Effect and molecular mechanism of Sulforaphane alleviates brain damage caused by acute carbon monoxide poisoning:Network pharmacology analysis, molecular docking, and experimental evidence

Sulforaphane (SFN) has attracted much attention due to its ability on antioxidant, anti-inflammatory, and anti-apoptotic properties, while its functional targets and underlying mechanism of action on brain injury caused by acute carbon monoxide poisoning (ACOP) have not been fully elucidated. Herein, we used a systematic network pharmacology approach to explore the mechanism of SFN in the treatment of brain damage after ACOP. In this study, the results of network pharmacology demonstrated that there were a total of 81 effective target genes of SFN and 36 drug-disease targets, which were strongly in connection with autophagy-animal signaling pathway, drug metabolism, and transcription disorders in cancer. Upon the further biological function and KEGG signaling pathway enrichment analysis, a large number of them were involved in neuronal death, reactive oxygen metabolic processes and immune functions. Moreover, based on the results of bioinformatics prediction associated with multiple potential targets and pathways, the AMP-activated protein kinase (AMPK) signaling pathway was selected to elucidate the molecular mechanism of SFN in the treatment of brain injury caused by ACOP. The following molecular docking analysis also confirmed that SFN can bind to AMPKα well through chemical bonds. In addition, an animal model of ACOP was established by exposure to carbon monoxide in a hyperbaric oxygen chamber to verify the predicted results of network pharmacology. We found that the mitochondrial ultrastructure of neurons in rats with ACOP was seriously damaged, and apoptotic cells increased significantly. The histopathological changes were obviously alleviated, apoptosis of cortical neurons was inhibited, and the number of Nissl bodies was increased in the SFN group as compared with the ACOP group (p < .05). Besides, the administration of SFN could increase the expressions of phosphorylated P-AMPK and MFN2 proteins and decrease the levels of DRP1, Caspase3, and Casapase9 proteins in the brain tissue of ACOP rats. These findings suggest that network pharmacology is a useful tool for traditional Chinese medicine (TCM) research, SFN can effectively inhibit apoptosis, protect cortical neurons from the toxicity of carbon monoxide through activating the AMPK pathway and may become a potential therapeutic strategy for brain injury after ACOP.

A charred body inside a burning car with a garden hose connected to the exhaust pipe: Post-mortem self-immolation, a complex or a complicated suicide after the ingestion of alcohol? The importance of an interdisciplinary approach

The analysis of charred bodies represents a serious challenge for forensic pathologists, and an interdisciplinary approach is often the only way to determine the cause and manner of death. We present an unusual case in which the charred body of a 61-year-old man was found inside his burning vehicle. In order to determine cause and manner of death, an interdisciplinary team was employed, with experts in forensic pathology, forensic radiology, toxicology and fire investigations. Post-mortem computed tomography, autopsy and toxicology ruled out the presence of trauma injury and detected signs of vital exposure to fire and blood alcohol levels. On the other hand, according to fire investigations, the fire started inside the car and partially burned fragments of a garden hose were found along the right side of the car. A suicide could therefore be hypothesized, with the man having attempted to poison himself with the car's exhaust fumes and having set the car on fire. The death was consistent with a complicated suicide in which the victim, in a state of reduced capability, accidentally set his car on fire and was unable to escape. The hypothesis of a complex suicide, with the car having been set deliberately on fire, could not, however, be ruled out.

Global, regional, and national mortality due to unintentional carbon monoxide poisoning, 2000-2021: results from the Global Burden of Disease Study 2021

BACKGROUND

Unintentional carbon monoxide poisoning is a largely preventable cause of death that has received insufficient attention. We aimed to conduct a comprehensive global analysis of the demographic, temporal, and geographical patterns of fatal unintentional carbon monoxide poisoning from 2000 to 2021.

METHODS

As part of the latest Global Burden of Diseases, Injuries, and Risk Factors Study (GBD), unintentional carbon monoxide poisoning mortality was quantified using the GBD cause of death ensemble modelling strategy. Vital registration data and covariates with an epidemiological link to unintentional carbon monoxide poisoning informed the estimates of death counts and mortality rates for all locations, sexes, ages, and years included in the GBD. Years of life lost (YLLs) were estimated by multiplying deaths by remaining standard life expectancy at age of death. Population attributable fractions (PAFs) for unintentional carbon monoxide poisoning deaths due to occupational injuries and high alcohol use were estimated.

FINDINGS

In 2021, the global mortality rate due to unintentional carbon monoxide poisoning was 0·366 per 100 000 (95% uncertainty interval 0·276-0·415), with 28 900 deaths (21 700-32 800) and 1·18 million YLLs (0·886-1·35) across all ages. Nearly 70% of deaths occurred in males (20 100 [15 800-24 000]), and the 50-54-year age group had the largest number of deaths (2210 [1660-2590]). The highest mortality rate was in those aged 85 years or older with 1·96 deaths (1·38-2·32) per 100 000. Eastern Europe had the highest age-standardised mortality rate at 2·12 deaths (1·98-2·30) per 100 000. Globally, there was a 53·5% (46·2-63·7) decrease in the age-standardised mortality rate from 2000 to 2021, although this decline was not uniform across regions. The overall PAFs for occupational injuries and high alcohol use were 13·6% (11·9-16·0) and 3·5% (1·4-6·2), respectively.

INTERPRETATION

Improvements in unintentional carbon monoxide poisoning mortality rates have been inconsistent across regions and over time since 2000. Given that unintentional carbon monoxide poisoning is almost entirely preventable, policy-level interventions that lower the risk of carbon monoxide poisoning events should be prioritised, such as those that increase access to improved heating and cooking devices, reduce carbon monoxide emissions from generators, and mandate use of carbon monoxide alarms.

FUNDING

Bill & Melinda Gates Foundation.

