Publications by authors named "Hossein Hassanian-Moghaddam"

123 Publications

Fatal Outcome in Acutely Poisoned Children With Hospitalization: A 10-Year Retrospective Study From Tehran, Iran.

Pediatr Emerg Care 2021 Apr 9. Epub 2021 Apr 9.

From the *Department of Pediatrics, Loghman Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran †King's College London, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom ‡Kish Institute of Science and Technology §Social Determinants of Health Research Center ∥Department of Clinical Toxicology, Loghman Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Acute poisoning is a significant and preventable cause of mortality among children internationally. The aims of this study were to assess the case fatality rate of children admitted to an inner-city hospital for acute poisoning and to compare the demographics and source of poisoning of fatal cases.

Methods: This was a retrospective review of patient data recorded in the Hospital Information System for Loghman Hakim Hospital, that is, the central referral hospital for poisoning in Tehran, Iran. We searched Hospital Information System for all admissions for poisoning in children (age, 0-12 years) over the 10-year period from March 2010 to March 2020, and all cases were included in the analysis. We determined the case fatality rate by dividing the number of fatal cases by the number of included cases.

Results: Of 8158 children admitted for poisoning, 28 cases (0.3%) died, among whom 19 (67.9%) were boys and 9 (32.1%) girls. The median age was 42 months, ranging from 2 to 144 months. Twenty-two cases (78.6%) were 0 to 5 years old. The most common cause of mortality in acute poisoning was methadone (n = 13, 46.4%), followed by raw opium (n = 5, 17.9%), aluminum phosphide, carbon monoxide, and wild mushrooms (n = 2 deaths each, 7.1%). Tramadol, colchicine, and petroleum accounted for 1 death each (3.6%).

Conclusions: Mortality from unintentional poisoning disproportionately affects children younger than 5 years. Opioids (ie, methadone, opium, tramadol) accounted for two thirds of deaths in our sample. Our findings highlight the importance of educating parents that any toxic materials (licit or illicit) must be stored out of reach for children.
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http://dx.doi.org/10.1097/PEC.0000000000002429DOI Listing
April 2021

Troponin, A Predictor of Mortality in Methadone Exposure: An Observational Prospective Study.

J Am Heart Assoc 2021 Apr 6;10(8):e018899. Epub 2021 Apr 6.

Social Determinants of Health Research CenterShahid Beheshti University of Medical Sciences Tehran Iran.

Background Methadone poisoning/overdose is a global public health problem. We aimed to determine whether methadone poisoning increased cardiac troponin and whether high-sensitivity cardiac troponin I (hs-cTnI) levels predicted the need for intensive care unit admission, intubation, and mortality. Methods and Results This observational, prospective single-center study was done at Loghman-Hakim Hospital (Tehran, Iran) from June 2018 until February 2019. Patients aged >14 years admitted with a diagnosis of methadone exposure were included. Patients were excluded if they had coexisting conditions associated with elevated hs-cTnI levels. An ECG and hs-cTnI levels were obtained on emergency department presentation. Patients were followed up on their need for intubation, intensive care unit admission, and in-hospital mortality. Of 245 included patients (186 [75.9%] men; median age, 33 years), most referred to loss of consciousness (210 cases, 89%). Nineteen (7.7%) patients had hs-cTnI levels of >0.1 ng/mL (positive), and 41 (16.7%) had borderline levels of 0.019 to 0.1 ng/mL. Twenty-three (9.3%) cases were admitted to the intensive care unit, 21 (8.5%) needed intubation, and 5 (2%) died during hospitalization. An hs-cTnI cutoff value of 0.019 ng/mL independently predicted mortality. For optimal concomitant sensitivity and specificity, receiver operating characteristic curve analysis was conducted and showed that hs-cTnI had an independent significant association with mortality, with a cutoff value of 0.0365 ng/mL (odds ratio, 38.1; 95% CI, 2.3-641.9; <0.001). Conclusions Methadone exposure/toxicity is a newly identified cause of elevated hs-cTnI. Values >0.019 ng/mL, and particularly >0.0365 ng/mL, of hs-cTnI predicted mortality in our sample. Future studies should measure troponin levels in methadone maintenance treatment clients to assess the risk of myocardial injury from long-term exposure.
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http://dx.doi.org/10.1161/JAHA.120.018899DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8174177PMC
April 2021

Complications and hospital stay after endoscopic retrieval of drug baggies in body stuffers: an observational prospective study.

Sci Rep 2021 Mar 8;11(1):5359. Epub 2021 Mar 8.

National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Addiction Sciences, London, UK.

Body stuffers routinely receive conservative treatment, i.e. administration of the laxative polyethylene glycol for the passage of ingested drug baggies and observation. Endoscopic baggie removal may offer a safe alternative that could result in shorter hospitalization. We aimed to compare complications, hospital stay, and final outcome in body stuffers assigned to endoscopy versus conservative treatment. This is an observational prospective study of body stuffers presenting to a clinical toxicology center in Tehran (Iran) in 2016-2019, irrespective of the drug ingested. Eligible patients had baggies in their upper gastrointestinal tract and presented without severe poisoning. Patients received either endoscopy or conservative treatment, and clinical outcomes were compared between the groups. A total of 69 patients were enrolled, with a median age of 29 years (range 18-64), among whom 1 was female (2%). Eighteen and 51 patients were endoscopically and conservatively managed, respectively. Drugs most commonly ingested were heroin in endoscopy patients (8/18 cases; 44%) and methamphetamine in the conservative group (28/51 cases; 55%). Endoscopy patients had a shorter hospital stay (median 1.5 vs. 2 days, P = 0.018). In the conservative group, one patient died, and the rate of complications was significantly higher, with more patients experiencing side effects (OR = 1.4, 95% CI = 1.2, 1.7) and requiring intubation (OR = 1.3, 95% CI = 1.1, 1.5). Endoscopic retrieval was associated with fewer complications and shorter hospitalization. Endoscopy may be a safe treatment for body stuffers without severe poisoning on presentation.
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http://dx.doi.org/10.1038/s41598-021-84898-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7940431PMC
March 2021

Correction to: Protective effect of flumazenil infusion in severe acute benzodiazepine toxicity: a pilot randomized trial.

