Clinical outcome of paraquat poisoning during pregnancy

Association between toxicity-index of diquat and in-hospital mortality in patients with acute diquat poisoning: a retrospective cohort study

BACKGROUND

This study investigates the impact of diquat toxicity levels on in-hospital mortality rates among patients with acute diquat poisoning. It aims to clarify the relationship between diquat toxicity scores and the likelihood of death during hospitalization.

METHODS

A retrospective cohort study was conducted on 98 individuals with acute diquat poisoning. Data on post-ingestion time, initial diquat plasma concentration, and clinical outcomes were systematically collected for all participants. The toxicity-index of diquat was calculated based on post-ingestion time and initial diquat plasma concentration. Logistic regression analysis was utilized to assess the association between the toxicity-index of diquat and in-hospital mortality rates, adjusting for potential confounding variables such as age, comorbidities, and treatment interventions.

RESULTS

The study found that the overall prevalence of in-hospital mortality was 34.7%, with 58.2% in males. The multivariable-adjusted regression coefficient for in-hospital mortality associated with the toxicity-index was 1.09, with a 95% confidence interval (CI) of 1.01-1.17. Subsequent exploratory subgroup analysis indicated that there were no significant interactions (all p values for interaction were >0.05).

CONCLUSIONS

The study found that higher diquat toxicity-index values correlate with increased in-hospital mortality in acute diquat poisoning cases, indicating that the toxicity-index could be a useful biomarker for assessing mortality risk.

Construction of prognosis prediction model and visualization system of acute paraquat poisoning based on improved machine learning model

Objective

This study aims to develop a prognosis prediction model and visualization system for acute paraquat poisoning based on an improved machine learning model.

Methods

101 patients with acute paraquat poisoning admitted to 6 hospitals from March 2020 to March 2022 were selected for this study. After expiry of the treatment period (one year of follow-up for survivors and up to the time of death for deceased patients) and they were categorized into the survival group (n = 37) and death group (n = 64). The biochemical indexes of the patients were analyzed, and a prognosis prediction model was constructed using HHO-XGBoost, an improved machine-learning algorithm. Multivariate logistic analysis was used to verify the value of the self-screening features in the model.

Results

Seven features were selected in the HHO-XGBoost model, including oral dose, serum creatinine, alanine aminotransferase (ALT), white blood cell (WBC) count, neutrophil count, urea nitrogen level, and thrombin time. Univariate analysis showed statistically significant differences between these features' survival and death groups (P < 0.05). Multivariate logistic analysis identified four features significantly associated with prognosis- serum creatinine level, oral dose, ALT level, and WBC count - indicating their critical significance in predicting outcomes.

Conclusion

The HHO-XGBoost model based on machine learning is precious in constructing a prognosis prediction model and visualization system for acute paraquat poisoning, which can help clinical prognosis prediction of patients with paraquat poisoning.

Hemoadsorption and continuous venovenous hemodiafiltration in the management of paraquat poisoning during pregnancy: A case report

We describe the case of a mother in the second trimester of pregnancy with severe paraquat poisoning who ended her pregnancy at term and a healthy newborn. Management was initiated after 34 h of paraquat administration with the HA-230 hemoadsorption cartridge, followed by continuous venovenous hemodiafiltration for 120 h, in addition to cyclophosphamide and methylprednisolone. There was no evidence of adverse effects associated with treatment or extracorporeal therapy, and maternal and fetal well-being was maintained during the 26 days of hospitalization and at the end of pregnancy. This case treated with hemoadsorption and hemodiafiltration for paraquat poisoning during pregnancy is one of the few procedures reported in the literature and can be used as a guide for the management of subsequent cases.

Características sociodemográficas y clínicas relacionadas con la condición final de pacientes intoxicados por paraquat en un hospital del suroccidente de Colombia

Introducción.

El herbicida paraquat constituye la primera causa de decesos por intoxicaciones en distintos países.

Objetivo.

Relacionar las características sociodemográficas y clínicas con la condición final de pacientes intoxicados por paraquat atendidos en un hospital del suroccidente de Colombia.

Materiales y métodos.

En este estudio observacional, descriptivo, analítico, transversal y retrospectivo, se revisaron las historias clínicas de pacientes atendidos por intoxicación con paraquat en una institución de tercer nivel de complejidad en Pasto (Colombia) entre el 2013 y el 2018. Se recolectó la información sobre la condición final (vivo o fallecido) de cada paciente, así como los datos sociodemográficos, clínicos y de los exámenes paraclínicos. Se establecieron comparaciones por grupos y se diseñó un modelo de regresión logística binaria.

Resultados.