A man in his sixties with acute chest pain

BACKGROUND

Chest pain is a frequent symptom of acute myocardial infarction, but the cause is not always coronary atherothrombosis. We present a case where the patient himself had made a correct non-cardiac diagnosis, but this was initially overlooked by the doctor.

CASE PRESENTATION

A man with a history of cardiac infarction was admitted with acute chest pain and troponin elevation. Electrocardiogram suggested ST elevations, echocardiography showed a possible slight hypokinesia, and we primarily suspected an acute coronary syndrome. However, invasive coronary angiography was negative and a primary acute myocardial infarction was less likely. A renewed interview revealed that the patient had worked with a propane burner indoors without adequate ventilation. The patient himself suspected carbon monoxide poisoning. Arterial blood gas showed HbCO 27.4 %, which was unfortunately overlooked initially. The patient had carbon monoxide poisoning with symptoms of dizziness, hand ataxia and myocardial ischaemia. He received 100 % oxygen and HbCO was normalised.

INTERPRETATION

The imbalance between oxygen demand and supply resulted in a type 2 cardiac infarction. A thorough medical history is crucial for correct diagnosis but can unfortunately be missed on a busy shift. This case illustrates the importance of the patient's own diagnostic assumption.

[Investigation of a carbon monoxide poisoning accident with a hidden source]

In June 2022, a carbon monoxide poisoning accident with hidden source occurred in a bonded gold/silver wire manufacturing enterprise in Guangzhou, causing 10 people to be poisoned, of which 1 was caused by carbon monoxide poisoning and 9 by carbon monoxide contact reaction. The symptoms were dizziness, fatigue and vomiting. After 5 to 7 h, the saturation of carboxyhemoglobin in finger pulse was 4% to 10%, and the saturation of carboxyhemoglobin in blood gas biochemical analysis was 1.9% to 5.8%. The concentration of carbon monoxide detected in the carbon borne purification plant of the enterprise was 34.46-37.26 mg/m(3). It was judged that the accident was carbon monoxide poisoning caused by carbon monoxide gas being transported to the work post along the gas transmission pipeline due to abnormal operation of the carbon borne purification plant. By investigating the source and cause of poison, this paper provides a warning for the similar process to prevent similar events, and provides a new idea for the identification of chemical poisoning risk. At the same time, it is warned that similar enterprises should fully consider the risk of poisoning under specific circumstances, strengthen equipment maintenance and repair, and prevent the occurrence of similar incidents.

An artificial intelligence algorithm for analyzing globus pallidus necrosis after carbon monoxide intoxication

Globus pallidus necrosis (GPN) is one of typical neurological imaging features in patients with carbon monoxide (CO) poisoning. Current clinical guideline recommends neurological imaging examination for CO-intoxicated patients with conscious disturbance rather than routine screening, which may lead to undiagnosed GPN. We aimed to develop an artificial intelligence algorithm for predicting GPN in CO intoxication patients. We included CO intoxication patients with neurological images between 2000 and 2019 in Chang Gung Memorial Hospital. We collected 41 clinical and laboratory parameters on the first day of admission for algorithm development. We used fivefold cross validation and applied several machine learning algorithms. Random forest classifier (RFC) provided the best predictive performance in our cohort. Among the 261 patients with CO intoxication, 52 patients presented with GPN. The artificial intelligence algorithm using the RFC-based AI model achieved an accuracy = 79.2 ± 2.6%, sensitivity = 77.7%, precision score = 81.9 ± 3.4%, and F1 score = 73.2 ± 1.8%. The area under receiver operating characteristic was approximately 0.64. Top five weighted variables were Platelet count, carboxyhemoglobin, Glasgow Coma scale, creatinine, and hemoglobin. Our RFC-based algorithm is the first to predict GPN in patients with CO intoxication and provides fair predictive ability. Further studies are needed to validate our findings.

Effect of carbon monoxide administration using haemoglobin-vesicles on the hippocampal tissue

Carbon monoxide (CO) is a toxic gas that causes neuropathy. However, CO is endogenously produced in small amounts showing various beneficial effects. We hypothesized that CO-bound haemoglobin-vesicle (HbV) administration would reduce cerebral ischaemia-reperfusion injury without causing neuropathy. Three experiments were conducted. First, rats were exposed to CO inhalation to create a CO-poisoning group, and they were sacrificed on 0, 7, 14, and 21 days after CO exposure. Histopathologically, hippocampal damage was prominent at 14 days. Second, the rats were administered with CO-HbV equivalent to 50 or 25% of circulating blood volume (CO-HbV50 or CO-HbV25 group). Rats were sacrificed 14 days after administration. Third, rats put into haemorrhagic shock by 50% of circulating blood withdrawal were resuscitated using saline, autologous blood, and CO-HbV. They were sacrificed 14 days after resuscitation. Hippocampal damage assessment clarified that almost no necrotic cells were observed in the CO-HbV50 group. Necrotic cells in the CO-HbV25 group were comparable to those found for the control group. In rats resuscitated from haemorrhagic shock, the hippocampal damage in the group using CO-HbV was the mildest. Administration of CO-HbV did not lead to marked hippocampal damage. Furthermore, CO-HbV was effective at preventing cerebral ischaemia-reperfusion injury after haemorrhagic shock.

