Taiwan National Poison Center: epidemiologic data 1985-1993

Clinical toxicology of acute glyphosate self-poisoning: impact of plasma concentrations of glyphosate, its metabolite and polyethoxylated tallow amine surfactants on the toxicity

INTRODUCTION

Common major co-formulants in glyphosate-based herbicides, polyethoxylated tallow amine surfactants, are suspected of being more toxic than glyphosate, contributing to the toxicity in humans. However, limited information exists on using polyethoxylated tallow amine concentrations to predict clinical outcomes. We investigated if plasma concentrations of glyphosate, its metabolite and polyethoxylated tallow amines can predict acute kidney injury and case fatality in glyphosate poisoning.

METHODS

We enrolled 151 patients with acute glyphosate poisoning between 2010 and 2013. Plasma concentrations of glyphosate, its metabolite, aminomethylphosphonic acid, and polyethoxylated tallow amines were determined in 2020 using liquid chromatography-tandem mass spectrometry. Associations between exposure and poisoning severity were assessed.

RESULTS

Plasma concentrations of glyphosate and aminomethylphosphonic acid demonstrated good and moderate performances in predicting acute kidney injury (≥2), with an area under the receiver operating characteristic curve of 0.83 (95% CI 0.69-0.97) and 0.76 (95% CI 0.59-0.94), respectively. Polyethoxylated tallow amines were detected in one-fifth of symptomatic patients, including one of four fatalities and those with unsaturated tallow moieties being good indicators of acute kidney injury (area under the receiver operating characteristic curve ≥0.7). As the number of repeating ethoxylate units in tallow moieties decreased, the odds of acute kidney injury increased. Glyphosate and aminomethylphosphonic acid concentrations were excellent predictors of case fatality (area under the receiver operating characteristic curve >0.9).

DISCUSSION

The 2.7% case fatality rate with 49% acute, albeit mild, acute kidney injury following glyphosate poisoning is consistent with previously published data. A population approach using model-based metrics might better explore the relationship of exposure to severity of poisoning.

CONCLUSIONS

Plasma concentrations of glyphosate and its metabolite predicted the severity of clinical toxicity in glyphosate poisoning. The co-formulated polyethoxylated tallow amine surfactants were even more strongly predictive of acute kidney injury but were only detected in a minority of patients.

Human Poisoning with Chlorpyrifos and Cypermethrin Pesticide Mixture: Assessment of Clinical Outcome of Cases Admitted in a Tertiary Care Hospital in Taiwan

Background and Purpose

There is an overall paucity of data regarding the human toxicity of chlorpyrifos and cypermethrin pesticide mixture. Both organophosphate and pyrethroid insecticides are metabolized by carboxylesterases. Thus, its pesticide combination, organophosphates may boost the toxicity of pyrethroids via inhibited its detoxification by carboxylesterases. This study examined the clinical course, laboratory tests, and outcomes of patients with chlorpyrifos, cypermethrin or their pesticide mixture poisoning, and to determine what association, if any, might exist between these findings.

Patients and Methods

Between 2000 and 2021, 121 patients poisoned with chlorpyrifos, cypermethrin, or their pesticide mixture were treated at Chang Gung Memorial Hospital. Patients were categorized as chlorpyrifos (n=82), cypermethrin (n=27) or chlorpyrifos and cypermethrin (n=12) groups. Demographic, clinical, laboratory and mortality data were collected for analysis.

Results

The patients experienced a broad range of clinical symptoms, including aspiration pneumonia (44.6%), salivation (42.5%), acute respiratory failure (41.3%), acute kidney injury (13.9%), seizures (7.5%), hypotension (2.6%), etc. Leukocytosis (12,700±6600 /uL) and elevated serum C-reactive protein level (36.8±50.4 mg/L) were common. The acute respiratory failure rate was 41.3%, comprising 48.8% in chlorpyrifos, 11.1% in cypermethrin as well as 58.3% in chlorpyrifos and cypermethrin poisoning. Patients with chlorpyrifos and cypermethrin pesticide mixture poisoning suffered higher rates of acute respiratory failure (P=0.001) and salivation (P=0.001), but lower Glasgow Coma Scale score (P=0.011) and serum cholinesterase level (P<0.001) than other groups. A total of 17 (14.0%) patients expired. The mortality rate was 14.0%, including 17.1% in chlorpyrifos, 3.7% in cypermethrin as well as 16.7% in chlorpyrifos and cypermethrin poisoning. No significant differences in mortality rate were noted (P=0.214).

Conclusion

Chlorpyrifos pesticide accounted for the major toxicity of the pesticide mixture. While the data show a higher rate of respiratory failure in the chlorpyrifos and cypermethrin pesticide mixture group than others, other measures of toxicity such as mortality and length of stay were not increased.

Drug self-poisoning in adolescents: A report of 267 cases

Introduction

The current study aims at describing a sample of adolescents admitted to a tertiary referral pediatric hospital for drug self-poisoning and to identify variables that could explain and predict a higher severity of intoxication.

Methods

We retrospectively reviewed the cases of drug self-poisoning in adolescents admitted to the Bambino Gesù Children's Hospital between January 2014 and June 2022 requiring consultation by the local Pediatric Poison Control Center (PPCC). We reported the type and class of drug ingested and correlated the clinical characteristics of the patients with their Poison Severity Score.

Results

The data of 267 patients were reported. Most patients were female (85.8 %), with a median age of 15.8 years at presentation. Half of the patients were symptomatic at admission (44.2 %), and most had at least one psychiatric comorbidity (71.1 %). Most patients were hospitalized (79.6 %), 16.6 % of cases required antidote administration and a minority required intensive care. Most patients received a PSS score of 0 (59.6 %). The most frequently ingested drug was acetaminophen (28.1 %) followed by ibuprofen (10.1 %) and aripiprazole (10.1 %). Antipsychotics as a class were the most abused drugs (33.1 %). The correlation of clinical variables with the PSS showed that older and male patients were more prone to be severely intoxicated.

