Taiwan National Poison Center: epidemiologic data 1985-1993

Human poisoning in Thailand: The Ramathibodi Poison Center's experience (2001–2004)

OBJECTIVE

To identify poisoning and toxic exposure pattern, severity, and clinical outcome in Thailand during 2001 to 2004.

METHOD

This is a prospective study. All inquiries were registered, followed up, and verified. Interlocutors, poisons, patients' profiles, severity, and medical outcome after exposure or poisoning were analyzed.

RESULTS

A total 14,428 events was suspected as human poisoning or exposure. After follow-up and verification, 98.9% were confirmed as poisoning or poison exposure. These involved 15,016 patients and accounted for 6.0 per 100,000 populations per year. The vast majority of calls (92.4%) were from physicians. Pesticides, household products, and pharmaceutical products were the most common poisons involved in human exposure, which were 41.5%, 19.5%, and 18.9%, respectively. Patients aged 0-6 years, teenagers and adults with 20-29 years of age had the highest rates of exposure, which were 33.0, 24.5, and 10.5 exposures per 100,000 per year, respectively. Unintentional accidental exposure is the major reason of exposure in children, but intentional suicide was the main reason of exposure in teenagers and adults. The death rate of all exposure was 5.5%. Pesticides cause more severe clinical course and the highest death rate (10.0%).

CONCLUSION

Features of poisoning in Thailand were different from those in Western countries. Pesticide poisoning was the major problem in Thailand. Intentional suicide was the major circumstance of poison exposure in adults, but accidental exposure was the major reason of exposure in children.

Etiology and outcome of patients presenting for poisoning to the emergency department in Taiwan: a prospective study

Poisoning is one of the most common reasons for visiting the emergency department in many countries, and the pattern varies from countries to countries and time to time. To compare the etiology and outcome of poisoning patients in different gender and age groups, we conducted a prospective study at the emergency departments of two medical centers in southern Taiwan between January 2001 and December 2002. All cases of poisoning, excluding patients diagnosed as cases of alcohol or food poisoning, were included, and relevant information was collected. There were 1512 cases of poisoning observed with a male to female ratio of 1:1.2 (684/828). Overall, drugs (49.9%) were the main agents involved, and a suicidal attempt (66.1%) was the predominant etiology. A total of 63 fatalities (4.2%) were observed and pesticides, especially paraquat, resulted in most fatalities. Patients aged 19–30 years constituted the most cases, and significant differences in exposure agents, causes, and fatality rates were found among different age and gender groups. The results are compatible with the trend reported by other Asian countries. This study also shows important differences existing in poisoning patients of different age and gender groups. Therefore, different poisoning-prevention strategies should be applied to different groups.

Suicide mortality trends by sex, age and method in Taiwan, 1971-2005

BACKGROUND

Method-specific suicide trends varied across countries, and studies of the trends in different countries can contribute to the understanding of the epidemiology of suicide. The purpose of this study was to examine the changes in suicide trends by sex, age and method in the years 1971 to 2005 in Taiwan.

METHODS

Mortality data files of suicide and undetermined deaths for the years 1971-2005 were obtained for analyses. Age-, sex- and method-specific suicide rates were calculated by four age groups (15-24, 25-44, 45-64 and 65 and above) and five suicide methods (solids/liquids poisoning, other gases poisoning, hanging, jumping, and others).

RESULTS

Both sexes experienced downward trends from 1971 to 1993, and then an upward trend since 1993. People aged 65 years and above had the highest suicide rates throughout the study periods. However, males aged 25-64 years experienced the steepest increasing trends. As to suicide methods, an annual increase, since 1991, of people jumping from heights to commit suicide, and a marked increase, since 1998, of people completing suicide by poisoning with other gases (mainly charcoal-burning) were observed.

CONCLUSION

Suicide by means of charcoal-burning and jumping from heights has become a serious public health problem in Taiwan. Preventive measures to curb these increasing trends are urgently needed.

Presentations of patients of poisoning and predictors of poisoning-related fatality: findings from a hospital-based prospective study

BACKGROUND

Poisoning is a significant public health problem worldwide and is one of the most common reasons for visiting emergency departments (EDs), but factors that help to predict overall poisoning-related fatality have rarely been elucidated. Using 1512 subjects from a hospital-based study, we sought to describe the demographic and clinical characteristics of poisoning patients and to identify predictors for poisoning-related fatality.

