Cassava (Bitter Manioc Linamarin) ne Apricot Kernel (Amygdalin / Laetrile) a Wɔnom: Awuduru a Wɔde Hyehyɛ Awotwaa Mu a Ɛkyɛ¶

cassava a ɛyɛ nwononwono ( .Manihot esculenta, manioc/yuca), a wɔwe apricot a ɛyɛ nwononwono, peach/cherry/plum amena a wɔabubu, anaa almond a ɛyɛ nwononwono, anaasɛ mene nnuru foforo "Vitamin B17" (amygdalin anaasɛ laetrile) nnuru a wɔde ka aduan ho ma ɛde nkwa to asiane mu yafunu mu Hydrogen Cyanide a ɛkyɛ (HCN) awuduru a wɔde ma. Frɛ wo mpɔtam hɔ ntɛmpɛ nɔma (911 wɔ United States ne Canada, 112 wɔ Europa Aman Nkabom no nyinaa mu, 999 wɔ United Kingdom) anaa hwehwɛ yɛn amanaman ntam nɔma ahorow a wɔde ma ntɛmpɛ ho kyerɛwtohɔ ntɛm ara, na ka kyerɛ nea ɔde amena no sɛ ɔyarefo no hia Hydroxocobalamin a wɔde fa ntini mu (Cyanokit) anaasɛ Cyanide Antidote Kit ( .Sodium Thiosulfate / Sodium Nitrite) na ɛyɛ. Bere a woretwɛn nnuruyɛfo a wɔboa nkurɔfo no, fa wo hwɛ a wobɛhwɛ ntɛm ara no ne yɛn cyanide ne mfiridwuma mu mframa a wɔhome ho akwankyerɛ a edi kan, kyerɛ nsonsonoe a ɛda mogya a ɛyɛ kɔkɔɔ a ɛhyerɛn a cyanide awuduru wom no ne methemoglobinemia a ɛyɛ chocolate a ɛyɛ bruu, na siesie wo ho ma status epilepticus a ɛma obi ho kyere no bere tenten anaasɛ CPR a wɔde yɛ adwuma.

Nea ɛnte sɛ hydrogen cyanide mframa a wɔhome (a ɛma ɛhwe ase wɔ mu no 10 to 60 seconds), mene cyanogenic glycosides, titiriw linamarin (wɔ cassava a ɛyɛ nwononwono, lima bankye, ne flaxseed mu) anaa amygdalin / prunasin (wɔ apricot nnua a ɛyɛ nwononwono, almond a ɛyɛ nwononwono, Rosaceae nnuaba abo, ne bamboo nkorabata mu), da nnaadaa ** adi.30-minute to 4-hour latency window a sɛnkyerɛnne biara nni ho**. Wɔ saa bere a ɛyɛ komm yi mu no, afifide ne dwensɔtwaa mu beta-glucosidase ne hydroxynitrile lyase enzymes ma glycosides a wɔamene no yɛ nsu bere nyinaa wɔ alkaline dwensɔtwaa ketewaa ne akyi berɛmo no mu, na ɛma hydrogen cyanide (HCN) kɔ portal mogya no mu. Cyanide a wɔatwe no de abusuabɔ a emu yɛ den kyekyere ferric (Fe3+) dade atom a ɛwɔ mitochondrial mu cytochrome c oxidase ( .Complex IV), a ɛma nkwammoaa mu mframa a ɛma mframa bɔ no gyae koraa ɛwom mpo sɛ mframa pa kɔ so yɛ ɔyarefo no ntini ne ne ntini mu ma (arterialization of venous blood). Sɛ wɔmfa oxygen a wɔde ka ho 100% mma ntɛmntɛm, wɔmfa efĩ fi yafunu mu, na wɔmfa Hydroxocobalamin (5 grams IV) anaa Sodium Thiosulfate ( .12.5 grams IV) + Sodium Nitrite a wɔde yɛ nneɛma ( .300 mg IV), wɔn a wɔayɛ wɔn basabasa no nya nkɔso ntɛmntɛm fi adwenemhaw, ɔfe, ne ahomegye a emu dɔ a ɛyɛ tachypnea (Kussmaul breathing) kosi anion-gap a ɛdɔɔso a ɛnyɛ den so lactic acidosis ( .serum lactate > 8 to 10 mmol/L), akisikuru a ɛkɔ so wɔ baabiara, koma a ɛyɛ mmerɛw, ne owu.

+-------------------------------------------------------------------------+
|       CYANOGENIC GLYCOSIDE DELAYED GUT CYANIDE TRIAGE TIMELINE          |
+-------------------------------------------------------------------------+
|  0 TO 60 MINUTES (THE SILENT ENZYMATIC HYDROLYSIS WINDOW):              |
|  * Victim eats bitter Apricot Kernels, Laetrile, or Bitter Cassava      |
|  * Plant beta-glucosidase (emulsin/linamarase) + Human gut microflora   |
|    cleave Amygdalin/Linamarin -> Mandelonitrile/Acetone Cyanohydrin     |
|    -> Lethal HYDROGEN CYANIDE (HCN) absorbed across intestinal wall     |
|  * Immediate Action: Call 911/112/999; give Activated Charcoal (< 1-2h) |
+-------------------------------------------------------------------------+
|  30 MINUTES TO 4 HOURS (ONSET OF CELLULAR HYPOXIA / HISTOTOXIC SHOCK):  |
|  * Early Signs: Headache, dizziness, anxiety, nausea/vomiting, cherry-  |
|    red flushed skin, tachycardia, and deep gasping hyperventilation     |
|  * Late Signs: Coma, tonic-clonic seizures, hypotension, bradycardia    |
|  * Lab Clues: Venous blood looks bright "cherry-red" (PvO2 > 50-60 mmHg)|
|    + Serum Lactate > 8 to 10 mmol/L (confirms acute cyanide poisoning)  |
+-------------------------------------------------------------------------+
|  DEFINITIVE HOSPITAL ANTIDOTAL RESCUE:                                  |
|  * Give 100% High-Flow Oxygen (ALWAYS safe & beneficial in cyanide)     |
|  * 1st Choice Antidote: IV Hydroxocobalamin (Cyanokit) 5 g (70 mg/kg)   |
|    + IV Sodium Thiosulfate 12.5 g (25% solution, 50 mL) for slow release|
|  * 2nd Choice Antidote: IV Sodium Nitrite (300 mg) + Sodium Thiosulfate |
+-------------------------------------------------------------------------+

--- .