Conclusions

This single-center study identifies the most commonly ingested drugs in a large sample of adolescents with voluntary drug self-poisoning, also showing that older and male patients are more susceptible to severe intoxication.

Outcomes of wasp and bee stings in Taiwan

BACKGROUND

The families of Hymenoptera causing commonly poisonous animal stings in Taiwan include Apoidea (bee) and Vespidae (wasp). This study aimed to investigate the epidemiologic, clinical characteristics, and outcomes of the severity of envenomation following wasp or bee stings in Taiwan.

METHODS

We conducted a retrospective study by identifying all wasp and bee sting-related envenomation reported to the Taiwan National Poison Control Center between January 2001 and November 2021. Data were reviewed and abstracted by two independent reviewers. We then used ordinal logistic regression analysis to find potential predictors of severe wasp and bee sting-related envenomation.

RESULTS

In Taiwan, bee or wasp stings mainly occur in late summer and autumn. A total of 611 patients were reported to the Taiwan National Poison Control Center with 7.5% resulting in severe or fatal envenomation. Four-hundred and forty-one patients were eligible for the final analysis of the predictors of severity. Logistic regression analysis showed that a greater number of stings, being stung by wasps, older age, and stings over the body were significant predictors for greater severity. The systemic effects following wasp and bee sting included anaphylactic reaction, prolongation of activated partial thromboplastin time, rhabdomyolysis, acute kidney injury, and elevated liver enzymes.

CONCLUSIONS

Wasps generally inflicted more severe envenomation than bees. Only 7.5% of patients had severe or fatal outcomes. Patients with older age, multiple stings, and/or multiple sites of stings were more likely to have severe outcomes.

Epidemiology of poisoning in Syria (1999 through 2020)

INTRODUCTION

Acute poisoning is a significant international public health issue and one of the leading causes of death in the emergency department (ED). In the absence of any previous reports describing the poisoning profile in Syria, we present this study to assess the epidemiological and clinical characteristics of poisoning over 21 years.

METHODS

We collected the data retrospectively from the Syrian Poisons Information Centre (SPIC) from January 1999 until December 2020. The data included patients who had accidental or non-accidental exposure to poisons, either by drugs, medicaments, and biological substances or substances chiefly nonmedicinal sources such as soaps and detergents, corrosive substances, pesticides, and other miscellaneous products.

RESULTS

We collected the data of 120,972 poisoned patients, of whom 52.6% were females, and 47.4% were males. Aleppo governorate reported the highest number of poisoned cases (28.6%), followed by Damascus governorate (19.9%). The highest poisoning rates were recorded in 2020, 2014, and 2010. Pharmaceutical (37.0%) and animal (33.8%) sources were the most common causative agents. The oral route was the route of poisoning in 58.3% of patients, and 33.4% through the skin. The most common poison was scorpion stings 19.5% while the most common cause of death was organophosphates 15.7%.

DISCUSSION

The differences in socioeconomic status, cultural habits, and agricultural and industrial activities between countries have led to a state of fluctuation regarding the most common poisoning agents.

CONCLUSION

Damascus and Aleppo, the two major governorates in Syria, had the highest poisoning cases. Oral administration of pharmaceutical agents was responsible for most of the poisoning cases. The most common individual poison was the scorpion poison, while the top killer was organophosphates.

When your lungs get cleaned by Harpic: A case report

Introduction

The use of household cleaning agents as a method of self-harm has been reported in the literature frequently. However, reports of Harpic ingestion a commonly used toilet cleaner is significantly lacking. Due to the ease of access of household cleaning agents, people tend to choose it as quick method of self-harm. The main focus after ingestion of acid is on the digestive tract injury. But due to the tendency to vomit after ingestion of such substance and inhalation of fumes generated there is a high possibility of injury to the respiratory tract as well.

Case presentation

Here we present a case of 19-year-old female with injury to the aerodigestive tract presenting with stridor after ingestion of Harpic - a hydrochloriacid-based cleaning solution. In addition to the gastric mucosal injury a diagnosis of chemical pneumonitis was made and her airway was protected in time for her to have a good recovery.

Discussion

Inducing vomiting in patients with hydrochloric acid is not advised because it can increase the risk of pulmonary complications as a result of aspiration [8]. Moreover, blind insertion of a nasogastric (Ryle's) tube is not done due to the risk of perforation and induction of regurgitation or vomiting. In few cases steroids have also been tried with no promising results [9]. Since there are no therapeutic standards for caustic injuries, treatment centers on correcting metabolic imbalances, coagulopathy, and emergency surgical intervention for severe injury and late sequelae. However, it is crucial to watch out for aspiration and respiratory tract injury and perform timely protection of the airway.

Conclusion

An awareness of the potential impacts of acid ingestion on the respiratory tract with a high level of suspicion towards airway injury and timely protection of airway is crucial for proper management of the patient.

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Incidence of ingestion of household cleaning agents like harpic: the toilet cleaner in Nepal.

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Complication of respiratory tract injury after ingestion of a corrosive.

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Management of the respiratory tract injury and improved outcome of early recognition.

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Educational awareness about the prevalence of suicide and use of toilet cleaners like harpic for self-harm.

Sex-based differences in the predisposing factors of overdose: A retrospective study

Drug overdose is one of the common events encountered in the emergency department (ED). The aim of the present study was to investigate the sex difference and predisposing factors of overdose in the ED. Data of 299 patients with self-poisoning reported at our poison center from January 2018 to August 2019 were retrospectively analyzed. Study cases categorized using the International Classification of Diseases, Tenth Revision coding system, which include codes T36 to T50, were selected. Data were collected including Glasgow Coma Scale scores and vital signs upon arrival (including body temperature, heart rate, systolic blood pressure, and diastolic blood pressure, sex, age, marital status, arrival time, season on admission, previous suicide attempts, psychiatric history, related comorbidities, recent arguments, categories of overdose with or without concurrent ethanol use, length of hospital stay, and survival to discharge) were analyzed. The top three types of substances that were frequently involved in drug overdose were benzodiazepine (42.9%), mixed medications (32.1%), and acetaminophen (6.1%). The 196 enrolled patients were aged 14 to 92 years (mean ± standard deviation, 39.2±18.3), and of these patients, male intentional overdose patients were 8.1 years older than their female counterparts (45.3±19.5 vs. 37.2±17.5, respectively; P<0.05). Most intentional overdose cases occurred during the spring season (n=63, 32.1%), especially in male patients (n=28, 57.1%; P<0.001). Approximately 11.2% (22/196) and 2% (4/196) of the total patients were admitted to the Toxicology ward and intensive care units, respectively. The length of hospital stay was 2±4.1 days. In summary, it is suggested that physicians notify the suicide prevention centers to be on alert for middle-aged men who are facing conflicts, especially during the spring season.

