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Meng N, Sun Y, Dong Y, Lv B, Yao D, Gao H, Ma Y, Jin Y, Zhu T, Tian Y. Prognostic value of plasma diquat concentration in patients with acute oral diquat poisoning: a retrospective study. Front Public Health 2024; 12:1333450. [PMID: 38894984 PMCID: PMC11184952 DOI: 10.3389/fpubh.2024.1333450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 01/08/2024] [Indexed: 06/21/2024] Open
Abstract
Objectives Diquat poisoning is an important public health and social security agency. This study aimed to develop a prognostic model and evaluate the prognostic value of plasma diquat concentration in patients with acute oral diquat poisoning, focusing on how its impact changes over time after poisoning. Methods This was a retrospective cohort study using electronic healthcare reports from the Second Hospital of Hebei Medical University. The study sample included 80 patients with acute oral Diquat poisoning who were admitted to the hospital between January 2019 and May 2022. Time-to-event analyses were performed to assess the risk of all-cause mortality (30 days and 90 days), controlling for demographics, comorbidities, vital signs, and other laboratory measurements. The prognostic value of plasma DQ concentration on admission was assessed by computing the area under a time-dependent receiver operating characteristic curve (ROC). Results Among the 80 patients, 29 (36.25%) patients died, and 51 (63.75%) patients survived in the hospital. Non-survivors had a median survival time (IQR) of 1.3(1.0) days and the longest survival time of 4.5 days after DQ poisoning. Compared with non-survivors, survivors had significantly lower amounts of ingestion, plasma DQ concentration on admission, lungs injury within 24 h after admission, liver injury within 24 h after admission, kidney injury within 24 h after admission, and CNS injury within 36 h after admission, higher APACHE II score and PSS within 24 h after admission (all p < 0.05). Plasma Diquat concentration at admission (HR = Exp (0.032-0.059 × ln (t))) and PSS within 24 h after admission (HR: 4.470, 95%CI: 1.604 ~ 12.452, p = 0.004) were independent prognostic factors in the time-dependent Cox regression model. Conclusion Plasma DQ concentration at admission and PSS within 24 h after admission are independent prognostic factors for the in-hospital case fatality rate in patients with acute oral DQ poisoning. The prognostic value of plasma DQ concentration decreased with time.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Yingping Tian
- Department of Emergency, The Second Hospital of Hebei Medical University, Shijiazhuang, China
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2
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Carneiro P, Ferreira M, Marisa Costa V, Carvalho F, Capela JP. Protective effects of amphetamine and methylphenidate against dopaminergic neurotoxicants in SH-SY5Y cells. Curr Res Toxicol 2024; 6:100165. [PMID: 38562456 PMCID: PMC10982568 DOI: 10.1016/j.crtox.2024.100165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/10/2024] [Accepted: 03/19/2024] [Indexed: 04/04/2024] Open
Abstract
Full treatment of the second most common neurodegenerative disorder, Parkinson's disease (PD), is still considered an unmet need. As the psychostimulants, amphetamine (AMPH) and methylphenidate (MPH), were shown to be neuroprotective against stroke and other neuronal injury diseases, this study aimed to evaluate their neuroprotective potential against two dopaminergic neurotoxicants, 6-hydroxydopamine (6-OHDA) and paraquat (PQ), in differentiated human dopaminergic SH-SY5Y cells. Neither cytotoxicity nor mitochondrial membrane potential changes were seen following a 24-hour exposure to either therapeutic concentration of AMPH or MPH (0.001-10 μM). On the other hand, a 24-hour exposure to 6-OHDA (31.25-500 μM) or PQ (100-5000 μM) induced concentration-dependent mitochondrial dysfunction, assessed by the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay, and lysosomal damage, evaluated by the neutral red uptake assay. The lethal concentrations 25 and 50 retrieved from the concentration-toxicity curves in the MTT assay were 99.9 µM and 133.6 µM for 6-OHDA, or 422 µM and 585.8 µM for PQ. Both toxicants caused mitochondrial membrane potential depolarization, but only 6-OHDA increased reactive oxygen species (ROS). Most importantly, PQ-induced toxicity was partially prevented by 1 μM of AMPH or MPH. Nonetheless, neither AMPH nor MPH could prevent 6-OHDA toxicity in this experimental model. According to these findings, AMPH and MPH may provide some neuroprotection against PQ-induced neurotoxicity, but further investigation is required to determine the exact mechanism underlying this protection.
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Affiliation(s)
- Patrícia Carneiro
- Associate Laboratory i4HB – Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO – Applied Molecular Biosciences Unit, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050‐313 Porto, Portugal
| | - Mariana Ferreira
- Associate Laboratory i4HB – Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO – Applied Molecular Biosciences Unit, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050‐313 Porto, Portugal
| | - Vera Marisa Costa
- Associate Laboratory i4HB – Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO – Applied Molecular Biosciences Unit, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050‐313 Porto, Portugal
| | - Félix Carvalho
- Associate Laboratory i4HB – Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO – Applied Molecular Biosciences Unit, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050‐313 Porto, Portugal
| | - João Paulo Capela
- Associate Laboratory i4HB – Institute for Health and Bioeconomy, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
- UCIBIO – Applied Molecular Biosciences Unit, Laboratory of Toxicology, Department of Biological Sciences, Faculty of Pharmacy, University of Porto, 4050‐313 Porto, Portugal
- FP3ID, Faculdade de Ciências da Saúde, Universidade Fernando Pessoa, Rua Carlos da Maia 296, 4200-150 Porto, Portugal
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Tang G, Jiang Z, Xu L, Yang Y, Yang S, Yao R. Development and validation of a prognostic nomogram for predicting in-hospital mortality of patients with acute paraquat poisoning. Sci Rep 2024; 14:1622. [PMID: 38238454 PMCID: PMC10796350 DOI: 10.1038/s41598-023-50722-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 12/23/2023] [Indexed: 01/22/2024] Open
Abstract
This study aimed to develop and validate a predictive model to determine the risk of in-hospital mortality in patients with acute paraquat poisoning. This retrospective observational cohort study included 724 patients with acute paraquat poisoning whose clinical data were collected within 24 h of admission. The primary outcome was in-hospital mortality. Patients were randomly divided into training and validation cohorts (7/3 ratio). In the training cohort, the least absolute shrinkage and selection operator regression models were used for data dimension reduction and feature selection. Multivariate logistic regression was used to generate a predictive nomogram for in-hospital mortality. The prediction model was assessed for both the training and validation cohorts. In the training cohort, decreased level of consciousness (Glasgow Coma Scale score < 15), neutrophil-to-lymphocyte ratio, alanine aminotransferase, creatinine, carbon dioxide combining power, and paraquat plasma concentrations at admission were identified as independent predictors of in-hospital mortality in patients with acute paraquat poisoning. The calibration curves, decision curve analysis, and clinical impact curves indicated that the model had a good predictive performance. It can be used on admission to the emergency department to predict mortality and facilitate early risk stratification and actionable measures in clinical practice after further external validation.
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Affiliation(s)
- Guo Tang
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Zhen Jiang
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Lingjie Xu
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Ying Yang
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Sha Yang
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Rong Yao
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China.
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4
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Asaduzzaman M, Chando MR, Ahmed N, Rezwanul Islam KM, Alam MMJ, Roy S. Paraquat-induced acute kidney and liver injury: Case report of a survivor from Bangladesh. Clin Case Rep 2021; 9:e05020. [PMID: 34765204 PMCID: PMC8572334 DOI: 10.1002/ccr3.5020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/23/2021] [Accepted: 10/04/2021] [Indexed: 12/02/2022] Open
Abstract
Despite high fatality following paraquat ingestion, a few percentages of patients survive even after organ damage appears. We need to focus more on careful clinical and laboratory monitoring. Early diagnosis and Supportive therapy are crucial.
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Affiliation(s)
- Md Asaduzzaman
- Department of MedicineSylhet M.A.G Osmani Medical College HospitalSylhetBangladesh
| | | | - Nasad Ahmed
- Department of MedicineSylhet M.A.G Osmani Medical College HospitalSylhetBangladesh
| | | | | | - Soumitra Roy
- Department of MedicineSylhet M.A.G Osmani Medical College HospitalSylhetBangladesh
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Chen CK, Chen YC, Mégarbane B, Yeh YT, Chaou CH, Chang CH, Lin CC. The acute paraquat poisoning mortality (APPM) score to predict the risk of death in paraquat-poisoned patients. Clin Toxicol (Phila) 2021; 60:446-450. [PMID: 34543159 DOI: 10.1080/15563650.2021.1979234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONTEXT Mortality prediction in paraquat poisoning is a major issue since most prediction rules are inapplicable if the exact ingestion time cannot be determined and/or the serum paraquat concentration is not readily available, as in most countries. Therefore, we aimed to develop and validate a new prediction rule not requiring these two parameters. METHODS We designed a 10-year observational cohort study including all consecutive paraquat-poisoned patients managed in two Taiwanese hospitals. We built one cohort to define and one cohort to validate this prediction rule. Parameters independently related to mortality determined using a multivariate analysis were used to formulate the Acute Paraquat Poisoning Mortality (APPM) score. RESULTS Overall, 321 paraquat-poisoned patients were included, 156 in the derivation and 165 in the validation cohort. Mortality rates in the derivation and validation cohorts were 73% and 81%, respectively (p = 0.20). The three parameters chosen of 28-day mortality at presentation were urine paraquat level >10 ppm (using a colorimetric sodium dithionite-based test; odds ratio (OR), 12.70; 95% confidence interval (CI), 2.64-61.24), white blood cells >13.0 G/L (OR, 5.50; CI, 1.41-21.48) and blood glucose >140 mg/dL [7.8 mmol/L] (OR, 7.45; CI, 1.70-32.86). In the derivation cohort, the area under the ROC curve (AUC-ROC) of the APPM score did not significantly differ from AUC-ROCs of serum paraquat (0.95, p = 0.25) and the Severity Index of Paraquat Poisoning (0.95, p = 0.33). AUC-ROCs of the APPM score in the derivation and validation cohorts were 0.91 and 0.94, respectively. CONCLUSION We built and validated a reliable score to predict 28-day mortality in paraquat-poisoned patients at presentation, independently from the ingestion time and serum paraquat measurement.
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Affiliation(s)
- Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Medical and Toxicological Critical Care, Lariboisière Hospital, AP-HP, Paris University, Paris, France
| | - Yen-Chia Chen
- Department of Emergency medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, AP-HP, Paris University, Paris, France
| | - Ying-Tse Yeh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Yuli branch, Taiwan
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Hsun Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Chen CK, Yeh YT, Mégarbane B, Chen YC, Chen KF, Chang CH, Lin CC. A novel flowchart to predict mortality and analyse effectiveness of routinely used pharmacological regimens in paraquat poisoning. Basic Clin Pharmacol Toxicol 2021; 129:496-503. [PMID: 34478614 DOI: 10.1111/bcpt.13652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 11/29/2022]
Abstract
Paraquat is responsible for an extremely high case-fatality rate poisoning. Mortality prediction remains a major issue since evidence to support benefits of routinely used treatments is lacking. We aimed to develop an easy-to-use prediction flowchart not requiring the ingestion time, for which accuracy is frequently questionable, and to evaluate the effectiveness of routinely used pharmacological therapies on mortality. We designed a two-centre cohort study including consecutive paraquat-poisoned adults with confirmed diagnosis based on serum/urine paraquat measurement. We built a flowchart using a multivariate analysis of death predictors and analysed the outcome according to the administered therapies. Overall, 256 patients were enrolled. Mortality rate was 75%. Independent death predictors on admission were serum creatinine (odds ratio [OR], 5.07; 95% confidence interval [CI], 1.97-13.05) and serum paraquat concentration (OR, 2.26; CI, 1.66-3.09). The area-under-the flowchart curve was 0.91. Overall sensitivity and specificity were 81.5% and 94.8%, respectively. More survivors than non-survivors of severe poisoning received methylprednisolone (P = 0.04). While not significantly differing in severity, methylprednisolone-treated patients had better survival (P = 0.04). To conclude, we defined an efficient flowchart to predict mortality in paraquat poisoning at presentation, even if ingestion time is undetermined. Methylprednisolone seems effective to improve the outcome, especially in the most severe cases.