Eur J Clin Pharmacol 2021 Apr;77(4):555-556

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

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http://dx.doi.org/10.1007/s00228-021-03117-wDOI Listing
April 2021

Public Knowledge, Attitudes, and Practices Related to COVID-19 in Iran: Questionnaire Study.

JMIR Public Health Surveill 2021 02 23;7(2):e21415. Epub 2021 Feb 23.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: The COVID-19 pandemic is a rapidly growing outbreak, the future course of which is strongly determined by people's adherence to social distancing measures.

Objective: The objective of this study was to determine the knowledge level, attitudes, and practices of the Iranian population in the context of COVID-19.

Methods: A nationwide study was conducted from March 24 to April 3, 2020, whereby data were collected via an online self-administered questionnaire.

Results: Responses from 12,332 participants were analyzed. Participants' mean knowledge score was 23.2 (SD 4.3) out of 30. Most participants recognized the cause of COVID-19, its routes of transmission, its symptoms and signs, predisposing factors, and prevention measures. Social media was the leading source of information. Participants recognized the dangers of the situation and felt responsible for following social distancing protocols, as well as isolating themselves upon symptom presentation. Participants' mean practice score was 20.7 (SD 2.2) out of 24. Nearly none of the respondents went on a trip, and 92% (n=11,342) washed their hands before touching their faces.

Conclusions: Knowledge of COVID-19 among people in Iran was nearly sufficient, their attitudes were mainly positive, and their practices were satisfactory. There is still room for improvement in correcting misinformation and protecting people from deception. Iranians appear to support government actions like social distancing and care for their and others' safety.
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http://dx.doi.org/10.2196/21415DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903976PMC
February 2021

Unintentional buprenorphine and methadone poisoning in children: a matched observational study.

Clin Toxicol (Phila) 2021 Jan 21:1-11. Epub 2021 Jan 21.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Objective: To compare accidental pediatric poisoning from methadone vs. buprenorphine in terms of clinical indicators and in-hospital morbidity.

Methods: A matched observational study conducted on children aged ≤12 years admitted to our center between March 2018 and March 2019 with acute poisoning from methadone or buprenorphine. Data were extracted from the electronic patient files of the pediatric methadone poisoning cases, and buprenorphine poisoning cases were followed from ED, during the study period. Cases were compared regarding rates of bradypnea/apnea (primary outcome), the need for antidote therapy and intubation, duration of hospital stay, miosis, loss of consciousness, blood gas analyses, and mortality (secondary outcomes).

Results: A total of 90 methadone- and 30 buprenorphine-poisoned children were evaluated. Methadone cases had significantly higher rates of apnea (20/90 methadone vs. 0/30 buprenorphine; OR = 17.7, 95% CI 1.1, 302.8;  = 0.047), but there was no group difference in bradypnea (39/90 methadone vs. 10/30 buprenorphine; = ns). 28 (31%) methadone and 3 buprenorphine (10%) cases had been referred to as fully awake ( = 0.013). Methadone cases required higher median naloxone doses for initial bolus (0.4 vs. 0.02 mg;  = 0.014) and maintenance infusion (14.4 vs. 2.4 mg;  < 0.001). 20 apnea cases (all from the methadone group) had miotic pupils, and miotic pupils were seen in 44 (90%) cases with bradypnea (OR = 3.2, 95% CI 1.1, 9.3;  = 0.026). Intubation was needed in only 5 methadone cases (5.5%; = ns). All patients survived.

Conclusion: Compared to children poisoned with methadone, buprenorphine cases had higher rates of loss of consciousness on admission but subsequently experienced fewer complications during hospital treatment, which is likely due to the buprenorphine partial antagonist effect. Our findings suggest that methadone exposure is more toxic than buprenorphine in pediatric populations.
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http://dx.doi.org/10.1080/15563650.2020.1869755DOI Listing
January 2021

A study of the effectiveness of naltrexone in preventing recurrence of methadone poisoning in opioid-naive children.

Drug Alcohol Depend 2021 02 24;219:108425. Epub 2020 Nov 24.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Clinical Toxicology, Loghman Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Electronic address:

Background: The prevalence of poisoning from methadone and prescription opioids is increasing in pediatric populations. Naloxone is the main antidote for treatment. Long-acting opioid toxicity may need close observation in the intensive care unit (ICU). In our previous study, naltrexone prevented re-narcotization in methadone-poisoned adults. Here, we aim to share our experience with the use of oral naltrexone for preventing recurrence of toxicity in opioid-naïve children.

