Abnormal pancreatic enzymes and their prognostic role after acute paraquat poisoning

Liver injury in paraquat poisoning: A retrospective cohort study

BACKGROUND AND AIMS

Liver injury is one of the common complications of paraquat (PQ) poisoning, but whether the degree of liver injury is related to patient prognosis is still controversial. This study aimed to investigate whether liver injury was a risk factor for death in PQ-poisoned patients.

METHODS

We conducted a retrospective cohort study of PQ-poisoned patients from the past 10 years (2011-2020) from a large tertiary academic medical centre in China. PQ-poisoned patients were divided into a normal liver function group (n = 580) and a liver injury group (n = 60). Propensity score matching (PSM) analysis was then performed.

RESULTS

A total of 640 patients with PQ poisoning were included in this study. To reduce the impact of bias, dose of PQ, urinary PQ concentration and time from poisoning to hospital admission were matched between the two groups. A 3:1 PSM analysis was performed, ultimately including 240 patients. Compared with the normal liver function group, patients in the liver injury group were older, had a higher R value ([ALT/ULN]/[ALP/ULN]) (p < .001) and had a higher mortality rate. Cox regression analysis showed that there was no significant association between alanine aminotransferase, alkaline phosphatase, total bilirubin levels and hazard of death, but age, PQ dose, creatine kinase isoenzyme, creatine kinase, white blood cell count, neutrophil percentage and lymphocyte percentage were associated with mortality in patients with PQ poisoning.

CONCLUSIONS

The occurrence of liver injury within 48 h after PQ poisoning was a risk factor for mortality, and such liver injury was likely of a hepatocellular nature. Age, PQ dose, creatine kinase isoenzyme and white blood cell count were positively correlated with mortality, while creatine kinase, percentage of neutrophils and lymphocytes were inversely correlated.

Comparison of Biochemical Parameters between Mouse Model and Human after Paraquat Poisoning

Background. This study was designed to investigate differences in biochemical parameters between mouse and humans after paraquat (PQ) poisoning and develop a suitable animal model for studying organ damage after PQ poisoning. The prognostic factors of PQ-poisoned patients were further analyzed. Methods. Thirty C57BL/6J mice were randomly divided into five groups (control, sham, and 3 PQ doses), and the mouse model was established by intragastric administration of PQ. Physiological indexes such as the body weight, mental state, and mortality rate were observed. Biochemical parameters were analyzed 24 h after PQ poisoning. We also performed a retrospective analysis of clinical data from 29 patients with PQ poisoning admitted to the Emergency Department of the Affiliated Hospital of Taishan Medical College between April 2016 and February 2018. Biochemical parameters were compared between the mouse model and patients with PQ poisoning. Results. In the PQ poisoning mouse model, the lethal dose group PQ360 showed remarkable increases in serum levels of potassium (K+), carbon dioxide (CO2), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) compared with the nonlethal dose PQ100 and PQ200 groups. The biochemical results of the patients showed that K+ and Cl- levels were significantly reduced in the death group compared to the survival group. Levels of ALT, AST, blood urea nitrogen (BUN), and amylase were higher, and the neutrophil-to-lymphocyte ratio (NLR) was increased in the death group compared with the survival group. Conclusions. The combination of age, PQ dosage, K+, Cl-, BUN, ALT, AST, amylase, and NLR can be used to more accurately predict the outcome of patients with PQ poisoning. C57 mice are an appropriate animal model to study liver and kidney functions following PQ exposure.