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Affiliation(s)
- Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Medical and Toxicological Critical Care, Lariboisière Hospital, AP-HP, Paris University, INSERM UMRS-1144, Paris, France
| | - Ying-Tse Yeh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Yuli Branch, Hualian, Taiwan
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, AP-HP, Paris University, INSERM UMRS-1144, Paris, France
| | - Yen-Chia Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Emergency Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Kuan-Fu Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chia-Hsun Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
| | - Chih-Chuan Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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7
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Li LR, Chaudhary B, You C, Dennis JA, Wakeford H. Glucocorticoid with cyclophosphamide for oral paraquat poisoning. Cochrane Database Syst Rev 2021; 6:CD008084. [PMID: 34190331 PMCID: PMC8243635 DOI: 10.1002/14651858.cd008084.pub5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND This an update of a Cochrane Review. Paraquat is a widely used herbicide, but is also a lethal poison. In some low- and middle-income countries (LMICs) paraquat is commonly available and inexpensive, making poisoning prevention difficult. Most of the people poisoned by paraquat have taken it as a means of self-poisoning. Standard treatment for paraquat poisoning prevents further absorption and reduces the load of paraquat in the blood through haemoperfusion or haemodialysis. The effectiveness of standard treatments is extremely limited. The immune system plays an important role in exacerbating paraquat-induced lung fibrosis. Immunosuppressive treatment using glucocorticoid and cyclophosphamide in combination has been developed and studied as an intervention for paraquat poisoning. OBJECTIVES To assess the effects of glucocorticoid with cyclophosphamide for moderate to severe oral paraquat poisoning. SEARCH METHODS The most recent searches were run in September 2020. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Injuries Trials Register), Ovid MEDLINE(R), Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid OLDMEDLINE, Embase Classic + Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), and trials registries. We also searched the following three resources: China National Knowledge Infrastructure database (CNKI ); Wanfang Data (); and VIP () on 12 November 2020. We examined the reference lists of included studies and review papers. SELECTION CRITERIA We included randomised controlled trials (RCTs). For this update, in accordance with Cochrane Injuries' Group policy (2015), we included only prospectively registered RCTs for trials published after 2010. We included trials which assessed the effects of glucocorticoid with cyclophosphamide delivered in combination. Eligible comparators were standard care (with or without a placebo), or any other therapy in addition to standard care. Outcomes of interest included mortality and infections. DATA COLLECTION AND ANALYSIS We calculated the mortality risk ratio (RR) and 95% confidence interval (CI). Where possible, we summarised data for all-cause mortality at relevant time periods (from hospital discharge to three months after discharge) in meta-analysis, using a fixed-effect model. We conducted sensitivity analyses based on factors including whether participants were assessed at baseline for plasma paraquat levels. We also reported data on infections within one week after initiation of treatment. MAIN RESULTS We included four trials with a total of 463 participants. The included studies were conducted in Taiwan (Republic of China), Iran, and Sri Lanka. Most participants were male. The mean age of participants was 28 years. We judged two of the four included studies, including the largest and most recently conducted study (n = 299), to be at low risk of bias for key domains including sequence generation. We assessed one study to be at high risk of selection bias and another at unclear risk, since allocation concealment was either not mentioned in the trial report or explicitly not undertaken. We assessed three of the four studies to be at unclear risk of selective reporting, as no protocols could be identified. An important source of heterogeneity amongst the included studies was the method of assessment of participants' baseline severity using analysis of plasma levels (two studies employed this method, whilst the other two did not). No studies assessed the outcome of mortality at 30 days following ingestion of paraquat. Low-certainty evidence from two studies indicates that glucocorticoids with cyclophosphamide in addition to standard care may slightly reduce the risk of death in hospital compared to standard care alone ((RR 0.82, 95% CI 0.68 to 0.99; participants = 322); results come from sensitivity analysis excluding studies not assessing plasma at baseline). However, we have limited confidence in this finding as heterogeneity was high (I2 = 77%) and studies varied in terms of size and comparators. A single large study provided data showing that there may be little or no effect of treatment at three months post discharge from hospital (RR 0.98, 95% CI 0.85 to 1.13; 1 study, 293 participants; low-certainty evidence); however, analysis of long-term results amongst participants whose injuries arose from self-poisoning must be interpreted with caution. We remain uncertain of the effect of glucocorticoids with cyclophosphamide on infection within one week after initiation of the treatment; this outcome was assessed by two small studies only (31 participants, very low-certainty evidence) that considered leukopenia as a proxy or risk factor for infection. Neither study reported infections in any participants. AUTHORS' CONCLUSIONS Low-certainly evidence suggests that glucocorticoids with cyclophosphamide in addition to standard care may slightly reduce mortality in hospitalised people with oral paraquat poisoning. However, we have limited confidence in this finding because of substantial heterogeneity and concerns about imprecision. Glucocorticoids with cyclophosphamide in addition to standard care may have little or no effect on mortality at three months after hospital discharge. We are uncertain whether glucocorticoid with cyclophosphamide puts patients at an increased risk of infection due to the limited evidence available for this outcome. Future research should be prospectively registered and CONSORT-compliant. Investigators should attempt to ensure an adequate sample size, screen participants for inclusion rigorously, and seek long-term follow-up of participants. Investigators may wish to research the effects of glucocorticoid in combination with other treatments.
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Affiliation(s)
- Luying Ryan Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | | | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jane A Dennis
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
| | - Helen Wakeford
- Cochrane Injuries Group, London School of Hygiene & Tropical Medicine, London, UK
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Zhang S, Song S, Luo X, Liu J, Liu M, Li W, Cao T, Li N, Zeng C, Zhang B, Cai H. Prognostic value of liver and kidney function parameters and their correlation with the ratio of urine-to-plasma paraquat in patients with paraquat poisoning. Basic Clin Pharmacol Toxicol 2021; 128:822-830. [PMID: 33411948 DOI: 10.1111/bcpt.13555] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/23/2020] [Accepted: 01/04/2021] [Indexed: 12/12/2022]
Abstract
Acute paraquat poisoning resulting from multiple organ failure usually has a high mortality rate. Liver and kidney, as the key oranges of paraquat detoxification and elimination, their injuries may suppress toxin excretion and enhance the toxicity of paraquat in other organs and worsen the prognosis. Therefore, we intended to explore the prognostic value of liver and kidney function parameters, and further evaluate their correlation with a more stable index urine-to-plasma paraquat (urine paraquat concentrations/plasma paraquat concentrations) instead of considering paraquat concentrations in plasma or urine alone. The study included 33 patients with acute paraquat poisoning admitted to four centres in China from January 2018 to December 2019. Seventeen patients (10 male/7 female) survived, whereas 16 patients (7 male/9 female, 48.48%) died from paraquat poisoning. Alanine aminotransferase (ALT) and the blood urea nitrogen (BUN) represent liver and kidney function parameters, respectively. The ratio of urine-to-plasma paraquat is negatively correlated with ALT (r = -0.94, P = 0 .02) and BUN (r = -0.82, P = 0.03). For receiver operating characteristic curve (ROC) analysis, ALT, BUN and urine-to-plasma paraquat have an AUC over 0.80. The study shows that the functional indexes of liver and kidney, as well as the ratio of urine-to-plasma paraquat, could be considered for evaluating the extent of organ injury and excretion rate of paraquat.
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Affiliation(s)
- Shuangyang Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Shuai Song
- Department of Pharmacy, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xuemei Luo
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University of Medical School, Nanjing, China
| | - Jianfeng Liu
- Department of Pharmacy, The First Affiliated Hospital of Hunan University of Medicine, Huaihua, China
| | - Mouze Liu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Wenqun Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Ting Cao
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Nana Li
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Cuirong Zeng
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Bikui Zhang
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Hualin Cai
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China.,Institute of Clinical Pharmacy, Central South University, Changsha, China
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Montoya-Giraldo MA, Díaz LF, Gómez UE, Quintero J, Zuluaga AF. Use of low-molecular-weight heparin in severe paraquat poisoning: a case report. J Med Case Rep 2020; 14:240. [PMID: 33287885 PMCID: PMC7722312 DOI: 10.1186/s13256-020-02565-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 10/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute paraquat ingestion remains a leading cause of mortality in developing countries. There is currently no evidence that treatment with high-dose immunosuppressants and antioxidants improves survival in patients with paraquat poisoning, and better options are urgently needed. Here, we describe the unexpected survival and recovery of a patient with a potentially fatal paraquat poisoning. CASE PRESENTATION After ingesting 28 mL of paraquat (20% ion w/v), confirmed by a deep blue color in the urine dithionite test (UDT), a 17-year-old Hispanic Colombian boy was treated according to the hospital protocol with cyclophosphamide, methylprednisolone, N-acetylcysteine, vitamin E and propranolol. Gastrointestinal endoscopy showed extensive ulceration and necrosis. As a novelty, enoxaparin at a single dose of 60 mg was added to his treatment. Despite the evidence of severe mucosal burns in the gastrointestinal tract and high paraquat concentrations found in the UDT, the clinical condition began to improve after 1 day of treatment, with full recovery and discharge from hospital after 21 days. CONCLUSIONS Although the amount of paraquat ingested by the patient was large and the UDT indicated severe poisoning with a somber prognosis, unexpected survival of the patient was observed, and the addition of enoxaparin was the only change from the standard treatment.
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Affiliation(s)
- Maria A Montoya-Giraldo
- CIEMTO [Drug and Poison Research and Information Center], Calle 64 # 51-31, Laboratorio Integrado de Medicina Especializada (LIME), IPS Universitaria, Facultad de Medicina, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - Luisa F Díaz
- CIEMTO [Drug and Poison Research and Information Center], Calle 64 # 51-31, Laboratorio Integrado de Medicina Especializada (LIME), IPS Universitaria, Facultad de Medicina, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - Ubier E Gómez
- CIEMTO [Drug and Poison Research and Information Center], Calle 64 # 51-31, Laboratorio Integrado de Medicina Especializada (LIME), IPS Universitaria, Facultad de Medicina, Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - Juliana Quintero
- Hospital Universitario San Vicente Fundación, Medellín, Colombia
| | - Andres F Zuluaga
- CIEMTO [Drug and Poison Research and Information Center], Calle 64 # 51-31, Laboratorio Integrado de Medicina Especializada (LIME), IPS Universitaria, Facultad de Medicina, Universidad de Antioquia, Medellín, Antioquia, Colombia.