Methods: In a single-center, retrospective case series, children (age ≤12 years) admitted to a poison center in Tehran (Iran) between March 2014-March 2016 were included if they presented with methadone poisoning and received naltrexone treatment in hospital. Naltrexone (1 mg/kg) was administrated orally after initial administration of 0.1 mg/kg naloxone intravenously. Children were monitored for level of consciousness, cyanosis, respiratory rate, VBG results, and O2 saturation for ≥48 h during their hospitalization.

Results: Eighty patients with methadone poisoning were enrolled, with median age of three years (range: 0.2-12.0). None involved polysubstance poisoning. Following naltrexone treatment, none experienced recurrent opioid toxicity during hospitalization, and hospital records indicated no readmission within 72-h post-discharge.

Conclusion: Oral naltrexone could be a potential substitute for continuous naloxone infusion in methadone-poisoned children and reduce the need for ICU care.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108425DOI Listing
February 2021

Oral clonazepam versus lorazepam in the treatment of methamphetamine-poisoned children: a pilot clinical trial.

BMC Pediatr 2020 12 3;20(1):543. Epub 2020 Dec 3.

Infectious Diseases and Tropical Medicine Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Objectives: To evaluate the efficacy of oral clonazepam versus oral lorazepam following initial parenteral benzodiazepine administration to control methamphetamine-induced agitation in children.

Methods: In a single-center clinical trial, intravenous diazepam (0.2 mg/Kg) was initially administered to all methamphetamine-poisoned pediatric patients to control their agitation, followed by a single dose of oral clonazepam (0.05 mg/Kg; n = 15) or oral lorazepam (0.05 mg/Kg; n = 15) to prevent relapse of toxicity.

Results: The median age [IQR] (range) was 15 [10, 36] (6-144) months. The source of poisoning was methamphetamine exposure from oral ingestion in 23 (76.7%) and passive inhalation in 7 (23.3%) patients. The most common symptoms/signs were agitation (29; 96.7%), mydriatic pupils (26; 86.7%), and tachycardia (20; 66.6%). Two in each group (13.3%) needed re-administration of intravenous diazepam due to persistent agitation. There was no report of benzodiazepine complications in either group.

Conclusions: Clonazepam and lorazepam treatment was equally effective at similar doses. However, considering the higher potency of clonazepam, it seems that lorazepam is the safer benzodiazepine for oral maintenance treatment of methamphetamine-induced agitation in children and can be used with minimal complications.

Trial Registration: IRCT20180610040036N2, April 18th, 2020. Retrospectively registered.
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http://dx.doi.org/10.1186/s12887-020-02441-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713025PMC
December 2020

Blood Lead Levels in Opium-Poisoned Children: One Cross-Sectional Study in Iran.

Addict Health 2020 Jul;12(3):159-166

Legal Medicine Research Center, Legal Medicine Organization, Tehran, Iran.

Background: Lead poisoning is now more common due to accidental or intentional exposure to opium impregnated with lead. We aimed to determine the relationship between the blood lead levels (BLLs) and basic characteristics in opium-poisoned children.

Methods: In this cross-sectional study, 32 children younger than 13 years old who had been admitted to Loghman Hakim Poison Center, Tehran, Iran, due to opium poisoning, were evaluated for BLLs. Patients' demographics, symptoms, signs, and lab tests were evaluated as well as the BLLs.

Findings: The median and range of age in children with opium poisoning were 14 and 141 months with minimum and maximum age of 3 and 144 months, respectively, and 62.5% were boys. Their mean BLL was 9.78 ± 3.44 μg/dl and in 70% of opium-poisoned children, BLL was ≥ 5 μg/dl. There was a significant difference between mean BLLs in girls and boys (17.07 ± 6.57 μg/dl in girls and 6.61 ± 3.22 μg/dl in boys, P = 0.02). We found a significant correlation between BLL and hemoglobin (Hb) level. In very low Hb level (< 8 g/dl), the BLL was higher but with increasing Hb level, BLL increased as well; in Hb levels > 14 g/dl, BLL decreased again (P = 0.01).

Conclusion: Although none of the children needed chelation therapy, strategies should be developed to prevent children from being exposed to opium and other materials impregnated with lead regarding its effects on all organs of children.
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http://dx.doi.org/10.22122/ahj.v12i3.268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7679490PMC
July 2020

Atypical presentation of COVID-19; an observational retrospective study.

BMC Infect Dis 2020 Nov 23;20(1):870. Epub 2020 Nov 23.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: COVID-19 infection may present with atypical signs and symptoms and false negative polymerase chain reaction (PCR) tests predisposing healthy people and health care workers to infection. The aim of the current study is to evaluate the features of atypical presentations in COVID-19 infection in a referral center in Tehran, Iran.

Methods: Hospital database of inpatients admitted to Loghman Hakim hospital between February 20th and May 11th, 2020 was reviewed and all patients with final diagnosis of COVID-19 infection were evaluated for their presenting symptoms. Patients with chief complaints of "fever", "dyspnea", and/or "cough" as typical presentations of COVID-19 were excluded and those with other clinical presentations were included.

Results: Nineteen patients were included with a mean age of 51 ± 19 years, of whom, 17 were males (89%). Median [IQR] Glasgow coma scale (GCS) was 14 [13, 15]. Almost 10 had referred with chief complaint of methanol poisoning and overdose on substances of abuse. Only 8 cases (42%) had positive COVID-19 test. Nine (47%) needed invasive mechanical ventilation, of whom, two had positive COVID-19 test results (p = ns). Eight patients (42%) died with three of them having positive PCRs.