Homicidal paraquat poisoning: Poisoned while drinking

The incidence of paraquat poisoning has significantly decreased with the addition of odorizer and emetics to the liquid concentrate. Paraquat poisonings are usually attributed to suicidal and accidental or occupational exposure. Here, we report an unusual fatal case of homicidal paraquat poisoning. An intoxicated, a 37-year-old man consumed a mixture of white wine and paraquat prepared by his wife. This resulted in intermittent vomiting, which he attributed to being intoxicated. The man was admitted to the hospital for treatment 3 days later. Due to the lack of knowledge of paraquat exposure, the man did not receive effective treatment and died of respiratory failure 22 days later. High-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) was applied to detect paraquat in 16 postmortem specimens: kidney (1.31 ug/g), urine (0.91 ug/ml), liver (0.62 ug/g), lung (0.39 ug/g), muscle (0.35 ug/g), bile (0.32 ug/ml), heart (0.28 ug/g), brain (0.22 ug/g), pancreas (0.22 ug/g), spleen (0.18 ug/g), cardiac blood (0.15 ug/ml), cerebrospinal fluid (0.14 ug/ml), pericardial effusion (0.12 ug/ml), pleural effusion (0.09 ug/ml), peripheral blood (0.08 ug/ml), and vitreous humor (0.06 ug/ml). The highest concentration of paraquat was detected in the kidney followed by the urine in all tissues and body fluids. At present, although the cases of paraquat poisoning have decreased, the high mortality rate resulting from its irreversible lung damage and respiratory failure makes paraquat poisoning, especially occult paraquat poisoning, still needs to be carefully identified in forensic practice and clinical diagnosis.

Alveolar-arterial partial pressure difference as an early predictor for patients with acute paraquat poisoning

Objective

Paraquat (PQ) is associated with high mortality rates in acute poisoning. This study aimed to determine the importance of the alveolar–arterial partial pressure difference (A-aDo₂) in the expected consequences of acute PQ poisoning.

Methods

Patients who were hospitalized for PQ poisoning in 2018 were enrolled in this retrospective study. A-aDo₂ data were collected. Multivariate analysis was performed using binary logistic regression to determine whether A-aDo₂ is an independent risk factor for mortality from PQ.

Results

A total of 352 cases were analyzed. The mean PQ dose was 36.84 ± 50.30 mL (0.3–500 mL). There were 185 survivors and 167 non-survivors. The mean A-aDo₂ was not significantly correlated between survivors and non-survivors on day 1. However, there were significant differences in A-aDo₂ between survivors and non-survivors on days 3, 7, 14, and 21. Increased A-aDo₂ values were correlated with an increased mortality rate. The mean A-aDo₂ on day 14 showed the most significant difference between survivors and non-survivors.

Conclusion

Our study suggests that A-aDo₂ plays an important role as a reference index, which could be a useful predictor in assessing acute PQ poisoning, especially on the 14th day after onset of poisoning.

Effect of paraquat on cytotoxicity involved in oxidative stress and inflammatory reaction: A review of mechanisms and ecological implications

Paraquat (PQ) is a cheap and an effective herbicide, which is widely being used worldwide to remove weeds in cultivated crop fields. However, it can cause soil and water pollution, and pose serious harm to the environment and organisms. Several countries have started to limit or prohibit the use of PQ because of the increasing number of human deaths. Its toxicity can damage the organisms with a multi-target mechanism, which has not been fully understood yet. That is why it is hard to treat as well. The current research on PQ focuses on its targeted organ, the lungs, in which PQ mostly trigger pulmonary fibrosis. While there is a lack of systematic research, there are few studies published discussing its toxic effects at systematic level. This review summarizes the major damages caused by PQ in different organisms and partial mechanisms by which it causes these damages. For this purpose, we consulted several research articles that studied the toxicity of PQ in various tissues. We also listed some drugs that can be used to alleviate the toxicity of PQ. However, at present, the effectiveness of these drugs is still being explored in animal experiments and the study of their mechanism will also help in understanding the poisoning mechanism of PQ, which will ultimately lead to effective treatment in future.