Can Hyperbaric Oxygen Therapy Be Used to Treat Children after COVID-19? A Bibliographic Review

The coronavirus disease (COVID-19) epidemic is a public health emergency of international concern. It was believed that SARS-CoV-2 virus was much less likely affect children. Statistics show that children account for 2-13% of all COVID-19 patients in individual countries. In the youngest population, acute respiratory failure is not as serious a problem as complications after COVID-19, mainly pediatric inflammatory multisystem syndrome (PIMS, MIS-C). This study used a bibliography review. The Medline database (using the PubMed platform) and the Cochrane Clinical Trials database were searched using the following keywords: hyperbaric oxygen therapy for children, treatment of children with COVID-19, and use of HBOT in the treatment of children following COVID-19. Thirteen publications that quantitatively and qualitatively described the efficacy of HBOT application in the treatment of pediatric diseases were eligible among the studies; those relating to the use of HBOT in the treatment of children with COVID-19 and its complications were not found. The bibliographic review showed that hyperbaric oxygen therapy can be used in the treatment of children after carbon monoxide poisoning, with soft tissue necrosis, bone necrosis, after burns, or after skin transplant. No evidence supported by research has been found in scientific journals on the effectiveness of the use of hyperbaric oxygen therapy in children with a history of COVID-19 infection. Research data are needed to develop evidence-driven strategies with regard to the use of HBOT therapy in the treatment of children and to reduce the number of pediatric patients suffering because of complications after COVID-19.

YouTube as a source of information on carbon monoxide poisoning: a content-quality analysis

OBJECTIVES

The variety of clinical presentation on the topic of carbon monoxide (CO) intoxication ranges from slight headache to coma or death. YouTube allows patients to search not only for entertainment but also medical advice. Therefore, the aim of this study was to evaluate the content and quality of YouTube videos concerning CO poisoning as a source of knowledge for non-medical audience.

MATERIAL AND METHODS

On the December 8, 2020 a YouTube search was conducted for the following phrases: "carbon monoxide poisoning," "carbon monoxide symptoms," "CO poisoning," "carbon monoxide asphyxiation," "carbon monoxide intoxication" using the "incognito mode" and without attachment to Google Account. The search results were set as: "default" in the YouTube browser. The first 50 results were taken into consideration. Two raters, a specialist in emergency medicine and a specialist in clinical toxicology rated videos with Quality Criteria for Consumer Health Information (DISCERN), Global Quality Score (GQS) and Journal of the American Medical Association (JAMA). "VidIQ Vision for YouTube" plug-in was used.

RESULTS

Ninety-five videos were included. The interclass coefficient for DISCERN, GQS and JAMA scores were: 0.8, 0.74 and 0.62 reaching good and moderate reliability. The mean DISCERN/GQS/JAMA was 28.1 (SD 7.9), 2.5 (SD 0.8) and 1.1 (SD 0.7) respectively. Higher DISCERN/GQS/JAMA had videos providing information on: exposure time, treatment options, hyperbaric chamber indications as well as physician speaker (p < 0.05). Video Power Index was higher when the video contained animations and presented patients own history of CO exposure but not influenced the DISCERN/ GQS/JAMA scores. Videos providing misleading information had a higher like ratio.

CONCLUSIONS

The overall video quality was poor indicating inappropriate educational and informative value for patients who search information about carbon monoxide poisoning. Int J Occup Med Environ Health. 2022;35(3):285-95.

[Application value of BIS and S100β combined with Copeptin in patients with acute severe carbon monoxide poisoning]

Objective: To explore the application value of bispectral index(BIS) , specific protein 100β(S100β) combined with Copeptinin patients with acute severe carbon monoxide poisoning (ASCMP). Methods: A total of 256 patients with acute carbon monoxide poisoning admitted to Hengshui People's Hospital from June 2018 to June 2020 were collected, and they were divided into 30 mild cases, 40 moderate cases and 186 severe cases according to the degree of poisoning. Among them, patients with severe carbon monoxide poisoning were divided into a poor prognosis group (20 cases) and a good prognosis group (166 cases) according to whether adverse events occurred. The changes of creatine kinase isoenzyme (CK-MB) , N-terminal precursor B-type brain natriuretic peptide (NT-proBNP) , BIS, S100β, and Copeptin in poisoned patients were measured. Logistic regression analysis and receiver operating characteristic (ROC) curve were used to evaluate the significance of relevant indicators for ASCMP patients. Results: Compared with the mild-to-moderate group, CK-MB, NT-proBNP, S100β, Copeptin increased, and BIS value decreased in the severe group (P< 0.05). 24 hours after admission, compared with the good prognosis group, CK-MB, NT-proBNP, S100β, Copeptin in the poor prognosis group increased, and the BIS value decreased (P<0.05). In the poor prognosis group, CK-MB, NT-proBNP, S100β, and Copeptin at 72 hours after admission were all lower than those at 24 hours after admission, and the BIS value was higher than that at 24 hours after admission (P<0.05). Logistic regression analysis showed that ASCMP patients with increased S100β, Copeptin, and decreased BIS values had an increased risk of adverse events (P<0.05). The ROC curve showed that the area under the curve of the combined detection of BIS, S100β and Copeptin was 0.859, which had a great predictive value for the prognosis of ASCMP patients. Conclusion: BIS, S100β combined with Copeptin detection is of great value for early assessment of ASCMP disease and prognosis prediction.

Comparison of four low-level carbon monoxide alarms suitable for home use or when traveling

INTRODUCTION

Interest in carbon monoxide (CO) alarms that are more sensitive than is required for standard residential CO alarms is growing, as reflected by increased marketing of "low-level" alarms capable of measuring CO levels as low as 10 PPM. At the same time, publicity surrounding CO poisoning events among travelers in lodging facilities has stimulated interest in travel CO alarms. We sought to evaluate four low-level alarms that could be used in the home and especially when traveling.

MATERIALS/METHODS

Two each of four brands of low-level alarms (CO Experts, Forensics, Kidde, and Sensorcon) were acquired by retail purchase and tested. The eight alarms were simultaneously exposed in an environment with a slowly increasing level of CO from indoor burning of charcoal briquets. CO levels displayed on the alarms were recorded once per minute. Activation of preset alerts on the alarms were noted. Finally, alarms were compared for ease of use and features available..

RESULTS

All brands of alarms measured CO similarly over the range from 10-120 PPM. All alarms performed as claimed by their manufacturers, both regarding range of CO reported and preset alert activation. Each alerted at CO levels below that required by the Underwriters Laboratories 2034 Standard.