METHODS

Between January 2001 and December 2002 we prospectively recruited poisoning patients through the EDs of two medical centers in southwest Taiwan. Interviews were conducted with patients within 24 hours after admission to collect relevant information. We made comparisons between survival and fatality cases, and used logistic regressions to identify predictors of fatality.

RESULTS

A total of 1512 poisoning cases were recorded at the EDs during the study period, corresponding to an average of 4.2 poisonings per 1000 ED visits. These cases involved 828 women and 684 men with a mean age of 38.8 years, although most patients were between 19 and 50 years old (66.8%), and 29.4% were 19 to 30 years. Drugs were the dominant poisoning agents involved (49.9%), followed by pesticides (14.5%). Of the 1512 patients, 63 fatalities (4.2%) occurred. Paraquat exposure was associated with an extremely high fatality rate (72.1%). The significant predictors for fatality included age over 61 years, insufficient respiration, shock status, abnormal heart rate, abnormal body temperature, suicidal intent and paraquat exposure.

CONCLUSION

In addition to well-recognized risk factors for fatality in clinical settings, such as old age and abnormal vital signs, we found that suicidal intent and ingestion of paraquat were significant predictors of poisoning-related fatality. Identification of these predictors may help risk stratification and the development of preventive interventions.

Correlation between hospitalization for pharmaceutical ingestion and attention deficit disorder in children aged 5 to 9 years old

To determine if attention deficit hyperactivity disorder is a risk factor for pharmaceutical ingestions leading to hospital admission in children between ages 5 and 9, a retrospective, case-controlled chart review was conducted at a children's hospital. Cases were children aged 5 to 9 admitted for oral ingestion of pharmaceuticals. Controls were children admitted during the same time period with abdominal pain, appendicitis, or gastroenteritis. Controls were matched to cases 3:1 by age and gender. An odds ratio was calculated to determine if attention deficit hyperactivity disorder is a statistically significant risk factor for hospitalization after pharmaceutical ingestion. A total of 36% of 31 identified cases had attention deficit hyperactivity disorder compared with 7% of controls. The odds ratio for attention deficit hyperactivity disorder in children hospitalized after pharmaceutical ingestion was 7.97 (95% confidence interval, 2.35-28.01; P < .01). Children hospitalized for pharmaceutical ingestion are nearly 8 times more likely to have attention deficit hyperactivity disorder than children hospitalized for an unrelated disorder.

The global distribution of fatal pesticide self-poisoning: systematic review

BACKGROUND

Evidence is accumulating that pesticide self-poisoning is one of the most commonly used methods of suicide worldwide, but the magnitude of the problem and the global distribution of these deaths is unknown.

METHODS

We have systematically reviewed the worldwide literature to estimate the number of pesticide suicides in each of the World Health Organisation's six regions and the global burden of fatal self-poisoning with pesticides. We used the following data sources: Medline, EMBASE and psycINFO (1990-2007), papers cited in publications retrieved, the worldwide web (using Google) and our personal collections of papers and books. Our aim was to identify papers enabling us to estimate the proportion of a country's suicides due to pesticide self-poisoning.

RESULTS

We conservatively estimate that there are 258,234 (plausible range 233,997 to 325,907) deaths from pesticide self-poisoning worldwide each year, accounting for 30% (range 27% to 37%) of suicides globally. Official data from India probably underestimate the incidence of suicides; applying evidence-based corrections to India's official data, our estimate for world suicides using pesticides increases to 371,594 (range 347,357 to 439,267). The proportion of all suicides using pesticides varies from 4% in the European Region to over 50% in the Western Pacific Region but this proportion is not concordant with the volume of pesticides sold in each region; it is the pattern of pesticide use and the toxicity of the products, not the quantity used, that influences the likelihood they will be used in acts of fatal self-harm.

CONCLUSION

Pesticide self-poisoning accounts for about one-third of the world's suicides. Epidemiological and toxicological data suggest that many of these deaths might be prevented if (a) the use of pesticides most toxic to humans was restricted, (b) pesticides could be safely stored in rural communities, and (c) the accessibility and quality of care for poisoning could be improved.