Comparison of Pancreatic Damage in Rats for Two Methods of Paraquat Administration

It is noted that elevated serum amylase levels suggesting pancreatic damage has an association with prognosis in PQ patients. This study aimed to determine whether PQ can cause pancreatic damage. The two conventional models (intragastric infusion (iG) and intraperitoneal injection (iP)) may exhibit different effects on the pancreas depending on whether or not they pass through the digestive tract. In this study, the rats were divided into four groups: the intragastric infusion group (PQ-iG, n = 45), intraperitoneal injection group (PQ-iP, n = 53), normal control group 1 (NC-iG, n = 6) and normal control group 2 (NC-iP, n = 6). Pancreatic damage was compared between groups using serum amylase activity assay, hematoxylin and eosin (H&E) staining, TUNEL assay, and transmission electron microscopy (TEM). Serum amylase levels in group PQ-iG were significantly higher than in group PQ-iP (p < 0.05). Examination of the H&E sections showed damage to the pancreas. Both experimental groups were displayed inflammatory infiltration within 9 h of PQ treatment. After 9 h, patchy necrosis was observed in group PQ-iP, when inflammatory infiltration was still the dominant pathology. Necrosis appeared and gradually worsened in group PQ-iG, in which necrosis was the dominant pathology. The TUNEL assay showed significantly higher numbers of apoptotic cells in the pancreas of PQ-groups than in the control NC- groups (p < 0.05). TEM showed expansive endoplasmic reticulum lumens and mitochondria swelling in the pancreas of the PQ-groups. It is concluded that both methods of modeling could cause pancreatic damage and the type and degree of damage would change over time. Note that pancreatic damage in group PQ-iG was more severe than that in group PQ-iP. Therefore, clinical practitioners should pay close attention to pancreatic damage caused by PQ, especially when the route of PQ administration was oral.

Development and Validation of a Radiomics Nomogram for Prognosis Prediction of Patients with Acute Paraquat Poisoning: A Retrospective Cohort Study

Objective

To evaluate the efficiency of a radiomics model in predicting the prognosis of patients with acute paraquat poisoning (APP).

Materials and Methods

Chest computed tomography images and clinical data of 80 patients with APP were obtained from November 2014 to October 2017, which were randomly assigned to a primary group and a validation group by a ratio of 7 : 3, and then the radiomics features were extracted from the whole lung. Principal component analysis (PCA) and least absolute shrinkage and selection operator (LASSO) regression were used to select the features and establish the radiomics signature (Rad-score). Multivariate logistic regression analysis was used to establish a radiomics prediction model incorporating the Rad-score and clinical risk factors; the model was represented by nomogram. The performance of the nomogram was confirmed by its discrimination and calibration.

Result

The area under the ROC curve of operation was 0.942 and 0.865, respectively, in the primary and validation datasets. The sensitivity and specificity were 0.864 and 0.914 and 0.778 and 0.929, and the prediction accuracy rates were 89.5% and 87%, respectively. Predictors included in the individualized predictive nomograms include the Rad-score, blood paraquat concentration, creatine kinase, and serum creatinine. The AUC of the nomogram was 0.973 and 0.944 in the primary and validation datasets, and the sensitivity and specificity were 0.943 and 0.955, respectively, in the primary dataset and 0.889 and 0.929 in the validation dataset, and the prediction accuracy was 94.7% and 91.3%, respectively.

Conclusion

The radiomics nomogram incorporates the radiomics signature and hematological laboratory data, which can be conveniently used to facilitate the individualized prediction of the prognosis of APP patients.

Prognostic value of liver and kidney function parameters and their correlation with the ratio of urine-to-plasma paraquat in patients with paraquat poisoning

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.

A novel simple risk model to predict the prognosis of patients with paraquat poisoning

To identify risk factors and develop a simple model to predict early prognosis of acute paraquat (PQ) poisoning patients, we performed a retrospective cohort study of acute PQ poisoning patients (n = 1199). Patients (n = 913) with PQ poisoning from 2011 to 2018 were randomly divided into training (n = 609) and test (n = 304) samples. Another two independent cohorts were used as validation samples for a different time (n = 207) and site (n = 79). Risk factors were identified using a logistic model with Markov Chain Monte Carlo (MCMC) simulation and further evaluated using a latent class analysis. The prediction score was developed based on the training sample and was evaluated using the testing and validation samples. Eight factors, including age, ingestion volume, creatine kinase-MB [CK-MB], platelet [PLT], white blood cell [WBC], neutrophil counts [N], gamma-glutamyl transferase [GGT], and serum creatinine [Cr] were identified as independent risk indicators of in-hospital death events. The risk model had C statistics of 0.895 (95% CI 0.855-0.928), 0.891 (95% CI 0.848-0.932), and 0.829 (95% CI 0.455-1.000), and predictive ranges of 4.6-98.2%, 2.3-94.9%, and 0-12.5% for the test, validation_time, and validation_site samples, respectively. In the training sample, the risk model classified 18.4%, 59.9%, and 21.7% of patients into the high-, average-, and low-risk groups, with corresponding probabilities of 0.985, 0.365, and 0.03 for in-hospital death events. We developed and evaluated a simple risk model to predict the prognosis of patients with acute PQ poisoning. This risk scoring system could be helpful for identifying high-risk patients and reducing mortality due to PQ poisoning.