SUMMARY/CONCLUSION

Since all low-level CO alarms tested measured CO similarly, consumers seeking a low-level CO alarm for use while traveling should base their decision on features desired and price. There are definite differences between the alarms tested, in terms of features, expected durability, ease of operation and price.

Comprehensive analysis and investigation of accident/occupational disease responsibility rates: A case study for accidental CO poisoning

One of the major problems of courts and insurance companies is the lack of a proper technique to determine the rate of responsibility of the parties involved in the accident. The aim of this study was to determine the Accident/Occupational Diseases Responsibility Rates (AOD RR) for complex events. Accordingly, a case study of a complex accident of carbon monoxide (CO) poisoning was selected and Occupational Accident Tree Analysis (OATA) and Occupational Accident Component Analysis (OACA) techniques, which were solely used to investigate occupational accidents, were used with the new names Accident/Occupational Disease Tree Analysis (AOD TA) and Accident/Occupational Disease Component Analysis (AOD CA) to evaluate their applicability to investigate non-occupational accidents and occupational diseases. For this purpose, causes of CO penetration to victims' room was assessed using gas tracking methods. Finally, Fuzzy Accident/Occupational Disease Tree/Component Analysis (FAOD TA and FAOD CA) techniques were developed and used for determining AOD RR in fuzzy environment. The results showed that the AOD RR obtained by AOD TA and AOD CA based on the average of experts' personal opinions and consensus between experts, and AOD TA and AOD CA in a fuzzy environment were close to each other, with the power terminal and the power cable crossing route being the main routes of transmission and penetration of CO to the victims' room. Also, the owner, contractor, tenant, and serviceman were responsible for the CO poisoning of victims. It can be concluded that any hole, crack, or fission in the building can result in CO penetration to the individuals' living rooms, and gas tracking in early winter, especially in older buildings, plays a very significant role in preventing residents' poisoning. Further, due to the uncertainty of AOD TA and AOD CA techniques, it is recommended to use FAOD TA and FAOD CA techniques for increasing the accuracy of the results. This will enhance the court and insurance companies' trust in the opinions of accident investigation experts, decrease delays in the proceedings, and prevent any violation of the individual rights.

Prediction of troponin I and N-terminal pro-brain natriuretic peptide levels in acute carbon monoxide poisoning using advanced electrocardiogram analysis, Alexandria, Egypt

The study aimed at assessing the diagnostic ability of advanced electrocardiogram (ECG) analysis to predict the levels of NT-proBNP and Troponin I. ECG and the blood NT-proBNP and Troponin I were taken from 50 acutely carbon monoxide poisoned patients and 21 control subjects matched with age and sex. The severity of the studied cases was classified into mild, moderate, and severe using clinical classification. ECG parameters (RR interval, corrected QT (QTc) interval, P wave dispersion (Pwd)), and cardiac biomarkers (NT-proBNP and Troponin I) were significantly higher in cases than in control (p= 0.015, 0.008, 0.002, <0.001, and <0.001 respectively). Cut-off values resulted from combined ROC curves analysis can predict blood Troponin I more than 0.05 ng/ml and NT-proBNP more than 125 pg/ ml (with 88% and 84% accuracy respectively). In addition, two regression equations were developed using all studied ECG parameters to predict Troponin I and NT-proBNP (with 68% and 43% accuracy respectively). RR average, PR average, QRS average, QTd, QTc, and Pwd could be used to predict Troponin I and NT-proBNP levels with good accuracy in carbon monoxide poisoning patients.

[Predictive value of neutrophil/lymphocyte ratio combined with soluble growth stimulating expression gene 2 protein on the occurrence of in-hospital major adverse cardiaovascular events in patients with myocardial injury from moderate-severe acute carbon monoxide poisoning: a single-center prospective observational study]

OBJECTIVE

To investigate the predictive neutrophil/lymphocyte ratio (NLR) combined with soluble growth stimulating expression gene 2 protein (sST2) on in-hospital major adverse cardiovascular events (MACE) in patients with myocardial injury following moderate-severe acute carbon monoxide poisoning (ACOP).

METHODS

A single-cente prospective observational approach was conducted. Moderate-severe ACOP patients with myocardial damage from November 2016 to February 2020 in department of emergency medicine of Harrison International Peace Hospital Affiliated to Hebei Medical University were enrolled. The baseline data of the patients, NLR and sST2 (T0 sST2) on admission, sST2 at 3 days after admission (T3 d sST2), and the other myocardial injury and biochemical indicators were collected. According to whether MACE occurred, the patients were divided into MACE group and non-MACE group. The clinical data of the two groups were compared. Pearson correlation analysis was used to analyze the correlation of each index. Binary Logistic regression was used to analyze the independent risk factors of in-hospital MACE in patients with moderate-severe ACOP myocardial injury. The receiver operator characteristic curve (ROC curve) was drawn and area under ROC curve (AUC) was calculated to analyze the predictive value of NLR, sST2, and NLR combined with sST2 for the occurrence of in-hospital MACE in patients with moderate-severe ACOP myocardial injury.