Prognostic Factors of Organophosphate Poisoning Between the Death and Survival Groups

In this prospective case series study, we consider the different factors between death and survival groups of organophosphate poisoning. Patients in tertiary-care medical center who had been exposed to organophosphate were included in the study. Pralidoxime (PAM) was discontinued after atropine had controlled the clinical situation. We recorded the demographic data, amount of organophosphate consumption, duration of coma, duration of ventilator use, duration of hospitalization, findings of chest X-ray, white blood cell count, acetylcholinesterase concentration, plasma cholinesterase concentration, total atropine amount, duration of atropine use, total PAM amount, duration of PAM use, urine organophosphate peak concentration, duration of urine organophosphate and mortality rate. Urine was collected every 8 hours and was analyzed by gas chromatography equipped with a flame photometric detector and gas chromatography with mass spectrometer detector for organophosphate determination. The urine organophosphate peak concentration was recorded. Wilcoxon rank sum test was used to compare the factors between death and survival groups. Fisher's exact test was used to compare the different findings of chest X-ray between the death and survival groups. Evidently, the death group had a higher amount of organophosphate consumption, duration of coma, and higher white blood cell count than those in the survival group. Also, the death group had lower duration of hospitalization, and decreased concentrations of acetylcholinesterase and plasma cholinesterase. Total PAM amount use and duration of PAM use were lower. However, the duration of ventilator use, findings of chest X-ray, total atropine amount, duration of atropine, urine organophosphate peak concentration and duration of urine organophosphate were similar in both groups. The mortality rate of our 50 cases was 20%. As stated earlier, the cases of the death group had insufficient PAM therapy. The maximum duration of PAM use was shorter than the maximum duration of urine organophosphate, although the medians of duration of PAM use were more than the medians of duration of urine organophosphate in both the survival and death groups. Prolonged coma duration, lower level of acetylcholinesterase and lower level of plasma cholinesterase were related to the poor prognosis of the patients.

Effects of paraquat on development of preimplantation embryos in vivo and in vitro

Paraquat can cause oxidative stress through redox cycling, and preimplantation embryos are sensitive to oxidative stress in vitro. In this study, the effects of paraquat on preimplantation embryo development were examined. Exposure of preimplantation embryos (collected on the day after ovulation) to paraquat in vitro for 24 h at concentrations as low as 8 microM caused a significant decrease in the percentage of 8-cell embryos and an increase in the percentage of compacted morulae, but the content of reduced glutathione (GSH) in embryos was not changed. Altered embryo development was most likely due to premature compaction because a 42% decrease in cell number per compacted morulae was observed in embryos exposed to paraquat at 1 mM. Exposure of preimplantation embryos to paraquat in vitro for 4 days at 200 microM or higher eliminated development beyond the blastocyst stage. Exposure of bred female mice to paraquat at 30 mg/kg on day 2 after ovulation led to a small but significant decrease in the percentage of 8-cell embryos on day 3 without a detectable increase in the percentage of compacted morulae. No detectable change in preimplantation embryo development was found following paraquat exposure on the day of ovulation (day 0), although a significant decrease in embryo GSH was found on day 1. These data indicate that paraquat can adversely impact the development of preimplantation embryos in vitro and in vivo without consistent modulation of GSH level.

Toxicological features of deliberate self-poisonings

BACKGROUND

Deliberate self-poisoning (DSP) is a major health problem with increasing incidence mainly among young people.

OBJECTIVE

To examine the clinical and toxicological characteristics of DSP, it is compared to unintentional (non-DSP) exposures and those characteristics which might be associated with increased toxicological risk are identified.

METHODS

Two-year retrospective poison centre chart review.

STATISTICS

chi2 analysis.