Yɛ eyi mprempren¶

1. Frɛ ntɛmpɛ adwumayɛfo ne Poison Control ntɛm ara, sɛ mpo onipa no da so ara te nka sɛ ɔte ase koraa a. Trɛ 911 (US ne Canada), 112 (European Union), 999 (United Kingdom), 000 (Australia), anaa 111 (New Zealand). Ka ade pɔtee a wɔamene no kyerɛ nea ɔde kɔmaa no ( .bitter apricot kernels, . laetrile / amygdalin tablets, . bitter cassava / manioc, anaa bitter almonds), nnuadewa anaa gram dodow a wɔwei, ne bere a wɔnom sɛnea ɛbɛyɛ a ayaresabea a wogye no betumi asiesie Hydroxocobalamin (Cyanokit) ne Sodium Thiosulfate wɔ baabi a wɔsan nya nkwa ansa na ɔyarefo no ahwe ase.
2. Mma n’afe da, na nyɛ ano-to-ano a wɔde kanyan obi da a wunhia akwanside akataso. Sɛ ɔyarefo bi a ɔmenee cyanogenic glycosides anaa cyanide nkyene fe a, yafunu mu acid dan cyanide ma ɛbɛyɛ hydrogen cyanide a ɛyɛ hyew (HCN) gas ( ) .which smells weakly like bitter almonds to the 40% to 60% of people genetically able to detect the odor). Sɛ ɔyarefo no gyae home a, fa bag-valve-mask (BVM) anaasɛ kotoku mu CPR akataso a ɛkɔ ɔkwan biako so a oxygen a ɛsen kɛse wom sen sɛ ɛbɛka ano tẽẽ.
3. Fa high-flow 100% Oxygen ma bere a ayarehwɛfo aba ara pɛ. Ɛwom mpo sɛ pulse oximetry (SpO2) bɛkenkan 98% to 100% efisɛ nkwammoaa a awuduru wom ntumi nyi mframa pa mfi mogya no mu, na ɛde ** .100% normobaric oxygen** ma plasma oxygen nhyɛso a apete no yɛ kɛse, ɛne cyanide si akan wɔ mmeae a cytochrome c oxidase kyekyere, na ɛma sodium thiosulfate ne hydroxocobalamin a ɛko tia ɔyare mmoawa no yɛ adwuma yiye.
4. Siw Vitamin C a wɔnom no ano ( .Ascorbic Acid) supplements. Sɛ obi faa apricot kernels anaasɛ ɔnom a laetrile, hwɛ sɛ ebia wɔnom Vitamin C a ɛdɔɔso nso anaa. Vitamin C a wɔnom no dodow kɛse ( .> 1 to 3 grams) ma amygdalin dan hydrogen cyanide wɔ yafunu mu ntɛmntɛm na ɛma cysteine a ɛwɔ nipadua no mu a mmerɛbo no mu rhodanese detoxifying enzyme hia no sa.
5. Fa ade a wɔde ahyɛ mu, aba kotoku, anaa cassava ntini a aka no sie. Fa ahina a apricot nnua wom no bra, . B17 fa toa, anaa cassava tuber a wɔannoa a wɔde ka ho ma dwumadibea a wɔhwɛ ntɛmpɛ so. Kan anaa bu akontaa sɛnea nnuadewa dodow pɔtee a wodi: chewing just ** .5 to 10 bitter apricot kernels wɔ abofra kumaa bi mu** anaa ** .20 to 60 bitter apricot kernels (0.5 to 3.5 mg/kg of cyanide equivalent) wɔ ɔpanyin mu** betumi ama cyanide awuduru a ɛde ne nkwa to asiane mu anaasɛ edi awu.

--- .

Gyinaesi dua: gut cyanogenic glycoside triage a ɛkyɛ ne nnuru a wɔde kum ɔyare mmoawa a wɔpaw¶

flowchart TD
    A["Cassava a Ɛyɛ Nwononwono, Apricot a Ɛyɛ Nwononwono, Nnuaba Amena, anaa Laetrile (Amygdalin) a Wɔwe ."] --> B{"Dɛn na Wɔnom & Ɔkwan Bɛn so?"}
    B -->|"1-3 Cherry/Plum/Peach Amena a Wɔanbubu no Nyinaa anaa Apɔw-mu-teɛteɛ Aba Kakraa"| C["Asiane a Ɛba Fam: Aba a wɔde kata so a enni dɛm no mma Amygdalin ntumi nkɔ mu; Hwɛ wɔ fie gye sɛ woawe"]
    B -->|"Apricot a Ɛyɛ Nwononwono a Wɔawe/Wɔyam, Almond a Ɛyɛ Nwononwono, Laetrile Nnua, anaa Cassava a Ɛyɛ Nwononwono"| D["ASIANE KƐSE A ƐWƆ GUT HCN AWURADE A ƐKWƐ HO (Latency 30 min to 4 hours) ."]
    D --> E["Frɛ 911/112/999 wɔ telefon so; Fa Oxygen a Ɛsen Kɔ soro 100% gu so; Ma Activated Charcoal (1 g/kg kosi 50-100 g) sɛ < Nnɔnhwerew 1-2 na Nyan"]
    E --> F["Order Stat Mogya Mframa a Ɛma Ntini Mu (VBG), Mogya Mframa a Ɛma Ntini Mu (ABG), Serum Lactate, ne Basic Metabolic Panel"]
    F --> G{"Hwɛ sɛnea Ayaresa Mu Den & Serum Lactate"}
    G -->|"Nsɛnkyerɛnne biara nni ho & Lactate < 3.0 mmol/L"| H["Hwɛ wɔ ED/ICU mu anyɛ yiye koraa no Nnɔnhwerew 6 kosi 12 (Delayed Gut Hydrolysis); Tia Lactate no mu bio q1-2h"]
    G -->|"Adwene mu Gyinabea a Ɛsakra, Akisikuru, Mogya Mmirikatu, Tachypnea, ANAA Lactate >= 8-10 mmol/L"| I["AKWANKYERƐ A WƆDE MA NTAM (Ntwɛn mma lab cyanide dodow) ."]
    I --> J{"Cyanide Antidote Bɛn na Ɛwɔ Hɔ Ntɛm ara?"}
    J -->|"Hydroxocobalamin (Cyanokit) a Ɛwɔ Hɔ (1st Choice) ."| K["Fa Hydroxocobalamin 5 g IV (70 mg/kg wɔ mmofra mu) gu mu simma 15 + Fa Sodium Thiosulfate 12.5 g IV ka ho ma ɛkɔ so yi awotwaa mu"]
    J -->|"Nitrite + Thiosulfate Kit Nkutoo na Ɛwɔ Hɔ"| L["Fa Sodium Nitrite 300 mg IV (10 mL a ɛyɛ 3%) ma wɔ simma 2-4 mu (Hwɛ Hemoglobin kan) -> Fa Sodium Thiosulfate 12.5 g IV di akyi"]

--- .