Serum Amylase and Lipase for the Prediction of Pancreatic Injury in Critically Ill Children Admitted to the PICU

OBJECTIVES

Pancreatic injury is multifactorial and potentially devastating for critically ill children. We aimed to evaluate whether serum amylase and lipase among critically ill children could serve as an independent biomarker to predict pancreatic injury.

DESIGN

Retrospective cohort.

SETTING

PICU of a tertiary, pediatric medical center.

PATIENTS

Seventy-nine autopsies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A group of 79 children who died of different causes were investigated by autopsy. They were divided into pancreatic injury group and pancreatic noninjury group according to autopsy findings. Data based on patients' demographics, vital signs, laboratory findings, and clinical features at admission were collected and compared. Logistic regression was used to identify predictive factors for pancreatic injury. Receiver operating characteristic curve was constructed for assessing serum amylase and serum lipase to predicting pancreatic injury. Forty-one patients (51.9%) exhibited the pathologic changes of pancreatic injury. The levels of lactate, erythrocyte sedimentation rate, alanine transaminase, aspartate transaminase, and troponin-I in the injury group were significantly higher than that in the noninjury group, whereas the level of calcium was significantly lower than that in the noninjury group (p < 0.05). Multivariable logistic regression analysis showed that serum amylase, serum lipase, and septic shock were significantly associated with the occurrence rate of pancreatic injury. The statistically significant area under the curve results were as follows: serum amylase: area under the curve = 0.731, at a cutoff value of 97.5, sensitivity = 53.7, and specificity = 81.6; and serum lipase: area under the curve = 0.727, at a cutoff value of 61.1, sensitivity = 36.6, and specificity = 92.1.

CONCLUSIONS

Serum amylase and lipase could serve as independent biomarkers to predict pancreatic injury in critically ill children.

Immunosuppressive drugs to reduce the mortality rate in patients with moderate to severe paraquat poisoning: A Meta-analysis

The benefits and adverse effects of immunosuppressive drugs (ISDs) in patients with paraquat (PQ) poisoning have not been thoroughly assessed. This meta-analysis study aims to evaluate the effect of ISDs in patients with moderate to severe PQ poisoning. We searched PubMed, Embase, Cochrane Library, Ovid Medline, CNKI and Wanfang Data from inception to January 2019. The Mantel-Haenszel method with a random-effects model was used to calculate the pooled relative risks (RRs) and 95% Confidence Intervals (CIs) as described by DerSimonian and Laird. An L'Abbé plot was drawn to explore the relationship between the degree of poisoning and mortality. Four randomized controlled trials, two prospective and seven retrospective studies were identified. ISDs were significantly associated with reduced mortality (RR 0.76; 95% CI, 0.58-0.99) and the incidence rate of multiple-organ dysfunction syndrome (MODS) (RR 0.63; 95% CI, 0.48-0.83) in patients with moderate to severe PQ poisoning. They were not associated with an increased incidence rate of hepatitis and reduced incidence rate of acute renal failure and hypoxia. The L'Abbé plot results showed a slight increase in mortality rate in the ISD group with increased mortality in the placebo group. This indicates a possible advantage of ISDs in most of the patients with severe PQ poisoning. These findings suggest that ISDs may reduce the mortality and incidence rate of MODS in moderate to severe PQ poisoning patients, and severe PQ poisoning patients might benefit more from ISDs.