RESULTS

A total of 278 patients with moderate-severe ACOP myocardial injury were included in the final analysis, and the incidence of MACE was 11.51% (32/278). Cardiac troponin I (cTnI), lactic acid (Lac), NLR, and T3 d sST2 in the MACE group were significantly higher than those in the non-MACE group [cTnI (μg/L): 0.83±0.15 vs. 0.46±0.37, Lac (mmol/L): 2.96±1.14 vs. 2.43±1.35, NLR: 13.14±4.37 vs. 9.49±4.21, T3 d sST2 (μg/L): 59.88±23.42 vs. 39.83±12.60, all P < 0.05], there was no significant difference in T0 sST2 between the MACE group and the non-MACE group (μg/L: 269.09±90.89 vs. 240.14±113.02, P > 0.05). Pearson correlation analysis showed that there were significantly positive correlations in NLR with acute physiology and chronic health evaluation II (APACHE II), T3 d sST2 with APACHE II, and NLR with T3 d sST2 (r values were 0.226, 0.209, 0.193, all P < 0.01). Binary Logistic regression analysis showed that T3 d sST2 and NLR were both independent risk factors for MACE in moderate-severe ACOP patients with myocardial injury [odds ratio (OR) and 95% confidence interval (95%CI) respectively was 1.064 (1.039-1.090), 1.176 (1.066-1.298), both P < 0.01]. ROC curve analysis showed that the predictive efficacy of NLR combined with T3 d sST2 for the occurrence of in-hospital MACE in patients with ACOP myocardial injury (AUC = 0.876) was better than that of NLR (AUC = 0.754) and T3 d sST2 (AUC = 0.813). When the optimal critical value of NLR was 10.02 and that of T3 d sST2 was 43.50 μg/L, the sensitivity of predicting the occurrence of MACE in patients with moderate-severe ACOP myocardial injury was 69.8% and 86.2% respectively, and the specificity was 74.3% and 70.4%, respectively. The specificity and sensitivity of the combined detection was 83.4% and 79.8%, respectively.

CONCLUSIONS

NLR and T3 d sST2 were independent predictors of in-hospital MACE in moderate-severe ACOP patients with myocardial injury, and combined application of NLR and T3 d sST2 had good predictive value. For patients with moderate-severe ACOP myocardial injury with NLR > 10.02 and T3 d sST2 > 43.50 μg/L, the occurrence of in-hospital MACE should be alert.

Risk of late appearance of acute myocardial infartion after carbon monoxide (CO) intoxication

BACKGROUND

After acute carbon monoxide intoxication, there may be a higher risk for late adverse cardiac events. However, these patients are usually not followed to monitor the appearance of these effects.

AIM

To follow patients seen at an emergency department for carbon monoxide intoxication, monitoring the appearance of myocardial infarction. To assess the predictive value for such complication of serum troponin, carboxyhemoglobin, and procalcitonin levels at the moment of intoxication.

MATERIAL AND METHODS

We followed 237 patients receiving emergency care for carbon monoxide intoxication, with a serum carboxyhemoglobin of 5% or more, between 2010 and 2012. Levels of procalcitonin and troponin I were measured. Patients were followed for five years after the intoxication.

RESULTS

During the follow up period, 35 patients had a myocardial infarction. These patients had significantly higher carboxyhemoglobin, procalcitonin and troponin I levels at the moment of the intoxication than their counterparts who did not had a myocardial infarction in the follow up. A logistic regression analysis showed that age, carboxyhemoglobin levels, procalcitonin, troponin 1 and length of CO exposure were associated with a higher risk of myocardial infarction. Procalcitonin, troponin and carboxyhemoglobin levels had a high sensitivity and specificity to predict the appearance of myocardial infarction, with high areas under the receiver operating characteristic (ROC) curves.

CONCLUSIONS

In patients with CO intoxication, carboxyhemoglobin, troponin and procalcitonin levels at the moment of the intoxication are significant predictors of the late appearance of myocardial infarction.

Carbon Monoxide, Cigarettes and Family Doctors

Aims and Background

General practitioners could play a key role in preventive programs against tobacco-related diseases. However, they seldom take action in the office even with minimal advice counselling. Such behaviour might reflect the lack of academic teaching and the lack of practice with motivational and dependence questionnaires, considered basic tools to help smokers to quit successfully. The study was aimed to investigate the awareness of a sample of Italian family doctors as regards tobacco epidemiology and smoking cessation strategies.

Methods

A total of 428 family doctors were administered a questionnaire with a set of questions on their personal smoking habits and on personal initiatives in the office towards smokers. Another set of questions regarded their knowledge on tobacco issues, with special attention to carbon monoxide, which is widely perceived as a very dangerous poison and works as a motivational tool on smokers and adolescents. Carbon monoxide measurement was carried out on all participants to obtain objective data on smoking and to show the feasibility of the test.

Results

The percentage of self-reported current smokers among general practitioners was 24%, with a high prevalence of ex-smokers (46%), and 29% of never smokers. Family doctors were more keen to counsel adolescents than adults about tobacco, and they were very interested in continuing medical education on the issue. The doctors who took part in our study showed a surprising limited knowledge of all the issues associated with smoking cessation and prevention such as epidemiology, cigarette characteristics, success rate of smoking cessation programs, Fagerström's tolerance questionnaire, safety of nicotine replacement therapy and the knowledge of carbon monoxide as a product of cigarette smoke.

Conclusions

The scenario depicted by our survey underscores the necessity to improve the knowledge and performance of primary care physicians on tobacco-related issues in order to implement primary and secondary prevention in clinical practice.

Parieto-Occipital Syndrome Following Carbon Monoxide Poisoning

Suicidal attempts by coal-gas poisoning are very common. Carbon monoxide is a principal constituent of this gas, and can produce severe and permanent brain damage. It is surprising, therefore, to find so few cases of chronic organic psychosis attributed to this cause in mental hospital practice. Rosseter (1928) found only one example of permanent psychosis in 2,000 cases of carbon monoxide asphyxiation. Shillito, Drinker and Shaughnessy (1936) made a follow-up study of 21,000 cases of acute carbon monoxide poisoning. In only 43 of these were the after-effects sufficiently severe to warrant their admission to a mental hospital. Twenty-three subsequently recovered, 11 died, and 9 suffered permanent nervous and mental sequelae. They found that the ratio of psychosis following carbon monoxide poisoning to other psychoses was 1 in 2,000. Henderson and Gillespie (1944) could find only one such case in 5,000 consecutive admissions.