Conclusions: In patients referring to emergency departments with chief complaint of poisoning (especially poisonings that can result in dyspnea including substances of abuse and toxic alcohols), gastrointestinal, and constitutional respiratory symptoms, attention should be given not to miss possible cases of COVID-19.
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http://dx.doi.org/10.1186/s12879-020-05617-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7681183PMC
November 2020

Protective effect of flumazenil infusion in severe acute benzodiazepine toxicity: a pilot randomized trial.

Eur J Clin Pharmacol 2021 Apr 30;77(4):547-554. Epub 2020 Oct 30.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Objective: We aimed to investigate the efficacy of flumazenil infusion in the maintenance of arousal and prevention of development of complications in severe benzodiazepine poisoning.

Materials And Method: Sixty severely poisoned patients (intubated due to loss of consciousness) intoxicated by sole benzodiazepines referred to Loghman Hakim hospital between May 2018 and August 2019 were considered to be included in the current study. All were evaluated for possible contraindications of flumazenil administration. If there were no contraindications, we continued supportive care in one group and supportive care plus flumazenil infusion in the second group. Following response to the stat dose of flumazenil, complications, hospital stay, and outcome were compared between these two groups.

Results: A total of 60 benzodiazepine-poisoned patients aged between 16 and 84 years old (37 males and 23 females) were enrolled. There was no statistically significant difference between these two groups regarding the period of hospital stay. Need for intubation significantly decreased in the infusion group. None of the patients experienced seizure or dysrhythmia. One patient died in the control group which received only a stat dose of flumazenil.

Conclusions: Administration of flumazenil is safe in benzodiazepine-poisoned patients with appropriate indications. Flumazenil infusion can significantly decrease the need for intubation and subsequent ICU admission. Even though flumazenil is an expensive antidote, its administration may decrease the need for ICU beds in the setting of acute poisoning.
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http://dx.doi.org/10.1007/s00228-020-03031-7DOI Listing
April 2021

Time-Dependent Changes in the Serum Levels of Neurobiochemical Factors After Acute Methadone Overdose in Adolescent Male Rat.

Cell Mol Neurobiol 2020 Jul 25. Epub 2020 Jul 25.

Neuroscience Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, P.O. Box: 19615-1178, Tehran, Iran.

Acute methadone toxicity is a major public health concern which has adverse effects on brain tissue and results in recurrent or delayed respiratory arrest. Our study aimed to investigate the time-dependent changes in several serum biochemical markers of brain damage, spatial working memory, and the brain tissue following acute methadone overdose. Adolescent male rats underwent an intraperitoneal (i.p.) injection of 15 mg/kg methadone. In case of apnea occurrence, resuscitation was performed by a ventilatory pump and administrating naloxone (2 mg/kg; i.p.). The animals were classified into groups of treated rats; methadone and naloxone-Apnea (M/N-Apnea), M/N-Sedate, Methadone, Naloxone, and control (saline) groups. The serum levels of S100B, neuron-specific enolase (NSE), myelin basic protein factors, and (Lactate/Pyruvate) L/P ratio were evaluated at the time-points of 6, 24, and 48 h (h). We found that the alterations of S100B and L/P ratio were considerable in the M/N-Apnea and Methadone groups from the early hours post-methadone overdose, while NSE serum levels elevation was observed only in M/N-Apnea group with a delay at 48 h. Further, we assessed the spatial working memory (Y-maze test), morphological changes, and neuronal loss. The impaired spontaneous alternation behavior was detected in the M/N-Apnea groups on days 5 and 10 post-methadone overdose. The morphological changes of neurons and the neuronal loss were detectable in the CA1, striatum, and cerebellum regions, which were pronounced in both M/N-Apnea and Methadone groups. Together, our findings suggest that alterations in the serum levels of S100B and NSE factors as well as L/P ratio could be induced by methadone overdose with the presence or absence of apnea before the memory impairment and tissue injury in adolescent male rats.
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http://dx.doi.org/10.1007/s10571-020-00931-1DOI Listing
July 2020

Vitamin D toxicity in a pediatric toxicological referral center; a cross-sectional study from Iran.

BMC Pediatr 2020 07 20;20(1):350. Epub 2020 Jul 20.

Kish Institute of Science and Technology, Tehran, Iran.

Background: Vitamin D is an essential element for body health with its supplements generally administered to prevent vitamin D deficiency. Since these supplements are available in domestic settings, vitamin D toxicity may happen in children.

Methods: All children younger than 12 years who presented to the pediatric emergency department of Loghman Hakim Hospital, Tehran, Iran with history of ingestion of more than 1500 IU/day of vitamin D supplements were enrolled. Patients' demographic data, on-presentation signs and symptoms, laboratory findings, treatments given, and outcome were evaluated.

Result: Fifteen patients presented during the study period. Their mean age was 46.53 ± 10.14 months and 12 (80%) were girls. All of them had unintentionally ingested vitamin D. Mean ingested dose was 406700.7 ± 227400.1 IU. In eight patients (53.3%), 25 hydroxy vitamin D level was more than 100 ng/mL. One patient experienced hypercalcemia while all of them were asymptomatic and discharged without complications. There was no significant difference between patients with and without high levels of 25 OH vitamin D regarding lab tests, toxicity course, and outcome.

Conclusions: It seems that acute vitamin D toxicity is a benign condition in our pediatric population which may be due to high prevalence of vitamin D deficiency in Iran.
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http://dx.doi.org/10.1186/s12887-020-02240-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370494PMC
July 2020

A Preliminary Report on the Largest Ongoing Outbreak of Lead Toxicity in Iran.