Hyperamylasemia as an early predictor of mortality in patients with acute paraquat poisoning

Objective

This study aimed to evaluate the relationship between elevated serum amylase levels and the prognosis of paraquat poisoning.

Methods

Patients were categorized into the elevated and non-elevated serum amylase groups according to serum amylase levels. Demographics, mortality, risk factors of elevated serum amylase levels, and injury to the pancreas were analyzed.

Results

A total of 457 patients were enrolled in this study and the overall mortality rate was 51.9%. Patients in the elevated group had worse indices than those in the non-elevated group. Kaplan–Meier survival analysis showed that the mortality rate in the elevated group was significantly higher than that in the non-elevated group (hazard ratio: 10.65, 95% confidence interval [CI]: 7.55–15.02). Multivariate Cox proportional hazards analysis showed that elevated serum amylase levels were related to mortality (hazard ratio: 2.066, 95% CI: 1.239–3.444). The receiver operating characteristic curve showed that the area under the curve was 0.724 (95% CI: 0.666–0.783) for serum amylase levels with 70.4% sensitivity and 74.0% specificity.

Conclusion

Elevated serum amylase levels are observed in PQ poisoning. This elevation might be one of the most accurate early prognostic factors for predicting severity and mortality.

Lymphocyte and its CD4+ and CD8+ subgroup changes after paraquat poisoning

OBJECTIVE

Paraquat (PQ) poisoning is a significant cause of mortality and morbidity in developing countries. Poor prognostic outcomes have been attributed to the herbicide's toxicity and the lack of effective treatments. Our study aims to investigate the changes in lymphocyte count in both patients who survived and died from PQ poisoning and explore the prognostic value.

METHOD

This is a retrospective case serials observational study. Adult patients admitted with acute PQ poisoning. The notes of 1000 patients who presented with acute PQ poisoning were reviewed. One hundred thirty patients having the T lymphocyte met the inclusion criteria and were grouped into those that survived the poisoning (95) and non-survivors (35).

RESULTS

On admission, non-survivors had a higher ingestion volume of PQ and urine PQ concentration as well as higher severity indices (Acute Physiology and Chronic Health Evaluation 2, Sequential Organ Failure Assessment, and Poisoning Severity Score). Patients in the survival group had a higher dosage of immunosuppressant and a longer hospital stay. Leukocytes, especially neutrophils, were higher among non-survivors; however, the converse was found with lymphocytes. T lymphocyte (CD3) count was consistently higher among survivors as well as the subgroups CD4+ and CD8+. No differences in the ratio of CD4/CD8 were found between the groups.

CONCLUSION

Our study has shown that changes in lymphocyte count as its subgroups could indicate a host's immune status and lymphocytes play an important role as a surrogate marker of host immunity, which could be a useful prognostic tool in the assessment of this disease.

Does hemoperfusion in combination with other treatments reduce the mortality of patients with paraquat poisoning more than hemoperfusion alone: A systematic review with meta-analysis

Background:

Paraquat (PQ) poisoning is a serious public health problem in many countries. In spite of different treatments, the mortality is still high. We performed a meta-analysis to see whether hemoperfusion (HP) in combination with other treatments reduces the mortality more than HP alone in patients with PQ poisoning.

Materials and Methods:

We searched EMBASE, PubMed, Google Scholar, ISI Web of Knowledge, Cochrane Central Register of Controlled Trials, Scopus, Springer, TRIP, ProQuest, and references of the included studies from January 2000 to August 2017. Two reviewers independently searched and extracted data. We measured I² to determine variance contributed by heterogeneity. To investigate the publication bias, Begg's and Egger's tests were used along with funnel plot analysis.

Results:

Ultimately 12 articles were included in the meta-analysis. Five articles compared HP with conventional therapy with a total of 1311 patients, and seven articles compared mortality of patients received HP versus those received HP in combination with an additional treatment. HP alone reduced the odds of death (odds ratio [OR] = 0.20; 95% confidence interval [CI]: 0.11–0.40, P < 0.0001) compared to conventional therapy. Furthermore, the odds of death was higher in HP group compared to those received HP in combination of additional treatments (OR = 1.24; 95% CI: 1.05–1.46, P = 0.01).