Case Fatality as an Indicator for the Human Toxicity of Pesticides-A Systematic Scoping Review on the Availability and Variability of Severity Indicators of Pesticide Poisoning

Objective: To investigate if case fatality and other indicators of the severity of human pesticide poisonings can be used to prioritize pesticides of public health concern. To study the heterogeneity of data across countries, cause of poisonings, and treatment facilities. Methods: We searched literature databases as well as the internet for studies on case-fatality and severity scores of pesticide poisoning. Studies published between 1990 and 2014 providing information on active ingredients in pesticides or chemical groups of active ingredients were included. The variability of case-fatality-ratios was analyzed by computing the coefficient of variation as the ratio of the standard deviation to the mean. Findings: A total of 149 papers were identified of which 67 could be included after assessment. Case-fatality-ratio (CFR) on 66 active ingredients and additionally on 13 groups of active ingredients were reported from 20 countries. The overall median CFR for group of pesticides was 9%, for single pesticides 8%. Of those 12 active ingredients with a CFR above 20% more than half are WHO-classified as “moderately hazardous” or “unlikely to present acute hazard”. Two of seven pesticides considered “unlikely to present hazard in normal use” showed a CFR above 20%. The cross-study variability of reported case fatality was rather low. Studies most often utilized the Glasgow Coma Score for grading the severity of poisoning. Conclusion: Although human pesticide poisoning is a serious public health problem, an unexpectedly small number of publications report on the clinical outcomes within our study period. However, CFRs of acute human pesticide poisoning are available for several groups of pesticides as well as for active ingredients showing moderate cross-study variability. Our results underline that CFR is an indicator of the human toxicity of pesticides and can be utilized to prioritize highly hazardous pesticides especially since there is limited correspondence between the animal-test-based hazard classification and the human CFR of the respective pesticide. The reporting of available poisoning data should be improved, human case-fatality data are a reasonable tool to be included systematically in the periodic statutory review of pesticides and their regulation.

Hemodynamic and electromechanical effects of paraquat in rat heart

Paraquat (PQ) is a highly lethal herbicide. Ingestion of large quantities of PQ usually results in cardiovascular collapse and eventual mortality. Recent pieces of evidence indicate possible involvement of oxidative stress- and inflammation-related factors in PQ-induced cardiac toxicity. However, little information exists on the relationship between hemodynamic and cardiac electromechanical effects involved in acute PQ poisoning. The present study investigated the effects of acute PQ exposure on hemodynamics and electrocardiogram (ECG) in vivo, left ventricular (LV) pressure in isolated hearts, as well as contractile and intracellular Ca2+ properties and ionic currents in ventricular myocytes in a rat model. In anesthetized rats, intravenous PQ administration (100 or 180 mg/kg) induced dose-dependent decreases in heart rate, blood pressure, and cardiac contractility (LV +dP/dtmax). Furthermore, PQ administration prolonged the PR, QRS, QT, and rate-corrected QT (QTc) intervals. In Langendorff-perfused isolated hearts, PQ (33 or 60 μM) decreased LV pressure and contractility (LV +dP/dtmax). PQ (10-60 μM) reduced the amplitudes of Ca2+ transients and fractional cell shortening in a concentration-dependent manner in isolated ventricular myocytes. Moreover, whole-cell patch-clamp experiments demonstrated that PQ decreased the current amplitude and availability of the transient outward K+ channel (Ito) and altered its gating kinetics. These results suggest that PQ-induced cardiotoxicity results mainly from diminished Ca2+ transients and inhibited K+ channels in cardiomyocytes, which lead to LV contractile force suppression and QTc interval prolongation. These findings should provide novel cues to understand PQ-induced cardiac suppression and electrical disturbances and may aid in the development of new treatment modalities.

Incidence of intoxication events and patient outcomes in Taiwan: A nationwide population-based observational study

BACKGROUND

Intoxicated patients were frequently managed in the emergency departments (ED) with few studies at national level. The study aimed to reveal the incidence, outcomes of intoxications and trend in Taiwan.

METHODS

Adults admitted to an ED due to an intoxication event between 2006 and 2013 were identified using the Taiwan National Health Insurance Research Database. The rate of intoxication and severe intoxication events, mortality rate, hospital length of stay (LOS), and daily medical costs of these patients were analyzed. Changes over time were analyzed using Joinpoint models. Multivariable generalized regressions with GEE were used to assess the effect of sex, age, and presence of prior psychiatric illness.

RESULTS

A total of 20,371 ED admissions due to intoxication events were identified during the study period, and the incidence decreased with annual percentage change of 4.7% from 2006 to 2013. The mortality rate, hospital LOS, and daily medical costs were not decreased over time. Males and geriatric patients had more severe intoxication events, greater mortality rates, and greater daily medical costs. Patients with psychiatric illnesses had higher mortality rates and a longer hospital LOS, but lower daily medical expenses.

CONCLUSION

From 2006 to 2013, there was a decline in the incidence of ED admission for intoxication events in Taiwan. Males, geriatric patients, and those with psychiatric illnesses had greater risks for severe intoxication and mortality.

Acute Poisoning among Patients Presenting to the Emergency Department of a Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction:

Acute poisoning is a major global public health problem contributing to one of the leading causes for a visit to an emergency department. This study aims to analyse the demographic and psychosocial characteristics of patients with acute poisoning presented to the emergency department.

