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ORIGINAL RESEARCH / ORİJİNAL ARAŞTIRMA 2015 The Evaluation of Hospitalized Cases of Drug Intoxication Hastanede Yatan İlaç İntoksikasyonu Olgularının Değerlendirilmesi AUTHORS / YAZARLAR Özgür Erdem Kayapınar Family Health Centre Number 9, Diyarbakır, Turkey İsmail Hamdi Kara Department of Family Medicine, Düzce University Medical Faculty, Düzce, Turkey Orhan Ayyıldız Department of Internal Medicine, Dicle University Medical Faculty, Diyarbakır, Turkey ABSTRACT Aim: This study aims to determine the risk groups, socio demographic characteristics, and the drugs which had been taken by the patients who are hospitalized and attempted suicide. Methods: The documents and reports of the patients with the drug intoxication are obtained from Dicle University Hospital between January 2006 and December 2006 and analyzed retrospectively. Results: The average of age was 24.7±9.4. 74.5% (n=143) of them were females and 25.5% (n=49) were males (p=0,023). 44% of the patients were under 20 years old, 80% were under 30 years old, and 96% were under 40 years old. Organic phosphor was the highest among the taken drug by the patients. Most cases occurred in May, July and December, and most of the suicide attempts were in the spring. With regard to the time of suicide, majority of the patients tried to attempt suicide in the afternoon and evening times. Conclusions: It is observed that most of the people who attempted suicide were housewives, students and the girls who do not have schooling or job. It is thought that this is a behavior of people who have not got an adequate social status in society and so, they try to draw attention by attempting suicide. Keywords: organothiophosphorus compounds, social conditions, suicide, intoxication ÖZET Amaç: Bu çalışma intihar amaçlı ilaç alan ve hastanede yatan vakaların risk gruplarını, sosyo-demografik özelliklerini ve hangi ilaçları aldıklarını belirlemek amacıyla yapıldı. Yöntem: Dicle Üniversitesi Hastanesine 01/01/2006 ile 31/12/2006 tarihleri arasında ilaç intoksikasyonu nedeni ile başvuran vakaların dosyaları retrospektif olarak incelendi. Bulgular: Vakaların yaş ortalaması 24,7±9,4 idi. %74,5’i (n=143) kadın %25,5’i (n=49) erkekti (p=0,023). Vakaların %44’ü ≤ 20 yaş, %80’ni ≤ 30 yaş ve %96’sı ≤ 40 yaş idi. Vakaların aldığı ilaç grupları incelendiğinde; ilk sırayı organik fosfor oluşturmaktadır. Aylara göre incelendiğinde en çok vaka sırasıyla Mayıs, Temmuz ve Aralık aylarında başvurmuştu. Mevsimlere göre incelendiğinde en fazla intoksikasyon vakası ilkbaharda meydana gelmişti. Vakaların inihar girişiminde bulunma saatleri incelendiğinde özellikle akşam saatleri ve öğle saatlerinde yoğunluk kazandığı tespit edildi. Sonuç: İntihar girişiminde bulunanların çoğunlukla ev hanımı/kızı ve öğrenci olduğu saptandı. Bu bize toplumda yeterli bir sosyal statüsü olmayan insanların dikkatleri üzerine çekmek için intihar girişiminde bulunduğunu düşündürmektedir. Anahtar kelimeler: organik tiyofosfor bileşikleri, sosyal durumlar, intihar, zehirlenme Introduction Drug intoxication takes place either with having the intention of suicide or taking the drugs unintentionally. In general, intoxication of children occurs by accident, but intoxication of adults take place intentionally to commit suicide. The death among the people who take drugs for suicide has been observed more often all around the world. In developed countries the victims who are exposed to intoxication both accidentally and intentionally are between 0.2 and 9.3 among 1000 people in a year (1). Moreover, in the United State of America (USA) suicide is the fourth reason for Corresponding Author / İletişim için Dr. Özgür Erdem, MD Kayapınar 9 Nolu ASM, Peyas Mah. 455. Sok. No:5, 21070-Kayapınar, Diyarbakır, Turkey E-posta: dr.oerdem@hotmail.com Date of submission: 17.03.2015 / Date of acceptance: 18.07.2015 71 Erdem O et al. The Evaluation of Hospitalized Cases of Drug Intoxication deaths after accidents, cancer and murders of the teenagers who are between 10-14 years old. However, it is the third death reason after accidents and murders of the teenagers who are between 15-24 years old. Additionally, it is stated that suicide rates of the teenagers between 15-19 years old have increased 350% since 1950. 