Sci Rep 2020 07 16;10(1):11797. Epub 2020 Jul 16.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

No countrywide data exists on the patients' characteristics of lead exposure in Iran. We aimed to evaluate the demographic characteristics and blood lead level (BLL) of these patients in the country scale during five consecutive years, including the epidemic outbreak year (2016). Between 2014 and 2018, records of all patients who had referred to two reference laboratories in Tehran, Iran, to check BLL were evaluated. Of 58,642 patients, 48,589 were male. Mean age was 44.9 ± 20.7 years. Males had higher BLLs and were significantly older. Median BLL was 16 µg/dL (0.3 to 263 µg/dL). Median BLL was significantly higher in 45- to 60-year-old patients. The highest median BLL was reported in May 2016 confirming our records about the peak of the epidemic. Although the frequency of high BLL declined after 2016, it never returned to the measures before that. Considering the ongoing high prevalence of increased BLLs after 2016 and similar environmental and occupational exposures as before, lead-contaminated opium still seems to persist in the Iranian opium black market. Substitution of this lead-contaminated opium by Opioid Maintenance Therapy (OMT)-prescribed opium tincture is recommended.
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http://dx.doi.org/10.1038/s41598-020-64859-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367297PMC
July 2020

Double trouble: methanol outbreak in the wake of the COVID-19 pandemic in Iran-a cross-sectional assessment.

Crit Care 2020 07 9;24(1):402. Epub 2020 Jul 9.

The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.

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http://dx.doi.org/10.1186/s13054-020-03140-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7344025PMC
July 2020

Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report.

Cardiovasc Toxicol 2020 10;20(5):525-530

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Zinc phosphide is a gray to black powder mainly used as a rodenticide. In contact with gastric fluid, it releases phosphine which is the main toxic material of this compound. Phosphine interferes with oxidative respiratory cycle of the cells, but is generally expected to manifest its toxicity with prodromal signs and symptoms including abdominal pain, nausea and vomiting, metabolic acidosis, and increased liver function tests. A 64-year-old man was referred to our center with the history of ingestion of three full table spoons of zinc phosphide powder with only a mild GI discomfort. Abdominal X-ray revealed radiopaque material in epigastric and abdominal right upper quadrant. Despite treatment with polyethylene glycol and completely normal vital signs and lab tests, he experienced sudden cardiac arrest 19 h after admission. Autopsy showed clues of focal myopathy and fibrosis with evidences of ischemia and congestion in cardiac tissue, pulmonary edema, shrunken bilateral kidneys, and nutmeg yellow liver. Toxicology panel confirmed the presence of phosphine and zinc phosphide in the gastric fluid. The patient deteriorated suddenly despite being completely symptom-free during the hours preceding cardiovascular arrest. Since the cardiopulmonary injury is the most rampant cause of early death, checking of the cardiac enzymes and cardiac monitoring could be beneficial for early detection and efficient management of these patients.
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http://dx.doi.org/10.1007/s12012-020-09578-2DOI Listing
October 2020

Sudden Cardiac Arrest in an Asymptomatic Zinc Phosphide-Poisoned Patient: A Case Report.

Cardiovasc Toxicol 2020 10;20(5):525-530

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Zinc phosphide is a gray to black powder mainly used as a rodenticide. In contact with gastric fluid, it releases phosphine which is the main toxic material of this compound. Phosphine interferes with oxidative respiratory cycle of the cells, but is generally expected to manifest its toxicity with prodromal signs and symptoms including abdominal pain, nausea and vomiting, metabolic acidosis, and increased liver function tests. A 64-year-old man was referred to our center with the history of ingestion of three full table spoons of zinc phosphide powder with only a mild GI discomfort. Abdominal X-ray revealed radiopaque material in epigastric and abdominal right upper quadrant. Despite treatment with polyethylene glycol and completely normal vital signs and lab tests, he experienced sudden cardiac arrest 19 h after admission. Autopsy showed clues of focal myopathy and fibrosis with evidences of ischemia and congestion in cardiac tissue, pulmonary edema, shrunken bilateral kidneys, and nutmeg yellow liver. Toxicology panel confirmed the presence of phosphine and zinc phosphide in the gastric fluid. The patient deteriorated suddenly despite being completely symptom-free during the hours preceding cardiovascular arrest. Since the cardiopulmonary injury is the most rampant cause of early death, checking of the cardiac enzymes and cardiac monitoring could be beneficial for early detection and efficient management of these patients.
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http://dx.doi.org/10.1007/s12012-020-09578-2DOI Listing
October 2020

COVID-19 pandemic, healthcare providers' contamination and death: an international view.

Crit Care 2020 05 8;24(1):208. Epub 2020 May 8.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, 1546817613, Iran.

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http://dx.doi.org/10.1186/s13054-020-02938-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7209975PMC
May 2020

Lead poisoning; a neglected potential diagnosis in abdominal pain.

BMC Gastroenterol 2020 May 6;20(1):134. Epub 2020 May 6.

University of Colorado Anchutz Medical Campus, Rocky Mountain Poison & Drug Safety, Denver, CO and Washington Poison Center, Seattle, WA, USA.

Background: Abdominal pain may be a presenting symptom of lead poisoning and is often difficult to diagnose. This study aimed to determine the prevalence of abdominal pain in patients seen in the Laghman Hakim Hospital ED and GI clinic who were lead-intoxicated, with or without opiate use disorder.