Methods:

This was a descriptive cross-sectional study conducted in a tertiary care hospital from June to December 2019 after obtaining ethical approval from Institutional review board (reference number. 041-075/0760). A convenient sampling method was applied. Epidemiological factors, types of poison consumed, reason, motive, and place to take poison, time elapse in the presentation to the hospital were studied. Statistical analysis was done using statistical package for the social sciences version 20. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data.

Results:

Out of 76 cases of acute poisoning, the organophosphorus poisoning was 18 (23.7%) followed by unknown 12 (15.8). Of total, 28 (36.8%) had quarrel before taking poison and 41 (53.9%) had intention to commit suicide. Sixty-seven (88.2%) took a poison at home. The average elapsed time to the visit of the emergency department was 110±80 minutes

Conclusions:

The most common poisoning was organophosphorus with a suicide being the most common intention. Quarrel was the most frequent reason to take poison and the home was the most common place to take poison.

Paraquat exposure delays late-stage Leydig cell differentiation in rats during puberty

Paraquat is a fast and non-selective herbicide that is widely used in crop cultivation and conservation tillage systems. Animal experiments have shown that paraquat decreases sperm quality and testicular organ coefficient, but its effects on the development of Leydig cells remain unclear. The objective of the current study was to investigate the effects of paraquat exposure on the Leydig cell development in rats during puberty. Twenty-eight male 35-day-old Sprague-Dawley rats were divided into 4 groups: 0, 0.5, 2.0, and 8 mg kg^-1 d^-1 paraquat. Paraquat was gavaged for 10 d. Adult Leydig cells were isolated and treated with paraquat for 24 h. Paraquat in vivo significantly decreased body and testis weights at 8 mg kg^-1 and lowered serum testosterone levels at 2 and 8 mg kg^-1 without affecting the levels of serum luteinizing hormone and follicle-stimulating hormone. Paraquat did not alter Leydig cell number and PCNA labeling index. Real-time PCR showed that paraquat down-regulated the expression of Lhcgr, Scarb1, Cyp11a1, Cyp17a1, and Hsd17b3 genes and their proteins at 2 or 8 mg kg^-1, while it up-regulated the expression of Srd5a1 at 8 mg kg^-1. Paraquat increased ROS and decreased testosterone production by Leydig cells at 1 and 10 μM after in vitro 24-h exposure. Vitamin E (40 μg/ml) reversed paraquat-induced ROS and suppression of testosterone synthesis in vitro. In conclusion, paraquat directly delays Leydig cell differentiation to block testosterone synthesis via down-regulating the expression of critical testosterone synthesis-related genes and up-regulating the expression of testosterone metabolic enzyme (Srd5a1) gene and possibly via increasing ROS production.

Paraquat exposure delays stem/progenitor Leydig cell regeneration in the adult rat testis

Paraquat, a widely used nonselective herbicide, is a serious hazard to human health. However, the effects of paraquat on the male reproductive system remain unclear. In this study, adult male Sprague Dawley rats were intraperitoneally injected ethane dimethane sulfonate (EDS, 75 mg/kg) to initiate a regeneration of Leydig cells. EDS-treated rats were orally exposed to paraquat (0.5, 2, 8 mg/kg/day) from post-EDS day 17 to day 28 and effects of paraquat on Leydig and Sertoli cell functions on post-EDS day 35 and day 56 were investigated. Paraquat significantly decreased serum testosterone levels at 2 and 8 mg/kg. Paraquat lowered Leydig cell Hsd17b3, Srd5a1, and Hsd11b1 mRNA levels but increased Hsd3b1 on post-EDS day 35. Paraquat lowered Cyp11a1, Cyp17a1, and Hsd11b1 but increased Srd5a1 on post-EDS day 56. However, paraquat did not alter Leydig cell number and PCNA labeling index. Epididymal staining showed that few sperms were observed in paraquat-treated rats. Primary culture of adult Leydig cells showed that paraquat diminished testosterone output and induced reactive oxygen species generation at 1 and 10 μM and apoptosis rate at 10 μM. In conclusion, a short-term exposure to paraquat delays Leydig cell regeneration from stem/progenitor Leydig cells, causing low production of testosterone and an arrest of spermatogenesis.

Clinical spectrum of acute poisoning in children admitted to the pediatric emergency department

BACKGROUND

Pediatric poisoning is a common emergency worldwide. Routine surveillance is required for public health authorities and physicians to update strategies for prevention and management of pediatric poisoning. This study investigated the epidemiology of poisoning among children admitted to an emergency department (ED).

METHODS

This was a retrospective descriptive study. Data were collected from patients under 18 years old (y/o) presenting with poisoning at the largest ED in North Taiwan from 2011 to 2015.

RESULTS

Five-year records of 590 patients-309 (52.3%) boys and 281 (47.7%) girls-were analyzed. The mean age was 5.07 y/o (Standard Deviation [SD] = 5.02 years), and 94.7% of events occurred at home. Incidence was highest from 6 p.m. to 12 a.m. (42.2%, n = 249). Most patients younger than 11 y/o were male, but this gender distribution was reversed in adolescents (11-17 y/o). Pharmaceutical ingestion (41.4%, n = 244) was the leading cause of poisoning; pesticide was the most common non-pharmaceutical poison ingested (9.5%, n = 55). Carbon monoxide (CO) intoxication (87.6%, n = 99) and snakebite (75%, n = 9) were the common causes of inhalation (n = 113) and venom (n = 12) poisoning, respectively. The mean duration of the ED stay was 5.45 h (SD = 7.39 h), and 101 cases (17.2%), including 21 cases (3.6%) requiring intensive care, were admitted to the hospital. All patients survived.

CONCLUSION

Most poisonings occurred in young children, at home, by unintentional ingestion of a single substance, from 6 p.m. to 12 a.m. Female adolescents were the common intentional poisoning patients and pharmaceutical ingestion was the leading cause of poisoning. This kind of information enables ED physicians to improve preparations for pediatric poisoning cases and allows public health authorities to sharpen the focus of poisoning prevention efforts.