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Zhao Y, Feng SY, Li Y. Serum anion gap at admission as a predictor of the survival of patients with paraquat poisoning: A retrospective analysis. Medicine (Baltimore) 2020; 99:e21351. [PMID: 32756123 PMCID: PMC7402740 DOI: 10.1097/md.0000000000021351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Paraquat (PQ) poisoning is associated with high mortality rate. Therefore, an accurate method for predicting the survival of patients with PQ poisoning is required. This study evaluated the value of serum anion gap (AG) at admission in predicting the survival of such patients.Cases of patients with PQ poisoning admitted to Cangzhou Central Hospital between May 2012 and March 2019 were retrospectively analyzed. The patients were classified into survival and nonsurvival groups on the basis of their 90-day prognosis. Correlation analysis, Cox regression analysis, and receiver operating characteristic and Kaplan-Meier curve analyses were performed to assess the value of AG in predicting the 90-day survival of patients with PQ poisoning.Only 44 of the 108 patients with PQ poisoning survived; thus, the 90-day survival was 40.74%. AG levels at admission were significantly higher in nonsurvivors (26.53 ± 4.93 mmol/L) than in survivors (20.88 ± 2.74 mmol/L) (P < .001) and negatively correlated with 90-day survival (r = -0.557; P < .001). Cox regression analysis revealed that AG at admission is an independent prognostic marker of the 90-day survival of patients with PQ poisoning. AG level at admission had an area under the receiver operating characteristic curve of 0.836 (95% confidence interval: 0.763-0.909) and an optimal cut-off value of 25.5 mmol/L (59.4% sensitivity and 95.5% specificity).AG level at admission may serve as a candidate marker for predicting the survival of patients with PQ poisoning.
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Reisinger A, Rabensteiner J, Hackl G. Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications. Biomarkers 2020; 25:112-125. [PMID: 32011177 DOI: 10.1080/1354750x.2020.1725787] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.
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Affiliation(s)
- Alexander Reisinger
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Jasmin Rabensteiner
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Gerald Hackl
- Intensive Care Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
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Usui K, Minami E, Fujita Y, Kobayashi H, Hanazawa T, Kamijo Y, Funayama M. A fast paraquat quantitation method in human serum using probe electrospray ionization–tandem mass spectrometry for emergency settings. J Pharmacol Toxicol Methods 2019; 100:106610. [DOI: 10.1016/j.vascn.2019.106610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/04/2019] [Accepted: 07/06/2019] [Indexed: 11/25/2022]
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Wang WJ, Cao ZX, Feng SY, Song YQ, Zhang SL, Bai WJ, Li Y. Platelet-lymphocyte ratio is not a prognostic predictor for acute paraquat-intoxicated patients: A retrospective analysis. Medicine (Baltimore) 2019; 98:e15702. [PMID: 31096516 PMCID: PMC6531261 DOI: 10.1097/md.0000000000015702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study aimed to investigate the prognostic predictive value of the platelet-lymphocyte ratio (PLR) in patients with acute paraquat (PQ) intoxication.A total of 107 patients with acute PQ intoxication via oral ingestion were admitted in Cangzhou Central Hospital from May 2012 to September 2018. Valuable detection indices were screened out by using Cox proportional hazard regression and receiver operating characteristic (ROC) curve analyses, and their diagnostic efficiency was evaluated by using Kaplan-Meier curve.The 90-day mortality was 58.9% (63/107). The Kaplan-Meier curve showed that PLR was not associated with 90-day survival (log-rank test; P = .661). In Cox proportional hazard regression analyses, PLR was not an independent risk factor. Meanwhile, the ROC curves showed that PLR had an AUC value of 0.569 (95% confidence interval: 0.459-0.679, P = .227) in predicting 90-day survival.PLR is not a prognostic predictor for patients with acute PQ intoxication.
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Meng Z, Dong Y, Gao H, Yao D, Gong Y, Meng Q, Zheng T, Cui X, Su X, Tian Y. The effects of ω-3 fish oil emulsion-based parenteral nutrition plus combination treatment for acute paraquat poisoning. J Int Med Res 2018; 47:600-614. [PMID: 30392424 PMCID: PMC6381463 DOI: 10.1177/0300060518806110] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective To investigate the effects of parenteral nutrition (PN) including ω-3 fish-oil emulsion on nutritional state, inflammatory response, and prognosis in patients with acute paraquat poisoning. Methods Patients randomized to receive medium chain triglycerides (MCT)/long chain triglycerides (LCT)-based PN (control group) or MCT/LCT-based PN containing ω-3 fish-oil emulsion (intervention group) were compared for 90-day survival and short-term treatment efficacy. Results Tumour necrosis factor-α levels were significantly lower in the intervention group (n = 101) versus controls (n = 73) on treatment days 4 and 7. Intervention group C-reactive protein (CRP) levels were significantly increased on day 4, decreased to baseline (day 1) levels on day 7, and were significantly lower than baseline on day 10. Control group CRP levels were significantly increased on days 4 and 7 versus baseline, and returned to baseline levels on day 10. On day 7, retinol binding protein had recovered to baseline levels in the intervention group only. Intervention group mortality rate (36.6%) was significantly lower than controls (57.5%). ω-3 fish-oil PN was associated with reduced risk of death (hazard ratio 0.52; 95% confidence interval 0.33, 0.82). Conclusion In patients with acute paraquat poisoning, MCT/LCT with ω-3 fish-oil emulsion PN plus combination treatment advantageously attenuated the inflammatory response, modified the nutritional state, and was associated with significantly improved 90-day survival versus treatment without ω-3 fish oil.
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Affiliation(s)
- Zhaohua Meng
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Yanling Dong
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Hengbo Gao
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Dongqi Yao
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Yu Gong
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Qingbing Meng
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Tuokang Zheng
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Xiaolei Cui
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Xiaoyun Su
- 2 Division of Health Care, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
| | - Yingping Tian
- 1 Emergency Department, Second Hospital of Hebei Medical University, Xinhua District, Shijiazhuang, Hebei, China
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Predictive value of the maximum serum creatinine value and growth rate in acute paraquat poisoning patients. Sci Rep 2018; 8:11587. [PMID: 30072769 PMCID: PMC6072775 DOI: 10.1038/s41598-018-29800-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 07/17/2018] [Indexed: 01/26/2023] Open
Abstract
This retrospective and a single-center study evaluated the prognostic value of the maximum serum creatinine value (maxCr) and the maximum serum creatinine growth rate (Vmax) after paraquat (PQ) ingestion. One hundred and seventy-one patients with PQ poisoning were treated with a uniform protocol. Demographic variables, clinical manifestations, relevant laboratory data, maxCr and Vmax of all patients were recorded and calculated. The time after PQ ingestion of maxCr and Vmax were also recorded. Vmax and MaxCr exhibited statistically significant differences between the survivor (n = 53) and death (n = 118) groups. Vmax appeared earlier in the death group than the survivor group. Regard to the receiver operating characteristic (ROC) curve analysis, Vmax had an AUC of 0.861 (95% CI, 0.801–0.921) and the optimal cut-off value of 6.21 μmol/(L·h) (sensitivity, 76.3%; specificity, 81.1%). MaxCr had an area under the curve (AUC) of 0.821 (95% CI, 0.752–0.889) and the optimal cut-off value of 225.5 µmol/L (sensitivity, 82.2%; specificity, 67.9%). The comparison of the AUC in the two parameters showed no significant difference, but Vmax appeared earlier than maxCr. Based on binary logistic regression analysis, MaxCr and Vmax both showed strong predictive powers for evaluating the prognosis of acute PQ poisoning patients.
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A retrospective analysis of leucocyte count as a strong predictor of survival for patients with acute paraquat poisoning. PLoS One 2018; 13:e0201200. [PMID: 30044873 PMCID: PMC6059481 DOI: 10.1371/journal.pone.0201200] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 07/10/2018] [Indexed: 12/27/2022] Open
Abstract
The aim of this study is the identification of a reliable predictor of prognosis to optimize the treatment of acute paraquat (PQ) poisoning patients. We performed a retrospective analysis on 96 patients with acute PQ poisoning to evaluate leucocyte count as a predictor of 90-day survival. These patients were admitted to the emergency department from May 2012 to February 2017. Kaplan–Meier method was used to compare the 90-day survival. Cox proportional hazard models were utilized to estimate the hazard ratios (HR) and 95% confidence intervals (CI). Receiver operating characteristic (ROC) analysis was conducted to analyze the discriminatory potential of leucocyte with respect to 90-day survival. Result showed that leucocyte was significantly higher among nonsurvivors than that among survivors (p<0.001). Leukocyte was also an independent predictor of survival according to the multivariate Cox analysis (HR 1.103; 95%CI: 1.062–1.146; p<0.001). The area under the curve (AUC) for leucocyte (AUC 0.911; 95%CI: 0.855–0.966; p<0.001) showed a discriminatory potential similar to that of the plasma PQ concentration (AUC 0.961; 95%CI: 0.926–0.997; p<0.001) in predicting 90-day survival. The leucocyte count is a strong predictor of survival in patients with acute PQ poisoning.
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Chen CW, Wu YH, Chien SC, Lin JC. A survival case of intravenous paraquat intoxication: A case report. Medicine (Baltimore) 2018; 97:e11669. [PMID: 30045322 PMCID: PMC6078682 DOI: 10.1097/md.0000000000011669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/27/2018] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Paraquat, an agent highly toxic to humans and animals, is a widely used herbicide and also commonly used for suicide attempts in Taiwan. The most common route of intoxication is oral ingestion, and parenteral poisoning is respectively rare. PATIENT CONCERNS A 39-year-old illicit abuser of heroin and amphetamine injected 0.5 mL of 24% paraquat directly into his right cephalic vein due to hallucination. The patient was brought to our emergency department for management 4 hours after injection. He was fully conscious and had normal vital signs. Systemic review showed mild dyspnea, abdominal pain and right wrist pain over the injection site. The only abnormal physical finding was erythema over the injection site and epigastric tenderness. DIAGNOSIS Laboratory investigations, including complete blood count, liver and renal function, and electrolytes initially yielded normal results. Urinalysis showed normal findings except a positive urine paraquat test (4+). The initial plasma paraquat concentration was 0.51 μg/mL. INTERVENTIONS He was admitted to the intensive care unit and underwent one session of charcoal hemoperfusion therapy. Acute kidney injury developed on the fourth day after intoxication, with the level of serum creatinine rising rapidly from 0.96 to 4.57 mg/dL and the daily urine output decreased noticeably from > 2000 to 900 mL. The serum creatinine level improved gradually with adequate fluid supplementation. OUTCOMES The patient was discharged 13 days later in a stable condition. LESSONS Intravenous paraquat intoxication is rare. Patients who suffer from intravenous intoxication may not directly suffer from mucosal irritation, but the clinical onset of systemic effects is more immediate and lethal. The prognosis of paraquat poisoning is determined by the time of poisoning and the plasma paraquat concentration before treatment. Proudfoot's curve provides a simple method of predicting the survival rate. The most effective mode of management is extracorporeal therapy, and immunosuppressive or antioxidant therapies have shown insufficient evidence of benefit.
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Affiliation(s)
- Chi-Wei Chen
- Department of Emergency Medicine, Kaohsiung Medical University Hospital
| | - Yen-Hung Wu
- Department of Emergency Medicine, Kaohsiung Medical University Hospital
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shun-Ching Chien
- Department of Emergency Medicine, Kaohsiung Medical University Hospital
| | - Jhong-Ching Lin
- Department of Emergency Medicine, Kaohsiung Medical University Hospital
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Ratio of Injured Lung Volume Fraction in Prognosis Evaluation of Acute PQ Poisoning. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4501536. [PMID: 29651433 PMCID: PMC5832052 DOI: 10.1155/2018/4501536] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 12/15/2017] [Accepted: 01/18/2018] [Indexed: 11/17/2022]
Abstract
Although paraquat (PQ) concentrations are the most reliable prognosis predictors of PQ poisoning, these laboratory tests are not readily available in all hospitals. In this study, we proposed an imaging related parameter, that is, the ratio of injured lung volume fraction, for the prognosis evaluation of acute PQ poisoning based on the correlation between disease progress and lung imaging features. An artificial neural network was trained and then used to classify the injured and normal lung regions. The ratio of injured lung volume fraction was calculated from the injured lung volume fractions in the first and second CT scans after three-dimensional reconstruction. Parameters of blood tests were collected. A significant difference was observed with respect to the ratio of injured lung volume fraction between survivors and nonsurvivors (0.73 ± 0.17 versus 0.40 ± 0.14, P < 0.001). No patients survived when the ratio of injured lung volume fraction was less than 0.3, while all patients survived as the ratio of injured lung volume fraction was greater than 0.8. Thus, the ratio of injured lung volume fraction may provide an alternative and informative measure for the prognosis of acute PQ poisoning.
