Suicide victim of paraquat poisoning make suitable corneal donor

Donor Risk Factors and Environmental Conditions Associated With Poor-Quality Corneas: An Analysis of the Central Eye Bank of Iran (2018-2021)

PURPOSE

The purpose of this study was to investigate the donor risk factors and environmental conditions associated with poor-quality corneas using the database of the Central Eye Bank of Iran over 4 years.

METHODS

This cohort study was conducted on the recorded data of all donated corneas at the Central Eye Bank of Iran database from March 2018 to March 2022. Donors' characteristics and tissue variables were extracted from the database. The final corneal quality was determined based on slitlamp biomicroscopic observations and the results of specular microscopy. Environmental variables were also obtained from reliable resources. Risk factors for poor-quality corneas were calculated using logistic mixed-effect regression analysis. All analyses were performed with STATA 17.0. The significance level of 0.05 was considered for all the analyses.

RESULTS

The data of 20,625 eyes of 10,601 donors were evaluated. We found that donor age had an inverse correlation with endothelial cell density (r = -0.28, P < 0.001). The trend of donated corneal poor quality decreased between 2018 and 2021. Several factors, including intoxication (odds ratio [OR] = 1.29), obesity (OR = 1.34), diabetes mellitus (OR = 1.63), hypertension (OR = 1.52), and pseudophakic eyes (OR = 1.56), were associated with the poor quality of donated corneal tissues. The outdoor temperature over 26°C was associated with higher odds of poor corneal quality (OR = 1.31), whereas high relative humidity decreased the odds of poor corneal quality (OR = 0.82).

CONCLUSIONS

This study revealed that the cause of donor death, obesity, donor comorbidities, pseudophakia, and environmental factors could affect the corneal quality and make the donated corneas less suitable for transplantation.

Quality assurance in corneal transplants: Donor cornea assessment and oversight

The cornea is the most frequently transplanted human tissue, and corneal transplantation represents the most successful allogeneic transplant worldwide. In order to obtain good surgical outcome and visual rehabilitation and to ensure the safety of the recipient, accurate screening of donors and donor tissues is necessary throughout the process. This mitigates the risks of transmission to the recipient, including infectious diseases and environmental contaminants, and ensures high optical and functional quality of the tissues. The process can be divided into 3 stages: (1) donor evaluation and selection before tissue harvest performed by the retrieval team, (2) tissue analysis during the storage phase conducted by the eye bank technicians after the retrieval, and, (3) tissue quality checks undertaken by the surgeons in the operating room before transplantation. Although process improvements over the years have greatly enhanced safety, quality, and outcome of the corneal transplants, a lack of standardization between centers during certain phases of the process still remains, and may impact on the quality and number of transplanted corneas. Here we detail the donor screening process for the retrieval teams, eye bank operators. and ophthalmic surgeons and examine the limitations associated with each of these stages.

Skin donations after suicide by acute poisoning

The demand for skin tissue allografts to treat burns and other types of injuries increases each year to the extent that categories of donors formerly deemed "unsuitable", such as victims of suicide by polytrauma or poisoning, are now considered. Patients who died by ingestion of/exposure to toxic substances can be accepted as tissue donors after assessment of graft safety to rule out any risks of transferring toxic substances to the recipient. A cadaveric skin donation was obtained from a 57-year-old woman who died from intoxication after ingesting colchicine tablets (0.2 mg/kg). To determine the safety of cadaveric skin allografts, high-performance liquid chromatography-mass spectrometry (LC-MS/MS) was used to identify and quantify colchicine in procured skin. Results revealed that colchicine concentrations were lower than the instrument limit of detection (LOD) of 0.5 ng/mg both in epidermis and dermis. Cell viability assessed through the MTT ([3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide]) test was within standard limits. Thanks to accurate tests performed, which are routinely applied also in clinical diagnostics and forensic toxicology, it was possible to ascertain the safety and suitability of skin tissue for donation.

Successful Liver Transplantation from a Deceased Donor After Ethylene Glycol Ingestion: A Case Report and Review of the Literature of Organ Donation from Poisoned Donors

Despite the increase in deceased organ donation over the past ten years, the gap between patients awaiting transplant and available organs continues to widen. Deceased donors secondary to acute fatal poisonings represent less than 1% of all organ donors. Organs from poisoned donors have largely been discarded due to concerns of toxin transmission and poor organ function as well as the paucity of data that exists regarding this donor population. Here, we report a case of a 40-year-old male who underwent successful liver re-transplantation from a donor who died following ethylene glycol ingestion. To our knowledge this case report is the first to describe successful re-transplantation from an ethylene glycol-poisoned donor. We also provide a comprehensive review of the literature describing organ donation from poisoned donors.