Clinical and demographic characteristics of geriatric patients with acute poisoning in the state of Uttarakhand

Background:

Acute poisoning in geriatric age group is a clinical challenge due to multiple comorbidities and complications in this age group. There are very few studies done in the past, which have addressed this issue.

Materials and Methods:

This retrospective observational study was a carried out in the Department of Emergency Medicine of a tertiary care hospital of Uttarakhand over a period of 1 year from November 2017 to October 2018. Detailed demographic data and clinical history of patients with alleged history of acute poisoning was obtained from the hospital record section.

Results:

During the period of 1 year, 156 patients of acute poisoning attended the medical emergency department, of which 53 (33.9%) patients belonged to geriatric age group (>60 years). Maximum number of patients belonged to the age group of 71–80 years (n = 26, 16.6%). Males outnumbered female patients. The most common toxidrome in geriatric age group was alcohol intoxication followed by pesticide (organophosphorus) poisoning. Unintentional exposure of toxin in the form of drug over dosage encompassed more than one-third of poisonings in geriatric population. Nine (16.9%) geriatric patients succumbed to poisoning. Complications such as acute renal failure, shock, respiratory distress, acute liver injury, and need for ventilator support were more common in nonsurvivors as compared with survivors.

Conclusion:

The study demonstrated mortality of 16.9% (n = 9) among geriatric patients with alleged history of acute poisoning. The risk factors attributing to mortality were shock, aspiration pneumonia, and acute liver injury. Although cases of suicidal exposure outnumbered cases of unintentional exposure, the latter group comprised of a considerable number. Clearly, more attention is needed while managing a case of acute poisoning of geriatric age group as their pattern of presentation and complications differ from that of younger age group.

One-year mortality among hospital survivors of cholinesterase inhibitor poisoning based on Taiwan National Health Insurance Research Database from 2003 to 2012

Background

Acute cholinesterase inhibitor (CI) poisoning, including organophosphate and carbamate poisoning, is a crucial problem in developing countries. Acute intoxication results in a cholinergic crisis, neurological symptoms, or respiratory failure. However, the short-term and long-term outcomes of CI poisoning are seldom reported.

Methods

Data from the National Health Insurance Research Database were used to investigate the outcomes after organophosphate and carbamate poisoning. Patients who were hospitalized for a first episode of acute CI poisoning between 2003 and 2012 were enrolled in this study. Outcomes of acute CI poisoning with or without mechanical ventilation were analyzed.

Results

Among 6832 patients with CI poisoning, 2010 developed respiratory failure requiring mechanical ventilation, and the other 4822 patients did not require mechanical ventilation. The hospital mortality rate was higher in patients requiring mechanical ventilation than in those not requiring mechanical ventilation (33.3% versus 4.7%, p < 0.0001). In patients with respiratory failure with mechanical ventilation, the patients without pneumonia had higher mortality rate than those with pneumonia. (36.0% versus 19.9%, p < 0.0001). The 1-year mortality rate the survivors of CI poisoning was 6.7%. Among 5932 survivors after cholinesterase inhibitor poisoning, the one-year mortality rate in patients with mechanical ventilation during hospitalization was higher than those without mechanical ventilation during hospitalization (11.4% versus 5.4% respectively, p < 0.0001).

Conclusions

The one-year mortality rate of survivors after CI poisoning was 6.7%. Meanwhile, age, pneumonia, and mechanical ventilation may be predictive factors for the one-year mortality among the survivors after CI poisoning. Diabetes mellitus was not a risk factor for hospital mortality in patients with CI poisoning.

Cost Benefits of the Drug and Poison Information Centre in Preventing Unnecessary Hospitalisation: The Singapore Experience

Background

The Drug and Poison Information Centre (DPIC) in Singapore was piloted as a new service in April 2004. This study evaluated the cost benefits of its interventions in the first two years of its operation.

Method

A two-year retrospective review of DPIC call records was performed and the following outcome measures were noted: (A) proportion of patients who were managed onsite and hence did not need to attend the emergency department (ED); and (B) proportion of patients who were managed in the ED without the need for admission. Cost savings were calculated based on admission costs for patients with poisoning, including other out-of-hospital costs. This amounted to savings of S$1390 and S$1170 for patients who fulfilled outcome measures A and B respectively. Savings for the hospital was S$1477 per case. The cost of operating the DPIC over the same period was S$507,922.

Results

There were 831 calls on acute toxic exposures over the study period. Of these, 115 and 405 patients fulfilled outcome measure A and B respectively with consequent cost savings of S$159,850 (115 x S$1390 per patient), and S$473,850 (405 x S$1170 per patient). The hospitals saved S$768,040 (520 x S$1477) from prevented admissions. Excluding operating cost, this gave net savings of S$893,818 over the two years from DPIC interventions.

Conclusion

The cost savings from DPIC services is evident from this study. This translates to more effective use of limited healthcare resources.

Patients with acute poisoning presenting to an urban emergency department of a tertiary hospital in Tanzania

Background

Poisoning is a major public health concern in sub-Saharan Africa, affecting patients of all age groups. Poisoned patients often present to the emergency department (ED) and prompt evaluation and appropriate management are imperative to ensure optimal outcomes. Unfortunately, little is known about the specific presentations of poisoned patients in East Africa. We describe the clinical and epidemiological features of patients presenting to the Muhimbili National Hospital (MNH) ED with suspected toxicological syndromes.

Methods

This prospective study enrolled a consecutive sample of ED patients who presented with a suspected toxicological syndrome from March 2013 to June 2013. Trained investigators completed a structured case report form (CRF) for each eligible patient, documenting the suspected poison, demographic information, the clinical presentation, and the ED outcome and disposition. The study data were analyzed and summarized with descriptive statistics.