Conclusion:

The mortality was less in HP-treated group compared to those received only conventional therapy. Addition of other treatments with HP reduced the mortality more than HP alone.

A Synthetic Receptor as a Specific Antidote for Paraquat Poisoning

Accidental or suicidal ingestion of the world's most widely used herbicide, paraquat (PQ), may result in rapid multi-organ failure with a 60% fatality rate due to the absence of an effective detoxification solution. Effective, specific antidotes to PQ poisoning have been highly desired.

Methods: The binding constant of PQ and a synthetic receptor, cucurbit[7]uril (CB[7]), was first determined in various pH environments. The antidotal effects of CB[7] on PQ toxicity were firstly evaluated with in-vitro cell lines. With in-vivo mice models, the pharmacokinetics and the biodistribution of PQ in major organs were determined to evaluate the influence of CB[7] on the oral bioavailability of PQ. Major organs' injuries and overall survival rates of the mice were systemically examined to evaluate the therapeutic efficacy of CB[7] on PQ poisoning.

Results: We demonstrate that CB[7] may complex PQ strongly under various conditions and significantly reduce its toxicity in vitro and in vivo. Oral administration of PQ in the presence of CB[7] in a mouse model significantly decreased PQ levels in the plasma and major organs and alleviated major organs' injuries, when compared to those of mice administered with PQ alone. Further studies indicated that oral administration of CB[7] within 2 h post PQ ingestion significantly increased the survival rates and extended the survival time of the mice, in contrast to the ineffective treatment by activated charcoal, which is commonly recommended for PQ decontamination.

Conclusion: CB[7] may be used as a specific oral antidote for PQ poisoning by strongly binding with PQ and inhibiting its absorption in the gastrointestinal tracts.

Sequential organ failure assessment in predicting mortality after paraquat poisoning: A meta-analysis

Sequential organ failure assessment (SOFA) score is commonly used to determine disease severity and predict prognosis in critically ill patients. However, the prognostic value of SOFA after acute paraquat (PQ) poisoning remains unclear. This meta-analysis aimed to study the capability of SOFA to predict mortality in patients with PQ poisoning. Databases that included PubMed, Embase, Web of Science, ScienceDirect, Embase, and Cochrane Library were searched through May 2018. Six studies involving 946 patients were included in the meta-analysis. Study-specific odds ratios (ORs) and 95% confidence intervals (CIs) were calculated, and then ORs with 95% CIs were pooled for the estimation of the prognostic role of SOFA in patients with PQ poisoning. Results showed that higher SOFA in patients with PQ poisoning was related to severe mortality (OR = 8.14, 95%CI 4.26–15.58, p<0.001). The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic OR, and area under the curve were 72% (95%CI 0.65–0.79), 75% (95%CI 0.65–0.83), 2.9 (95%CI 2.0–4.1), 0.37 (95%CI 0.28–0.41), 8 (95%CI 4–14), and 0.79 (95%CI 0.76–0.83), respectively. No evidence of publication bias was detected by funnel plot analysis and formal statistical tests. Sensitivity analyses showed no important differences in the estimates of effects. The high SOFA score (8.1-fold) was associated with severe mortality in patients with PQ poisoning.

Predictive value of the maximum serum creatinine value and growth rate in acute paraquat poisoning patients

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.

A retrospective analysis of leucocyte count as a strong predictor of survival for patients with acute paraquat poisoning

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.

Metabolic Profiling of Amino Acids Associated with Mortality in Patients with Acute Paraquat Poisoning

Background

Paraquat is a major cause of fatal poisoning after ingestion in many parts of Asia and the Pacific nations. However, optimal prognostic indicators to evaluate patient mortality have not been unequivocally established. Following acute paraquat poisoning, a number of amino acids (AA), are abnormally expressed in metabolic pathways. However, the alterations in AA metabolite levels after paraquat poisoning remain unknown in humans.