RESULTS

3802 DSP cases were reported. Most calls (95%) were made by physicians compared to 51% in non-DSP exposures, P <0.0001. There were almost twice as many females as males, contrary to unintentional exposures (P <0.001). Peak frequency involvement was at the age of 15-20 years for females and older for males. Only 19.8% of DSP calls were made within the first hour of exposure compared to 46% of the non-DSP calls (P < 0.001). Younger patients tended to present earlier. The vast majority of exposures occurred by ingestion and at home. Pharmaceuticals and chemicals were involved in 86% and 12% of DSP cases, respectively (compared to 29% and 44% in non-DSP exposures, respectively, P < 0.001). Psychiatric drugs were more commonly used in older age groups and analgesics among the younger. Insecticides, sodium hypochlorite and rodenticides were the most frequently used chemicals. Neurological involvement was observed in 48.2% of DSP patients compared to 16.9% in non-DSP exposures. DSP was associated with greater severity than non-DSP exposures (21% and 10% had moderate to severe toxicity, respectively, P <0.001). Severity was greater among males, aged older than 45 years, with time from exposure to consultation 8 hours or longer and with exposure to chemicals, psychiatric drugs or combinations.

CONCLUSIONS

Most DSP patients were females, aged 15-20 years, used pharmaceuticals and had neurological involvement. Males, aged over 45 years, with longer time to toxicology consult and the use of chemicals were associated with increased severity. These parameters should alert the treating physician to the possibility of a poor course and hence to a more aggressive therapeutic approach.

A patient-tailored N-acetylcysteine protocol for acute acetaminophen intoxication

BACKGROUND

Hepatotoxicity as a result of acetaminophen(APAP) intoxication has become an important problem, but early intervention with N-acetylcysteine (NAC) is effective in preventing hepatic injury. Two NAC regimens are currently approved for acute APAP intoxication: NAC administered orally every 4 hours for 72 hours, and NAC administered intravenously for 20 hours within 8 to 10 hours after ingestion of a potentially hepatotoxic amount of APAP. However, clinical observations suggest that a variable treatment duration may be more appropriate than use of these predetermined, fixed-duration protocols.

OBJECTIVES

This study investigated the tolerability and efficacy of a patient-tailored NAC protocol for acute APAP intoxication by comparing the incidence of hepatotoxicity in patients receiving this protocol and in historical controls receiving 1 of 2 fixed-duration protocols: oral NAC for 72 hours and intravenous NAC for 20 hours within 8 to 10 hours after ingestion of a potentially hepatotoxic amount of APAP.

METHODS

This was a retrospective case series study that included all patients admitted through the emergency department (ED) of the National Taiwan University Hospital with a diagnosis of APAP intoxication between October 1997 and October 2002. According to the patient-tailored protocol, which had been used in the ED since 1997, patients with a serum APAP concentration above the limit for possible risk based on a modified Rumack-Matthew nomogram received oral treatment with NAC 140 mg/kg, followed by maintenance doses of 70 mg/kg every 4 hours. NAC treatment was discontinued when the APAP concentration was <10 mg/L and serum aspartate aminotransferase (AST) was <40 IU/L. For the purposes of assessing clinical outcomes, patients were divided into 3 groups based on duration of treatment: the short-course group (</=36 hours), the intermediate-course group (37-72 hours), and the long-course group (>/=73 hours). The primary outcome measure was development of hepatotoxicity, defined as a serum AST or alanine aminotransferase concentration >1000 IU/L.

RESULTS

Twenty-seven patients were included in the study, 17 in the short-course group, 4 in the intermediate-course group, and 6 in the long-course group. The mean (SD) durations of NAC treatment in the respective groups were 22.1 (5.5) hours, 45.0 (8.2) hours, and 97.3 (33.2) hours. All 6 patients (22%) in the long-course group had hepatotoxicity (peak AST range, 1083-9770 IU/L); their treatment duration ranged from 80 to 164 hours. No patients in the short- or intermediate-course group had evidence of hepatotoxicity. One woman in the long-course group in whom initiation of NAC treatment was delayed by 28 hours died of fulminant hepatic failure. The overall incidence of hepatotoxicity was similar to that in the historical controls.

CONCLUSIONS

In this retrospective case series inpatients who received patient-tailored NAC therapy for acute APAP intoxication, the incidence of hepatotoxicity was low and comparable to that in historical controls who received treatment with 1 of 2 fixed-duration regimens. Use of this protocol may have the potential to shorten hospital stays without increasing the risk to patients. However, the sample size was small, and the findings require confirmation in prospective clinical trials.