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Ghorbani A, Masoumi K, Forouzan A, Rahmani A, Rahim F, Taeybi BT, Feli M. Effect of Pulse Therapy with Glucocorticoids and Cyclophosphamide in Patients with Paraquat Poisoning. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791502200405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Introduction Paraquat (PQ) is a widely used herbicide with a high mortality rate when ingested. The aim of the present study was to assess the effectiveness of repeated cyclosphosphamide (CP) and methylprednisolone (MP) combination in the treatment of PQ poisoning. Design Randomised, double-blinded, placebo-controlled trial. Methods Eligible participants were 47 patients with moderate to severe PQ poisoning within 24 hours of hospitalisation. Patients were allocated in a random fashion, 24 as the intervention and 23 as the control group. All patients received two cycles of eight hours of haemoperfusion with charcoal, and underwent emergency haemodialysis. After the dialysis, the intervention group received 15 mg/kg CP for two days and 1g MP for three days. The control group received routine supportive care. Outcome parameters, including mortality, incidence of hypoxia, hepatitis and renal failure were compared between the two groups. Results There were no significant differences between the two groups with regard to age, sex, baseline liver function test, creatinine, time from poisoning to dialysis, and time from poisoning to the hospitalisation. Although the incidence of hepatitis and acute renal failure did not differ significantly between the two groups, the incidence of hypoxia and mortality rate was lower in the intervention group. The number need-to-treat to reduce one mortality was 2.8. Conclusion The results suggest that CP and MP repeated treatment can reduce the mortality rate in moderate to severe PQ intoxication.
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Affiliation(s)
- A Ghorbani
- Razi Hospital, Department of Forensic Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz
| | - K Masoumi
- Imam Khomeini General Hospital, Department of Emergency Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - A Forouzan
- Imam Khomeini General Hospital, Department of Emergency Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ah Rahmani
- Razi Hospital, Department of Forensic Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz
| | - F Rahim
- Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - B Taherinezhad Taeybi
- Imam Khomeini General Hospital, Department of Emergency Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - M Feli
- Imam Khomeini General Hospital, Department of Emergency Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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Abstract
Paraquat is highly toxic to human and is widely used in agriculture as a contact herbicide. However, it is easily accessible in agricultural product shops. Seven cases of paraquat poisoning were treated in Tuen Mun Hospital from 1998–2005. The mortality (4 out of 7) was very high. One patient died after oral exposure to paraquat despite immunosuppressive and antioxidant therapies. The mechanism of toxicity and potential new therapies of paraquat poisoning are discussed in the article.
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Liu ZQ, Wang HS, Gu Y. Hypokalemia is a biochemical signal of poor prognosis for acute paraquat poisoning within 4 hours. Intern Emerg Med 2017; 12:837-843. [PMID: 27395362 DOI: 10.1007/s11739-016-1491-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 06/17/2016] [Indexed: 12/17/2022]
Abstract
Anecdotal reports have suggested that hypokalemia is an independent predictor of mortality in patients with acute paraquat poisoning. However, the clinical significance of hypokalemia has not been systematically investigated in the early stage of paraquat poisoning. This study aimed to evaluate whether initial hypokalemia is a good predictor of mortality in patients with acute paraquat poisoning within 4 h. We retrospectively analyzed patients who were admitted to the emergency department after paraquat poisoning between September 2012 and January 2015. Demographic, clinical, and laboratory data were recorded, and the prognostic significance of hypokalemia was analyzed. A total of 120 patients were included. The 60-day mortality was 71.7 %. Serum potassium concentrations were significantly lower in non-survivors (3.1 ± 0.5 mmol/L) than in survivors (3.8 ± 0.3 mmol/L, P < 0.001). Independent predictors of death were amount of paraquat ingested (hazard ratio 1.005; 95 % confidence interval 1.002-1.007), serum potassium (0.498, 0.277-0.897), bicarbonate (0.934, 0.876-0.995), and white blood cell count (1.032, 1.001-1.065). For receiver operating characteristic curve analysis, serum potassium had an area under the curve of 0.852 (95 % confidence interval 0.784-0.920, P < 0.001), and the best cutoff value was 3.5 mmol/L (sensitivity, 88.2 %; specificity, 75.6 % in predicting survivors). Kaplan-Meier analysis showed that decreased serum potassium concentrations were associated with an increase in 60-day mortality (P < 0.001). Hypokalemia may be a reliable predictor in evaluating prognosis in paraquat poisoning within 4 h. The mechanism is not clear, and further studies verifying the precise mechanism of hypokalemia are required.
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Affiliation(s)
- Zun-Qi Liu
- Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, China.
| | - Hai-Shi Wang
- Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
| | - Yan Gu
- Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong Province, China
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Vu AP, Nguyen TN, Do TT, Doan TH, Ha TH, Ta TT, Nguyen HL, Hauser PC, Nguyen TAH, Mai TD. Clinical screening of paraquat in plasma samples using capillary electrophoresis with contactless conductivity detection: Towards rapid diagnosis and therapeutic treatment of acute paraquat poisoning in Vietnam. J Chromatogr B Analyt Technol Biomed Life Sci 2017; 1060:111-117. [PMID: 28609698 DOI: 10.1016/j.jchromb.2017.06.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Revised: 05/26/2017] [Accepted: 06/05/2017] [Indexed: 10/19/2022]
Abstract
The employment of a purpose-made capillary electrophoresis (CE) instrument with capacitively coupled contactless conductivity detection (C4D) as a simple and cost-effective solution for clinical screening of paraquat in plasma samples for early-stage diagnosis of acute herbicide poisoning is reported. Paraquat was determined using an electrolyte composed of 10mM histidine adjusted to pH 4 with acetic acid. A detection limit of 0.5mg/L was achieved. Good agreement between results from CE-C4D and the confirmation method (HPLC-UV) was obtained, with relative errors for the two pairs of data better than 20% for 31 samples taken from paraquat-intoxicated patients. The results were used by medical doctors for identification and prognosis of acute paraquat poisoning cases. The objective of the work is the deployment of the developed approach in rural areas in Vietnam as a low-cost solution to reduce the mortality rate due to accidental or suicidal ingestion of paraquat.
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Affiliation(s)
- Anh Phuong Vu
- Poison Control Center, Bach Mai Hospital, 78 Giai Phong road, Dong Da, Hanoi, Viet Nam; Department of Analytical Chemistry, Faculty of Chemistry, VNU University of Science, Vietnam National University, Hanoi - 19 Le Thanh Tong, Hanoi, Viet Nam(1)
| | - Thi Ngan Nguyen
- Poison Control Center, Bach Mai Hospital, 78 Giai Phong road, Dong Da, Hanoi, Viet Nam; Department of Analytical Chemistry, Faculty of Chemistry, VNU University of Science, Vietnam National University, Hanoi - 19 Le Thanh Tong, Hanoi, Viet Nam(1)
| | - Thi Trang Do
- Poison Control Center, Bach Mai Hospital, 78 Giai Phong road, Dong Da, Hanoi, Viet Nam; Department of Analytical Chemistry, Faculty of Chemistry, VNU University of Science, Vietnam National University, Hanoi - 19 Le Thanh Tong, Hanoi, Viet Nam(1)
| | - Thu Ha Doan
- Poison Control Center, Bach Mai Hospital, 78 Giai Phong road, Dong Da, Hanoi, Viet Nam
| | - Tran Hung Ha
- Poison Control Center, Bach Mai Hospital, 78 Giai Phong road, Dong Da, Hanoi, Viet Nam
| | - Thi Thao Ta
- Department of Analytical Chemistry, Faculty of Chemistry, VNU University of Science, Vietnam National University, Hanoi - 19 Le Thanh Tong, Hanoi, Viet Nam(1)
| | - Hung Long Nguyen
- Vietnam Food Administration, Ministry of Health, 138A Giang Vo, Ba Đinh, Hanoi, Viet Nam
| | - Peter C Hauser
- University of Basel, Department of Chemistry, Spitalstrasse 51, 4056 Basel, Switzerland
| | - Thi Anh Huong Nguyen
- Department of Analytical Chemistry, Faculty of Chemistry, VNU University of Science, Vietnam National University, Hanoi - 19 Le Thanh Tong, Hanoi, Viet Nam(1).
| | - Thanh Duc Mai
- PNAS, Institut Galien de Paris-Sud, Faculté de Pharmacie, Université Paris-Sud, CNRS, 5 rue JB Clément, 92296 Châtenay-Malabry, France.
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Time-dependent haemoperfusion after acute paraquat poisoning. Sci Rep 2017; 7:2239. [PMID: 28533543 PMCID: PMC5440400 DOI: 10.1038/s41598-017-02527-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 04/12/2017] [Indexed: 12/18/2022] Open
Abstract
Early haemoperfusion (HP) therapy has been found to be very effective in acute paraquat (PQ) poisoning, but the effective rescue window is still uncertain. Demographic data and the type of therapies administered of 621 patients were included as confounding factors in this retrospective study. After receiver operating characteristic curve analysis and intra-group/subgroup analysis, the initiation of glucocorticoid therapy within 3 hrs of exposure with a second treatment given <21 hrs after exposure, HP initiated within 4 hrs of exposure with a second treatment given <20 hrs after exposure, the appearance of pulmonary lesions ≤8 days after exposure and six other variables were used in a multiple analysis. The strength of positivity of the PQ urine test on admission, HP initiated within 4 hrs of exposure with a second treatment given <20 hrs after exposure, the appearance of pulmonary lesions ≤8 days after exposure, and stage III AKI on admission were independent factors of survival probability. HP therapy for acute PQ poisoning was the main therapeutic intervention investigated in this study. Outcomes were time dependent, and the crucial factor was the initiation of therapy within 4 hrs of PQ poisoning followed by a second treatment within 20 hrs.
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25
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Mizutani T, Yamashita M, Okubo N, Tanaka M, Naito H. Efficacy of Whole Bowel Irrigation Using Solutions with or without Adsorbent in the Removal of Paraquat in Dogs. Hum Exp Toxicol 2016; 11:495-504. [PMID: 1361139 DOI: 10.1177/096032719201100610] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
1 The efficacy of whole bowel irrigation with a solution containing either polyethylene glycol (PEG) with electrolyte or an adsorbent (Kayexalate™) with a cathartic (sorbitol) was investigated in 18 dogs who had been given 250 mg kg -1 paraquat dichloride via a jejunal tube to eliminate the influence of gastric absorption. 2 Plasma paraquat concentrations 2 and 3 h after the initiation of bowel irrigation and at the end of the study (5 h later) were significantly lower in the bowel irrigation groups than in the control (no bowel irrigation) group. 3 The total body clearances of paraquat in the bowel irrigation groups were significantly greater than in the control group. 4 There were no significant differences between the two different irrigation solution groups in plasma paraquat concentration, the area under the plasma concentration time curve and the total body clearance. 5 In the PEG with electrolyte group, about 70% of the administered dose of paraquat was removed by means of bowel irrigation (n=4). 6 The adjunction of the adsorbent had no beneficial effects. 7 Haemodynamic changes associated with whole bowel irrigation were unremarkable except that right atrial and pulmonary arterial pressures were elevated in the latter part of the study.