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.

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.

Is endotracheal intubation a non-beneficial treatment in patients with respiratory failure due to paraquat poisoning?

Introduction

Paraquat poisoning can result in dysfunction of multiple organs, and pulmonary fibrosis with respiratory failure is the major cause of mortality. For terminally ill patients, some life-prolonging treatments can be non-beneficial treatments (NBT). The objective of this study was to determine if intubation is a NBT for patients with respiratory failure due to paraquat poisoning.

Methods

The study included 68 patients with respiratory failure due to paraquat poisoning. Patients were hospitalized at MacKay Memorial Hospital, Taitung Branch, Taiwan, between 2005 to April 2016. Composite outcomes of intra-hospital mortality, the rate of do-not-resuscitate (DNR) orders, prescribed medications, length of stay, and medical costs were recorded and compared between the do-not-intubate (DNI) group and endotracheal intubation (EI) group.

Results

Intra-hospital mortality rate for the entire population was 100%. There were significantly more patients with DNR orders in the DNI group (P = 0.007). There were no differences in the length of hospital stay. However, patients in DNI group had significantly less vasopressor use and more morphine use, shorter time in the intensive care unit, and fewer medical costs.

Conclusion

The procedure of intubation in patients with respiratory failure due to paraquat poisoning can be considered inappropriate life-prolonging treatment.

Paper-based diagnostic devices for clinical paraquat poisoning diagnosis

This article unveils the development of a paper-based analytical device designed to rapidly detect and clinically diagnose paraquat (PQ) poisoning. Using wax printing technology, we fabricated a PQ detection device by pattering hydrophobic boundaries on paper. This PQ detection device employs a colorimetric sodium dithionite assay or an ascorbic acid assay to indicate the PQ level in a buffer system or in a human serum system in 10 min. In this test, colorimetric changes, blue in color, were observable with the naked eye. By curve fitting models of sodium dithionite and ascorbic acid assays in normal human serum, we evaluated serum PQ levels for five PQ-poisoned patients before hemoperfusion (HP) treatment and one PQ-poisoned patient after HP treatment. As evidenced by similar detection outcomes, the analytical performance of our device can compete with that of the highest clinical standard, i.e., spectrophotometry, with less complicated sample preparation and with more rapid results. Accordingly, we believe that our rapid PQ detection can benefit physicians determining timely treatment strategies for PQ-poisoned patients once they are taken to hospitals, and that this approach will increase survival rates.

Predictors of acute respiratory distress syndrome in patients with paraquat intoxication

Introduction

Paraquat poisoning is characterized by acute lung injury, pulmonary fibrosis, respiratory failure, and multi-organ failure, resulting in a high rate of mortality and morbidity. The objectives of this study were to identify predictors of acute respiratory distress syndrome (ARDS) in cases of paraquat poisoning and determine the association between these parameters.

Materials and Methods

In total, 187 patients were referred for management of intentional paraquat ingestion between 2000 and 2010. Demographic, clinical, and laboratory data were recorded. Sequential organ failure assessment (SOFA) and Acute Kidney Injury Network (AKIN) scores were collected, and predictors of ARDS were analyzed.

Results

The overall mortality rate for the entire population was 54% (101/187). Furthermore, the mortality rate was higher in the ARDS patients than in the non-ARDS patients (80% vs. 43.80%, P<0.001). Additionally, the ARDS patients not only had higher AKIN_48-h scores (P<0.009), SOFA_48-h scores (P<0.001), and time to ARDS/nadir PaO₂ (P=0.008) but also suffered from lower nadir PaO₂ (P<0.001), nadir AaDO₂ (P<0.001), and nadir eGFR (P=0.001) compared to those in the non-ARDS patients. Moreover, pneumomediastinum episodes were more frequent in the ARDS patients than in the non-ARDS patients (P<0.001). A multivariate Cox regression model revealed that blood paraquat concentrations (P<0.001), SOFA_48-h scores (P=0.001), and steroid and cyclophosphamide pulse therapies (P=0.024) were significant predictors of ARDS. The cumulative survival rates differed significantly (P<0.001) between patients with SOFA_48-h scores <3 and SOFA_48-h scores ≥3, with a sensitivity of 95.8%, specificity of 58.4%, and overall correctness of 67.6%. Finally, the area under the receiver operating characteristic (AUROC) analysis showed that SOFA_48-h scores (P<0.001) had a better discriminatory power than blood paraquat concentrations (P=0.01) for predicting ARDS.