Pathophysiology: Sɛnea afifide mu glycosides dan Hydrogen Cyanide (HCN) wɔ onipa awotwaa mu¶

Awiei 2,500 afifide ahorow yɛ cyanogenic glycosides sɛ abɔde mu nnuru a ɛbɔ wɔn ho ban fi mmoa a wodi nhabannuru ho. Wɔ afifide ahaban, ntini, anaa aba a enni dɛm mu no, wɔkora cyanogenic glycoside no so dwoodwoo wɔ nkwammoaa mu vacuoles mu, na honam fam atew ne ho afi ne hydrolytic enzymes a ɛma ɛyɛ adwuma no ho (beta-glucosidase ne hydroxynitrile lyase), a ɛtra afifide no nkwammoaa fasu anaa cytoplasm mu.

1. Amygdalin ne Linamarin a ɛma enzymatic mu paapae wɔ anammɔn abien mu¶

+-------------------------------------------------------------------------+
|       BIOCHEMICAL CONVERSION OF AMYGDALIN & LINAMARIN TO CYANIDE        |
+-------------------------------------------------------------------------+
|                                                                         |
|  PATHWAY 1: APRICOT KERNELS, BITTER ALMONDS, PEACH/CHERRY PITS, LAETRILE|
|  Amygdalin (D-mandelonitrile-beta-D-gentiobioside)                      |
|      |                                                                  |
|      |  Step 1: Beta-Glucosidase (Plant 'Emulsin' when chewed OR        |
|      |          Human intestinal microflora beta-glucosidase in gut)    |
|      v                                                                  |
|  Prunasin + Glucose  --->  Mandelonitrile + Glucose                     |
|                                  |                                      |
|                                  |  Step 2: Hydroxynitrile Lyase OR     |
|                                  |  Spontaneous dissociation in         |
|                                  |  alkaline duodenum (pH > 6.5)        |
|                                  v                                      |
|              Benzaldehyde  +  HYDROGEN CYANIDE (HCN)                    |
|              (Almond odor)    (Lethal Complex IV inhibitor)             |
|                                                                         |
+-------------------------------------------------------------------------+
|  PATHWAY 2: BITTER CASSAVA (MANIOC / YUCA), LIMA BEANS, BAMBOO SHOOTS   |
|  Linamarin (alpha-hydroxyisobutyronitrile-beta-D-glucopyranoside)       |
|      |                                                                  |
|      |  Step 1: Linamarase (plant beta-glucosidase) OR Gut bacteria     |
|      v                                                                  |
|  Acetone Cyanohydrin + Glucose                                          |
|      |                                                                  |
|      |  Step 2: Hydroxynitrile Lyase OR Spontaneous breakdown at pH > 5 |
|      v                                                                  |
|  Acetone  +  HYDROGEN CYANIDE (HCN)                                     |
+-------------------------------------------------------------------------+

• Dɛn nti na wɔde ano ka Laetrile / . Amygdalin no yɛ awuduru boro nea wɔde fa ntini mu no so mpɛn 40 Laetrile: "Vitamin B17" ho nkuranhyɛfo a wɔyɛ nnaadaa wɔ abakɔsɛm mu no kae sɛ laetrile yɛ nea asiane biara nni ho efisɛ nnuru a wɔde twitwiw mmoa mu wɔ ntini mu no ma awuduru kakraa bi na ɛba ntɛm ara. Sɛ wɔde fa ntini mu a, amygdalin a ɛnyɛ ɔyare mmoawa no twa aduan mu ntini no ho na ɛkɔ nipadua no mu > 90% ɛnsakra wɔ nsu mu efisɛ nnipa mogya ne ntini ahorow nni beta-glucosidase enzymes. Nanso, sɛ wɔfa ano a, nnipa akyi berɛmo ne dwensɔtwaa nketewa mu mmoawa wɔ beta-glucosidase dwumadi pii. Sɛ mpo obi noa aprɛko aba de sɛe afifide no ankasa de a emulsin enzyme, anaasɛ mene nnuru a wɔatew ho laetrile tablets, wɔn ankasa dwensɔtwaa mu mmoawa paapae glycoside no mu 1 to 4 hours akyiri yi wɔ ileum ne akyi berɛmo no ase, na ɛde hydrogen cyanide a edi awu (HCN) na ɛyɛ.
• Nea enti a Bitter Cassava de awuduru gu mmusua mu wɔ ɔpɛ ne aduan a ɛho yɛ na mu: Wɔkyekyɛ cassava ahorow mu sɛ "sweet" cassava (< 50 milligrams a ɛyɛ HCN a ɛne ntini foforo kilogram biara yɛ pɛ, a ne fã kɛse no ara wɔ akyi ntini no mu) ne "nwononwono" cassava (100 to > 500 milligrams a ɛyɛ HCN kilogram biara a wɔkyekyɛ wɔ nam a starch wom no nyinaa mu). Wɔ ɔpɛ a emu yɛ den mu no, cassava afifide ma linamarin dodow kɔ soro mprɛnsa kosi anum. Amanneɛ kwan so ahosiesie a ahobammɔ wom a wɔde siesie cassava a ɛyɛ nwononwono no hwehwɛ sɛ woyiyi mu, wɔde grating/abubu, wɔde gu nsu mu/a ɛyɛ hyew nnafua 3 kosi 5 (a ɛma kwan ma ɛyɛ endogenous linamarase sɛ wɔbɛdan linamarin ayɛ no acetone cyanohydrin), na afei wɔde owia ayow anaasɛ wɔayam wɔ ɔhyew a ano yɛ den mu de ama acetone cyanohydrin no ayɛ hyew na HCN gas. Sɛ abusua bi a ɔkɔm de wɔn noa cassava ntini a ɛyɛ nwononwono a wɔmfa nsu nhyɛ mu de gye nkutoo a 20 minutes, anaasɛ odi cassava a wɔayam no fã wɔ mu 24 hours, ɔhyew no denatures no linamarase enzyme ansa na linamarin no abubu, na ama linamarin ne acetone cyanohydrin a enni dɛm wɔ aduan no mu. Sɛ wɔmene acetone cyanohydrin wie a, ɛno ara porɔw ma ɛyɛ owuyare HCN wɔ alkaline duodenum no mu, bere a awotwaa mu mmoawa ma linamarin a aka no yɛ nsu wɔ nea edi hɔ no mu 2 to 6 hours.

