Applied clinical pharmacology and public health in rural Asia--preventing deaths from organophosphorus pesticide and yellow oleander poisoning

The role of alcohol use in pesticide suicide and self-harm: a scoping review

PURPOSE

Suicide and self-harm by pesticide self-poisoning is common in low- and middle-income countries (LMICs). Alcohol is an important risk factor for self-harm; however, little is known about its role in pesticide self-poisoning. This scoping review explores the role that alcohol plays in pesticide self-harm and suicide.

METHODS

The review followed the Joanna Briggs Institute scoping review guidance. Searches were undertaken in 14 databases, Google Scholar, and relevant websites. Articles were included if they focussed on pesticide self-harm and/or suicide and involvement of alcohol.

RESULTS

Following screening of 1281 articles, 52 were included. Almost half were case reports (n = 24) and 16 focussed on Sri Lanka. Just over half described the acute impact of alcohol (n = 286), followed by acute and chronic alcohol use (n = 9), chronic use, (n = 4,) and only two articles addressed harm to others. One systematic review/meta-analysis showed increased risk of intubation and death in patients with co-ingested alcohol and pesticides. Most individuals who consumed alcohol before self-harming with pesticides were men, but alcohol use among this group also led to pesticide self-harm among family members. Individual interventions were recognised as reducing or moderating alcohol use, but no study discussed population-level alcohol interventions as a strategy for pesticide suicide and self-harm prevention.

CONCLUSION

Research on alcohol's role in pesticide self-harm and suicide is limited. Future studies are needed to: further assess the toxicological effects of combined alcohol and pesticide ingestion, explore harm to others from alcohol including pesticide self-harm, and to integrate efforts to prevent harmful alcohol use and self-harm.

Alcohol use, self-harm and suicide: a scoping review of its portrayal in the Sri Lankan literature

Background

Suicide is a global public health problem. Compared to other middle-income countries, much literature has been generated on the topic of self-harm and suicide in Sri Lanka. Harmful use of alcohol is a well-known risk factor to self-harm and suicide, however the connection needed further exploration.

Aim

The aim was to investigate alcohol's role in self-harm and suicide in Sri Lanka to inform policy and prevention programs and future research priorities.

Methods

We performed a scoping review exploring how the association between alcohol use, self-harm and suicide in Sri Lanka is presented in scientific literature from August 1, 2008 to December 31, 2022. Thematic analysis was used to explore emerging themes.

Results

Altogether 116 peer-reviewed articles were included. Three themes emerged: (i) gendered, inter-relational explanations of alcohol's role in self-harm, (ii) hospital management of patients who co-ingested alcohol and pesticides, and (iii) proposed research and interventions targeting alcohol, self-harm and suicide. The articles' recommendations for policy, prevention and research priorities included: Family- and community-based alcohol, self-harm and suicide reduction interventions; viewing self-harm as a window of opportunity for health personnel to intervene in families affected by harmful alcohol consumption; and introduction of and increased access to treatment of alcohol use disorder at the individual level.

Conclusion

Suggestions for alcohol, self-harm, and suicide prevention interventions were primarily targeted at the community, though this might also reflect the limited treatment, mental health, and alcohol support available in the country. Future research should explore and test context-appropriate interventions integrating alcohol and self-harm prevention and treatment.

Suicides by pesticide ingestion in Pakistan and the impact of pesticide regulation

INTRODUCTION

Suicide is a major public health problem in Pakistan, accounting to approximately 19,331 deaths every year. Many are due to consumption of acutely toxic pesticides; however, there is a lack of national suicide data, limiting knowledge and potential for intervention. In this paper, we aimed to review the literature on pesticide self-poisoning in Pakistan to identify the most problematic pesticides in relation to national pesticide regulations.

METHODS

Information on the currently registered and banned pesticides was obtained from Ministry of National Food Security and Research while data on pesticide import and use was extracted from FAOSTAT. We searched the following sources for articles and research papers on poisoning in Pakistan: Cumulative Index to Nursing and Allied Health (CINAHL), Google Scholar, Applied Social Sciences Index and Abstracts (ASSIA), Excerpta Medica (EMBASE), National Library of Medicine's MEDLINE (PUBMED), PS102YCHINFO and Pakmedinet.com using the search terms 'self-poisoning', 'deliberate self-harm', 'suicide', 'methods and means of suicide', 'organophosphate', 'wheat pill', 'aluminium phosphide', 'acute poisoning', OR 'pesticides', AND 'Pakistan'.