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Affiliation(s)
- T Mizutani
- Department of Critical Care Medicine, University of Tsukuba, Ibaraki, Japan
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Yoshioka T, Sugimoto T, Kinoshita N, Shimazu T, Hiraide A, Kuwagata Y. Effects of Concentration Reduction and Partial Replacement of Paraquat by Diquat on Human Toxicity: A Clinical Survey. Hum Exp Toxicol 2016; 11:241-5. [PMID: 1354970 DOI: 10.1177/096032719201100401] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Paraquat poisoning was studied in 174 patients over a 12-month period when a new, low concentration paraquat product (4.5% w/v paraquat ion mixed with 4.5% w/v diquat ion; 6 3 cases) replaced the original high concentration paraquat product (20% w/v paraquat ion only; 111 cases). In both groups approximately 60% of the patients died from circulatory failure accompanied by multiple organ failure within a week of ingesting the products. However, a remarkable reduction in late deaths from respiratory failure was noted in the new product group (17.1% vs 6.3%). This was reflected in this group's improved survival (23.4% vs 34.9%). The improvement in survival seems to be attributable to the dilution of paraquat with diquat which seems to have a different toxicological profile to paraquat.
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Affiliation(s)
- T Yoshioka
- Department of Traumatology, Osaka University School of Medicine, Japan
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Hong SY, Yang JO, Lee EY, Kim SH. Effect of haemoperfusion on plasma paraquat concentration in vitro and in vivo. Toxicol Ind Health 2016; 19:17-23. [PMID: 15462533 DOI: 10.1191/0748233703th171oa] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This study was to observe the paraquat (PQ) reduction rate after haemoperfusion (HP) on the groups of a relatively large number: 50 survivors out of 105 patients with acute PQ poisoning. We started off by measuring the clearance of haemodialysis (HD) and HP for the PQ in vitro. At the blood flow of 250 mL/min, the PQ clearance was greater in HP than in HD during the first 90 minutes: 215 versus 175 mL/min at 30 minutes, 213 versus 201 mL/min at 60 minutes, and 199 versus 179 mL/min at 90 minutes. The clearance in HP decreased rapidly after two hours. By the end of the dialysis, however, the final concentration in container decreased to 5.7 mg/mL in HD and 1.5 mg/mL in HP, which implied that although HD was cleared more effectively during the later stages, the overall elimination was greater in HP. Following this preliminary investigation, we performed HP on all the patients in order to assess the extracorporeal elimination. One hundred and five patients who had swallowed one to three mouthfuls of PQ (24.5% w/v) solution were subjected to the in vivo study. The reduction rate of PQ was checked out by measuring the PQ concentration in plasma before and after four hours of HP. Seeing the reduction rate was significantly higher in the survivors group than in the nonsurvivors group (80.39 ± 19.9 versus 67.29 ± 19.2%, P <0.01), we concluded that adequate HP appears to be an indispensable treatment for patients with acute PQ poisoning.
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Affiliation(s)
- Sae-Yong Hong
- Department of Internal Medicine and Clinical Research Institute, Soonchunhyang University College of Medicine, Cheonan, Korea
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Liu S, Wang Q, Zhou R, Li C, Hu D, Xue W, Wu T, Mohan C, Peng A. Hyperamylasemia as an Early Predictor of Mortality in Patients with Acute Paraquat Poisoning. Med Sci Monit 2016; 22:1342-8. [PMID: 27101346 PMCID: PMC4844273 DOI: 10.12659/msm.897930] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background Paraquat (PQ) is a non-selective and fast-acting contact herbicide which has been widely used in developing countries. Hyperamylasemia was reported in patients with PQ poisoning. This study investigated the predictive value and clinical characteristics of hyperamylasemia in patients with PQ poisoning. Material/Methods This study included 87 patients with acute PQ poisoning admitted from July 2012 to May 2015. Data were collected from medical records. Receiver operating characteristic (ROC) analysis was conducted to analyze the discriminatory potential of serum amylase with respect to 90-day mortality. Results Of 87 patients, 29 patients had elevated serum amylase. We found that serum amylase was significantly higher among patients with AKI than those with non-AKI (p<0.001), and was an independent predictor of mortality (hazard ratio [HR]=3.644; 95% [CI], 1.684–7.881; p=0.001). The area under the ROC curve for the serum amylase (area under curve [AUC]=0.796; 95% [CI], 0.690–0.903) had a better discriminatory potential than plasma PQ concentration (0.698;0.570–0.825) or urinary PQ concentration (0.647;0.514–0.781) in predicting 90-day mortality. Conclusions Hyperamylasemia is a valuable early predictor of 90-day mortality in PQ poisoning.
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Affiliation(s)
- Shuai Liu
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Qiang Wang
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Rong Zhou
- Department of Nephrology, Shanghai Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Changbin Li
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Dayong Hu
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Wen Xue
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Tianfu Wu
- Department of Nephrology, Shanghai Yangpu Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Chandra Mohan
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
| | - Ai Peng
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China (mainland)
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Tsai JL, Chen CH, Wu MJ, Tsai SF. Paraquat Poisoning in Patients With HIV Infection: A Case Report and Literature Review. Medicine (Baltimore) 2016; 95:e3350. [PMID: 27057917 PMCID: PMC4998833 DOI: 10.1097/md.0000000000003350] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Paraquat poisoning is very severe. Most victims, including those who have ingested a small amount, will die from Paraquat poisoning. The cause of death in the majority of such cases is lung fibrosis. Paraquat poisoning in patients with positive human immunodeficiency virus (HIV) infection status has seldom been reported. Herein, we report a case of an HIV patient with Paraquat poisoning who had an excellent outcome even without standard treatment. Currently, only 3 such cases have been reported in the literature and in each case there was a good outcome, which was not expected according to predictive models. A possible mechanism may involve the relative lack of functional macrophages in HIV patients, which would tend to result in much less severe lung injury. None of the available predictive models of Paraquat poisoning appear to be appropriate for HIV patients.Paraquat poisoning in HIV patients may have better survival due to less lung injury.
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Affiliation(s)
- Jun-Li Tsai
- From the Department of Family Medicine (J-LT), Cheng Ching General Hospital; Division of Nephrology, Department of Internal Medicine (C-HC, M-JW, S-FT), Taichung Veterans General Hospital; School of Medicine (C-HC, M-JW, S-FT), China Medical University; Department of Life Science (C-HC, S-FT), Tunghai University; and Taichung; and Department of Medicine (S-FT), Nation Yang Ming University, Taipei, Taiwan
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Sun IO, Shin SH, Yoon HJ, Lee KY. Predicting the probability of survival in acute paraquat poisoning. Kidney Res Clin Pract 2016; 35:102-6. [PMID: 27366665 PMCID: PMC4919560 DOI: 10.1016/j.krcp.2016.01.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 01/24/2016] [Accepted: 01/31/2016] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Paraquat (PQ) concentration-time data have been used to predict prognosis for 3 decades. The aim of this study was to find a more accurate method to predict the probability of survival. METHODS This study included 788 patients with PQ poisoning who were diagnosed using plasma PQ concentration between January 2005 and August 2012. We divided these patients into 2 groups (survivors vs. nonsurvivors), compared their clinical characteristics, and analyzed the predictors of survival. RESULTS The mean age of the included patients was 57 years (range, 14-95 years). When we compared clinical characteristics between survivors (n = 149, 19%) and nonsurvivors (n = 639, 81%), survivors were younger (47 ± 14 years vs. 59 ± 16 years) and had lower plasma PQ concentrations (1.44 ± 8.77 μg/mL vs. 80.33 ± 123.15 μg/mL) than nonsurvivors. On admission, serum creatinine was lower in survivors than in nonsurvivors (0.95 ± 0.91 mg/dL vs. 1.88 ± 1.27 mg/dL). In multivariate logistic regression analysis, age and logarithmically converted serum creatinine [ln(Cr)], [ln(time)], and [ln(PQ)] were assessed as prognostic factors to predict survival in PQ poisoning. The predicted probability of survival using significant prognostic factors was exp (logit)/[1 + exp(logit)], where logit = -1.347 + [0.212 × sex (male = 1, female = 0)] + (0.032 × age) + [1.551 × ln(Cr)] + [0.391 × ln(hours since ingestion)] + [1.076 × ln(plasma PQ μg/mL)]. With this equation, the sensitivity and specificity were 86.5% and 98.7%, respectively. CONCLUSION Age, ln(Cr), ln(time), and ln(PQ) were important prognostic factors in PQ poisoning, and our equation can be helpful to predict the survival in acute PQ poisoning patients.
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Affiliation(s)
- In O Sun
- Division of Nephrology & Toxicology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Sung Hye Shin
- Department of Biochemistry, Christian Medical Research Center, Jeonju, Korea
| | - Hyun Ju Yoon
- Division of Nephrology & Toxicology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Kwang Young Lee
- Division of Nephrology & Toxicology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea; Department of Biochemistry, Christian Medical Research Center, Jeonju, Korea
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Kim HJ, Kim HK, Lee H, Bae JS, Kown JT, Gil HW, Hong SY. Toxicokinetics of paraquat in Korean patients with acute poisoning. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY : OFFICIAL JOURNAL OF THE KOREAN PHYSIOLOGICAL SOCIETY AND THE KOREAN SOCIETY OF PHARMACOLOGY 2015; 20:35-9. [PMID: 26807021 PMCID: PMC4722189 DOI: 10.4196/kjpp.2016.20.1.35] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/15/2015] [Accepted: 09/24/2015] [Indexed: 12/01/2022]
Abstract
To conduct a kinetic study of paraquat (PQ), we investigated 9 patients with acute PQ intoxication. All of them ingested more than 20 ml of undiluted PQ herbicide to commit suicide and arrived at our hospital early, not later than 7 h after PQ ingestion. The urine dithionite test for PQ in all of the nine patients was strongly positive at emergency room. Blood samples were obtained every 30 min for the first 2~3 h and then every 1 or 2 h, as long as the clinical progression was stable among the patients for 30 h after PQ ingestion. The area under the plasma concentration-time curve (AUCinf), which was extrapolated to infinity, was calculated using the trapezoidal rule. Toxicokinetic parameters, such as the terminal elimination half-life, apparent oral clearance, and apparent volume of distribution (Vd/F) were calculated. The maximum PQ concentration (Cmax) and the time to reach maximum PQ concentration (Tmax) were also obtained. Plasma PQ concentrations in nine patients were well described by a bi-exponential curve with a mean terminal elimination half-life of 13.1±6.8 h. Cmax and AUCinf were 20.8±25.7 mg/l and 172.5±160.3 h·mg/l, respectively. Apparent volume of distribution and apparent oral clearance were 50.9±61.3 l/kg and 173.4±111.2 l/h, respectively. There were a significant correlation (r =0.84; p<0.05) between the PQ amount ingested and Cmax. AUCinf also showed a significant correlation (r =0.83; p<0.05) with the PQ amount ingested. These correlations provide evidence that PQ has dose-linear toxicokinetic characteristics.
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Affiliation(s)
- Hak-Jae Kim
- Department of Clinical Pharmacology, Soonchunhyang University College of Medicine, Cheonan 31151, Korea
| | - Hyung-Ki Kim
- Department of Clinical Pharmacology, Soonchunhyang University College of Medicine, Cheonan 31151, Korea
| | - Hwayoung Lee
- Department of Clinical Pharmacology, Soonchunhyang University College of Medicine, Cheonan 31151, Korea
| | - Jun-Seok Bae
- Department of Clinical Pharmacology, Soonchunhyang University College of Medicine, Cheonan 31151, Korea
| | - Jun-Tack Kown
- Department of Clinical Pharmacology, Soonchunhyang University College of Medicine, Cheonan 31151, Korea
| | - Hyo-Wook Gil
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan 31151, Korea
| | - Sae-Yong Hong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan 31151, Korea
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Abnormal pancreatic enzymes and their prognostic role after acute paraquat poisoning. Sci Rep 2015; 5:17299. [PMID: 26603772 PMCID: PMC4658566 DOI: 10.1038/srep17299] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 10/26/2015] [Indexed: 02/07/2023] Open
Abstract
Ingestion of paraquat causes multi-organ failure. Prognosis is best estimated through
measurement of blood paraquat concentrations but this facility is not available in
most hospitals. We studied the prognostic significance of abnormal pancreatic
enzymes for survival. Patients with acute paraquat poisoning were recruited. An
extensive series of blood tests including serum amylase were serially checked.