70% of the people who attempted suicide took drugs excessively and 63% of these people preferred guns to suicide (2). The ratio of the people who attempted suicide in Turkey is less than European countries. Moreover, most of the people attempting suicide are teenagers between 15 and 19 similar to European countries (3). However, it is mentioned that there are not any systematic and reliable data about the attempts of suicide in Turkey (4). In a study conducted in Turkey, 94.73% of the teenager attempted to suicide killed themselves by taking drugs (5). This study aims to describe the sociodemographic features and groups of medicine of the patients who were accepted to Dicle University Hospital because of drugs intoxication. All of the cases were analyzed retrospectively. Methods The data of patients who attempted suicide by taking drugs, who were treated in Internal Diseases Department of Dicle University Medical Faculty in Diyarbakır between the first of January and thirtyfirst of December in 2006 were analyzed retrospectively. The patients were from eleven cities of South East and East Anatolian regions (Diyarbakır, Mardin, Batman, Bingöl, Hakkari, Van, Muş, Bitlis, Şanlıurfa, Şırnak and Siirt). However, the children who were under 12 were not included in this study, as they were followed by pediatricians. The patients were firstly evaluated in the emergency service and then they were taken to the Internal Diseases Department after their first treatment. In this study, parameters were evaluated according to age, gender, marital status, occupation, the sort of medicine, type of intoxication (suicide-accident), the time of the arrival to hospital, dispersion according to the months, evaluating complications, and biochemical parameters. The results were categorized according to gender, season 72 and kind of drugs. Statistical Package for Social Sciences (SPSS) 11.5 program was used for analysis. The independent groups were compared by student test, chi-square test or Fisher’s exact test. The valve of p<0,05 was accepted as statistically significant. Results The average age of the patients was 24.7±9.4. 74.5% of them were females (n=143) and 25.5% were males (n=49) (p=0,023). 44% of the patients were younger than the age of 20, 80% were younger than 30, while 96% of them were younger than 40 years old. Socio-demographic characteristics of the patients and their occupations are given in Table 1 and Table 2. Table 1. Socio-Demographic Characteristics of Patients Women Men Total Parameter n n n p (%) (%) (%) Married 75 17 92 (39.1) (8.9) (47.9) Marital status 0.023 Single 68 32 100 (35.4) (16.7) (52.1) Present 32 12 44 Psychiatric (16.7) (6.3) (22.9) treatment 0.451 Absent 111 37 148 background (57.8) (19.3) (77.1) First 141 48 189 (73.4) (25.0) (98.5) Number of Second 1 0 1 suicide 0.614 (0.5) (0) (0.5) attempt Third 1 (0.5) 1 (0.5) 2 (1) One 99 34 133 Number of (51.6) (17.7) (69.3) 0.494 drug(s) taken Multiple 44 15 59 (22.9) (7.8) (30.7) Table 3 shows the clinical characteristics of the patients during the first evaluation. Table 2. Job distribution of patients Women Men Job n (%) n (%) Total n (%) Housewife 72 (37.5) 0 (0) 72 (37.5) Student 36 (18.8) 19 (9.9) 55 (28.6) House girl 31 (16.1) 0 (0) 31 (16.1) Artisan 1 (0.5) 8 (4.2) 9 (4.7) Worker 0 (0) 9 (4.7) 9 (4.7) Officer 3 (1.6) 5 (2.6) 8 (4.2) 0 (0) 8 (4.2) 8 (4.2) Unemployed Total 143 (74.5) 49 (25.5) 192 (100) p <0.0001 Euras J Fam Med 2015;4(2):71-77 Table 3. Clinical characteristics of patients Women Men P Clinic Characteristics n (%) n (%) Open 1.08 (56.3) 33 (17.2) Conscious Close 22 (11.5) 6 (3.1) 0.106 ECG* Confused 13 (6.8) Normal 69 (35.9) 28 (14.6) compounds (OP) 28.1% (n=54), antidepressants 24% (n=46), and non-categorized group of 20.3% (n=39) (Table 5). There were two patients ended up death; one of them was 50 years old and married, and the other was 22 years old single woman. Both of the patients who died had taken OP for suicide. Tachycardia 72 (37.5) 17 (8.9) 0.020 Table 5. Distribution of taken drug groups Bradycardia Reason Suicide 4 (2.1) 130 (67.7) 42 (21.9) Mistakenly Healthy Outcome 2 (1.0) 10 (5.2) 13 (6.8) 7 (3.6) 0.050 141 (73.4) 48 (25.0) Exitus Transfer to another hospital 1 (0.5) 1 (0.5) 1 (0.5) 0.614 0 (0) When the patients were examined based on the time of the year, most of them occurred in May, June and December. When it was examined according to the seasons, most of the intoxication cases occurred in spring (p>0.05) (Table 4). Winter Paraceta mol Antiepileptic NSAİD* Amitraz Antibiotic P Other January 8 (4.2) 2 (1.0) 10 (5.2) Total February 11 (5.7) 2 (1.0) 13 (6.8) p † OP:Organic