--- .

Ntotoe a ɛfa aduan mu cyanogenic glycoside fibea ne awuduru a ɛwɔ ayaresabea ho¶

--- .

Mpa ho nhwehwɛmu: Sɛnea wosi Cyanide awuduru a emu yɛ den so dua ansa na reference labs asan aba¶

Mogya mũ no nyinaa mu cyanide nhwehwɛmu dodow gye nnɔnhwerew anaa nna pii wɔ reference laboratories na ɛnyɛ nea ɛwɔ hɔ da wɔ bere mu mfa nkyerɛ kwan wɔ ntɛmpɛ a wɔde san nya nkwa mu. Ayaresayɛfo si so dua sɛ awuduru a ɛyɛ hu a wɔfrɛ no gut cyanide wɔ mpa no nkyɛn wɔ 5 minutes nsateaa abiɛsa a wɔde hwehwɛ yare ntɛm ara a wɔde bedi dwuma:

1. "Arterialization" a ɛwɔ Ntini Mogya (Cherry-Red Ntini Mogya ne Narrow A-V O2 Kwan)¶

• Akwan a wɔfa so yɛ adwuma: Efisɛ cyanide to mitochondrial cytochrome c oxidase (Complex IV) wɔ ne oxidized ( .Fe3+) ka sɛ, ntini a ɛwɔ akyi no ntumi nyi mframa pa mfi oxyhemoglobin a ɛretwam no mu.
• Mpa ho sɛnkyerɛnne: Sɛ ɔyarehwɛfo anaa phlebotomist no twe peripheral venous blood sample a, venous mogya no te sɛ bright "cherry-red" (a wontumi nhu nsonsonoe a ɛda arterial mogya ntam) sen sɛ ɛbɛyɛ tuntum purple-red.
• Mogya mu mframa a wɔde si so dua: Fa toto Arterial Blood Gas (ABG) ne mfinimfini/akyi Venous Blood Gas ( .VBG):
• Bere a arterial PaO2 ne pulse oximetry ( .SpO2) kɔ so yɛ nea ɛfata ( .97% to 100%) mfiase no, ntini mu oxygen a ɛdɔɔso ( .ScvO2 anaasɛ SvO2) boro so 85% to 90% ne ntini mu ntini PvO2 ɛboro so 50 to 60 mmHg na ɛyɛ.
• Nsonsonoe a ɛwɔ oxygen a ɛwɔ ntini mu ( .A-V O2 gradient) teateaa ma ɛyɛ nea ennu 1 to 2 vol%, a ɛkyerɛ sɛ histotoxic nkwammoaa mu hypoxia (shared only by cyanide, hydrogen sulfide, sodium azide, and high-oxygen resuscitation).
• Fundoscopic confirmation: Direct ophthalmoscopy of the retina kyerɛ retina ntini a ne kɔla kɔkɔɔ a ɛhyerɛn te sɛ retina ntini no pɛpɛɛpɛ.

2. Serum Lactate a ɛwɔ mogya mu >= 8 to 10 mmol/L ( Sikakɔkɔɔ-Gyinapɛn Agyiraehyɛde a Wɔde Si Ananmu)¶

• Efisɛ aerobic ATP synthesis no yɛ nea wɔatoto mu (producing only 2 ATP molecules per glucose via anaerobic glycolysis instead of 36 ATP), nkwammoaa dan pyruvate ntɛmntɛm ma ɛbɛyɛ lactic acid.
• Ayaresa mu awuduru ho nhwehwɛmu (Baud ne afoforo, New England Journal of Medicine) kyerɛe sɛ wɔ ɔyarefo a awuduru a ɛnyɛ wusiw home mu no, plasma lactate dodow a ɛyɛ >= 8 mmol/L (72 mg/dL) (anaasɛ >= 10 mmol/L wɔ wusiw a wɔhome mu) wɔ ** .> 90% nkate ne pɔteeyɛ a ɛfa cyanide awuduru a emu yɛ den ho** (blood cyanide > 40 micromoles/L anaasɛ > 1.0 mg/L) na ɛne nkwammoaa mu cyanide adesoa wɔ abusuabɔ linearly.

3. Biphasic Hemodynamic ne Ɔhome mu Nkɔmmɔbɔ¶

• Ɔfã 1 (Chemoreceptor Nkannyan a Edi Kan, . 30 to 90 minutes): Cyanide kanyan carotid nipadua mu chemoreceptors no tẽẽ, na ɛkanyan "cyanide gasp" mpofirim a ɛno akyi no, wɔahyɛ no agyirae sɛ hyperventilation / tachypnea (Kussmaul breathing), sinus tachycardia, mogya mmoroso, tiyɛ, vertigo, adwene a ɛyɛ basaa, ne flushing.
• Ɔfã 2 (Late Hypoxic Decompensation, 1999 mu. 1 to 4 hours): Sɛ́ nea ɛwɔ nkwammoaa mu no ATP sɛ obi hwe ase wɔ amemene no dua ne ne koma ntini mu a, ɔyarefo no dan mpofirim kɔ ahomegye / bradypnea, profound sinus bradycardia anaa AV block, ntini mu mogya mmoroso a emu yɛ den, generalized tonic-clonic seizures, decerebrate posturing, ne anyinam ahoɔden dwumadi a enni koma (PEA) anaasɛ asystole.

--- .

Ayaresabea Antidote ne Decontamination Protocol a wɔyɛ no anammɔn anammɔn¶

Efisɛ gut hydrolysis a amygdalin ne linamarin kɔ so ** nnɔnhwerew** wɔ yafunu mu (a ɛnte sɛ pɛnkoro home a HCN gas), afifide cyanogenic glycoside awuduru a wɔde sa no hwehwɛ sɛ wɔgye nnuru a wɔde kum ɔyare mmoawa a wɔde fa ntini mu ntɛm ara NE yafunu mu efĩ a wɔkɔ so yi + sulfur-donor infusion a wɔde ma bere tenten nyinaa.