Patients were sorted according to their serum amylase activity (normal
[<220 U/L], mildly elevated [220 to 660 U/L],
elevated [>660 U/L]), and survival compared between groups. 177
patients were enrolled to the study, of whom 67 died and 110 survived. 122 (70.62%),
27 (15.25%) and 25 (14.13%) patients were in the normal, mildly elevated and
elevated amylase activity groups, respectively. The case fatality in the elevated
group was 100% compared to 17% in the normal group
(P < 0.001). We found four independent factors for
paraquat death prediction: amylase, PaCO2, leukocyte number, and
neutrophil percentage. Models using pancreatic enzyme activity showed good
prediction power. We have found that abnormal pancreatic enzymes are useful
prognostic marker of death after acute paraquat poisoning. Including serum amylase
activity into a prognostic model provides a good prognostication.
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Zhou CY, Kang X, Li CB, Li XH, Liu Y, Wang Z, Wang L, Wu T, Mohan C, Hu DY, Peng A. Pneumomediastinum predicts early mortality in acute paraquat poisoning. Clin Toxicol (Phila) 2015; 53:551-6. [PMID: 26072933 DOI: 10.3109/15563650.2015.1046183] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
CONTEXT In paraquat (PQ) poisoning, death often occurs after the appearance of pneumomediastinum (PM). However, the clinical features and eventual outcome of PM in PQ intoxication remains unclear. OBJECTIVE We aimed to characterize PM following PQ poisoning and its prognostic value for predicting mortality. MATERIALS AND METHODS Enrolled PQ-poisoned patients (n = 75) were divided into two groups according to whether PM could be detected by chest computed tomography or not. The study outcomes included 5- and 90-day death after intoxication. Survival curves were derived using the Kaplan-Meier method, and mortality risk factors were analyzed by forward stepwise Cox regression analysis. RESULTS PM was documented in 21.3% of the patients (16/75); in 13 of them PM set in within 3 days of PQ ingestion. 15 patients died within 3 days of appearance of PM. Compared with patients without PM, those with PM were younger (P = 0.011), and had higher scores of Acute Physiology and Chronic Health Evaluation (P < 0.001) and Sequential Organ Failure Assessment (P = 0.003). In addition, patients with PM had a higher incidence of acute renal failure (P = 0.001), toxic hepatitis (P = 0.008), and respiratory insufficiency (P = 0.003). PM predicted an increased risk of 90-day death (93.8% of patients with PM vs. 40.7% among those without PM; hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.0-5.6; P = 0.045), and increased risk of 5-day death (81.3% vs. 27.1%; HR, 3.2; 95% CI, 1.2-8.1; P = 0.017). DISCUSSION AND CONCLUSION Early PM, occurring within 8 days, is a specific predictor of mortality in PQ poisoning.
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Affiliation(s)
- Chun-Yu Zhou
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine , Shanghai , PR China
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The volume ratio of ground glass opacity in early lung CT predicts mortality in acute paraquat poisoning. PLoS One 2015; 10:e0121691. [PMID: 25830638 PMCID: PMC4382148 DOI: 10.1371/journal.pone.0121691] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 02/14/2015] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Pulmonary injury is the main cause of death in acute paraquat (PQ) poisoning. However, whether quantitative lung computed tomography (CT) can be useful in predicting the outcome of PQ poisoning remains unknown. We aimed to identify early findings of quantitative lung CT as predictors of outcome in acute PQ poisoning. METHODS Lung CT scanning (64-slide) and quantitative CT lesions were prospectively measured for patients after PQ intoxication within 5 days. The study outcome was mortality during 90 days follow-up. Survival curves were derived by the Kaplan-Meier method, and mortality risk factors were analyzed by the forward stepwise Cox regression analysis. RESULTS Of 97 patients, 41 (42.3%) died. Among the eight different types of lung CT findings which appeared in the first 5-day of PQ intoxication, four ones discriminated between survivors and non-survivors including ground glass opacity (GGO), consolidation, pneumomediastinum and "no obvious lesion". With a cutoff value of 10.8%, sensitivity of 85.4% and specificity of 89.3%, GGO volume ratio is better than adopted outcome indicators in predicting mortality, such as estimated amount of PQ ingestion, plasma or urine PQ concentration, acute physiology and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores. GGO volume ratios above 10.8% were associated with increased mortality (hazard ratio, 5.82; 95% confidence interval, 4.77-7.09; P < 0.001). CONCLUSIONS The volume ratio of GGO exceeding 10.8% is a novel, reliable and independent predictors of outcome in acute PQ poisoning.
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Hong SY, Lee JS, Sun IO, Lee KY, Gil HW. Prediction of patient survival in cases of acute paraquat poisoning. PLoS One 2014; 9:e111674. [PMID: 25415592 PMCID: PMC4240538 DOI: 10.1371/journal.pone.0111674] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 10/06/2014] [Indexed: 11/18/2022] Open
Abstract
Paraquat concentration-time data have been used to predict the clinical outcome following ingestion. However, these studies have included only small populations, although paraquat poisoning has a very high mortality rate. The purpose of this study was to develop a simple and reliable model to predict survival according to the time interval post-ingestion in patients with acute paraquat poisoning. Data were retrospectively collected for patients who were admitted with paraquat poisoning to Soonchunhyang University Choenan Hospital between January 2005 and December 2012. Plasma paraquat levels were measured using high-performance liquid chromatography. To validate the model we developed, we used external data from 788 subjects admitted to the Presbyterian Medical Center, Jeonju, Korea, between January 2007 and December 2012. Two thousand one hundred thirty six patients were included in this study. The overall survival rate was 44% (939/2136). The probability of survival for any specified time and concentration could be predicted as (exp(logit))/(1+exp(logit)), where logit = 1.3544+[−3.4688×log10(plasma paraquat μg/M)]+[−2.3169×log10(hours since ingestion)]. The external validation study showed that our model was highly accurate for the prediction of survival (C statics 0.964; 95% CI [0.952–0.975]). We have developed a model that is effective for predicting survival after paraquat intoxication.
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Affiliation(s)
- Sae-Yong Hong
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
| | - Ji-Sung Lee
- Biostatistical Consulting Unit, Soonchunhyang University Medical Center, Seoul, Korea
| | - In O. Sun
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Kwang-Young Lee
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Hyo-Wook Gil
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan, Republic of Korea
- * E-mail:
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Gao Y, Zhang X, Yang Y, Li W. Early haemoperfusion with continuous venovenous haemofiltration improves survival of acute paraquat-poisoned patients. J Int Med Res 2014; 43:26-32. [PMID: 25391306 DOI: 10.1177/0300060514549782] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective To determine whether haemoperfusion (HP) with continuous venovenous haemofiltration (CVVH) improves the survival of patients with acute paraquat poisoning, compared with those treated using HP alone. Methods Medical records of patients with acute paraquat poisoning were analysed. Patients were randomised to undergo HP or HP + CVVH within 24 h of paraquat ingestion. Mortality rate, survival duration and cause of death were recorded. Results There were no significant differences in mortality rate between the HP group ( n = 458) and the HP + CVVH group ( n = 226) (57.4% and 58.4%, respectively). The mean survival duration was significantly longer in the HP + CVVH group than the HP group (8.6 ± 3.1 and 5.1 ± 2.3 days, respectively). Early circulatory collapse was a major cause of death in the HP group. The major cause of death in the HP + CVVH group was late respiratory failure. Conclusion Combined therapy with HP and CVVH can prevent early death and prolong survival duration following acute paraquat poisoning, providing the opportunity for further treatment.
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Affiliation(s)
- Yanxia Gao
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Xiaofan Zhang
- Emergency Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Yanjie Yang
- Department of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Wenlu Li
- Department of Stomatology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
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Li LR, Sydenham E, Chaudhary B, Beecher D, You C. Glucocorticoid with cyclophosphamide for paraquat-induced lung fibrosis. Cochrane Database Syst Rev 2014:CD008084. [PMID: 25099931 DOI: 10.1002/14651858.cd008084.pub4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Paraquat is an effective and widely used herbicide but is also a lethal poison. In many developing countries paraquat is widely available and inexpensive, making poisoning prevention difficult. However most of the people who become poisoned from paraquat have taken it as a means of suicide.Standard treatment for paraquat poisoning both prevents further absorption and reduces the load of paraquat in the blood through haemoperfusion or haemodialysis. The effectiveness of standard treatments is extremely limited.The immune system plays an important role in exacerbating paraquat-induced lung fibrosis. Immunosuppressive treatment using glucocorticoid and cyclophosphamide in combination is being developed and studied. OBJECTIVES To assess the effects of glucocorticoid with cyclophosphamide on mortality in patients with paraquat-induced lung fibrosis. SEARCH METHODS The most recent search was run on the 15th April 2014. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (Ovid), ISI WOS (SCI-EXPANDED, SSCI, CPCI-S & CPSI-SSH), trials registries, Chinese databases (, , ) and reference lists. SELECTION CRITERIA RCTs were included in this review. All patients were to receive standard care, plus the intervention or control. The intervention was glucocorticoid with cyclophosphamide in combination versus a control of a placebo, standard care alone or any other therapy in addition to standard care. DATA COLLECTION AND ANALYSIS The mortality risk ratio (RR) and 95% confidence interval (CI) was calculated for each study on an intention-to-treat basis. Data for all-cause mortality at final follow-up were summarised in a meta-analysis using a fixed-effect model. MAIN RESULTS This systematic review includes three trials with a combined total of 164 participants who had moderate to severe paraquat poisoning. Patients who received glucocorticoid with cyclophosphamide in addition to standard care had a lower risk of death at final follow-up than those receiving standard care only (RR 0.72; 95% CI 0.59 to 0.89). AUTHORS' CONCLUSIONS Based on the findings of three small RCTs of moderate to severely poisoned patients, glucocorticoid with cyclophosphamide in addition to standard care may be a beneficial treatment for patients with paraquat-induced lung fibrosis. To enable further study of the effects of glucocorticoid with cyclophosphamide for patients with moderate to severe paraquat poisoning, hospitals may provide this treatment as part of an RCT with allocation concealment.
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Affiliation(s)
- Luying Ryan Li
- Department of Neurosurgery, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, Sichuan, China, 610041
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QTc prolongation as a useful prognostic factor in acute paraquat poisoning. J Emerg Med 2014; 47:401-7. [PMID: 25060011 DOI: 10.1016/j.jemermed.2014.02.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 12/10/2013] [Accepted: 02/08/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Acute paraquat poisoning has a high mortality rate. Several prognostic factors have been proposed to predict the mortality risk of paraquat-poisoned patients. However, these prognostic factors are complex and some require a laboratory. Corrected QT (QTc) has been used as a prognostic factor in several clinical conditions, such as acute organophosphate poisoning. In addition, the measurement can be obtained in a reasonable amount of time. STUDY OBJECTIVES This study's objective was to investigate whether QTc can predict mortality in paraquat-poisoned patients. METHODS This was a retrospective study. Potential prognostic factors such as QTc, vital signs at admission, and certain biochemistry variables were analyzed with Cox regression analyses for their ability to predict a patient's survival from paraquat poisoning. RESULTS Sixty acute paraquat-poisoned patients were admitted to the emergency department during the study period. The QTc of the survival group ranged from 0.35 to 0.48 s, whereas the nonsurvivor group ranged from 0.32 to 0.63 s. The nonsurvivor group contained a higher percentage of patients with QTc prolongation (≥0.45 s) compared with the survivor group (p = 0.04). The hazard ratio of QTc prolongation for a patient's death was found to be 2.47 (95% confidence interval [CI] 1.68-5.67) in patients with a lower potassium level (<3.2 mEq/L) and 3.71 (95% CI 1.53-8.97) in patients with a higher potassium level (≥3.2 mEq/L). In addition, hyperdynamic circulation was observed upon admission of these poisoned patients. CONCLUSION QTc prolongation is a useful prognostic factor for predicting death in acute paraquat-poisoned patients. Cardiovascular collapse may occur in some paraquat-poisoned patients. Physicians can use QTc as an indicator of a patient's severity of poisoning and mortality risk.