Taiwan’s venomous snakebite: epidemiological, evolution and geographic differences

Located at the juncture of tropical and subtropical regions, Taiwan has a warm and humid climate with abundant precipitation and food, which coupled with the island's diverse vegetation and landscape, makes it a suitable environment for many snake species. Among these, Naja atra, Bungarus multicinctus, Deinagkistrodon acutus, Trimeresurus mucrosquamatus, Trimeresurus stejnegeri, Daboia russelii siamensis are the 6 principal venomous species, and have caused significant injuries and death over the years. The natural environment of Taiwan has changed tremendously in the last 20-30 years, which is likely to have affected the number and distribution of venomous snakes, thus indirectly affecting incidence of snakebite. A retrospective analysis of 286 snakebite cases at a medical center in central Taiwan analyzed the snakebite-related epidemiological data in the past 30 years. The results showed that the bite rates of various venomous snakes vary geographically, which is related to the overlapping of the human living environment and snakes' habitat. In Taiwan, T. mucrosquamatus and T. stejnegeri bites are most common. Bites by Deinagkistrodon acutus and Daboia russelii siamensis generally occur in the south and east parts of the island and attacks by Naja atra are most common in central Taiwan. Aggressive antivenom treatment can reduce snakebite mortality rate, but for Bungarus multicinctus bites, maintaining the patient's airway and supporting their ventilation is vital to reducing mortality rate in addition to antivenom treatment.

Food poisoning due to methamidophos-contaminated vegetables

BACKGROUND

Organophosphate poisoning is well known for its characteristic symptoms and signs, but food poisoning caused by pesticide-contaminated food is seldom reported.

CASE REPORT

We report three incidents of food poisoning that resulted from exposure to the organophosphate insecticide methamidophos in vegetables. These outbreaks caused a cholinergic syndrome in 4 patients. The cholinergic overactivity led as to suspect organophosphate food poisoning. All patients recovered well following appropriate therapy. The clinical diagnosis of organophosphate poisoning was confirmed by reduced levels of erythrocytes and plasma cholinesterase and the presence of methamidophos in the vegetable leftovers. The implicated vegetables and levels of methamidophos were: Ipomoea batatas 255 ppm, Gynura bicolor 110 ppm, and red cabbage 26.3 ppm. Since methamidophos is normally applied to vegetables during planting, improper selection and/or overuse of pesticide or improper harvest times may explain the occurrence of these high residue levels of methamidophos.

Etiologic and demographic characteristics of poisoning: a prospective hospital-based study in Oman

BACKGROUND

The health care system in Oman is characterized by its rapid development and free medical services for all its nationals although traditional medicine still plays a major role in daily life. Epidemiological data on poisoning are scanty.

OBJECTIVE

To determine the annual rate of poisoning-related Accident & Emergency Department visits at Sultan Qaboos University Hospital in Oman and to evaluate, in both children and adults, the etiologic and demographic characteristics of poisoning cases. The poisoning pattern is contrasted to that of other countries.

METHODS

A prospective observational study included all symptomatic and asymptomatic poisoning-related Accident & Emergency Department visits over 4 years (1996-1999). Data were recorded on a specifically designed poison reporting form.

RESULTS

Two hundred and four poisoning-related Accident & Emergency Department visits were recorded corresponding to an average annual rate of 1.8/1000 Accident & Emergency Department visits. Therapeutic agents were most commonly involved (50% of all cases). Accidental poisoning in toddlers was most commonly caused by drugs. Intentional poisoning in adults involved mainly therapeutic agents (50%), particularly analgesics, followed by industrial and environmental agents (25%). Animal poisoning (14%) was most commonly encountered in adult males. Traditional remedies constituted 7% of all poisoning cases. A total of 148 patients (73%) were admitted for 1 to 175 days.

CONCLUSIONS

Compared to studies performed in urban hospitals in other countries, (1) the annual rate of poisoning-related Accident & Emergency Department visits was substantially lower, (2) psychoactive drugs were less frequently incriminated in intentional ingestions, and (3) we found a significantly higher frequency of poisoning by animals and traditional remedies than reported by urban hospitals in other Middle Eastern countries. The limitations of our study (Accident & Emergency Department-based data collection in an urban hospital) do not permit extrapolation to the rest of the country.