Occupational Carbon Monoxide Poisoning Associated with Diesel Motor Operation in an Air-raid Shelter in June 2015, Jinan City, China-An Epidemiological Investigation

Occupational carbon monoxide (CO) poisoning related to diesel motor fumes in an air-raid shelter (ARS) was first identified in Jinan City, China, in June 2015. A total of 17 cases were identified, including 14 possible cases of firemen and 3 confirmed cases of water channel clean-up workers. The overall attack rate (AR) of firemen was 42% (14/33). The firemen had a significantly higher AR with a longer exposure and more protracted time of rescue in the ARS (P < 0.05). All the cases stated that they did not realize the potentially high level of exposure to CO in the ARS. CO poisoning posed a risk to both patients and service providers. Occupational safety and health education should be promoted and enforced in all workplaces where CO sources exist.

Another perspective on ACEP policy on critical issues in carbon monoxide poisoning: Invited commentary

The American College of Emergency Physicians (ACEP) recently published its official policy on the evaluation and management of patients with acute carbon monoxide (CO) poisoning [1], an update of the policy previously published in 2008. Three questions regarding CO poisoning were posed to a 30-person ACEP subcommittee, which employed a comprehensive literature review to attempt to draw conclusions. While this is a major step forward, we feel that their conclusions warrant comment.

[Effect of hyperbaric oxygen therapy on antioxidant capacity in brains of rats after acute carbon monoxide poisoning]

OBJECTIVE

This study was designed to observe the antioxidant effects of hyperbaric oxygen (HBO) on brains of rats after acute carbon monoxide (CO) poisoning.

METHODS

Sixty-six Sprague-Dawley (SD) male rats were divided into three groups including control group, CO group and HBO group.Morris water maze experiments were used for monitoring cognitive function.Antioxidant capacities were evaluated by detecting T-AOC, GSH-PX, GR and CAT activities in the brain.

RESULTS

Compared with the control group (45±17, 43±14, 35±12, 34±11, 29±13) s and the HBO group (40±10, 39±6, 35±9, 31±11, 21±10) s, the CO group (57±5, 54±8, 52±8, 52±10, 46±8) s had the longer escape latency (P<0.05). Compared with the control group (51±6) s and the HBO group(40±10) s, the CO group (8±5) s had the shorter swimming time in I quadrant (P<0.05). Compared with the control group (1.25±0.40) U/mg and the HBO group(0.97±0.31, 0.97±0.39, 1.45±0.15, 1.40±0.25, 1.20±0.20) U/mg, the CO group (0.68±0.09, 0.45±0.17, 0.71±0.18, 0.69±0.29, 0.48±0.29) U/mg had the lower T-AOC activity of brain tissue.The GSH-PX activity (42±13, 106±46, 197±49, 173±42, 429±58) U/mg in the CO group decreased compared with the control group (182±53) U/mg and the HBO group (203±63, 325±86, 389±29, 385±100, 453±32) U/mg.GR activity (4.3±0.7, 2.6±0.5, 3.0±1.2, 1.8±0.8, 3.2±1.9) U/mg in the CO group decreased compared with the control group(14.5±3.0) U/mg and the HBO group (13.9±3.3, 4.3±1.0, 3.9±0.7, 4.8±0.9, 4.6±0.9) U/mg.CAT activity (1.6±0.8, 4.3±1.6, 3.9±1.0, 8.5±2.6, 5.4±1.7) U/mg in the CO group decreased compared with the control group(5.2±1.3) U/mg and the HBO group (5.2±2.2, 8.8±2.8, 5.3±1.0, 9.2±2.1, 14.1±3.8) U/mg.

CONCLUSIONS

HBO can improve the behavior of rats after acute CO poisoning.The antioxidant capacity in rat brain tissue after acute CO poisoning decreases, while after the HBO therapy, the antioxidant capacity in rat brain tissue can increase.

Engineering evidence for carbon monoxide toxicity cases

Unintentional carbon monoxide poisonings and fatalities lead to many toxicity cases. Given the unusual physical properties of carbon monoxide-in that the gas is odorless and invisible-unorganized and erroneous methods in obtaining engineering evidence as required during the discovery process often occurs. Such evidence gathering spans domains that include building construction, appliance installation, industrial hygiene, mechanical engineering, combustion and physics. In this paper, we attempt to place a systematic framework that is relevant to key aspects in engineering evidence gathering for unintentional carbon monoxide poisoning cases. Such a framework aims to increase awareness of this process and relevant issues to help guide legal counsel and expert witnesses.

Unusual way of suicide by carbon monoxide. Case Report

OBJECTIVES

Authors discuss the case of a suicide of a 29-year-old man caused by carbon monoxide (CO) intoxication. What the authors found interesting was the unusual way of committing suicide that required good technical skills and expert knowledge.

METHODS

The level of carboxyhemoglobin (COHb) in the blood of the deceased man was routinely determined by the modified method by Blackmoore (1970), using gas chromatography/thermal conductivity detection. The level of saturation of the hemoglobin by CO in the collected blood sample is determined relatively to the same sample saturated to 100%.

RESULTS

In the blood sample of the deceased man the lethal concentration of COHb of 76.5% was determined. Within the following examinations the blood alcohol concentration of 0.05 g.kg(-1) was determined. Further analysis revealed traces of sertraline, its metabolite N-desmethylsertraline, omeprazole and caffeine in the liver tissue, traces of N-desmethylsertraline, ibuprofen and caffeine in urine sample, and only traces of caffeine in the stomach content and blood samples were proved. To commit suicide the man used a sophisticated double container-system equipped with a timer for controlled generation of CO based on the chemical reaction of concentrated sulphuric acid and formic acid. The used timer was set by an electromechanical timer switch that triggered the fatal reaction of the acids while the man was sleeping.

CONCLUSIONS

The authors discuss an unusual case of suicide by CO intoxication rarely seen in the area of forensic medicine and toxicology that is specific due to its sophisticated way of execution.