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Sun L, Li GQ, Yan PB, Liu Y, Li GF, Wei LQ. Prediction of outcome following paraquat poisoning by arterial lactate concentration-time data. Exp Ther Med 2014; 8:652-656. [PMID: 25009635 PMCID: PMC4079403 DOI: 10.3892/etm.2014.1773] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Accepted: 05/06/2014] [Indexed: 11/10/2022] Open
Abstract
The present study retrospectively analyzed 170 patients diagnosed with paraquat (PQ) poisoning with the aim of clarifying whether the arterial lactate-time (arterial lactate concentration × time between ingestion and arterial lactate measurement) was a good predictor of mortality in patients with acute PQ poisoning. The results indicated that there was a positive correlation between the arterial lactate-time and PQ concentration-time (ρ=0.485). In addition, the arterial lactate-time data exhibited a similar discriminative power to the plasma PQ concentration-time data (z=0.712; P=0.864). For the receiver operating characteristic curve analysis, the lactate-time data had an area of 0.782 with a cut-off value of 11.95 mmol/l.h (sensitivity, 64.52%; specificity, 84.42%). To calculate the predicted probability of survival for any specified time and initial arterial lactate concentration, the following formula was derived based on the logistic regression coefficients: Logit(p) = 3.066 − 0.139 × (time lag following PQ ingestion) − 0.177 × (initial arterial lactate concentration); where the probability of survivors = 1/1 + e−logit(p). Therefore, the arterial lactate-time data exhibited a good predictive power for evaluating the prognosis of patients with acute PQ poisoning.
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Affiliation(s)
- Liang Sun
- Department of Respiratory and Critical Care Medicine, Pingjin Hospital, Logistics University of the Chinese People's Armed Police Forces, Tianjin 300162, P.R. China
| | - Guo-Qiang Li
- Department of Respiratory and Critical Care Medicine, Pingjin Hospital, Logistics University of the Chinese People's Armed Police Forces, Tianjin 300162, P.R. China
| | - Peng-Bo Yan
- Department of Respiratory and Critical Care Medicine, Pingjin Hospital, Logistics University of the Chinese People's Armed Police Forces, Tianjin 300162, P.R. China
| | - Yang Liu
- Department of Respiratory and Critical Care Medicine, Pingjin Hospital, Logistics University of the Chinese People's Armed Police Forces, Tianjin 300162, P.R. China
| | - Guo-Feng Li
- Department of Respiratory and Critical Care Medicine, Pingjin Hospital, Logistics University of the Chinese People's Armed Police Forces, Tianjin 300162, P.R. China
| | - Lu-Qing Wei
- Department of Respiratory and Critical Care Medicine, Pingjin Hospital, Logistics University of the Chinese People's Armed Police Forces, Tianjin 300162, P.R. China
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Ghannoum M, Roberts DM, Hoffman RS, Ouellet G, Roy L, Decker BS, Bouchard J. A stepwise approach for the management of poisoning with extracorporeal treatments. Semin Dial 2014; 27:362-70. [PMID: 24697864 DOI: 10.1111/sdi.12228] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of an extracorporeal treatment (ECTR) in a poisoned patient may be life-saving in a limited number of scenarios. The decision-processes surrounding the use of ECTR in poisoning is complex: most nephrologists are not trained to assess a poisoned patient while clinical toxicologists rarely prescribe ECTRs. Deciding on which ECTR is most appropriate for a poison requires a good understanding of the poison's physicochemical and pharmacokinetic properties. Further, a detailed understanding of the capabilities and limitations of the different ECTRs can be useful to select the most appropriate ECTR for a given clinical situation. This manuscript provides a stepwise approach to assess the usefulness of ECTRs in poisoning.
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Affiliation(s)
- Marc Ghannoum
- Department of Nephrology, Verdun Hospital, University of Montreal, Montreal, Canada
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Sun S, Li F, Liu F, Wang J, Peng X. Fluorescence detecting of paraquat using host-guest chemistry with cucurbit[8]uril. Sci Rep 2014; 4:3570. [PMID: 24389647 PMCID: PMC3880963 DOI: 10.1038/srep03570] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/25/2013] [Indexed: 01/04/2023] Open
Abstract
Paraquat (PQ) is one of the most widely used herbicides in the world, which has a good occupational safety record when used properly. While, it presents high mortality index after intentional exposure. Accidental deaths and suicides from PQ ingestion are relatively common in developing countries with an estimated 300,000 deaths occurring in the Asia–Pacific region alone each year, and there are no specific antidotes. Good predictors of outcome and prognosis may be plasma and urine testing within the first 24 h of intoxication. A fluorescence enhancement of approximately 30 times was seen following addition of PQ to a solution of the supramolecular compound 2MB@CB[8], which comprised two methylene blue (MB) molecules within one cucurbit[8]uril (CB[8]) host molecule. The fluorescence intensity was linearly proportional to the amount of PQ added over the concentration range 2.4 × 10−10 M–2.5 × 10−4 M. The reaction also occurred in living cells and within live mice.
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Affiliation(s)
- Shiguo Sun
- 1] State Key Laboratory of Fine Chemicals, Dalian University of Technology, E 224 West Campus, No. 2, Linggonglu, 116024, Dalian, China [2]
| | - Fusheng Li
- 1] State Key Laboratory of Fine Chemicals, Dalian University of Technology, E 224 West Campus, No. 2, Linggonglu, 116024, Dalian, China [2]
| | - Fengyu Liu
- 1] School of Chemistry, Dalian University of Technology, No. 2, Linggonglu, 116024, Dalian, China [2]
| | - Jitao Wang
- State Key Laboratory of Fine Chemicals, Dalian University of Technology, E 224 West Campus, No. 2, Linggonglu, 116024, Dalian, China
| | - Xiaojun Peng
- State Key Laboratory of Fine Chemicals, Dalian University of Technology, E 224 West Campus, No. 2, Linggonglu, 116024, Dalian, China
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Gao L, Liu J, Wang C, Liu G, Niu X, Shu C, Zhu J. Fast determination of paraquat in plasma and urine samples by solid-phase microextraction and gas chromatography-mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2013; 944:136-40. [PMID: 24316524 DOI: 10.1016/j.jchromb.2013.10.028] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 10/15/2013] [Accepted: 10/18/2013] [Indexed: 10/26/2022]
Abstract
A simple, sensitive and reliable gas chromatographic-mass spectrometric method (GC-MS) for quantifying paraquat concentration in biological samples has been developed, using ethyl paraquat as an internal standard. The method involved the procedures of sodium borohydride-nickel chloride (NaBH4-NiCl2) reduction and solid-phase microextraction (SPME) of the perhydrogenated products. GC-MS was used to identify and quantify the analytes in selected ion monitoring (SIM) mode. Under the optimal conditions, recoveries in plasma and urine samples were 94.00-99.85% and 95.00-100.34%, respectively. Excellent sample clean-up was observed and good linearities (r=0.9982 for plasma sample and 0.9987 for urine sample) were obtained in the range of 0.1-50μg/mL. The limits of detection (S/N=3) were 0.01μg/mL in plasma and urine samples. The intra-day precision was less than 8.43%, 4.19% (n=3), and inter-day precision was less than 10.90%, 10.49% (n=5) for plasma and urine samples, respectively. This method was successfully applied to the analysis of the biological samples collected from a victim who died as a result of ingestion of paraquat.
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Affiliation(s)
- Lina Gao
- School of Pharmacy, China Medical University, Shenyang 110001, PR China
| | - Junting Liu
- School of Pharmacy, China Medical University, Shenyang 110001, PR China.
| | - Chunyuan Wang
- School of Pharmacy, China Medical University, Shenyang 110001, PR China
| | - Guojie Liu
- College of Basic Medical Science, China Medical University, Shenyang 110001, PR China
| | - Xiaodong Niu
- School of Pharmacy, China Medical University, Shenyang 110001, PR China
| | - Cuixia Shu
- School of Pharmacy, China Medical University, Shenyang 110001, PR China
| | - Juan Zhu
- School of Pharmacy, China Medical University, Shenyang 110001, PR China
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Sun IO, Lee KY. Cyclophosphamide dose: how much is needed to win the war against paraquat poisoning? Korean J Intern Med 2013; 28:410-2. [PMID: 23864798 PMCID: PMC3712148 DOI: 10.3904/kjim.2013.28.4.410] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 05/09/2013] [Indexed: 01/20/2023] Open
Affiliation(s)
- In O Sun
- Division of Nephrology and Toxicology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
| | - Kwang Young Lee
- Division of Nephrology and Toxicology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea
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P. LEXIKON DER MEDIZINISCHEN LABORATORIUMSDIAGNOSTIK 2013. [PMCID: PMC7123940 DOI: 10.1007/978-3-642-12921-6_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hsu CW, Lin JL, Lin-Tan DT, Chen KH, Yen TH, Wu MS, Lin SC. Early hemoperfusion may improve survival of severely paraquat-poisoned patients. PLoS One 2012; 7:e48397. [PMID: 23144759 PMCID: PMC3483292 DOI: 10.1371/journal.pone.0048397] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 09/25/2012] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thousands of paraquat (PQ)-poisoned patients continue to die, particularly in developing countries. Although animal studies indicate that hemoperfusion (HP) within 2-4 h after intoxication effectively reduces mortality, the effect of early HP in humans remains unknown. METHODS We analyzed the records of all PQ-poisoned patients admitted to 2 hospitals between 2000 and 2009. Patients were grouped according to early or late HP and high-dose (oral cyclophosphamide [CP] and intravenous dexamethasone [DX]) or repeated pulse (intravenous methylprednisolone [MP] and CP, followed by DX and repeated MP and/or CP) PQ therapy. Early HP was defined as HP <4 h, and late HP, as HP ≥ 4 h after PQ ingestion. We evaluated the associations between HP <4 h, <5 h, <6 h, and <7 h after PQ ingestion and the outcomes. Demographic, clinical, laboratory, and mortality data were analyzed. RESULTS The study included 207 severely PQ-poisoned patients. Forward stepwise multivariate Cox hazard regression analysis showed that early HP <4 h (hazard ratio [HR] = 0.38, 95% confidence interval (CI) 0.16-0.86; P = 0.020) or HP <5 h (HR = 0.60, 95% CI: 0.39-0.92; P = 0.019) significantly decreased the mortality risk. Further analysis showed that early HP reduced the mortality risk only in patients treated with repeated pulse therapy (n = 136), but not high-dose therapy (n = 71). Forward stepwise multivariate Cox hazard regression analysis showed that HP <4.0 h (HR = 0.19, 95% CI: 0.05-0.79; P = 0.022) or <5.0 h (HR = 0.49, 95% CI: 0.24-0.98; P = 0.043) after PQ ingestion significantly decreased the mortality risk in repeated pulse therapy patients, after adjustment for relevant variables. CONCLUSION The results showed that early HP after PQ exposure might be effective in reducing mortality in severely poisoned patients, particularly in those treated with repeated pulse therapy.