Pesticide use in developing countries

Chemical pesticides have been a boon to equatorial, developing nations in their efforts to eradicate insect-borne, endemic diseases, to produce adequate food and to protect forests, plantations and fibre (wood, cotton, clothing, etc.). Controversy exists over the global dependence on such agents, given their excessive use/misuse, their volatility, long-distance transport and eventual environmental contamination in colder climates. Many developing countries are in transitional phases with migration of the agricultural workforce to urban centres in search of better-paying jobs, leaving fewer people responsible for raising traditional foods for themselves and for the new, industrialized workforce. Capable of growing two or three crops per year, these same countries are becoming "breadbaskets" for the world, exporting nontraditional agricultural produce to regions having colder climates and shorter growing seasons, thereby earning much needed international trade credits. To attain these goals, there has been increased reliance on chemical pesticides. Many older, nonpatented, more toxic, environmentally persistent and inexpensive chemicals are used extensively in developing nations, creating serious acute health problems and local and global environmental contamination. There is growing public concern in these countries that no one is aware of the extent of pesticide residue contamination on local, fresh produce purchased daily or of potential, long-term, adverse health effects on consumers. Few developing nations have a clearly expressed "philosophy" concerning pesticides. There is a lack of rigorous legislation and regulations to control pesticides as well as training programs for personnel to inspect and monitor use and to initiate training programs for pesticide consumers.

Inadequate stocking of antidotes in Taiwan: is it a serious problem?

OBJECTIVE

Insufficient hospital stock of a variety of poisoning antidotes is a worldwide problem. In an attempt to establish an antidote storage and distribution system for the response of the various poisoning accidents, we conducted a nationwide survey to characterize the current availability of selected antidotes and their anticipated need in Taiwan.

MATERIALS AND METHODS

A questionnaire was mailed to 834 hospitals to gather information on the availability, anticipated need, and preferred purchase policy of 20 selected antidotes. A survey on the availability of cyanide antidote in 523 cyanide-handling facilities and their neighboring hospitals was also conducted.

RESULTS

Hospitals of different size and service levels had a statistically significant difference in response rates. Except for pyridoxine, the availability and anticipated need for antidotes also varied significantly among different hospital groups. We found that physostigmine, cyanide antidote kit, BAL, EDTA, methylene blue, Vipera Russell formosensis antivenin, and botulism antitoxin were not available in most (>90%) hospitals. Interestingly, these antidotes are also among the most needed antidotes. Most hospitals preferred a government-ordered purchase of antidotes. In the survey of cyanide-processing facilities, a response rate of 24.1% was obtained and only 9.3% of these 107 facilities that both replied to the questionnaire and continued handling cyanide products had stocked cyanide antidote. It is noteworthy that cyanide antidote was also frequently lacking in the neighboring hospitals.

CONCLUSIONS

The appropriate storage of antidotes in hospitals or workplaces in rural areas is instrumental in the timely treatment of certain poisonings, while nationwide unavailability is the critical problem. Raising awareness of the importance of antidotes by education, regular review of antidote storage, distribution plans, and appropriate legislation might provide solutions.

Acute poisoning with a herbicide containing imazapyr (Arsenal): a report of six cases

BACKGROUND

Acute pesticide poisoning is a major cause of morbidity and mortality in Taiwan and herbicides are most frequently implicated. Imazapyr [2-(4-isopropyl-4-methyl-5-oxo-2 imidazoline-2-yl)nicotinic acid] is a new herbicide, recently registered in Taiwan under the tradename "Arsenal" (Imazapyr 23.1%, Cyanamid Taiwan Corporation, Taipei). Imazapyr is also marketed as Assault, Chopper, Contain, and Pivot. To the best of our knowledge, there is no information in the literature concerning acute toxicity in humans after ingestion of herbicides containing this compound.

METHOD

Six cases of acute poisoning with Arsenal occurred during the period 1993-1997 in a single hospital. Emergency room records and medical charts were reviewed.