Conclusions

The analytical results indicate that SOFA_48-h scores, blood paraquat concentrations, and steroid and cyclophosphamide pulse therapies are significantly associated with ARDS complications after paraquat intoxication.

Tissue concentration of paraquat on day 32 after intoxication and failed bridge to transplantation by extracorporeal membrane oxygenation therapy

Background

Paraquat is a highly toxic herbicide, which not only leads to acute organ damage, but also to pulmonary fibrosis. There are only anecdotal reports of rescue lung transplantation, as paraquat is stored and only slowly released from different tissues. Bridging the time to complete depletion of paraquat from the body could render this exceptional therapy strategy possible, but not much is known on the time interval after which transplantation can safely be performed.

Case presentation

We report on a case of accidental paraquat poisoning in a 23 years old Caucasian man, who developed respiratory failure due to pulmonary fibrosis. The patient was listed for high urgency lung transplantion, and extracorporeal membrane oxygenation was implemented to bridge the time to transplantation. The patient died 32 days after paraquat ingestion, before a suitable donor organ was found. In postmortem tissue specimen, no paraquat was detectable anymore.

Conclusion

This case report indicates that complete elimination of paraquat after oral ingestion of a lethal dose is achievable. The determined time frame for this complete elimination might be relevant for patients, in which lung transplantation is considered.

Spectrum of corrosive esophageal injury after intentional paraquat or glyphosate-surfactant herbicide ingestion

BACKGROUND

Data on the spectrum of corrosive injury to the esophagus after paraquat or glyphosate-surfactant ingestion are sparse in the literature and confined to case studies and brief reports. Therefore, this study aimed to examine the clinical features, degrees of esophageal injury, and clinical outcomes after paraquat or glyphosate herbicide ingestion, and sought to determine what association, if any, may exist between these findings.

METHODS

We performed an observational study on 47 patients with paraquat or glyphosate ingestion who underwent endoscopic evaluation over a period of 11 years (2000-2011).

RESULTS

Corrosive esophageal injuries were classified as grade 1 in 14 (glyphosate-surfactant) and three (paraquat), grade 2a in nine (glyphosate-surfactant) and 18 (paraquat), and grade 2b in one (glyphosate-surfactant) and two (paraquat) patients. No patients had grade 0, 3a, or 3b esophageal injuries. Therefore, the severity of corrosive injury was more severe in the paraquat group (P = 0.005). After toxin ingestion, systemic toxicity occurred, with rapid development of systemic complications in many cases. Neurologic complications occurred more frequently in the glyphosate-surfactant group (29.2% versus 0%, P = 0.005), although respiratory failure (4.2% versus 34.8%, P = 0.008), hepatitis (12.5% versus 52.2%, P = 0.004), and renal failure (20.8% versus 52.2%, P = 0.025) developed more frequently in the paraquat group. Patients with glyphosate poisoning had shorter hospital stays than patients with paraquat poisoning (13.3 ± 15.1 days versus 26.8 ± 10.2 days, P = 0.001). Nevertheless, there was no significant difference in mortality rate between the glyphosate-surfactant and paraquat groups (8.3% versus 13.0%, P = 0.601). We ultimately found that patients with grade 2b esophageal injury suffered from a greater incidence of respiratory (100.0% versus 5.9%, P = 0.001) and gastrointestinal (66.7% versus 11.8%, P = 0.034) complications than patients with grade 1 injury, regardless of herbicide type.

CONCLUSION

Paraquat and glyphosate are mild caustic agents that produce esophageal injuries of grades 1, 2a, and 2b only. Our data also suggest a potential relationship between the degree of esophageal injury and systemic complications.

Paraquat poisoning in pediatric patients

OBJECTIVE

This observational study examined the outcome of Taiwanese pediatric patients with paraquat poisoning and compared these data with the published data on paraquat poisonings from other international poisoning centers.