Skin messages in suicide--an unusual occurrence

Notes are found in only a minority of cases of suicide and occasionally may involve writing messages on skin surfaces. A prospective study was undertaken for cases of suicide with skin messaging over a 12-year period from 1/1/2000 to 31/12/2011. A total of 498 cases of suicide were examined with only 2 cases (0.4%) having suicide notes written on their skin. Both cases involved young males (aged 18 and 30 years respectively) with the deaths occurring by hanging. In both cases typical parchmented ligature marks were present around the neck running up to the point of suspension. Both decedents had written messages on their hands/arms expressing mixtures of sorrow and hopelessness. There were no other suicide notes present. It is not clear whether writing on skin rather than on more conventional material suggests that the suicide may not have been planned, or instead that the decedent wanted to ensure that the message was found. Messages on skin may be slightly different to messages written on other surfaces, as space is limited and pens and markers may not write as effectively. An additional problem with skin messages is their vulnerability to erasure, making clear documentation of these findings at the scene important.

[Acute poisonings in children in the years 2010-2012--single-centre study in Poznań]

Poisoning is a clinical syndrome caused by the poison, which entered into the body. Poison is every substance that taken in the specified amounts may cause adverse effects.

OBJECTIVE

Statistical analysis of acute poisoning in children in the years 2010-2012.

MATERIAL AND METHODS

The study group consisted of 308 children who went to the Admissions Room of the Specialized Health Care Mother and Child in Poznań because acute poisoning suspicion or diagnosis, in the period from 1 January 2010 to 31 December 2012.

RESULTS

In the group of 308 children, girls accounted for 57.14% and 42.86% boys. Children age ranged from 5 day old to 215 months of age (average 122 +/- 74). Toxic substances, which children have been exposed were drugs in 144 patients, ethyl alcohol in 75 children, carbon monoxide - 55 injured and chemicals in 34. The most commonly acute poisoning occurred in October (11.69%), December (11.04%) and September (10.71%). Of the 308 admitted children, 278 (90.26%) were hospitalized, including 11 patients (3.57%) in the Intensive Care Unit (ICU). In study population poisonings with drugs were dominated and related to 63.89% of girls and 36.11% of boys, aged from 2 to 213 months of age (average 120 +/- 75). In 50.69% of children intentional poisoning was diagnosed, in 18 patients (12.5%) mixture of different drugs was ingested, in five of them together ethyl alcohol. At 4.86% of the children reported a suicide attempt. This group accounted for girls with an average age of 178 +/- 8 months. Ethyl alcohol poisoning related to 56% of girls and 44% of boys between the ages of 152 to 215 months, giving an average age of 184 +/- 17 months. At 5.33% of the patients reported alcohol consumption along with medication, and 2.66% in addition took psychoactive substances. Because carbon monoxide poisoning aid granted to 50.91% girls and 49.09% boys between the ages of five day old to 209 months of age (mean 96 +/- 64). Poisoning with household chemicals related to 58.82% of boys and 41.18% of girls (mean age 32 +/- 36 months). Detergents were the most frequent ingested chemicals in 50% of children with an average age of 3 years.

CONCLUSIONS

Acute poisoning with the exception of household products ingestion were more common in girls than in boys. The most common cause of poisoning in children were drugs overdose and ethanol ingestion. Cases of suicidal poisoning target group included only female sex. Accidental poisoning were observed mainly in young children and usually caused by chemicals.

Generation rate of carbon monoxide from burning charcoal

Charcoal, often used as cooking fuel at some restaurants, generates a significant amount of carbon monoxide (CO) during its combustion. Every year in Japan, a number of cooks and waiters/waitresses are poisoned by CO emanating from burning charcoal. Although certain ventilation is necessary to prevent the accumulation of CO, it is difficult to estimate the proper ventilation requirement for CO because the generation rate of CO from burning charcoal has not been established. In this study, several charcoals were evaluated in terms of CO generation rate. Sample charcoals were burned in a cooking stove to generate exhaust gas. For each sample, four independent variables -- the mass of the sample, the flow rate of the exhaust gas, CO concentration in the exhaust gas and the combustion time of the sample -- were measured, and the CO generation rate was calculated. The generation rate of CO from the charcoal was shown to be 137-185 ml/min/kW. Theoretical ventilation requirements for charcoals to prevent CO poisoning are estimated to be 41.2-55.6 m(3)/h/kW.

An unusual case of suicidal carbon monoxide poisoning

The authors present a case of suicide by carbon monoxide poisoning in a confined space with interesting elements related to the method and the circumstances in which it took place. Carbon monoxide poisoning is a very common cause of death in accidental and suicidal cases, but the method used in this case, consisting of burning charcoal in a small office bathroom, presents some particularly interesting aspects. The circumstances, moreover, appear very interesting because the person who committed suicide was an employee of the Public Administration and he had received notification regarding his involvement in a legal prosecution.

Out-of-hospital cardiac arrest caused by acute intoxication

We experienced 20 cases of out-of-hospital cardiac arrest (OHCA) caused by acute intoxication between April 1999 and March 2008. The causative agents were organophosphates in 8 cases, carbon monoxide in 5 cases, and barbiturates in 3 cases. Other agents were paraquat, tricyclic anti-depressants, lime sulfur, and amphetamine. Cardiac arrest was witnessed by bystanders while waiting for the ambulance arrival in 3 cases, and by emergency medical personnel during transfer to our hospital in 4 cases. In these 7 witnessed cases, prehospital resuscitation was provided in 6 cases. No case demonstrated ventricular arrhythmia at the prehospital scene. The restoration of spontaneous circulation was achieved in 8 cases, and 4 cases were discharged alive with overall performance category 1. All the survivors were victims of organophosphate or barbiturate intoxication. It is assumed that these agents caused myocardial depression or respiratory insufficiency following cardiac arrest. From the review of the OHCA caused by organophosphate or barbiturate intoxication, cardiopulmonary resuscitation alone seemed to be effective for restoration of spontaneous circulation and should be emphasized in the prehospital care setting as well as in cardiogenic OHCA.