Methods: Between July 2017 and January 2018, patients seen in the ED and GI clinic of Loghman Hakim Hospital with unexplained abdominal pain or abdominal pain resistant to treatment were enrolled. Informed consent was obtained from potential enrollees. For standardization, a pre-designed data collection tool was developed for uniform data acquisition. Opiate use was determined historically. For this study, lead poisoning was defined as a blood lead level (BLL) greater than or equal to 30 μg/dL (1.45 μmol/L) with concomitant GI symptoms.

Results: Of 125 patients admitted, 28 (22.4%) had BLLs higher than 30 μg/dL. None of the patients had signs and symptoms of opioid withdrawal syndrome during evaluation. Elevated BLLs were significantly correlated with oral opium use/abuse, history of addiction for over the preceding 12 years. The daily opium use was more than 2.75 g. There was a statistical correlation between lead toxicity and abdominal pain consistency and intensity, constipation, and paresthesias. Anemia, leukocytosis, and abnormal liver enzyme tests were laboratory findings associated with lead toxicity. Four patients died, one of whom was diagnosed with lead toxicity.

Conclusion: Lead toxicity should be considered in the potential differential diagnosis of severe and resistant abdominal pain in patients referring to general EDs or GI clinics if a positive history of opium abuse exists.
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http://dx.doi.org/10.1186/s12876-020-01284-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201765PMC
May 2020

Encephalopathy following ingestion of Lead-contaminated opium; magnetic resonance imaging findings.

BMC Neurol 2020 May 1;20(1):166. Epub 2020 May 1.

Department of Neurology, Loghman-Hakim Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Encephalopathy is an uncommon but serious presentation of lead toxicity.

Objective: We aimed to determine and follow-up the brain magnetic resonance imaging (MRI) abnormalities in the patients with lead encephalopathy due to ingestion of lead contaminated opium.

Methods: In a cross-sectional study during lead-contaminated opium outbreak, all lead-poisoned patients with any signs/symptoms of encephalopathy were included.

Results: Of 19 patients with lead encephalopathy, five died early and other five could not be sent to MRI during their hospitalization period. Mean age was 51 ± 11 years and males were dominant (89%). Median [IQR] blood lead level (BLL) was 101 [81, 108] μg/dL (range; 50 to 200 μg/dL). There was no correlation between MRI findings and signs/symptoms. MRI was normal in six and abnormal in three. Bilateral symmetric involvement of parieto-occipital lobes was observed. Gray matter, gray-white matter junction, and subcortical white matter were also affected. Follow-up MRI was performed in two with abnormal MRI which showed complete and near complete resolution of the abnormalities after cessation of opium use and treatment.

Conclusion: There was no correlation between MRI findings and BLL. Complete recovery of brain MRI lesions was detected after cessation of opium use.
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http://dx.doi.org/10.1186/s12883-020-01750-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7195795PMC
May 2020

Potential prognostic roles of serum lactate and Creatine kinase levels in poisoned patients.

BMC Emerg Med 2020 04 29;20(1):32. Epub 2020 Apr 29.

Tehran University of Medical Science, Tehran, Iran.

Background: Examination of serum lactate level and its changes, as an indicator of tissue oxygenation, as well as level of creatine kinase (CK) inhibitors, as a factor of mortality which partially expresses heart, brain, and muscle damage, may be considered as tools to determine prognosis in critically ill patients. We aimed to evaluate these two factors as potential prognostic factors in critically poisoned patients admitted to our toxicology ICU.

Method: This is a cross-sectional descriptive-analytic study that was performed on poisoned patients referred to emergency department of Loghman Hakim Hospital. One-hundred critically poisoned patients who had been admitted to ICU were conveniently chosen using a random number table and included into the study after obtaining consent forms from their next of kin. Their serum lactate and CK levels were checked on admission. These levels were compared subsequently between survivors and non-survivors to seek for their potential prognostic role.

Results: In a total of 100 patients enrolled, 61 were male. Serum level of lactate (with a cut off of 26 mg/dL) and serum CK with a cutoff point of 169 U/L could have prognosticated death with sensitivity and specificity of 78 and 77% (for lactate) and 74 and 62% (for serum CK), respectively.

Conclusions: In poisoned patients, serum lactate and CK can be used as possible prognostic factors because they rapidly increase in the serum and are easily detectable.
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http://dx.doi.org/10.1186/s12873-020-00326-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191820PMC
April 2020

Safety of Naloxone in Opioid-Naïve Methadone Intoxicated Patients; a Case Series Study.

Arch Acad Emerg Med 2020 2;8(1):e16. Epub 2020 Mar 2.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Introduction: Studies have shown that naloxone can cause behavioral changes in naïve normal volunteers. This study aimed to investigate the possible complications of naloxone in methadone-overdosed opioid-naïve patients.

Methods: In this pilot study, a total number of 20 opioid-naïve methadone-poisoned patients underwent naloxone challenge test to receive naltrexone. 0.2, 0.6, and 1.2 mg doses of naloxone were administered on minutes 0, 5, and 15-20. The patients were followed for 30 minutes after administration of naloxone and monitored for any upsetting signs and symptoms. Patients with clinical opiate withdrawal scale (COWS) lower than 5 were considered not addicted and the severity of patients' symptoms was calculated using subjective opiate withdrawal syndrome (SOWS).