Results

Of 8827 patients, who presented to ED-MNH, 106 (1.2%) met inclusion criteria, and all were enrolled. Among those enrolled, the median age was 28 years (interquartile range [IQR] 16 years), and 81 (76.4%) were male. Overall 55 (52%) were single, and 28 (26.4%) had professional jobs. 60 (56.6%) patients were referred from district hospitals, 86.8% of which were in Dar es Salaam. Only 13 (12.3%) of patients presented to the ED within 2 h of the toxic exposure. The etiology of poisoning included alcohol in 42 (50%), a mixture of different medications in 12 (14.3%), and snakebite in 6 (11.3%). Most exposures were intentional (63 [59.4%]) and were via the oral route (88 [83%]). The most common abnormal physical findings were altered mental status (66 [62.3%]) and tachypnoea (68 [64.2%]). One patient died in the ED and 98 (92.5%) required hospital admission.

Conclusions

Most patients presenting to the ED with a toxicological syndrome were adult males with intentional exposures. The most common toxic exposure was alcohol (ethanol) intoxication and the most common abnormal findings were altered mental status and tachypnoea. More than three-quarter of patients presented after 2 h of exposure. Almost all patients were admitted to the hospital.

Pesticide Practices and Suicide among Farmers of the Sundarban Region in India

Background

Deliberate self-poisoning by ingesting pesticides is a serious health problem among farmers, especially in low- and middle-income countries. Preventing these suicides is a priority for a public mental health agenda.

Objective

To examine the role of pesticide poisoning in suicide and nonfatal deliberate self-harm, and clarify awareness of risks, safe practices concerning storage and use of pesticides, and associated self-injury, both unintentional and intentional, within farmer households of the Sundarban region, India.

Methods

Retrospective record review of adult cases of deliberate self-poisoning at the Block Primary Health Centres of 13 Sundarban Blocks was performed to analyze the relative roles of various methods of self-harm and their lethality. Focus group discussions, questionnaires, and in-depth interviews were undertaken in a community study of farmer households to examine pesticide-related views and practices, with particular attention to storage, use, and health impact.

Results

Pesticide poisoning was the most common method of deliberate self-harm in both men and women. Pesticide storage in most households was unsafe and knowledge was inadequate concerning adverse effects of pesticides on health, crops, and the environment.

Conclusions

An intersectoral approach linking the interests of public health, mental health, and agriculture is well suited to serve the collective interests of all three agendas better than each in isolation. Such an approach is needed to reduce morbidity and mortality from unintentional and intentional self-injury in low-income agricultural communities like those of the Sundarban region.

The effectiveness of patient-tailored treatment for acute organophosphate poisoning

BACKGROUND

To determine a new pralidoxime (PAM) treatment guideline based on the severity of acute organophosphate intoxication patients, APACHE II score, and dynamic changes in serum butyrylcholinesterase (BuChE) activity.

METHODS

This is a randomization trial. All patients received supportive care measurements and atropinization. Each enrolled patient was treated with 2 gm PAM intravenously as the loading dose. The control group was treated according to the WHO's recommended PAM regimen, and the experimental group was treated according to their APACHE II scores and dynamic changes in BuChE activity. If a patient's APACHE II score was ≧26 or there was no elevation in BuChE activity at the 12th hour when compared to the 6th, doses of 1 g/h PAM (i.e., doubled WHO's recommended PAM regimen) were given. The levels of the serum BuChE and red blood cells acetylcholinesterase and the serum PAM levels were also measured.

RESULTS

Forty-six organophosphate poisoning patients were enrolled in this study. There were 24 patients in the control group and 22 patients in the experimental group. The hazard ratio of death in the control group to that of the experimental group was 111.51 (95% CI: 1.17-1.613.45; p = 0.04). The RBC acetylcholinesterase level was elevated in the experimental group but was not in the control group. The experimental group did not exhibit a higher PAM blood level than did the control group.

CONCLUSION

The use of PAM can be guided by patient severity. Thus, may help to improve the outcomes of organophosphate poisoning patients.

An epidemiological study of poisoning cases reported to the National Poisons Information Centre, All India Institute of Medical Sciences, New Delhi

A retrospective analysis of poisoning calls received by the National Poisons Information Centre showed a total of 2719 calls over a period of three years (April 1999-March 2002). The queries were made on poisoning management (92%) and information (8%) about various products and functioning of the centre. The data were analysed with respect to age, sex, mode and type of poisoning. The agents belonged to various groups: household products, agricultural pesticides, industrial chemicals, drugs, plants, animal bites and stings, miscellaneous and unknown groups respectively. The age ranged from less than 1 to 70 years, with the highest incidence in the range of 14-40 years, with males (57%) outnumbering females (43%). The most common mode of poisoning was suicidal (53%), followed by accidental (47%). The route of exposure was mainly oral (88%). Dermal (5%), inhalation and ocular exposure contributed 7% to the total. The highest incidence of poisoning was due to household agents (44.1%) followed by drugs (18.8%), agricultural pesticides (12.8%), industrial chemicals (8.9%), animals bites and stings (4.7%), plants (1.7%), unknown (2.9%) and miscellaneous groups (5.6%). Household products mainly comprised of pyrethroids, rodenticides, carbamates, phenyl, detergents, corrosives etc. Drugs implicated included benzodiazepines, anticonvulsants, analgesics, antihistamines, tricyclic antidepressants, thyroid hormones and oral contraceptives. Among the agricultural pesticides, aluminium phosphide was the most commonly consumed followed by organochlorines, organophosphates, ethylene dibromide, herbicides and fungicides. Copper sulphate and nitrobenzene were common among industrial chemicals. The bites and stings group comprised of snake bites, scorpion, wasp and bee stings. Poisoning due to plants was low, but datura was the most commonly ingested. An alarming feature of the study was the high incidence of poisoning in children (36.5%). The age ranged from less than 1 to 18 years and the most vulnerable age group included children from less than 1 year to 6 years. Accidental mode was the most common (79.7%). Intentional attempts were also noticed (20.2%) in the age group above 12 years. The present data may not give an exact picture of the incidence of poisoning in India, but represents a trend in our country. The Poisons Information Centre plays a vital role in providing timely management guidelines including the supply of necessary antidotes from the recently established National Antidote Bank, thereby helping to save precious lives.