[Students knowledge on carbon monoxide toxicity]

The results of questionnaire research on carbon monoxide (CO) poisoning in students of State Higher Vocational School in Nowy Sacz (Institutes of Economy, Pedagogic, Technical and Health) are presented in the study. The mean age of the group examined, with a female predomination (77.6%) was 22.7 +/- 4.94 years. The questionnaire covered demographic data and knowledge on CO source, exposure, most frequent and most severe symptoms, most severe sequels, risky behavior and risk groups in CO poisoning. The results obtained indicate on inadequate knowledge on CO poisoning even in young students population. The proper education and prophylaxis activity is necessary to avoid accidental CO poisoning, especially that they also occur in spring-summer season.

Demand for poison control center services “surged” during the 2003 blackout

BACKGROUND

Beginning 8/14/03, for 24 hours, the largest geographic power failure in U.S. history occurred. Our Poison Control Center (PCC) catchment area was one of the most severely affected, with most of the population left without electricity, fuel, water pressure, or municipal potable water. The paucity of reports on the impact of disasters on PCC operations led us to summarize our experience.

METHOD

Data sources included 1) Toxicall human exposures during 8/03 (with comparison to 2002 and to national trends) and 2) an after-action report completed by Specialists-in-Poison Information (SPI's) on duty during the disaster.

RESULTS

The average call volume for 8/03 increased by 7.8%. Significant increases in human exposure and information calls occurred in four categories: gasoline, carbon monoxide, food poisoning, and water contamination. After-action report findings included: vulnerability of PCC operations to interruptions in power supply; lack of redundant communication methods; staffing challenges; and exclusion of PCC staff from hospital disaster plans despite co-location.

CONCLUSION

During the blackout of 2003, there was a measurably increased demand for poison center services. PCC disaster plans should address increased staffing needs during the time of disaster, communication system redundancy, back-up power supply, and SPI needs (food, water, transportation, environmental safety, and rest/rotation).

Cerebral palsy due to nonlethal maternal carbon monoxide intoxication

BACKGROUND

Carbon monoxide (CO) poisoning in pregnancy is a relatively rare occurrence, but it can result in fetal mortality and neurologic complications in fetuses who survive to term.

CASE

We describe the course of an infant who was acutely exposed to CO at 20 weeks of gestation.

CONCLUSIONS

We conclude that despite maternal well-being, CO intoxication at critical periods of human brain development can lead to hypoxic-ischemic lesions in the globus pallidus and that dystonic cerebral palsy may develop in the infant during long-term follow-up.

[Two cases of diphenhydramine related suicide]

Two suicidal cases associated with ingestion of diphenhydramine (DPH) were reported. Case 1 is a typical DPH overdose case of a young man with the blood DPH concentration of 12.2 microg/ mL. Case 2 is a double suicide of a man and a woman. They ingested DPH and fell asleep in a vehicle which had a cooking clay charcoal stove. Their blood DPH concentrations were 0.4 and 0.7 microg/mL, which were high enough to make them sleep. Their cause of death, however, was carbon monoxide poisoning with blood CO-Hb concentration of 14 and 19%. DPH is a low toxic agent and is available as an OTC drug in Japan. Similar fatal cases can be expected to happen in Japan.

Carbon monoxide: the bad and the good side of the coin, from neuronal death to anti-inflammatory activity

The double origin of carbon monoxide (CO) as an atmospheric pollutant or as an endogenous gaseous modulator of many pathophysiological processes prompted us to review some aspects of the bad side and of the good side of coin among the pleiotropic effects of CO. On the bad side of the coin, we focus on the interval form in acute CO poisoning, discussing experimental evidence suggesting that the delayed neuropathology after CO poisoning is a free radical-driven event. In this context, we challenge the mandatory place of hyperbaric oxygen therapy (HBO) in CO poisoning as a possible summation of oxy-radicals generated by HBO and the free radical cascade set in motion during the reoxygenation phase of acute CO-poisoning. We also discuss an opposing view, which provides evidence suggesting that HBO therapy actually decreases the load of free radicals in acute CO-poisoning and may be beneficial in preventing delayed neuropsychiatric sequelae.On the good side of the coin, we briefly outline the endogenous generation of CO and the leading role of heme-oxygenases (HO) in relation to the place of CO in biology and medicine. The main focus of this section is on the growing literature on CO and inflammation. Here we report on in-vitro and in-vivo studies on the modulation afforded by exogenously administered/endogenously produced CO in a variety of experimental and clinical settings of inflammation. Our recent studies on experimental models of allergic inflammation are also discussed, and the CO-releasing molecules envisaged as potential anti-inflammatory drugs suitable for clinical use.

Effect of melatonin and atenolol on carbon monoxide cardiotoxicity: an experimental study in rats

The aim of this study was to define the characteristics of heart rates and myocardial changes in rats exposed to carbon monoxide (CO), and the effects of reoxygenation, atenolol (a beta-blocker) and melatonin after sublethal CO intoxication. Widespread use of beta-blockers in cardiology practice and growing literature on the positive effect of melatonin in ischaemia reperfusion lead us to question their effects in case of CO intoxication. Rats were exposed to CO. After sublethal intoxication the rats were reoxygenated with ambient air. Subsequently blood values, electrocardiographic recordings and pathological changes were examined for each groups. Five rats died after CO intoxication in the control group: no myocardial changes were seen in light microscopy. However, myocardium of seven reoxygenated rats presented contraction bands. Seven reoxygenated rats pretreated with atenolol had a higher number of contraction bands of myocardial cells. Seven reoxygenated rats pretreated with melatonin had more contraction bands than reoxygenated rats, and heart rate recordings of these animals revealed a profund and sustained bradycardia. Thus, melatonin and atenolol appear to have some adverse effects in CO intoxication on the myocardial cells.