+-------------------------------------------------------------------------+
|       TWO COMPLEMENTARY ANTIDOTAL MECHANISMS FOR GUT CYANIDE            |
+-------------------------------------------------------------------------+
|  1. HYDROXOCOBALAMIN (CYANOKIT - VITAMIN B12a PRECURSOR):               |
|     Hydroxocobalamin (Co3+ - OH)  +  Cyanide (CN-)                      |
|                     |                                                   |
|                     v  (Direct equimolar chelation in blood & cells)    |
|     Cyanocobalamin (Vitamin B12 - Non-toxic, excreted in crimson urine) |
|     * Pros: Instant onset, does NOT lower blood pressure, does NOT form |
|       methemoglobin (safe in children, pregnancy, and anemia)           |
+-------------------------------------------------------------------------+
|  2. SODIUM THIOSULFATE (SULFUR DONOR FOR HEPATIC RHODANESE):            |
|     Thiosulfate (S2O3 2-) + Cyanide (CN-) ---[Rhodanese]---> Thiocyanate|
|     * Pros: Provides continuous sulfur substrate to detoxify ongoing    |
|       slow release of HCN from apricot kernels or cassava in the gut    |
|     * CRITICAL RULE: Infuse Hydroxocobalamin and Sodium Thiosulfate     |
|       through SEPARATE IV lines (or flush thoroughly between them)      |
+-------------------------------------------------------------------------+

Anamɔn 1: Yafunu ne dwensɔtwaa mu Efĩ a Wɔde Fi Hɔ ( .Activated Charcoal ne Gastric Lavage) .¶

• Ɛwom mpo sɛ fango a wɔde ayɛ adwuma no tumi sua gram biara ma potassium cyanide a ɛnyɛ abɔde a nkwa wom a ɛho tew (1 gram of charcoal adsorbs -35 mg of KCN), mpanyimfo dodow a wɔtaa de ma ( .50 to 100 grams of activated charcoal) a ɛnyɛ den sɛ ɛbɛtwetwe amygdalin, linamarin a wɔmfa nsu nhyɛ mu, ne nea wɔagye no miligram dodow a edi awu HCN wɔ yafunu mu na ɛma nkwa a wonya no tu mpɔn kɛse wɔ awuduru a wɔde sɔ hwɛ ne ayaresabea mu.
• Sɛ ɔyarefo no de ne ho kyerɛ wɔ ** .1 to 2 hours** sɛ wobɛwe apricot nnua a ɛyɛ nwononwono a wɔabubu, laetrile tablets, anaa cassava a ɛyɛ nwononwono, fa mframa kwan no ho ban (intubate sɛ ɛyɛ obtunded a) na yɛ gastric aspiration/lavage de yi aba asinasin a aka no fi nipadua mu, na di akyi ntɛm ara fa Activated Charcoal (1 gram/kg, kosi sɛ 50 to 100 grams) na ɛyɛ.

Anamɔn 2: Aduru a Edi Kan a Wɔde Fa Ntini Mu: Hydroxocobalamin ( .Cyanokit) .¶

Nsu mu aduru a wɔfrɛ no hydroxocobalamin ( .Cyanokit) ne aduru a edi kan a wɔpɛ wɔ amansan nyinaa mu a wɔde sa cyanide awuduru a emu yɛ den wɔ Amerika Atifi fam, Europa, UK, ne Australia nyinaa efisɛ ɛkyekyere cyanide a ɛwɔ nkwammoaa mu ne ntini mu tẽẽ ma ɛyɛ cyanocobalamin a asiane biara nni ho (Vitamin B12) a ɛmma hemoglobin a oxygen kura no nsɛe anaasɛ ɛremma nitrites a ɛma ntini mu yare no yɛ basaa.

• Mpanyimfo Dose: San yɛ 5 gram (one 5 g vial anaasɛ two 2.5 g vials) a ɛwɔ Hydroxocobalamin mu wɔ 200 milliliters de 0.9% sodium chloride na fa fa ntini mu gu ** .15 minutes (-15 mL/minute)** na ɛyɛ.
• Mmofra Dose: Infuse ** .70 milligrams per kilogram (70 mg/kg, kosi dodow a ɛsen biara a wɔde ma mfiase no 5 grams)** wɔde fa ntini mu wɔ ** .15 minutes** na ɛyɛ.
• Mandatory Repeat Dosing for Delayed Gut Hydrolysis: Wɔ apricot kernel, laetrile, anaa cassava awuduru a ɛyɛ nwononwono mu no, ayarefo taa nya cyanide a ɛsan ba bio 2 to 6 hours nea edi kan no akyi 5 g Hydroxocobalamin dodow bere a dwensɔtwaa mu mmoawa kɔ so paapae glycosides a wɔannye wɔ akyi berɛmo no mu no. Sɛ lactic acidosis ( .> 4 mmol/L), hypotension, anaasɛ coma san ba anaasɛ ɛkɔ so, infuse a second 5 gram (70 mg/kg mmofra) dodow a wɔde Hydroxocobalamin di dwuma boro so 15 minutes to 2 hours.
• Nsunsuansoɔ bɔne a wɔhwɛ kwan (Harmless Chromaturia & Lab Interference): Hydroxocobalamin yɛ burgundy-red pigment a ɛyɛ den. Ntɛm ara na ɛma ɔyarefo no honam ani, ne nusu, ne fifiri, ne mogya mu nsu, ne ne nsu yɛ kɔkɔɔ-kɔkɔɔ a emu dɔ (chromaturia) ma 2 to 7 days (na ɛkɔsi 28 days wɔ nsu mu). Bɔ aduruyɛdan no kɔkɔ sɛ hydroxocobalamin spectrophotometrically siw colorimetric nhwehwɛmu a wɔyɛ de hwehwɛ creatinine, bilirubin, transaminases, magnesium, ne carboxyhemoglobin/methemoglobin co-oximetry no kwan, twetwe mogya nhama a wɔde fi ase ntɛm ara ansa na woafi ase de kɔkɔɔ no ahyɛ mu.