Phosphor, ‡AD:Anti-Depressant, *NSAID:Non Steroid Anti Inflammation Drug March 12 (6.3) 7 (3.6) 19 (9.9) April 10 (5.2) 5 (2.6) 15 (7.8) May 18 (9.4) 5 (2.6) 23 (12.0) June 9 (4.7) 4 (2.1) Summer July 16 (8.3) 5 (2.6) 21 (10.9) 13 (6.8) 3 (1.6) 16 (8.3) September 12 (6.3) 9 (4.7) Autumn October November 10 (5.2) 2 (1.0) 14 (7.3) 5 (2.6) 14 (7.3) 4 (2.1) 14 (7.3) Spring OP† AD‡ *ECG : Electrocardiography Table 4. Distribution of cases according to seasons Woman Man Total Seasons Months N (%) N (%) N (%) December 15 (7.8) 5 (2.6) 20 (10.4) Drugs Woman Man Total Married Single Married Single n p n n n n (%) (%) (%) (%) (%) 28 9 8 9 54 0.040 (14.6) (4.7) (4.2) (4.7) (28.1) 16 21 4 5 46 0.617 (8.3) (10.9) (2.1) (2.6) (24.0) 7 6 1 2 16 0.500 (3.6) (3.1) (0.5) (1.0) (8.3) 4 6 2 2 14 0.594 (2.1) (3.1) (1.0) (1.0) (7.3) 5 3 0 2 10 0.222 (2.6) (1.6) (0) (1.0) (5.2) 2 3 0 4 9 0.278 (1.0) (1.6) (0) (2.1) (4.7) 2 2 0 0 4 (1.0) (1.0) (0) (0) (2.1) 11 18 2 8 39 0.264 (5.7) (9.4) (1.0) (4.2) (20.3) 75 68 17 32 192 0.023 (39.1) (35.4) (8.9) (16.7) (100) August 13 (6.8) 0.490 According to the laboratory results, 3% of the patients had urea rising, 1.6% had creatine rising, 3.7% had aspartate aminotransferase (AST) rising, and 2.1% had alanine aminotransferase (ALT) rising. In the blood count values, it was stated that white blood cells (WBC) were found higher in 36.5% of the patients. While hemoglobin was below 12.3 gr/dl in 49% patients, hematocrit was below 37.7% in 62.5% of the patients. When the patients were examined, the groups of drugs were as follows: organothiophosphorus 0.072 0.414 <0.0001 The average age of the patients who took OP was 29.5±12.6 (Figure 1). Laboratory reports showed that the kind of drugs which made the WBC (Figure 2) and Lactate dehydrogenase (LDH) (Figure 3) higher was OP. Figure 1. The correlation of the drugs and the average age of the patients 73 Erdem O et al. The Evaluation of Hospitalized Cases of Drug Intoxication Figure 2. The correlation of the drugs which make the WBC higher Figure 3. The correlation of the drugs which make the LDH higher The times of suicide attempts were especially during evening and noon periods (Figure 4). Figure 4. The time of drugs taking Discussion It was stated that one million people attempt to suicide every year in the 2001 (6). Taking the drugs excessively to suicide is one of the common techniques of attempting suicide (7). Intoxications 74 which were among adult groups are mostly taking drugs for suicide. Furthermore, it is commonly used among the female population rather than males (8,9). The studies which were conducted in different periods and in different regions of Turkey such as Istanbul, Ankara, Bursa, Diyarbakır, and Elazığ, the average age of the patients attempting suicide was between 22.1 and 29.4. According the these studies, the ratio of female patients who attempted to suicide was between 67.5% and 82.5% (7,9-15). According to the results from the National Centre for Health Statistics in USA, the ratio of completed suicide of boy teenager is higher five times more than girl teenagers, at the age of 15 and 19 (16). On the other hand it is seen that, the girls thinking, planning and attempts to suicide are more often than boys (2). In this study, the average age of the people who attempted to suicide was 24.7±9.4 and 74.5% were females. The valves were compatible with the average of Turkey ratio and the data around the world. As it was shown in many studies, it was found out that age and gender are important variables which have clues for the probability of attempting suicide. It is assumed that the higher suicide rate among females is due to their sensitive and fragile natures, which make attempt suicide more often. Since the individuals whose ages were between 20 and 30 have little hope and sense about the future, they did not have ethical or religious values. Thus, the ratio of suicide among these individuals can be more often. The teenagers among these ages expose to university entry exams and unemployment after graduation due to Turkey standards (17). The studies about the attempt to suicide patients show that lower education level is an important factor in these cases. For example, in another study in Batman, it was shown that most of the individuals attempting to suicide were illiterate or primary school graduates (15,18,19). Competed with these results, it is indicated that 36% and 46% of the individuals who attempted suicide were housewives and the