RESULTS

As of May 2021, 382 pesticide active ingredients (substances) were registered in Pakistan, of which five were WHO hazard class Ia (extremely hazardous) and 17 WHO hazard class Ib (highly hazardous). Twenty-six pesticides, four formulations, and seven non-registered pesticides had been banned, of which two were WHO class Ia and five Ib. We identified 106 hospital-level studies of poisoning conducted in Pakistan, of which 23 did not mention self-poisoning cases and one reported no suicidal poisoning cases. We found no community or forensic medicine studies. Of 52,323 poisoning cases identified in these papers, 24,546 [47%] were due to pesticides. The most commonly identified pesticide classes were organophosphorus (OP) insecticides (13,816 cases, 56%) and the fumigant aluminium phosphide (3 g 56% tablets, often termed 'wheat pills'; 686 cases, 2.7%). Few studies identified the particular pesticides involved or the resulting case fatality.

CONCLUSION

We found pesticide poisoning to be a major cause of poisoning in Pakistan, with OP insecticides and the fumigant aluminium phosphide the main pesticides identified. Withdrawal of Class I pesticides (as proposed to occur nationally in 2022) and high concentration aluminium phosphide tablets should rapidly reduce suicidal deaths by reducing the case fatality for low-intention poisoning cases. National cause of death data and forensic toxicology laboratory data identifying the pesticides responsible for deaths will be important to assess impacts of the proposed national ban.

Deliberate Self-poisoning due to Plant Toxins: Verdant Footprints of the Past into the Present

Background

Plant poisoning is one of the common methods of deliberate self-poisoning (DSP). Exposure to plants and its consequence account for a considerable number of deaths in rural India.

Materials and methods

This retrospective observational study was conducted in the emergency department of a large tertiary care hospital in South India over a period of 2 years and recruited patients who presented with DSP from plant poisoning.

Results

During the study period, 150 cases of plant poisoning were included. The mean (standard deviation) age of presentation was 31.4 (12.2) years. The most common type of plant poison consumed was oleander (63%) followed by oduvanthalai (50%), Strychnos nux-vomica (3%), datura (3%), and others, which comprised about 5.3% included henna (1.3%), cactus (1.3%), and a case each of castor, Gloriosa superba, Adenanthera pavonina, and Abrus precatorius. Patients in age-group 16-30 years had the highest rate of ingestion. The seasonal pattern was found to peak in the month of April. Gastric lavage was done in 102/150:68%. Consumption of decoction [odds ratio (OR): 5, 95% confidence interval (CI): 2.27-14.00, p value: <0.001] and metabolic acidosis (pH <7.35) (OR: 11.48, 95% CI: 4.17-31.57, p value: <0.001) were more common in oduvanthalai poisoning as compared to oleander. The mortality among plant poisoning was 9.3% (14/150).

Conclusion

Our study sheds light on the spectrum of local plants consumed for DSP. Oleander and oduvanthalai were most commonly used for DSP. Consuming a decoction of leaves leading to severe metabolic acidosis at presentation is seen associated with oduvanthalai poisoning.

How to cite this article

Abhilash KPP, Murugan S, Rabbi AS, Pradeeptha S, Pradeep R, Gunasekaran K. Deliberate Self-poisoning due to Plant Toxins: Verdant Footprints of the Past into the Present. Indian J Crit Care Med 2021;25(4):392-397.

Pesticide-Poisoned Patients: Can They Be Used as Potential Organ Donors?

INTRODUCTION

The gap between the number of patients on transplant waiting lists and patients receiving transplants is growing. Use of organs from donors who have died following pesticide exposure remains controversial. This study reviews the literature related to transplantation from this group.

METHODS

A literature search was undertaken on PubMed using the following keywords: 'insecticide', 'pesticide', 'rodenticide', 'organophosphate', 'carbamate', 'paraquat', 'poisoning', 'toxicity', 'overdose', 'intoxication', 'ingestion', 'organ donation or procurement', 'transplant', 'allograft transplant', and 'expanded criteria organ donation'; 21 specific pesticides/insecticides were also added to the search; the indexes for EAPCCT/NACCT meeting abstracts 2008-2017 were also searched. Identified publications were reviewed and if described human donation/transplantation of ≥ 1 solid organ(s), the following was extracted: (i) compound(s) ingested; (ii) donor demographics; (iii) organ(s) transplanted; and (iv) graft function at follow-up.

RESULTS

Ten papers were identified describing 20 fatalities (1999-2017) related to the following pesticide exposures: organophosphate, 8 cases; aldicarb, 4; paraquat, 3; parathion, 1; malathion, 1; carbofuran/carbamate, 1; carbamate, 1; and brodifacoum, 1 and no further cases were identified from EAPCCT/NACCT abstracts. Donors were aged 12-50 (25.9 ± 11.9) years. Forty-four organs were transplanted: 28 kidneys, 7 livers, 6 corneas, and 3 hearts. Forty recipients had outcome reported: 3 (7.5%) patients died, 3 (7.5%) had graft failure/dysfunction and 34 (85.0%) had good graft function. Overall survival with good function was 96%, 71%, 83%, and 67% for kidneys, livers, corneas and hearts respectively.