Anamɔn 3: Sodium Thiosulfate a Wɔde Fa Ntini Mu (12.5 Grams) .¶

Efisɛ nipadua no abɔde mu enzyme a ɛma awuduru fi cyanide mu, mitochondrial rhodanese (thiosulfate sulfurtransferase) wɔ mmerɛbo ne nnompe mu ntini mu no, wɔn a wɔde sulfur ma wɔ nipadua no mu no sa ntɛmntɛm bere a wɔde awotwaa mu glycoside twetwe bere tenten no, Sodium Thiosulfate a wɔde fa ntini mu a wɔde ma no ma wonya sulfane sulfur a entumi nsɛe de dan cyanide ma ɛbɛyɛ thiocyanate a asiane biara nni ho (SCN-), a asaabo no yi fi nipadua no mu: * Mpanyimfo Dose: 12.5 grams (50 milliliters of a 25% Sodium Thiosulfate solution) a wɔde fa ntini mu wɔ ** .10 to 30 minutes** na ɛyɛ. * Mmofra Dose: 250 milligrams per kilogram (1.0 mL/kg de 25% ano aduru, anaasɛ 412.5 mg/kg [1.65 mL/kg] a egyina nsu a wɔde ma so, kosi 12.5 grams) a wɔde fa ntini mu no so 10 to 30 minutes.

Anamɔn 4: Nnuru Foforo a Wɔde Ko Tia Ho Nhyehyɛe (Bere a Hydroxocobalamin Nni): Sodium Nitrite + Sodium Thiosulfate ( .Nithiodote) anaa Dicobalt Edetate ( .Kelocyanor) .¶

Wɔ mmeae pii a afei na wɔrenya nkɔso a cassava a ɛyɛ nwononwono pae, anaasɛ nkuraase ayaresabea nketewa a wonni hɔ mu Cyanokit, ayaresabea adwumayɛfo de anammɔn abien Nitrite + Thiosulfate aduru a wɔtaa de di dwuma no di dwuma: 1. Amyl Nitrite (Wɔhome bridge ansa na IV akɔ): Bobɔ amyl nitrite ampoule (0.3 mL) wɔ gauze mu na fa kura ɔyarefo no hwene ase (anaasɛ bag-valve-mask intake no so) ma 15 to 30 seconds simma biara mu bere a wɔde IV kwan no si hɔ no. 2. Sodium Nitrite a wɔde fa ntini mu (3% anoyie): * Akwan a wɔfa so yɛ adwuma: Ɛma oxidizes 10% to 20% a ɛyɛ ferrous hemoglobin a ɛkyinkyini ( .Fe2+) mu kɔ ferric methemoglobin ( .Fe3+) na ɛyɛ. Efisɛ cyanide wɔ affinity a ɛkorɔn ma Fe3+, methemoglobin twe cyanide fi mitochondrial cytochrome c oxidase so ma ɛyɛ cyanmethemoglobin. * Mpanyimfo Dose: 300 milligrams (10 milliliters de 3% Sodium Nitrite) a wɔde fa ntini mu wɔ ** .2 to 4 minutes** (hwɛ mogya mmoroso so yiye, efisɛ nitrites ma ntini no trɛw denneennen na ɛma mogya mmoroso kɔ fam). * Mmofra Dose (Must Adjust for Hemoglobin to Prevent Fatal Methemoglobinemia): 6 to 10 mg/kg (0.2 to 0.33 mL/kg de 3% ano aduru, nea ɛboro so 300 mg), wɔtew so katee sɛ abofra no mogya so tew ( .hemoglobin < 10 g/dL). Hwɛ methemoglobin dodow wɔ 30 minutes na fa methemoglobin nyinaa sie katee ase 20% to 30% na ɛyɛ. 3. Sodium Thiosulfate a wɔde fa ntini mu (25% ano aduru): Di akyi ntɛm ara (after flushing the line) ne 12.5 grams (50 mL de 25% anoyie; mmofra ayaresa 1.0 to 1.65 mL/kg) sɛ ɛbɛdan cyanmethemoglobin daa ayɛ no thiocyanate a ɛwɔ nsu mu. 4. Dicobalt Edetate ( ) Ɔde ne nsa kyerɛɛ ne so.Kelocyanor - UK/Commonwealth Agyapadeɛ Stock): Wɔhwɛ so sɛ 300 mg (20 mL) IV a ɛboro so 1 minute dii akyi ntɛm ara 50 mL de 50% Dextrose a wɔde yɛ aduru. Esiane sɛ cobalt a wontua hwee ma koma no mu yɛ den kɛse, anim/anom a ɛyɛ mmerɛw, ne mogya mmoroso a ɛba fam sɛ cyanide biara nni mogya no mu a, Ɛsɛ sɛ wɔde Dicobalt Edetate ma ayarefo a wɔwɔ cyanide awuduru a akyinnye biara nni ho, a emu yɛ den wɔ ayaresabea (coma, apnea, anaa shock) NKUTOO, na wɔmfa nsiw ano da mma ayarefo a wonni sɛnkyerɛnne biara.

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Cassava ahosiesie a ahobammɔ wom ne mmara anohyeto ahorow a ɛfa Apricot Kernels ho¶

• Sɛnea wobɛma Bitter Cassava awuduru afi mu wɔ fie (The WHO / FAO "Wetting Method"):
• Grate anaa pound cassava ntini a wɔatutu no ma ɛyɛ mash anaa esiam pa (paapae nkwammoaa afasu so linamarase nkitahodi ahorow linamarin).
• Soak / ferment mash no wɔ nsu mu ma 3 to 5 days (anaasɛ sɛ wode cassava esiam a ayow dedaw a ɛda so ara yɛ nwononwono redi dwuma a, fa esiam no fra nsu mu ma ɛnyɛ nsu a ɛyɛ tratraa na fa petepete so tratraa wɔ sunsuma mu ma 5 hours at 30 degrees Celsius enti nkaeɛ linamarase ɛma linamarin no yɛ nsu mu ma ɛyɛ acetone cyanohydrin a ɛyɛ hyew).
• Noa anaa tow no yiye wɔ kuku a wɔabue mu enti nyinaa acetone cyanohydrin ne HCN gas no yɛ hyew kɔ mframa mu, na tow nsu a ɛregu/ɛrefɔw no gu.
• Mmara ho kɔkɔbɔ a ɛfa Bitter Apricot Kernels ho:
• Europa Aduan Ahobammɔ Dwumadibea (EFSA) ne UK Aduan Gyinapɛn Dwumadibea (FSA) de Acute Reference Dose (ARfD) firi 20 micrograms/kg of cyanide, na ɔde baa awiei sɛ apricot nnua nketewa a ɛyɛ nwononwono bɛboro 1 kosi 3 a wodi wɔ mpanyimfo mu (anaasɛ akutu ketewaa biako fã wɔ mmofra a wɔretu mmirika mu) boro ahobammɔ a ɛwɔ hɔ no so. EU no nyinaa (Regulation 2017/1237) ne UK bara sɛ wɔntɔn apricot a ɛyɛ nwononwono a wɔannoa mma adetɔfo a ɛboro so 20 mg/kg of hydrocyanic acid, ne Australia/New Zealand bara sɛ wɔbɛtɔn apricot aba a wɔannoa no wɔ sotɔɔ mu sɛ aduan koraa.
• Wɔ United States ne Canada no, US FDA bara laetrile (amygdalin) sɛ ade a wɔmpene so, ɛyɛ nnaadaa, na awuduru wom kɛse, na Health Canada to cyanide a wotumi yi fi mu nyinaa ano hye wɔ apricot aba a wɔtɔn mu 20 ppm bere a ɔbɔ mpanyimfo kɔkɔ sɛ ɛnsɛ sɛ wodi nnuadewa a ɛyɛ nwononwono da no.