Material/Methods

In the present study, 40 patients were enrolled, of whom 16 survived and 24 died. A metabolomics approach was used to assess changes in AA metabolites in plasma and its potential prognostic value following paraquat poisoning. Mass spectrometry (MS) based on metabolite identification was conducted.

Results

Twenty-five AA levels in plasma were abnormally expressed in non-survivor patients. Among them, creatinine, indolelactate, and 3-(4-hydroxyphenyl)lactate were found to be highly correlated with paraquat death prediction. It was noted that the intensity levels of these 3 AA metabolites in the non-survivor group were substantially higher than in the survivor group. Furthermore, we examined receiver operating characteristic (ROC) curves for clinical validation. ROC results showed that 3-(4-hydroxyphenyl)lactate had the highest AUC of 0.84, while indolelactate and creatinine had AUCs of 0.75 and 0.83, respectively, suggesting that they can be used to predict the clinical outcome (although this methodology is expensive to implement).

Conclusions

Metabolic profiling of AA levels could be a reliable tool to identify effective indicators for the early high precision prognosis of paraquat poisoning.

Point-of-care testing in the early diagnosis of acute pesticide intoxication: The example of paraquat

Acute pesticide intoxication is a common method of suicide globally. This article reviews current diagnostic methods and makes suggestions for future development. In the case of paraquat intoxication, it is characterized by multi-organ failure, causing substantial mortality and morbidity. Early diagnosis may save the life of a paraquat intoxication patient. Conventional paraquat intoxication diagnostic methods, such as symptom review and urine sodium dithionite assay, are time-consuming and impractical in resource-scarce areas where most intoxication cases occur. Several experimental and clinical studies have shown the potential of portable Surface Enhanced Raman Scattering (SERS), paper-based devices, and machine learning for paraquat intoxication diagnosis. Portable SERS and new SERS substrates maintain the sensitivity of SERS while being less costly and more convenient than conventional SERS. Paper-based devices provide the advantages of price and portability. Machine learning algorithms can be implemented as a mobile phone application and facilitate diagnosis in resource-limited areas. Although these methods have not yet met all features of an ideal diagnostic method, the combination and development of these methods offer much promise.

Effect of soluble CD14 subtype on the prognosis evaluation of acute paraquat poisoning patients

OBJECTIVE

To study the relationship between soluble CD14 subtype (also named presepsin) and the prognosis of acute paraquat poisoning (APP) patients.

METHODS

We studied 85 APP patients who were divided into three groups: light (21 cases), moderate (37 cases) and heavy poisoning (27 cases) groups. Fifty healthy subjects were as control group. According to the conditions of prognosis, they were divided into two groups: survive group (28 cases) and death group (57 cases). We measured the concentration of presepsin in serum and the levels of CRP, TNF-α, IL-6 and IL-10 in venous blood. APACHE II scores were observed before treatment, 72 h and 7 d after treatment.

RESULTS

The levels of presepsin, CRP, TNF-α, IL-6 and the scores of APACHE II in patients of three poisoning groups were increased at three different time points compared with control group, while the level of IL-10 was decreased. And there were significant differences between each poisoning groups (P<0.05). The levels of prespsin, CRP, TNF-α, IL-6 and the scores of APACHE II in patients of death group were higher than survive group at three different time points, while the level of IL-10 was lower (P<0.05). The mortality rates of three poisoning groups were 28.57%, 70.27% and 92.59%, and there were significant differences between each poisoning groups (P<0.05). The area under curve (AUC) of presepsin level and APACHE II scores of APP patients on admission were 0.862 and 0.731, respectively. Presepsin had a better predictive ability than APACHE II score for 28-day mortality rate in APP patients (P<0.05). The level of presepsin was negatively correlated with survival rates (r=0.291, P=0.007).

CONCLUSION

Monitoring the level of presepsin in serum has an important role in assessing the severity of APP patients, guiding treatment and predicting prognosis.

Hypokalemia is a biochemical signal of poor prognosis for acute paraquat poisoning within 4 hours

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.