Results: 20 patients with mean age of 25.5±8.09 years were evaluated (70% female). Median ingested dose of methadone was 25 mg [IQR; 10 to 50 mg] and mean time interval between ingestion of methadone and naloxone challenge test was 7.1±4.9 hours. Fourteen patients reported some discomfort after administration of a mean dose of 1.7±0.5 mg of naloxone lasting for a maximum of four hours. The most common patients' complaints were headache (45%) followed by nausea (20%), agitation (20%), abdominal pain (20%), and flushing (20%). Two (10%) mentioned severe panic attack and sensation of near-coming death. SOWS significantly correlated with female gender (p = 0.004) and time elapsed post methadone ingestion (p = 0.001).

Conclusion: It seems that naloxone is not a completely safe medication even in opioid-naïve patients, and administrating adjusted doses of naloxone even in opioid-naïve methadone intoxicated patients may be logical.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7130441PMC
March 2020

Intravenous calcium Gluconate alleviates Lead-induced abdominal pain, a randomized clinical trial.

BMC Pharmacol Toxicol 2020 03 17;21(1):23. Epub 2020 Mar 17.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, South Karegar Street, Tehran, Iran.

Background: In 2016, in a lead poisoning outbreak in Iran, physicians reported thousands of opium users who presented to emergency departments (EDs) with intractable severe abdominal pain which did not respond to any narcotic medication. During the same period of time, we investigated the efficacy of intravenous calcium gluconate in alleviating lead-induced abdominal pain.

Methods: In a single-center, single blinded, randomized controlled trial, a convenient sample of adult opium-addicted patients who presented to an academic ED with abdominal pain and had an initial diagnosis of lead poisoning were included and randomly subjected to two treatment groups receiving conventional treatment (morphine 0.1 mg/kg + normal saline; group 1) and conventional treatment plus 1 g of intravenous calcium gluconate (group 2) to alleviate their abdominal pain. The visual analogue scale (VAS) was determined by each patient (0 to 100 mm) before treatment, and 15, 30, and 60 min after intervention.

Results: A total of 50 patients (25 in each group) were enrolled. Blood lead levels, VAS scores before treatment, and mean administered dose of morphine were similar between the two groups. After treatment, mean VAS score dropped to 64.7± 10.4 vs. 67.1± 10.9 at 15 min (P = 0.437), 64.6± 10.9 vs. 58.0 ± 11.2 at 30 min (P = 0.041), and 63.8± 10.7 vs. 53.6± 10.9 at 60 min (P = 0.002) in groups 1 and 2, respectively.

Conclusion: Intravenous calcium gluconate administration along with morphine can improve abdominal pain in lead poisoning due to the ingestion of lead-contaminated opium. Further interventional studies are recommended to see if response to calcium salts in suspected lead-induced abdominal pain can rule in lead toxicity.

Trial Registration: IRCT20171009036661N2. Registered 27 May 2018 - Retrospectively registered.
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http://dx.doi.org/10.1186/s40360-020-00403-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7079520PMC
March 2020

Buprenorphine to reverse respiratory depression from methadone overdose in opioid-dependent patients: a prospective randomized trial.

Crit Care 2020 02 7;24(1):44. Epub 2020 Feb 7.

Social Determinant of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Naloxone is the usual drug used in opioid-induced respiratory depression but it has a short half-life, precipitates withdrawal in dependent patients, and thus for persistent reversal of long-acting opioids has to be given by titrated doses and infusions. The partial agonist buprenorphine has a much longer duration of action and causes less severe withdrawal, but still should largely reverse respiratory depression induced by full agonist opioids. We aimed to compare the efficacy/safety of buprenorphine and naloxone in reversing respiratory depression in methadone-poisoned opioid-dependent patients.

Methods: Patients with methadone-induced respiratory depression were randomized to receive naloxone (titrated doses), or lower or higher doses of buprenorphine (10 μg/kg or 15 μg/kg). The primary outcome was immediate reversal of respiratory depression. We also recorded acute opioid withdrawal, need for intubation/recurrent apnea, repeated doses of opioid antagonists, length of hospital stay, other morbidity, and mortality. The study was registered with the Iranian Registry of Clinical Trials (Trial ID: 18265; Approval code: IRCT2015011020624N1).

Results: Eighty-five patients were randomized; 55/56 patients who received buprenorphine had rapid reversal of respiratory depression, which persisted for at least 12 h. Naloxone was effective in 28/29 patients, but often required very high titrated doses (thus delaying time to respond) and prolonged infusions. Intubation (8/29 vs 5/56) and opioid withdrawal (15/29 vs 7/56) were less common with buprenorphine. There were no serious complications or deaths in those receiving buprenorphine. The 15-μg/kg buprenorphine dose appeared to provide a longer duration of action, but precipitated withdrawal more frequently than the 10-μg/kg dose.

Conclusion: Buprenorphine appears to be a safe and effective substitute for naloxone in overdosed opioid-dependent patients. Further studies are warranted to explore the optimal dosing strategy for buprenorphine to consistently maintain reversal of respiratory depression but not precipitate withdrawal.

Trial Registration Number: IRCT2015011020624N1. Registered 30 September 2015.
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http://dx.doi.org/10.1186/s13054-020-2740-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006192PMC
February 2020

Methadone-induced encephalopathy: a case series and literature review.

BMC Med Imaging 2020 01 17;20(1). Epub 2020 Jan 17.

Neuroscience Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Accidental ingestion or consumption of supra-therapeutic doses of methadone can result in neurological sequelae in humans. We aimed to determine the neurological deficits of methadone-poisoned patients admitted to a referral poisoning hospital using brain magnetic resonance (MR) and diffusion weighted (DW) imaging.