girls who do not have schooling or job and 38% of this ratio were students (19,20). However, in this study the 53.6% of the ratio were housewives and the girls who did not have schooling or job, and 28.6% were students. Euras J Fam Med 2015;4(2):71-77 Moreover this study showed that 82.2% of the individuals were among unemployed. These results showed that lower education level and inadequacy in the economical resources caused suicides more often. The mostly used technique to attempt suicide is by taking drugs (21). When the techniques for suicide are examined carefully, 55% and 75% of patients take drugs excessively since this technique is easier and cheaper. Generally the amount of the taken drug is very little and it is not a risky for life. Agriculture medicine, chemical materials and jumping from a high place are other following often suicide techniques (13-15). In some studies, it was reported that 2/3 of the patients take one drug; 1/3 of them take more than one drug (11,13). In our study, 69.3% of the patients attempted to suicide by one drug, while 30.7% of the patients attempted to suicide with more than one drug. This shows us that people can sometimes abuse the drugs which they prescribed from doctors. The results from several studies show that among the drugs which were taken for suicide were analgesics, antidepressants and psychoactive drugs. In other studies, it is reported that pesticides are also used (11,13,15,22). In our study, when the types of drugs are examined, in the first place there was OP 28.1% (n=54), the second place was antidepressants 24% (n=46) and the third place was non-categorized group as 20.3% (n=39). The average age of the victims who take OP was 29,5±12,6. The laboratory results indicate that OP is responsible for making WBC and LDH higher. Our results of taking antidepressants was compatible with literature. However, analgesics were used less than it is in literature. Also, OP takes the first place and that is different from the literature. East and South East regions of Turkey, where the study takes place, are poor places in terms of industrialization and the people here are busy with agriculture and growing animals. As they are busy with agriculture, it is easier to get the agriculture drugs and pesticides. OP, being among these drugs consists of the majority of these drugs. That is why, the pesticides which consist of OP, should be controlled densely and should be sold in a controlled way. The farmers should be more informed and thus, the suicide risks can be decreased when the easy reach is prevented. In some studies, it is reported that the time of suicide was in the afternoon and evening densely (20,23). In this study, they were during noon and evening. This was compatible with literature. When the season of suicide is examined, the results show that suicides were committed in summer time more often (13,24). In this study most cases occurred in May, July and December. However, analysis based on the seasons indicated that intoxication occurred more often in spring. In this regard, our study contrasts with the literature. In the literature, the ratio of death as a result of suicide is reported as males being higher than females. Otherwise the ratio of attempt to suicide is reported as females being higher than males (13,15,25-27). In several studies, the ratio of death due to intoxication has been found between 0% and 3.9% (12,13,15,28). In this study, both of the victims who died took OP in order for suicide. Even though, the ratio of death among males and elderly is higher than teenagers, suicidal intoxication among teenagers and females is higher than males and elderly (25,26,29,30). Conclusion As a result, the patients who attempted to suicide have been especially among teenagers and females. Their aims are to be focused on and to tackle with the daily problems and to call a S.O.S. message. However, older aged-people and male ones attempted to suicide to make an end of their lives mostly. In this way, age, gender and technique of suicide can help us to understand the patients mood. This study was presented at the second congress of Association of General Practice family Medicine of South East Europe Congress, 22-25 April 2010, Antalya, Turkey. It received “The Best Poster Presentation” award. 75 Erdem O et al. The Evaluation of Hospitalized Cases of Drug Intoxication References 1. Hanssens Y, Deleu D, Taqi A. 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