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Mpɔtam hɔ ntɛmpɛ ne nnuru a wɔde sa yare a wɔde di dwuma ho nhyehyɛe¶

• United States ne Canada: Frɛ 911 ntɛm ara na frɛ 1-800-222-1222 (US Poison Mmoa) anaa 1-844-POISON-X (1-844-764-7669 wɔ Canada). Nkwa mmoa a ɛkɔ akyiri (ALS) ambulance ne ayaresabea dwumadibea ahorow a wɔhwɛ ntɛmpɛ so wɔ Amerika Atifi fam nyinaa de Hydroxocobalamin ( .Cyanokit, . 5 g nsuhina) ne Nithiodote ( .Sodium Nitrite + Sodium Thiosulfate) na ɛyɛ.
• United Kingdom ne European Union: Frɛ 999 (UK) anaa 112 (EU). Ayaresayɛfo kɔ NPIS / TOXBASE (UK) anaa ɔman EU awuduru mmeae (CAPTV, . Giftnotruf). Wɔ UK ne EU no, dwumadibea ahorow a wɔhwɛ ntɛmpɛ so no de Hydroxocobalamin (Cyanokit) ne Sodium Thiosulfate wɔ aduru a wɔde kum ɔyare mmoawa a wɔde ma obi nya nkwa ntɛm ara no mu (Category A Antidotes required immediately at every acute hospital).
• Australia ne New Zealand: Frɛ 000 (Australia) anaa 111 (New Zealand), na kɔ Awuduru Ho Amanneɛbɔbea (13 11 26 wɔ Australia no; 0800 764 766 wɔ New Zealand) ma ntɛm ara Cyanokit ne Sodium Thiosulfate akwankyerɛ.
• Afrika Sahara Anafo fam, Amerika Kesee Fam, ne Asia Kesee Fam Apuei: Wɔ mmeae a wodi cassava titiriw (Democratic Republic of the Congo, Mozambique, Tanzania, Nigeria, Brazil, Indonesia, Philippines), baabi a Cyanokit ebia wɔremfa nsie wɔ nkuraase ayaresabea ahorow, wɔde 100% Oxygen + Activated Charcoal + Intravenous Sodium Thiosulfate (25%, . 50 mL IV) + Sodium Bicarbonate a wɔde fa ntini mu (de siesie lactic acidosis a emu yɛ den) gye nkwa na ɛwɔ nneɛma pii.

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Nsɛm a wɔtaa bisa¶

Dɛn nti na awuduru a cyanide a efi apricot aba anaa cassava a ɛyɛ nwononwono mu ba no gye nnɔnhwerew 1 kosi 4 ansa na wɔafi ase?¶

Nea ɛnte sɛ hydrogen cyanide mframa a wɔhome (a ɛkɔ ahurututu ne mogya mu wɔ sikɔne kakraa bi mu) no, afifide mu asikre a wɔakyekyere a wɔfrɛ no cyanogenic glycosides (amygdalin ne linamarin) wɔ apricot nnua ne cassava a ɛyɛ nwononwono mu. Saa nnuru yi nyɛ asiane biara kosi sɛ afifide mu enzymes (a ɛnam adidi so na ɛyɛ adwuma) ne nnipa dwensɔtwaa mu mmoawa de nkakrankakra twitwa asikre nketenkete a ɛwɔ alkaline dwensɔtwaa ketewaa ne akyi berɛmo no mu no, na ɛma hydrogen cyanide mframa a enni mu no kɔ mogya no mu simma 30 kosi nnɔnhwerew 4 wɔ aduan no akyi.

Dɛn nti na "Vitamin B17" (Laetrile) a wɔnom fa ano no di awu kɛse sen nnuru a wɔde fa ntini mu?¶

Onipa mogya ne akwaa nni beta-glucosidase enzyme a ɛho hia na ama amygdalin abubu abɛyɛ cyanide, enti sɛ wɔde laetrile gu ntini bi mu a, bɛboro 90% fi mu a ɛnsakra wɔ nsu mu. Nanso, sɛ wɔde ano mene a, abɔde mu mmoawa ɔpepepem pii a wɔte onipa dwensɔtwaa ketewaa ne ne dwensɔtwaa mu no ma beta-glucosidase enzymes pii a ɛpaapae laetrile a wɔnom no mu tẽẽ ma ɛbɛyɛ hydrogen cyanide a edi awu, na ɛma nnuru a wɔnom no yɛ awuduru bɛyɛ mpɛn 40 sen dodow a wɔde fa ntini mu no.

Sɛ abofra bi mene cherry amoa anaa peach bo mũ nyinaa wɔ akwanhyia mu a ɔnwe a, dɛn na ɛba?¶

Sɛ wɔmene cherry amoa, plum amena, peach bo, anaa apɔw-mu-teɛteɛ aba mũ koraa a ne akyi abon a ɛyɛ den a ɛte sɛ nnua no nsɛee a, amygdalin no kɔ so to aba no mu dwoodwoo na amoa no twam wɔ nsu mu a asiane biara nni ho wɔ nnafua 1 kosi 3 mu. Cyanide awuduru ba bere a wɔwe aba anaa amena no, wɔayam, wɔyam, frafra mu, anaasɛ wɔpaapae mu ansa na wɔamene no nkutoo.