CONCLUSION

Review of the published literature suggests that solid organ donation following exposure to a pesticide is associated with good short-to-medium-term graft organ function following transplantation, particularly for transplanted kidneys and corneas.

Acute myocardial infarction in yellow oleander poisoning

Self-harm by consuming yellow oleander seeds has become more frequent in South Asian countries, especially Sri Lanka and in southern parts of India. Yellow oleander poisoning usually presents with gastrointestinal, cardiovascular, and neurological manifestations as well as electrolyte abnormalities. Cardiac effects can manifest as nearly any type of dysrhythmia and sudden death with very few premonitory signs. To our knowledge yellow oleander poisoning related acute myocardial infarction has not yet been reported. We report a 37-year-old man with yellow oleander poisoning who had normal sinus rhythm at presentation but within few hours developed acute ST-segment myocardial infarction.

Successful use of digoxin-specific immune Fab in the treatment of severe Nerium oleander toxicosis in a dog

OBJECTIVE

To describe a case in which digoxin-specific immune Fab was used successfully in a dog with severe oleander toxicosis secondary to ingesting plant material.

CASE SUMMARY

A 6-year-old intact female Rhodesian Ridgeback mixed breed dog was presented for severe oleander toxicosis and was refractory to all antiarrhythmic therapies and supportive care. Digoxin-specific immune Fab was successful in treating this dog. The dog recovered but suffered ischemic injuries, the long-term effects of which are unknown.

NEW OR UNIQUE INFORMATION PROVIDED

This report describes the successful use of digoxin-specific immune Fab in the treatment of oleander toxicosis in a dog, which has not previously been published in veterinary literature. Oleander poisoning can be associated with permanent cardiac arrhythmias due to the ischemic damage.

Toxicology in the Service of Patient and Medication Safety: a Selected Glance at Past and Present Innovations

Medical and medication errors remain definite threats to patients in US health care. Medical toxicologists frequently encounter patients either harmed by or at risk for harm from adverse drug events, including medication errors and inadvertent exposures. An historical perspective, as viewed through the lens of specific disciplines, can be useful to trace systemic responses to safety threats. Early efforts to address anesthesia perioperative risks and recent actions in medicine, surgery, and obstetrics to introduce checklists, communication tools, and systems approaches are reviewed. Patient safety concepts can be utilized and disseminated by toxicologists to improve medication safety and drive innovative approaches to confront patient harm. Various approaches include simulation of high-risk scenarios which might predispose to medication error, assembling multidisciplinary groups of health care providers to review events and implement mitigation strategies, and proactive patient safety rounds in clinical areas to allow frontline staff to voice concerns and introduce solutions for administration, evaluation, and implementation. We review selected lessons from the past and current innovations to achieve safe medication practice.

Antioxidant, anti-inflammatory, anti-apoptotic, and skin regenerative properties of an Aloe vera-based extract of Nerium oleander leaves (nae-8(®))

Objective

The goal for this study was to evaluate the effects of an Aloe vera-based Nerium oleander extract (NAE-8^®), compared to an extract of A. vera gel alone (ALOE), and to an aqueous extract of N. oleander (AQ-NOE) in bioassays pertaining to dermatologic potential with respect to antioxidant protection, anti-inflammatory effects, and cytokine profiles in vitro.

Methods

Cellular antioxidant protection was evaluated in three separate bioassays: The cellular antioxidant protection of erythrocytes (CAP-e) assay, protection of cellular viability and prevention of apoptosis, and protection of intracellular reduced glutathione levels, where the last two assays were performed using human primary dermal fibroblasts. Reduction of intracellular formation of reactive oxygen species (ROS) was tested using polymorphonuclear cells in the absence and presence of oxidative stress. Changes to cytokine and chemokine profiles when whole blood cells and human primary dermal fibroblasts were exposed to test products were determined using a 40-plex Luminex array as a method for exploring the potential cross-talk between circulating and skin-resident cells.

Results

The NAE-8^® provided significantly better antioxidant protection in the CAP-e bioassay than AQ-NOE. NAE-8^® and AQ-NOE both protected cellular viability and intracellular reduced glutathione, and reduced the ROS formation significantly when compared to control cells, both under inflamed and neutral culture conditions. ALOE showed minimal effect in these bioassays. In contrast to the NAE-8^®, the AQ-NOE showed induction of inflammation in the whole blood cultures, as evidenced by the high induction of CD69 expression and secretion of a number of inflammatory cytokines. The treatment of dermal fibroblasts with NAE-8^® resulted in selective secretion of cytokines involved in collagen and hyaluronan production as well as re-epithelialization during wound healing.

Conclusion

NAE-8^®, a novel component of a commercial cosmetic product, showed beneficial antioxidant protection in several cellular models, without the induction of leukocyte activation and secretion of inflammatory cytokines. The biological efficacy of NAE-8^® was unique from both ALOE and AQ-NOE.