Methods: In this retrospective study, brain MRIs of the patients admitted to our referral center due to methadone intoxication were reviewed. Methadone intoxication was confirmed based on history, congruent clinical presentation, and confirmatory urine analysis. Each patient had an MRI with Echo planar T1, T2, FLAIR, and DWI and apparent deficient coefficient (ADC) sequences without contrast media. Abnormalities were recorded and categorized based on their anatomic location and sequence.

Results: Ten patients with abnormal MRI findings were identified. Eight had acute- and two had delayed-onset encephalopathy. Imaging findings included bilateral confluent or patchy T2 and FLAIR high signal intensity in cerebral white matter, cerebellar involvement, and bilateral occipito-parietal cortex diffusion restriction in DWI. Internal capsule involvement was identified in two patients while abnormality in globus pallidus and head of caudate nuclei were reported in another. Bilateral cerebral symmetrical confluent white matter signal abnormality with sparing of subcortical U-fibers on T2 and FLAIR sequences were observed in both patients with delayed-onset encephalopathy.

Conclusions: Acute- and delayed-onset encephalopathies are two rare adverse events detected in methadone-intoxicated patients. Brain MRI findings can be helpful in detection of methadone-induced encephalopathy.
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http://dx.doi.org/10.1186/s12880-020-0410-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6969410PMC
January 2020

Substance Use among Poisoned Teenage Patients.

Iran J Public Health 2019 Oct;48(10):1847-1854

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

Background: Substance use is a growing problem in many countries especially among teenagers. We aimed to estimate the prevalence and complications of substance use in teenagers referring to a tertiary hospital following intoxication.

Methods: In a cross-sectional study between 2012 and 2013 in Loghman Hakim Hospital, Tehran, Iran, sixteen substances were checked in teenagers referring due to poisoning. They divided into two groups of young (13 to <16 yr; group 1) and old-teenagers (16 to 19 yr; group 2). History of lifetime substance use and drug use within the week prior to admission were recorded.

Results: Mean (range) age of young teenagers was 14.5±0.6 [13, 15] and 17.7±1.1 [16, 19] in old-teenagers with female predominance. Of 264 teenagers, four in group 1 and 27 in group 2 were admitted due to drug overdose. Six and 69 patients in groups 1 and 2 claimed that they had used some kind of substance in the week prior to admission. Twenty (37%) and 106 (50.5%) patients in the young and old-teenager groups were defined as drug users and rates of unreported substance use were 27.8% (15 cases) and 23.8% (50 cases) respectively. Ninety-six substance users (36.4%) had referred due to poisonings other than recreational intoxication (<.001). Screening toxicological lab data showed significant opioid and sedative exposure in old-teenagers.

Conclusion: It seems young adolescents hide their drug abuse more than old teenagers. Using illicit drugs screening tests may help us to provide hidden rate of abuse in teenagers.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6908896PMC
October 2019

Evaluation of methanol content of illegal beverages using GC and an easier modified Chromotropic acid method; a cross sectional study.

Subst Abuse Treat Prev Policy 2019 12 16;14(1):56. Epub 2019 Dec 16.

Department of Chemistry, Rasht Branch, Islamic Azad University, Rasht, Iran.

Background: Methanol is highly toxic to human beings and naturally exists in some beverages. Having access to an easy and cheap method for its determination is of great importance to increase the safety of use of these beverages. Our main aim is to evaluate methanol concentration of some alcoholic beverages in Iran black market and compare it with the European and US standards. Also, we evaluated the efficacy of a newly designed and produced chemical kit in determining the risk of methanol toxicity by drinking of such samples compared to gas chromatography method.

Methods: Methanol content of suspected alcoholic beverages referred to forensic toxicology laboratory, Guilan province, Iran was measured using gas chromatography and a recently designed kit based on modified colorimetric chromotropic acid method.

Results: Of 1221 samples, 145 (11.9%) had no ethanol content, while in three samples (0.25%), methanol was high enough (700,000; 870,000; 920,000 mg/L) to cause severe methanol toxicity. Median [IQR] ethanol content of the suspected samples was 9% [3.7, 32.75]. Methanol was detected in 128 (10.48%) samples using gas chromatography method and 160 samples (13.1%) with designed kit with 100% sensitivity, 97.07% specificity, and 100% negative-predictive-value.

Conclusions: Alcoholic beverages produced in local black market in Iran are not safe at all. The application of the new method is practical, rapid, easy, and accurate to evaluate the risk of methanol toxicity in suspected alcoholic drinks.
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http://dx.doi.org/10.1186/s13011-019-0244-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6916049PMC
December 2019

Broken thermometer in foot: a source of mercury poisoning.

Trop Doct 2020 Jan 6;50(1):83-84. Epub 2019 Nov 6.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

A 17-year-old boy was referred after jumping from a ladder onto the ground, crushing a medical thermometer with his right foot. Some days later, he complained of loss of appetite and weakness. A radiograph of the affected foot demonstrated radiopaque densities. Blood and 24-h urine assays for mercury demonstrated toxic levels. Chelation therapy cured the patient dramatically.
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http://dx.doi.org/10.1177/0049475519884419DOI Listing
January 2020

Is fomepizole the antidote to recommend in mass methanol outbreaks?

Clin Toxicol (Phila) 2020 06 30;58(6):504. Epub 2019 Oct 30.

Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

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http://dx.doi.org/10.1080/15563650.2019.1682152DOI Listing
June 2020