The value of APACHE II in predicting mortality after paraquat poisoning in Chinese and Korean population: A systematic review and meta-analysis

BACKGROUND

The Acute Physiology and Chronic Health Evaluation II (APACHE II) score is used to determine disease severity and predict outcomes in critically ill patients. However, the prognostic significance of APACHE after acute paraquat (PQ) poisoning remains unclear. The meta-analysis was aimed to study the value of APACHE II in predicting mortality in PQ-exposed Chinese and Korean patients.

METHODS

Databases that included PubMed, Embase, Cochrane Library, and the Chinese National Knowledge Infrastructure were searched through August 2016. Studies using APACHE II to predict mortality in PQ-poisoned patients were selected. The odds ratio and weighted mean difference (WMD) were used to pool binary and continuous data. Additionally, we aggregated sensitivity, specificity, and other measures of accuracy. Statistical analyses were made using the Stata V.13.0 software.

RESULTS

This study included 29 studies, and 25 studies evaluated APACHE II scores on admission. Pooled data showed that survivors had significantly lower total scores than nonsurvivors (WMD = -7.29, and I = 98.2%, both P <.05). The pooled sensitivity of an APACHE II score ≥5 for predicting mortality was 75% and the pooled specificity was 86%. The positive likelihood ratio (PLR) was 5.3 and the negative likelihood ratio (NLR) was 0.29. The pooled sensitivity of an APACHE II score ≥10 for predicting mortality was 88% and the pooled specificity was 84%. The pooled PLR and NLR was 5.5 and 0.15, respectively.

CONCLUSION

This study showed PQ-poisoned nonsurvivors had significantly higher APACHE II score than did survivors. APACHE II scores satisfactorily predicted mortality.

Mumps caused by paraquat-induced poisoning: A case report

Paraquat (PQ) is a highly toxic herbicide that harms the liver, kidney, lungs and heart, and results in a variety of complications. The majority of patients with severe PQ poisoning may succumb to multiple organ failure, and the mortality rate is high. Although a large number of studies have been performed investigating PQ poisoning, cases of mumps caused by PQ-induced poisoning are rare. In the present case report, a 45-year-old female who ingested PQ was admitted to the Emergency Department of Liaocheng People's Hospital (Liaocheng, China). During the development of the disease, mumps was caused by a cavity ulcer following PQ poisoning. To the best of our knowledge, cases of mumps following PQ poisoning are rare.

Prognostic value of hematological parameters in patients with paraquat poisoning

Paraquat (PQ) is a non-selective contact herbicide, and acute PQ poisoning has a high mortality. The aim of the present study is to evaluate the prognostic value of hematological parameters in patients with acute PQ poisoning. We retrospectively reviewed the records of patients with acute PQ poisoning from January 2010 to December 2015 at the First Affiliated Hospital, Anhui Medical University (Hefei, China). A total of 202 patients were included in the study, and the 30-day mortality was 51.98%. Leukocyte, neutrophil counts and neutrophil-lymphocyte ratio (NLR) were significantly higher in non-survivors than in survivors. In the receiver operating characteristic (ROC) curve analysis, the NLR had an area of 0.916(95%CI, 0.877–0.954) and the optimal cut-off value was 10.57 (sensitivity, 86.70%; specificity, 83.51%; Youden’s index, 0.702). The leukocyte counts had an area of 0.849(95%CI, 0.796–0.902) and the optimal cut-off value was 13.15 × 10³/mm³ (sensitivity, 77.10%; specificity, 83.50%; Youden’s index, 0.606). The neutrophil counts had an area of 0.878(95%CI, 0.830–0.925) and the optimal cut-off value was 10.10 × 10³/mm³ (sensitivity, 83.80%; specificity, 79.38%; Youden’s index, 0.632). NLR, leukocyte and neutrophil counts are associated with the 30-day mortality, which may be useful and simple parameters in predicting the prognosis of PQ poisoning.

Hyperamylasemia as an Early Predictor of Mortality in Patients with Acute Paraquat Poisoning

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.