on existing and newer treatment options. A 35-year-old woman with a history of epilepsy was admitted to the University Clinic for Toxicology in Skopje two hours after deliberate ingestion of one tablet of phostoxin (AlP). The first signs of poisoning were vomiting and abdominal pain, leukocytosis, prolonged PT, as well as inverted T waves in D3, AVF and left precordial leads on ECG. After developing respiratory failure and hypotension she was transferred to the intensive care unit (ICU). Her blood pressure was 80/40 mmHg, pulse rate 120/min. Laboratory findings showed signs of hepatic lesion, rhabdomyolysis and renal failure (AST 2267.42 U/L, ALT 2102.26 U/L, CPK 1334.81U/L, blood urea nitrogen 23.03 mmol/L, creatinine 211.9 µmol/L). Arterial blood gas analyses showed metabolic acidosis (pO2 9.6 kPa, pCO2 4.14 kPa, pH 7.15, bicarbonate 11 mmol/L, BE -15). The patient was placed on mechanical ventilation. Despite fluid supplementation, intensive therapy and inotropic support, hemodynamic instability worsened and cardiopulmonary resuscitation was performed three times. Unfortunately, the patient had a fatal outcome on the fourth day of intoxication. Solid formulations of AlP are very toxic. One tablet of phostoxin containing 3 grams of AlP is sufficient for the progression of life-threatening symptoms and fatal outcome. In the absence of antidote and elucidated mechanisms of toxicity, the key to treatment is rapid decontamination and initiation of resuscitation measures.

CLINICAL AND BIOCHEMICAL FINDINGS OF RHABDOMYOLYSIS IN ACUTE INTOXICATIONS WITH PSYCHOACTIVE AND CHEMICAL SUBSTANCES.

The aim of the study is to identify possible differences in demographic, laboratory and clinical characteristics between patients with rhabdomyolysis due to intoxication with psychoactive and chemical substances. The study is a cross-sectional study conducted between 1 January and 30 June 2019. All the patients included during this period were treated due to intoxication (outpatient or hospitalized) at the University Clinic of Toxicology in Skopje. The patients with rhabdomyolysis were divided in two groups according to the nature of the substance used for intoxication: a) psychoactive substances and b) a chemical substance. Rhabdomyolysis was determined with a value of CPK (creatinine phosphate kinase) >250 U/L. Patients with rhabdomyolysis due to intoxication with chemical substances were significantly older than patients with rhabdomyolysis due to intoxication with psychoactive substances. There is a significant difference between the two groups of patients with rhabdomyolysis in terms of CPK, urea, hemoglobin values during the first day with regards to significantly higher values in the group where intoxication occurred with psychoactive substances. Five patients with rhabdomyolysis due to intoxication with psychoactive substances experienced muscle pain (10.9%), and one patient (3.8%) of those with rhabdomyolysis due to intoxication with chemicals, without any significant association between muscle pain and type of intoxication (Fisher exact test: p=0.3003). Muscle weakness and pigmented urine were identified consequently in six patients (13.0%) vs. five (10.9%) of patients with psychoactive intoxication and none with chemical. Rhabdomyolysis caused by psychoactive and chemical substances is associated with clinical manifestations and biochemical abnormalities. The values of CPK, myoglobin, AST, ALT, LDH, urea and creatinine were higher in favor of the group of intoxicated patients with rhabdomyolysis with psychoactive substances. The clinical symptoms of rhabdomyolysis are not present in all intoxicated patients, but are more present in the group intoxicated with psychoactive substances. Biochemical findings are crucial in establishing the diagnosis of rhabdomyolysis. Abnormalities of biochemical findings need to be identified in order to initiate appropriate treatment immediately to prevent mortality and morbidity.

Conservative therapeutic approach to corrosive poisonings in adults.

INTRODUCTION: In this study, we assess the effectiveness of a conservative therapeutic treatment of acute corrosive poisonings in adults, and we define therapeutic protocols based on clinical and endoscopic criteria. METHODS: We analyzed clinical records of patients with acute corrosive poisonings who were hospitalized and treated at the Toxicology Clinic at the University of Skopje, Republic of Macedonia, during a 5-year period (2006-2010). A total of 481 patients' records with cases of acute corrosive poisonings were analyzed. There were 317 female (65.9 %) and 164 male (34.1 %) patients. The purpose of the therapy in the cases of acute corrosive poisonings is to prevent perforation as well as progressive fibrosis and stenosis of the esophagus and stomach. Therapeutic approach mainly consists of proton pump inhibitors, H(2) blockers, antibiotics, and intensive hyperalimentation. There are different opinions regarding conservative treatment of acute corrosive poisonings in adults. CONCLUSION: Based on our study of corrosive poisonings of adults, we propose a list of optimal treatment recommendations.

Changes of some humoral immunologic indicators and clinical manifestations of cryoglobulinemia in heroin addicts.