Etiological and demographical characteristics of acute adult poisoning in Adana, Turkey

The objective of this study is to define the etiological and demographical characteristics of the patients applying to the emergency department in Faculty of Medicine, Çukurova University because of poisoning. This retrospective study was carried out by examining the records of 491 people who applied to the main emergency department in Faculty of Medicine, Cukurova University, with the complaint of poisoning between January 1, 2004 and December 31, 2004. It was determined that the reason why 491 of 20 817 persons (2.4%) applied during this term was because of poisoning: 159 (32.4%) of such patients were male and 332 of them (67.6%) were female. It was found that the average age of men was 27.1 ± 10.5 years and that of women was 24.4 ± 9.5 years ( P = 0.005); 427 of poisoning cases (87.0%) happened intentionally as suicide attempts and 64 of them (13.0%) were accidental. The rate of suicide-purposed poisoning was higher in women and the rate of unintentional poisoning was higher in men ( P ± 0.001). The drugs were accountable for 71.1% of all poisoning cases and the pesticides were accountable for 18.9% of such cases. Poisonings increase during summers. The mortality rate in poisonings was found as 0.8%. The drugs and pesticides in Ckurova region constitute 90.0% of all poisoning cases. The mortality rate in poisoning will be decreased by training the physicians employed in the emergency department about poisoning by drugs and pesticides. Human & Experimental Toxicology ( 2007) 26, 401—406

Mothers' Knowledge Levels Related to Poisoning

Objectives

This study was done to evaluate mothers’ level of knowledge regarding poisoning, to plan training for issues with an identified lack of knowledge, to collect required data regarding protection and approach issues on poisoning cases which may occur in children for various reasons.

Methods

This descriptive study was performed after obtaining permission from the County Health Department and involved mothers who applied to Family Health Centers No. 1-7 between April 1^st and May 31^st 2012, and who agreed to participate in the study (n=290). The questionnaire was composed of three parts: “Personal Information Form,” “House Poisoning Evaluation Form” and “Home Poisoning Prevention Knowledge Level Form.”

Results

Participant ages were between 16 and 50 years and the mean age was 33.09±7.10 years. The number of children ranged from 1 to 6, and 203 people had seven children under the age of six. 37.6% of the mothers were primary school graduates, while 74.5% were housewives. There was a significant relationship between the knowledge score of the mothers on poisoning and education, career, neighborhood, and social security (p<0.05).

Conclusions

Childhood poisoning is the most common cause of admission to the hospital. Protective precautions such as family education, storage of medication out of reach of children and use of secure lids are thought to be important.

Frequency of Anxiety in Patients With Drug Poisoning in Rafsanjan City, Iran, in 2013

BACKGROUND

Expansion of technology and progression of sciences have led to wider access to agricultural and industrial drugs and chemicals, which has resulted in many problems. Both in wanted and unwanted ways people may take these toxic agents, which perhaps may be along with many unpredictable, life-threatening and mortal outcomes. Based on many studies, most of intentional poisonings arise from an origin of patients' psychological backgrounds, which confirms necessity and importance of the recent study.

OBJECTIVES

This study aimed to study the prevalence of psychiatric disorders in patients with drug poisoning.

PATIENTS AND METHODS

In this descriptive cross-sectional study, 116 cases of poisoning referred to emergency room of Ali-Ebn-Abitaleb Hospital in Rafsanjan city, Iran, were randomly selected. Frequency of anxiety among participants was evaluated through the Spielberger questionnaire. A past history of depression and obsession was also evaluated through interview by a psychiatrist based on diagnostic and statistical manual of mental disorders (DSM-5) criteria. All data were then collected and analyzed using SPSS version 17.

RESULTS

Anxiety, as the second most common reason of psychiatric disorders in cases of poisoning, with a prevalence of 12.1% in form of mild, 75.9% moderate and 12.1% severe, was confirmed among the participants of this study.

CONCLUSIONS

The prevalence of anxiety among cases of poisoning with both drugs and chemicals are noticeably higher than general population. This fact strongly suggests the necessity of in-advance consultation and treatment of any underlying psychiatric disorders of patients to prevent prospective complications.

Which deliberate self-poisoning patients are most likely to make high-lethality suicide attempts?

BACKGROUND

The risk/rescue rating scale (RRRS) assesses the lethality of a suicide attempt, which is defined as the probability of inflicting irreversible damage. We assessed the lethality of suicide attempts using the RRRS and identified the socio-demographic profiles of patients who achieved high lethality in deliberate self-poisoning (DSP).

METHODS

A retrospective study was conducted to evaluate DSP patients who visited the emergency department of a tertiary teaching hospital between 2000 and 2011. The data included socio-demographic information, clinical variables, risk factors (e.g., the method used, whether consciousness was impaired, toxicity, reversibility and whether treatment was required) and rescue factors (e.g., location, who initiated the rescue, the probability of discovery, the accessibility of rescue, and delay until discovery). The high-risk group consisted of patients with 11-15 risk points, whereas patients in the low-rescue group had 5-11 risk points. We examined the characteristics of high-lethality suicide attempts (high-risk/low-rescue group).

RESULTS

A total of 1114 patients were enrolled in this study. Pearson's correlation analysis showed that the total risk score for patients with DSP was negatively associated with the total rescue score (r = -0.201, p < 0.001). Of the total number of DSP patients, 42 were included in the high-risk/low-rescue group. The multivariate logistic regression analyses showed significant associations between high-lethality suicide attempts and male gender (OR 2.70, 95 % CI 1.41-5.18, p = 0.003), older age (OR 1.02, 95 % CI 1.01-1.04, p = 0.015), and unemployment (OR 2.98, 95 % CI 1.41-6.33, p = 0.004).

CONCLUSION

This retrospective study demonstrates that male gender, advanced age, and unemployed status were associated with high-lethality suicide attempts in DSP patients.