Se filtró la información de 299 registros y se analizaron finalmente 160 casos. Las características relacionadas con la condición final de los pacientes fueron el tiempo de estancia (OR=0,124; IC_95% 0,03-0,6; p=0,009), la frecuencia cardiaca (OR=35,65; IC_95% 1,44-884,78; p=0,029) y la creatinina inicial (OR=1,73; IC_95% 1,23-2,44; p=0,002).

Conclusiones.

La proporción de la letalidad fue mayor entre los pacientes con estancia hospitalaria corta, taquicardia y elevación de la concentración sérica de creatinina al ingreso. Este reporte puede ser útil como fundamento de una escala de gravedad para detectar a los pacientes con resultados adversos en la fase temprana para que puedan recibir una intervención oportuna.

The toxicokinetics of acute paraquat poisoning in specific patients: a case series

Paraquat is a non-selective contact herbicide that is absorbed through the digestive tract and skin and can cause multiple organ damage. The toxicokinetics of paraquat poisoning in specific patients are rarely reported. Case 1 was a 76-year-old man who intermittently immersed his perineum in diluted paraquat solution for 3 consecutive days because of eczema of the perineal skin. On admission, the patient’s scrotal skin was severely corroded and his blood paraquat concentration was 0.5 μg/mL. He developed severe kidney and lung damage after admission and died on Day 6 of admission. Case 2 was a 23-year-old woman who ingested paraquat during gestational week 36. Her initial blood paraquat concentration was 0.81 μg/mL. The patient refused hemoperfusion and a cesarean section. She birthed a baby girl 83 hours after ingesting paraquat. Paraquat concentrations in postnatal maternal blood, fetal blood, umbilical cord blood, and amniotic fluid were 0.19 μg/mL, 0.23 μg/mL, 0.20 μg/mL, and 0.47 μg/mL, respectively. The baby died within hours of birth and the mother died of refractory respiratory failure 2 days after delivery. This paper provides clues about paraquat toxicokinetics in specific patient types and indicates that paraquat can be absorbed through the scrotal skin and the placental barrier.

Liver injury associated with drug intake during pregnancy

Drug use during pregnancy is not common. Drug-induced liver injury (DILI) is a potential complication that is rare but can adversely affect both the mother and the fetus. Although many drugs can directly cause hepatotoxicity, idiosyncratic liver injury is common in pregnancy. Underreporting of adverse drug reactions, lack of adequate literature regarding drug safety in pregnancy, and the inherent difficulty in diagnosing DILI during pregnancy make the management of this condition challenging. This review attempts to describe the existing literature regarding DILI in pregnancy, which is mainly in the form of case reports; several studies have looked at the safety of antithyroid drugs, antiretroviral drugs, and paracetamol, which have an indication for use in pregnancy; the relevant data from these studies with regard to DILI has been presented. In addition, the review describes the diagnosis of DILI, grading the disease severity, assessment of causality linking the drug to the adverse event, regulatory guidelines for evaluating the potential of drugs to cause liver injury, efforts to ensure better participation of women in clinical trials and studies in pregnant women population in particular, and the challenges involved in generating adequate research evidence. The establishment of DILI registries in various countries is an encouraging development; however, there is a need for promoting active, spontaneous reporting of adverse events during pregnancy to ensure rapid generation of evidence regarding the safety of a drug in pregnant women.

Relationship between acute kidney injury and mortality in poisoning - a systematic review and metanalysis

RATIONALE

Three consensus classifications of acute kidney injury have been published. These are RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease published by the Acute Dialysis Quality Initiative workgroup), AKIN (published by the Acute Kidney Injury Network) and KDIGO (published by the Kidney Disease Improving Global Outcome workgroup). Acute kidney injury has been reported consistently as associated with worsened outcomes. However, toxicant-related acute kidney injury has been excluded from the studies used to validate the classifications of acute kidney injury.

OBJECTIVE

To study whether poisoned patients who develop acute kidney injury, as defined by consensus definitions/classifications, have higher mortality compared to those who did not.

METHODS

Databases were searched from 2004 to 2019 using the following keywords (KDIGO OR "Kidney Disease: Improving Global Outcomes" OR "Kidney Disease Improving Global Outcomes" OR AKIN OR "AKI network" OR "Acute kidney Injury Network" OR ADQI OR RIFLE OR "Acute dialysis quality initiative") AND (intoxication OR poisoning OR overdose OR ingestion) AND (AKI OR kidney OR renal OR ARF). If data were available, we used a random-effects meta-analysis model and Fisher's exact test to compare mortality in patients according to kidney function definitions (acute kidney injury vs not) and stages (stages vs no acute kidney injury), respectively. If data were available, we assessed the correlation between mortality and renal function (no acute kidney injury, risk/stage 1, injury/stage 2 and failure/stage 3) using the Spearman correlation. If available, we collected the results of statistical analyses in studies that have used acute kidney injury to predict mortality.