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Affiliation(s)
- Ching-Wei Hsu
- Division of Clinical Toxicology, Department of Nephrology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taoyuan, Taiwan, Republic of China
- Chang Gung University and School of Medicine, Taoyuan, Taiwan, Republic of China
| | - Ja-Liang Lin
- Division of Clinical Toxicology, Department of Nephrology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taoyuan, Taiwan, Republic of China
- Chang Gung University and School of Medicine, Taoyuan, Taiwan, Republic of China
| | - Dan-Tzu Lin-Tan
- Division of Clinical Toxicology, Department of Nephrology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taoyuan, Taiwan, Republic of China
- Chang Gung University and School of Medicine, Taoyuan, Taiwan, Republic of China
| | - Kuan-Hsing Chen
- Division of Clinical Toxicology, Department of Nephrology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taoyuan, Taiwan, Republic of China
- Chang Gung University and School of Medicine, Taoyuan, Taiwan, Republic of China
| | - Tzung-Hai Yen
- Division of Clinical Toxicology, Department of Nephrology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taoyuan, Taiwan, Republic of China
- Chang Gung University and School of Medicine, Taoyuan, Taiwan, Republic of China
| | - Mai-Szu Wu
- Chang Gung University and School of Medicine, Taoyuan, Taiwan, Republic of China
- Department of Nephrology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan, Republic of China
| | - Shih-Chieh Lin
- Division of Clinical Toxicology, Department of Nephrology, Chang Gung Memorial Hospital, Lin-Kou Medical Center, Taoyuan, Taiwan, Republic of China
- Chang Gung University and School of Medicine, Taoyuan, Taiwan, Republic of China
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Yang CJ, Lin JL, Lin-Tan DT, Weng CH, Hsu CW, Lee SY, Lee SH, Chang CM, Lin WR, Yen TH. Spectrum of toxic hepatitis following intentional paraquat ingestion: analysis of 187 cases. Liver Int 2012; 32:1400-6. [PMID: 22672665 DOI: 10.1111/j.1478-3231.2012.02829.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 05/06/2012] [Indexed: 12/11/2022]
Abstract
INTRODUCTION This retrospective observational study examined the clinical features, the degrees of toxic hepatitis, physiological markers and clinical outcomes after intentional paraquat poisoning and sought to determine what association, if any, might exist between these findings. METHODS A total of 187 patients were referred for management of intentional paraquat ingestion between 2000 and 2010. Patients were categorized into two groups according to their hepatic complication, i.e. with (N = 87) or without (N = 100) toxic hepatitis. Demographic, clinical and laboratory data were obtained for analysis. Mortality rates were also analysed. RESULTS It was found that patients with toxic hepatitis were younger (39.7 ± 13.7 vs 44.2 ± 16.6 year old, P = 0.046), and suffered from greater incidences of acute respiratory failure (63.2 vs 48.0%, P = 0.037) and acute renal failure (75.9 vs 56.0%, P = 0.004) than patients without hepatitis. The hospitalization period was longer in patients with hepatitis than without hepatitis (16.2 ± 14.6 vs 11.2 ± 12.1 days, P = 0.012), even though there was no difference in mortality rate between both groups (56.3 vs 53.0%, P = 0.649). Notably, the symptoms of toxic hepatitis developed within 6.7 ± 6.3 days of exposure to paraquat with aspartate aminotransferase (AST) 138 ± 156 U/L, alanine aminotransferase (ALT) 127 ± 114 U/L and total bilirubin 2.7 ± 2.6 mg/dL. The hepatitis peaked at 9.5 ± 8.8 days with AST 125 ± 139 U/L, ALT 183 ± 181 U/L and total bilirubin 3.2 ± 3.6 mg/dL. Nevertheless, the symptoms resolved within 17.3 ± 9.8 days of paraquat exposure, and none of the patients died of hepatic complication. CONCLUSIONS A substantial proportion of paraquat patients suffered from hepatic complication (46.52%), but the spectrum of hepatitis in these patients seemed mild and transient.
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Affiliation(s)
- Chin-Jung Yang
- Department of Nephrology and Division of Clinical Toxicology, Chang Gung Memorial Hospital, Taipei, Taiwan
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Li LR, Sydenham E, Chaudhary B, You C. Glucocorticoid with cyclophosphamide for paraquat-induced lung fibrosis. Cochrane Database Syst Rev 2012:CD008084. [PMID: 22786512 DOI: 10.1002/14651858.cd008084.pub3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Paraquat is an effective and widely used herbicide but is also a lethal poison. In many developing countries paraquat is widely available and inexpensive, making poisoning prevention difficult. However most of the people who become poisoned from paraquat have taken it as a means of suicide.Standard treatment for paraquat poisoning both prevents further absorption and reduces the load of paraquat in the blood through haemoperfusion or haemodialysis. The effectiveness of standard treatments is extremely limited.The immune system plays an important role in exacerbating paraquat-induced lung fibrosis. Immunosuppressive treatment using glucocorticoid and cyclophosphamide in combination is being developed and studied. OBJECTIVES To assess the effects of glucocorticoid with cyclophosphamide on mortality in patients with paraquat-induced lung fibrosis. SEARCH METHODS To identify randomised controlled trials (RCTs) on this topic, we searched the Cochrane Injuries Group's Specialised Register (searched 1 February 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (Ovid SP) (1946 January Week 3 2012), EMBASE (Ovid SP) (1947 to Week 4 2012), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to January 2012), ISI Web of Science: Conference Proceedings Citation Index - Science (CPCI-S) (1990 to January 2012), Chinese Biomedical Literature and Retrieval System (CBM) (1978 to April 2012), Chinese Medical Current Contents (CMCC) (1995 to April 2012), and Chinese Medical Academic Conference (CMAC) (1994 to April 2012). Searches were completed on English language databases on 1 February 2012 and on Chinese language databases on 12 April 2012. SELECTION CRITERIA RCTs were included in this review. All patients were to receive standard care, plus the intervention or control. The intervention was glucocorticoid with cyclophosphamide in combination versus a control of a placebo, standard care alone or any other therapy in addition to standard care. DATA COLLECTION AND ANALYSIS The mortality risk ratio (RR) and 95% confidence interval (CI) was calculated for each study on an intention-to-treat basis. Data for all-cause mortality at final follow-up were summarised in a meta-analysis using a fixed-effect model. MAIN RESULTS This systematic review includes three trials with a combined total of 164 participants who had moderate to severe paraquat poisoning. Patients who received glucocorticoid with cyclophosphamide in addition to standard care had a lower risk of death at final follow-up than those receiving standard care only (RR 0.72; 95% CI 0.59 to 0.89). AUTHORS' CONCLUSIONS Based on the findings of three small RCTs of moderate to severely poisoned patients, glucocorticoid with cyclophosphamide in addition to standard care may be a beneficial treatment for patients with paraquat-induced lung fibrosis. To enable further study of the effects of glucocorticoid with cyclophosphamide for patients with moderate to severe paraquat poisoning, hospitals may provide this treatment as part of an RCT with allocation concealment.
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Affiliation(s)
- Luying Ryan Li
- Department of Neurosurgery,West China Hospital, Sichuan University, Chengdu, China.
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Abstract
Poisoning by paraquat herbicide is a major medical problem in parts of Asia while sporadic cases occur elsewhere. The very high case fatality of paraquat is due to inherent toxicity and lack of effective treatments. We conducted a systematic search for human studies that report toxicokinetics, mechanisms, clinical features, prognosis and treatment. Paraquat is rapidly but incompletely absorbed and then largely eliminated unchanged in urine within 12-24 h. Clinical features are largely due to intracellular effects. Paraquat generates reactive oxygen species which cause cellular damage via lipid peroxidation, activation of NF-κB, mitochondrial damage and apoptosis in many organs. Kinetics of distribution into these target tissues can be described by a two-compartment model. Paraquat is actively taken up against a concentration gradient into lung tissue leading to pneumonitis and lung fibrosis. Paraquat also causes renal and liver injury. Plasma paraquat concentrations, urine and plasma dithionite tests and clinical features provide a good guide to prognosis. Activated charcoal and Fuller's earth are routinely given to minimize further absorption. Gastric lavage should not be performed. Elimination methods such as haemodialysis and haemoperfusion are unlikely to change the clinical course. Immunosuppression with dexamethasone, cyclophosphamide and methylprednisolone is widely practised, but evidence for efficacy is very weak. Antioxidants such as acetylcysteine and salicylate might be beneficial through free radical scavenging, anti-inflammatory and NF-κB inhibitory actions. However, there are no published human trials. The case fatality is very high in all centres despite large variations in treatment.
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Affiliation(s)
- Indika B Gawarammana
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
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[Paraquat poisoning. Case report and overview]. Med Klin Intensivmed Notfmed 2012; 107:270-4. [PMID: 22349538 DOI: 10.1007/s00063-011-0074-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 12/01/2011] [Accepted: 12/04/2011] [Indexed: 10/28/2022]
Abstract
Paraquat poisoning in Germany is rare. Because plasma levels do not necessarily match the ingested amount of paraquat, repeated measurement of plasma levels is imperative. There is a large potential in the prehospital phase to improve prognosis: further resorption must be terminated by rigorous charcoal administration and early tracheal intubation if necessary. Because paraquat can be resorbed by dermal contact, steps to ensure sufficient protection of emergency medical personnel must be taken.As soon as further resorption has been prevented sufficiently, forced diuresis, renal replacement therapy, and hemoperfusion can be of help, but still remain controversial. To reduce pulmonary fibrosis, inspiratory oxygen concentrations must be adjusted to the minimal amount needed to ensure satisfactory tissue oxygenation. Data supporting the advantageous use of cyclophosphamide combined with methylprednisolone for the treatment of pulmonary fibrosis were recently published. Since the toxic mechanism implies a mismatch of oxidants and anti-oxidants, co-administration of ascorbic acid and N-acetylcysteine are simple treatments with few side effects.
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Yeo CD, Kim JW, Kim YO, Yoon SA, Kim KH, Kim YS. The role of pentraxin-3 as a prognostic biomarker in paraquat poisoning. Toxicol Lett 2011; 212:157-60. [PMID: 22210019 DOI: 10.1016/j.toxlet.2011.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 11/02/2011] [Accepted: 12/14/2011] [Indexed: 01/21/2023]
Abstract
Paraquat poisoning has been a public health problem in both the developing and developed countries. Pentraxin 3 is a member of the pentraxin family which is expressed as part of the acute-phase response that begins after injury, trauma, and infection. The aim of our study is to determine whether PTX3 levels can be a significant marker of pulmonary fibrosis and outcome of survival in paraquat poisoning. To measure the plasma paraquat level, we collected serum of the patients immediately after admission. EDTA plasma samples for checking the plasma PTX3 concentration were taken before and after the 1st hemoperfusion and after the 2nd hemoperfusion therapy. PTX3 concentrations in EDTA plasma were determined using a commercial solid-phase enzyme-linked immunosorbent assay (ELISA). Plasma paraquat concentration was higher in survivors than in non-survivors (p<0.05). Maximal plasma PTX3 level was significantly higher in the pulmonary fibrosis group, and plasma PTX3 was significantly increased throughout hemoperfusion therapy (p<0.01). Moreover, increase in PTX3 was greater in non-survivors than survivors (p<0.05). Our results show that PTX3 is a useful biomarker of severity and outcome predictor in paraquat poisoning.
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Affiliation(s)
- Chang-Dong Yeo
- Division of Pulmonology, Department of Internal Medicine, Uijeongbu St. Mary's Hospital, School of Medicine, Catholic University of Korea, Seoul, Republic of Korea
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