UNLABELLED: Different autoantibodies and immunologic abnormalities have been described in heroin addicts. AIMS: dpending on the route of heroin application in heroin addicts to determine: 1) immunoglobulins: IgA, IgG, IgM; 2) complement (C3, C4); 3) some other autoantibodies RF, anti ß2GP1 fractions: IgA, IgG, IgM, ANA; 4) CIC; 5)monitoring the cryoglobulin presence; 6) clinical manifestations in cryoglobulin positive heroin addicts. A total of 363 heroin addicts were analyzed after previously completed questionnaire; biochemical analyses of blood and urine; creatinine clearance (eC(Cr)) by Cockcroft-Gault formula; proteinuria; 24-hour proteinuria (Uprot/Ucreat); ECG; toxicological analyses; complement (C3, C4); immunoglobulins IgA, IgG, IgM; rheumatoid factor; cryoglobulins; circulating immune complexes; antiphospholipid antibodies (anti ß2GP1: IgA, IgG, IgM); antinuclear antibodies. Male patients were predominating (82.09%). Of them 161 were using intravenous heroin (45.4%). IgA was statistically significantly lower in intravenous heroin addicts. Intravenous heroin addicts contrary to those who inhaled heroin had highly significant levels of IgG, IgM, IgG, antiß2GP1 cryoglobulins; significantly higher mean values of: RF, anti ß2GP1 IgA and IgM. Cryoglobulin positive (CP) heroin addicts compared to cryoglobulin negative (CN) presented significantly more frequently with clinical signs of arthralgia, vasculitis, hematuria; whereas highly significantly were manifested respiratory difficulties, neurological disorders, Raynaud phenomenon, proteinuria, 24-hour proteinuria, highly significantly lower mean values of renal clearance. Intravenous heroin addicts compared to the non-parenteral heroin addicts have shown greater changes in certain parameters of humoral immunity. CP heroin addicts have presented with more frequent clinical manifestations than CN heroin addicts.

Post-corrosive injuries of upper gastrointestinal tract.

Acute poisonings with corrosive substances may cause serious chemical injuries to upper gastrointestinal tract, the most common location being the esophagus and the stomach. If the patient survives the acute phase of the poisoning, regenerative response may result in esophageal and/or gastric stenosis and increased risk for esophageal cancer. Acute corrosive intoxications pose a major problem in clinical toxicology since the most commonly affected population are the young with psychic disorders, suicidal intent and alcohol addiction. In establishing the diagnosis of acute corrosive poisonings, the severity of the post-corrosive endoscopic changes of the esophagus, stomach and duodenum is of major importance. According to Holinder and Fridman classification, post-corrosive endoscopic changes are classified in three degrees: First degree--superficial damage associated with hyperthermia, epithelial desquamation and mucous edema. Second degree--transmucous damage affecting all of the mucosal layers, followed by exudation, erosions and ulcerations. Third degree--transmural damage associated with ulcer's penetration in the deep layers of the tissue and neighboring organs. Severity of the lesions depends on the nature, quantity and concentration of the corrosive substance, the duration of exposure and current state of the exposed organs. Most often caustic injuries occur to the esophagus and stomach since the corrosive substance remains there for a longer period of time. Treatment of the acute corrosive intoxications include: neutralization of corrosive agents, antibiotics, corticosteroids, anti-secretory therapy, nutritional support, collagen synthesis inhibitors, esophageal dilation and stent placement, and surgery. The most common complications that may appear are: perforation, gastrointestinal bleeding, sepsis, esophageal strictures and stenosis, stenosis of gastric antrum and pylorus, cancer of the esophagus and the stomach. Today, owing to the substantially enhanced diagnostic and therapeutic approach, the mortality percentage has been reduced from 20% to 1-5%. Women more often than men are intoxicated with corrosive substances; suicidal poisonings prevail; the most abused agents are hydrochloric acid (HCl) and sodium hydroxide; intoxications are more common in children (80% out of the total number of intoxications). In spite of the preventive measures for restriction of the trade with corrosive substances, standardization of their concentration and protective safety bottle caps, still the number of corrosive intoxications, the percentage of post-corrosive complications and the handicap are high. Acute corrosive intoxications are the leading cause of death in clinical toxicology.

Predictive value of the duration of sciatica for lumbar discectomy.

The optimal time for lumbar discectomy due to sciatica is still under discussion. We examined a group of 177 consecutive patients with lumbar disc herniation, who underwent lumbar discectomy. According to the duration of the sciatica, patients were divided into 3 groups: 31 (17.5%) patient with a duration of sciatica from 0 to 3 months, 82 (46.3%) patients with a duration from 4 to 10 months, and 64 (36.2%) with a duration longer than 10 months. The assessment of postoperative health status was done with the Oswestry Disability Index 2.0 (ODI scoring) one year after the surgery. Statistical data have shown that there was no significant difference between the patients operated on in the period from 0-3 and 4-10 months (p > 0.05). There was a significant difference between the patients operated on in the period from 0-3 months and > 10 months (p > 0.001). There was also a significant difference between the patients operated on in the period from 4-10 months and those operated > 10 months (p < 0.001). This goes in favour of achieving the best results in patients with a duration of sciatica from 0 to 3 months. The worst results were obtained in those with a duration of sciatica > 10 months.