RESULTS

Study selection. Thirty-three relevant studies were found, 22/33 retrospective studies (67%) and 11/33 prospective studies (33%). Paraquat was the most frequent toxicant involved (13/33, 39%). We found a disparity between studies regarding the timeframe during which mortality was assessed, the temporality of the renal function considered to predict mortality (initial/worst) and the criteria used to define/grade acute kidney injury across studies. Univariate association between acute kidney injury definitions/stages and mortality. Consensus definitions/staging of acute kidney injury were associated with higher mortality, using univariate analyses, in twenty-eight (RIFLE = 7; AKIN = 12; KDIGO = 9) studies included but not in five (AKIN = 4, KDIGO = 1). When available data were pooled, RIFLE (5 studies), AKIN (16 studies) and KDIGO definitions (8 studies) of acute kidney injury were associated with a higher mortality (Log unadjusted Odds ratios [95%-confidence interval], 2.60 [2.23; 2.97], 2.02 [1.48; 2,52] and 3.22 [2,65; 3.78], respectively). However, we found high heterogeneity (I²=54,7%) and publication bias among studies using AKIN. In ten studies with available data, the correlation between renal function (no acute kidney injury, risk/stage 1, injury/stage 2, failure/stage 3) and mortality was significant in 5 studies (RIFLE = 2; AKIN = 3), but not in five studies (RIFLE = 1; AKIN = 3; KDIGO = 1).Multivariate association between acute kidney injury definitions/stages and mortality. The definitions of acute kidney injury were associated with higher mortality in two studies (RIFLE = 2), but not in four studies (AKIN = 1 and KDIGO = 3. The stages of acute kidney injury (including one or more stages) were associated with higher mortality in four (RIFLE = 1, AKIN = 1 and KDIGO = 2).

CONCLUSIONS

All three consensus definitions/classifications were associated independently with increased mortality in poisoning but with disparity between studies reporting acute kidney injury.

Mechanisms of deleterious effects of some pesticide exposure on pigs

The increase in the size of the global population increases the food and energy demand, making the use of pesticides in agricultural and livestock industries unavoidable. Exposure to pesticides can be toxic to the non-target species, such as humans, wildlife, and livestock, in addition to the target organisms. Various chemicals are used in the livestock industry to control harmful organisms, such as insects, weeds, and parasites. Pigs are one of the most important food sources for humans. In addition, pigs can be used as promising models for assessing the risk of absorption of environmental pollutants through the skin and oral exposure since they are physiologically similar to humans. Exposure to numerous environmental pollutants, such as mycotoxins, persistent organic pollutants, and heavy metals, has been reported to adversely affect growth, fertility, and endocrine homeostasis in pigs. Various pesticides have been observed in porcine tissues, blood, urine, and processed foods; however, there is a lack of comprehensive understanding of their effects on porcine health. This review provides a comprehensive description of the characteristics of pesticides that pigs can be exposed to and how their exposure affects porcine reproductive function, intestinal health, and endocrine homeostasis in vivo and in vitro.

Fetal outcomes after intentional ingestion of paraquat: A case report

RATIONALE

Despite the fact that treatment of paraquat poisoning in pregnant women and their fetuses is challenging and raises ethical issues, it is rarely reported in the literature. We report the case of a pregnant woman who took paraquat intentionally.

PATIENT CONCERNS

A 36-year-old woman at 38 weeks gestational age, in an apparent suicide attempt, drank 1 mouthful (about 20 ml) of paraquat solution. Ten hours later, her urine dithionate test showed light blue color with a plasma paraquat concentration of 0.547 μg/ml. Six hours after admission, a male infant, whose plasma paraquat concentration was 0.761 μg/ml, together with 0.673 μg/ml in the amniotic fluid measured by high-performance liquid chromatography, was delivered but the woman's lung, liver, and kidney function declined rapidly.

DIAGNOSIS

INTERVENTIONS:: Because of placenta previa and multiple organ failure, emergency cesarean section, and panhysterectomy were performed for the pregnant woman. Intravenous injection of antibiotic to prevent infection and dexamethasone 30 mg once a day were administered. Mechanical ventilation was performed for the infant and meropenem and penicillin injection was administered.

OUTCOMES

The infant died 33 hours after birth while the mother died on the 3rd day after ingestion.

LESSONS

Paraquat can enter the fetus through the placenta and the amniotic fluid via fluid exchange. The pathological changes of fetal organs may relate to gestational age, and the prognosis was very poor in both the mother and the fetus.