Ɔkwan bɛn so na nnuruyɛfo a wɔhwɛ ntɛmpɛ so hu cyanide awuduru wɔ simma 5 mu sɛ mogya mu cyanide nhwehwɛmu gye nna pii a?¶

Nnuruyɛfo hwehwɛ mpa ho sɛnkyerɛnne abien a wontumi nni ho mfomso a ɛkyerɛ sɛ nkwammoaa mu oxygen a wɔde di dwuma no asiw: nea edi kan no, mogya a ɛwɔ ntini a ɛwɔ akyi a wɔtwe fi abasa no mu no te sɛ nea ɛhyerɛn "cherry-red" (te sɛ ntini mu mogya ara pɛ) a ntini mu oxygen a ɛdɔɔso boro 85% kosi 90% efisɛ mitochondria a awuduru wom no ntumi nyi oxygen mfi mogya no mu na nea ɛto so abien no, mogya mu lactate dodow kɔ soro boro 8 kosi 10 mmol/L esiane anaerobic metabolism mpofirim nti.

Dɛn nti na nnuruyɛfo de Hydroxocobalamin (Cyanokit) ne Sodium Thiosulfate ABIEN NO BIARA ma apricot nnua mu awuduru?¶

Hydroxocobalamin (Cyanokit) dodow biako a emu duru yɛ gram 5 no ma cyanide a ɛredi akɔneaba mprempren wɔ mogya ne akwaa mu no yɛ chelate ntɛm ara ma ɛbɛyɛ Vitamin B12 a asiane biara nni ho, na egye koma ne amemene no wɔ simma kakraa bi mu. Nanso esiane sɛ apricot aba a wɔabubu anaa cassava a ɛyɛ nwononwono kɔ so tra dwensɔtwaa no mu na ɛma cyanide foforo fi adi nnɔnhwerew 4 kosi 12 bio nti, Sodium Thiosulfate a wɔde fa ntini mu (ɛnam IV nhama a ɛyɛ soronko anaasɛ wɔahoro so) ka ho no ma mmerɛbo no mu rhodanese enzyme no nya sulfur a ɛkɔ so ma ɛmma cyanide a ɛkɔ so wɔ awotwaa mu no yɛ nea ɛnyɛ hwee.

Dɛn ne "Konzo" na ɔkwan bɛn so na ɛne cassava a ɛyɛ nwononwono wɔ abusuabɔ?¶

Konzo yɛ anan abien no nyinaa mu ntini a ɛwɔ soro a ɛyɛ mmerɛw a wontumi nsakra (spastic paraparesis) a ɛbɔ mmofra ne mmea a wɔadi mfe a wɔbɛwo wɔ Afrika Sahara Anafo fam nkuraase wɔ ɔpɛ ne ɔkɔm bere mu. Ɛba bere a wɔhyɛ mmusua ma wodi cassava a ɛyɛ nwononwono a wɔde nsu afra mu yiye dapɛn biara bere a wɔrehu amane wɔ aduan mu protein a enni nipadua mu kɛse (a wonni amino acid a sulfur wom a wɔfrɛ no methionine ne cysteine ​​a mmerɛbo no hia na ama awuduru afi cyanide mu ayɛ no thiocyanate) no.

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Sɛnea ɛbɛyɛ na woadi awuduru, mframa kwan, ne komayare ho nsɛm a egye ntɛmpɛ ho dwuma yiye no, susuw ho sɛ wubewie mmoa a edi kan ne CPR adesua a wɔde nsa yɛ a efi Red Cross, St John Ambulance, anaa mpɔtam hɔ ntetee ahyehyɛde bi a wɔagye ho adanse hɔ.

Akwankyerɛ ahorow a ɛfa ho¶

• Cyanide, Hydrogen Sulfide, ne Mfiridwuma mu Mframa a Wɔhome Mmoa a Edi Kan
• Methemoglobinemia (Mogya a Ɛyɛ Chocolate-Brown), Benzocaine a Wɔde Petepete, ne Nitrate Awuduru
• Wild Mushroom Adidi (Amatoxin) ne Afifide a Awudi wom a Wɔwe
• Status Epilepticus, Akisikuru a Ɛkyɛ, ne Nnuru a Wɔde Gye Nnipa
• General Poisoning Mmoa a Edi Kan ne Efĩ a Wɔde Fi Ho

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Fibea ne aban akwankyerɛ¶

• Wiase Akwahosan Ahyehyɛde (WHO) & Aduan ne Kuadwuma Ahyehyɛde (FAO): *Amanaman Ntam Nnuruyɛ Nhwehwɛmu Nhoma a Ɛyɛ Tiawa 61: Hydrogen Cyanide ne Cyanides: Nnipa Akwahosan Afã; Cyanogenic Glycosides a ɛwɔ Cassava ne Bamboo Nnua * (Geneva) mu.
• European Food Safety Authority (EFSA) Panel on Contaminants in the Food Chain: Akwahosan ho asiane a emu yɛ den a ɛfa cyanogenic glycosides a ɛwɔ apricot aba a wɔannoa ne nneɛma a wonya fi apricot aba a wɔannoa mu (EFSA Journal).
• YƐN. Centers for Disease Control and Prevention (CDC) / ATSDR: Aduruyɛ Ho Akwankyerɛ a ɛfa Hydrogen Cyanide, Sodium Cyanide, ne Cyanogenic Compounds ho (United States).
• UK Ɔman Awuduru Ho Amanneɛbɔ Dwumadibea (NPIS) / TOXBASE & Royal College of Emergency Medicine: Aduru a Wɔde Ko Tia Akwankyerɛ: Hydroxocobalamin (Cyanokit), Sodium Thiosulfate, ne Sodium Nitrite wɔ Acute Cyanide ne Cyanogenic Glycoside Awuduru mu (United Kingdom).
• Baud F. J., Barriot P., Toffis V., ne afoforo. / Hall AH, Rumack BH: Mogya mu cyanide dodow ne plasma lactate a ɛkɔ soro wɔ cyanide awuduru a emu yɛ den mu; Laetrile (Amygdalin) ne Apricot Kernel Toxicity (New England Nsɛmma Nhoma a Ɛfa Aduruyɛ Ho / Aduruyɛ a Ɛho Hia Ntɛmntɛm Ho Nsɛmma Nhoma).