METHODS

We performed a retrospective study on children with acute paraquat poisoning that were admitted to the Chang Gung Memorial Hospital during a period of 10 years (2000-2010). Of the 193 paraquat poisoning patients, only 6 were children.

RESULTS

The mean age was 8.85 ± 5.55 (1-15.6) years. Younger patients had accidentally swallowed paraquat, whereas older patients had intentionally ingested paraquat. Most patients were referred within a relatively short period (0.5-2.0 hours). Paraquat poisoning was associated with high morbidity and often resulted in severe complications, including acute respiratory distress syndrome and multiple-organ failure. The complications included shock (50.0%), hypoxemia (33.3%), respiratory failure (33.3%), nausea/vomiting (16.7%), abdominal pain (33.3%), hepatitis (66.7%), gastrointestinal tract bleeding (33.3%), acute renal failure (33.3%), and seizures (16.7%). Patients were treated aggressively with a standard detoxification protocol consisting of gastric lavage, active charcoal, charcoal hemoperfusion, and cyclophosphamide and steroid pulse therapies. Secondary bacterial infections were common after hospitalization and included sepsis (33.3%), pneumonia (33.3%), and urinary tract infection (50.0%). In the end, 2 patients (33.3%) died from multiple-organ failure, despite intensive resuscitation.

CONCLUSIONS

Our data (mortality rate, 33.3%) are comparable to the data of other published reports from other international poison centers. Evidently, a prompt diagnosis of paraquat poisoning and an immediate institution of a detoxification protocol is a prerequisite for a favorable outcome.

Sequential organ failure assessment score can predict mortality in patients with paraquat intoxication

Introduction

Paraquat poisoning is characterized by multi-organ failure and pulmonary fibrosis with respiratory failure, resulting in high mortality and morbidity. The objective of this study was to identify predictors of mortality in cases of paraquat poisoning. Furthermore, we sought to determine the association between these parameters.

Methods

A total of 187 patients were referred for management of intentional paraquat ingestion between January 2000 and December 2010. Demographic, clinical, and laboratory data were recorded. Sequential organ failure assessment (SOFA) and acute kidney injury network (AKIN) scores were collected, and predictors of mortality were analyzed.

Results

Overall hospital mortality for the entire population was 54% (101/187). Using a multivariate logistic regression model, it was found that age, time to hospitalization, blood paraquat level, estimated glomerular filtration rate at admission (eGFR _{first day}), and the SOFA_48-h score, but not the AKIN_48-h score, were significant predictors of mortality. For predicting the in-hospital mortality, SOFA_48-h scores displayed a good area under the receiver operating characteristic curve (AUROC) (0.795±0.033, P<0.001). The cumulative survival rate differed significantly between patients with SOFA_48-h scores <3 and those ≥3 (P<0.001). A modified SOFA (mSOFA) score was further developed by using the blood paraquat level, and this new score also demonstrated a better AUROC (0.848±0.029, P<0.001) than the original SOFA score. Finally, the cumulative survival rate also differed significantly between patients with mSOFA scores <4 and ≥4 (P<0.001).

Conclusion

The analytical data demonstrate that SOFA and mSOFA scores, which are based on the extent of organ function or rate of organ failure, help to predict mortality after intentional paraquat poisoning.

Spectrum of toxic hepatitis following intentional paraquat ingestion: analysis of 187 cases

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.

Human poisoning with spinosad and flonicamid insecticides

This report describes the first known case in the literature of acute exposure to a mixture of spinosad and flonicamid that resulted in a substantial clinical toxicities. An 80-year-old depressed female attempted suicide by drinking a mixture of 80-mL Conserve (Dow AgroSciences, Taipei, Taiwan) and 2-3 gram powder of flonicamid (Ishihara Sangyo Kaisha, Taipei, Taiwan). Spinosad was the main compound ingested. The clinical manifestations were mostly neurological, i.e. consciousness disturbance, shock, respiratory failure, pneumonitis and urinary retention. Endoscopic examination found grade 2a corrosive esophageal injury. After resuscitation, detoxification procedures and intensive care, the patient recovered fully without leaving any chronic sequels. An emerging question arising from this report is, why are the clinical symptoms so severe, given that both compounds were claimed safe in laboratory animals? The answer is unclear. One possible explanation is, the amount of spinosad ingested was far beyond the physiological safety dose that can be handled by human body. Other potential contributors to the clinical toxicities in this patient are the solvent compositions that were found in the Conserve insecticide formulation.