RESULTS

Of 6 cases, 5 were suicide attempts and 1 was an act of violence inflicted on a child. Three of the 6 patients (50%) presented with severe symptoms, including impairment of consciousness and respiratory distress requiring intubation. Other presentations included metabolic acidosis (2), hypotension (2), leukocytosis (3), fever (2), mild elevation of hepatic transaminase and creatinine (2), unconjugated hyperbilirubinemia (2), oral ulceration (2), pharyngolaryngitis (2), and chemical burns of the cornea (1). All cases had copious vomiting after ingestion of Arsenal. No mortality occurred.

CONCLUSION

According to our observations, it appeared the toxic syndrome that results from a large quantity (> 100 mL) of Arsenal herbicide ingestion consists of hypotension, pulmonary dysfunction, oral mucosal and gastrointestinal irritation, and transient liver and renal dysfunction. However, the existence of a dose-response relationship, with increasing amounts of ingestion resulting in more severe symptoms, needs further observation and studies that include a larger series.

The clinical significance of hyperamylasemia in organophosphate poisoning

OBJECTIVE

Hyperamylasemia with a presumptive diagnosis of acute pancreatitis has been reported following organophosphate poisoning but there are no large-scale studies incorporating more specific diagnostic criteria.

METHODS

Retrospective review of the medical records of 159 patients with a diagnosis of organophosphate poisoning over 3 years. Serum amylase, pancreatic amylase, salivary amylase, lipase and cholinesterase levels, and the clinical manifestations were analyzed.

RESULTS

Serum amylase data was available for 121 of the 159 study patients. Hyperamylasemia (amylase > or = 360 U/L) was found in 44 patients (36%). Lipase was measured in 28 patients with hyperamylasemia; 9 of 28 had hyperlipasemia (lipase > or = 380 U/L). The finding of hyperamylasemia was closely related to clinical severity and presence of shock. A presumptive diagnosis of painless acute pancreatitis was diagnosed by hyperlipasemia associated with hyperamylasemia, clinical severity, serum LDH, and leukocyte counts. Two patients with presumptive pancreatitis died. Shock, coma, and hypoalbuminemia were the factors predicting fatality.

CONCLUSIONS

Hyperamylasemia is frequent in severe organophosphate poisoning. However, hyperamylasemia is not synonymous with acute pancreatitis and pancreatic amylase is not a reliable parameter in the diagnosis of organophosphate-induced pancreatitis due to its low sensitivity and specificity. Lipase assay is indicated in patients with hyperamylasemia for early diagnosis of pancreatitis. Proper image studies and even pathological examination are also needed to confirm the extent of pancreatic injury. With prompt diagnosis and appropriate treatment, a complete recovery can be anticipated unless the patient has otherwise unrelated complications.

Clinical experience in acute overdosage of diphenidol

BACKGROUND

Diphenidol (Cephadol, Vontrol), an antiemetic agent used in the treatment of vomiting and vertigo, has been reported to cause various adverse effects including drowsiness, hypotension, confusion, hallucination, restlessness, and other antimuscarinic effects. Serious toxic effects might be anticipated after intentional or accidental ingestion.

MATERIALS AND METHODS

Retrospective analysis of all case records of the PCC-Taiwan defining diphenidol overdose during 1985-1996.

RESULTS

The data of 21 patients with diphenidol overdose were analyzed; 17 were < 3 years old and unintentionally poisoned, in contrast to the suicide attempts by four adults. The average amount of ingestion was 222.5 mg with a range of 25-800 mg. Most patients manifested only transient CNS, cardiovascular, or oculo-facial effects, but four children suffered from severe toxicity after an ingestion of 11.7-80 mg/kg diphenidol. Commonly reported toxicity in diphenidol overdose included facial flush (10), tachycardia, restlessness (6), seizures (4), dyspnea, drowsiness, mydriasis, coma, and fever (3). With supportive therapy, a good recovery was the rule except for one fatality of a 2 1/2-year-old boy who ingested 15 mg/kg diphenidol and presented with recurrent seizures, hypotension, respiratory failure, and coma.

CONCLUSIONS

Although not previously reported, accidental diphenidol overdose may result in serious anticholinergic toxicity in children. Treatment is supportive and the therapeutic role of physostigmine in diphenidol poisoning is still unclear.