QTc prolongation as a useful prognostic factor in acute paraquat poisoning

BACKGROUND

Acute paraquat poisoning has a high mortality rate. Several prognostic factors have been proposed to predict the mortality risk of paraquat-poisoned patients. However, these prognostic factors are complex and some require a laboratory. Corrected QT (QTc) has been used as a prognostic factor in several clinical conditions, such as acute organophosphate poisoning. In addition, the measurement can be obtained in a reasonable amount of time.

STUDY OBJECTIVES

This study's objective was to investigate whether QTc can predict mortality in paraquat-poisoned patients.

METHODS

This was a retrospective study. Potential prognostic factors such as QTc, vital signs at admission, and certain biochemistry variables were analyzed with Cox regression analyses for their ability to predict a patient's survival from paraquat poisoning.

RESULTS

Sixty acute paraquat-poisoned patients were admitted to the emergency department during the study period. The QTc of the survival group ranged from 0.35 to 0.48 s, whereas the nonsurvivor group ranged from 0.32 to 0.63 s. The nonsurvivor group contained a higher percentage of patients with QTc prolongation (≥0.45 s) compared with the survivor group (p = 0.04). The hazard ratio of QTc prolongation for a patient's death was found to be 2.47 (95% confidence interval [CI] 1.68-5.67) in patients with a lower potassium level (<3.2 mEq/L) and 3.71 (95% CI 1.53-8.97) in patients with a higher potassium level (≥3.2 mEq/L). In addition, hyperdynamic circulation was observed upon admission of these poisoned patients.

CONCLUSION

QTc prolongation is a useful prognostic factor for predicting death in acute paraquat-poisoned patients. Cardiovascular collapse may occur in some paraquat-poisoned patients. Physicians can use QTc as an indicator of a patient's severity of poisoning and mortality risk.

Chlorpyrifos is associated with slower serum cholinesterase recovery in acute organophosphate-poisoned patients

PURPOSE

Organophosphate poisoning (OPP) accounts for 200,000 deaths annually in developing countries. Serum cholinesterase (SChE) is of diagnostic value in patients with OPP and is checked repeatedly during the course of treatment. This study aimed to investigate the recovery pattern in patients with OPP using linear mixed models.

METHODS

Using a retrospective cohort study design, we included 212 adult OPP patients who had visited the emergency department (ED) in a tertiary medical center between 2000 and 2010. One hundred and thirty-one patients were available for analysis, as 81 patients did not meet the criteria and were excluded. Information regarding basic personal characteristics, initial vital signs and severity scores, laboratory data, type and amount of organophosphate ingested, treatment, and serial SChE values was collected. A random coefficient model with a random intercept and a random slope of time were added to address the dynamic relationships of SChE with time and other associated factors.

RESULTS

The initial SChE activity and recovery rates varied among patients with OPP. The type of organophosphate, the first SChE activity, and the initial APACHE II score were significantly related to the SChE recovery trend. Chlorpyrifos and methamidophos had significantly slower and faster SChE recovery rates, respectively, than other organophosphates. Sex, dose of Pralidoxim (2-PAM), and delay in obtaining medical assistance did not significantly affect SChE recovery.

CONCLUSIONS

This study demonstrated the pattern and associated correlates of SChE activity recovery in patients with acute OPP. Chlorpyrifos appeared to have a slower SChE activity recovery rate than other organophosphates.

Acute poisoning with neonicotinoid insecticides: a case report and literature review

Neonicotinoids are a new class of insecticides widely applied for crop protection. These insecticides act as agonists at nicotinic acetylcholine receptors, which cause insect paralysis and death. The high specificity for receptors in insects was considered to possess highly selective toxicity to insects and relative sparing of mammals. However, an increasing number of cases of acute neonicotinoid poisoning have been reported in recent years. We reported a man who developed respiratory failure and shock after ingestion of neonicotinoid insecticide. A detailed literature review found that respiratory, cardiovascular and certain neurological presentations are warning signs of severe neonicotinoid intoxication. The amounts of ingested neonicotinoid insecticide and the plasma neonicotinoid concentration are not useful guides for the management of intoxicated patients. Supportive treatment and decontamination are the practical methods for the management of all neonicotinoid-poisoned patients.

Risk and prognostic factors of inpatient mortality associated with unintentional insecticide and herbicide poisonings: a retrospective cohort study

Introduction

Pesticide poisoning is an important public health problem worldwide. The study aimed to determine the risk of all-cause and cause-specific inpatient mortality and to identify prognostic factors for inpatient mortality associated with unintentional insecticide and herbicide pesticide poisonings.

Methods

We performed a retrospective cohort study of 3,986 inpatients recruited at hospitalization between 1999 and 2008 in Taiwan. We used the International Classification of Disease, 9th ed., Clinical Modification external causes of injury codes to classify poisoning agents into accidental poisoning by insecticides and herbicides. Comparisons in mortality rates were made between insecticide poisoning patients and herbicide poisoning patients by using the Cox proportional hazards models to estimate multivariable-adjusted hazard ratios (HRs) and their 95% confidence intervals (CIs).

Results

There were 168 deaths during 21,583 person-days of follow-up evaluation (7.8 per 1,000 person-days). The major causes of mortality for insecticide poisonings were the toxic effect of organophosphate and coma, and the major causes of mortality for herbicide poisonings were the toxic effect of other pesticides and the toxic effect of organophosphate. The mortality for herbicide exposure was fourfold higher than that for insecticide exposure. The factors associated with inpatient mortality were herbicide poisonings (HR = 4.58, 95% CI 3.29 to 6.37) and receiving mechanical ventilation treatment (HR = 3.85, 95% CI 2.73 to 5.42).

Conclusions

We demonstrated that herbicides stand out as the dominant agent for poisoning-related fatalities. The control of and limiting access to herbicide agents and developing appropriate therapeutic regimens, including emergency care, should be priorities.

Analysis of the pattern of acute poisoning in patients admitted to a governmental hospital in Palestine

The objectives were to (i) analyse the pattern of poisoning and (ii) study gender distribution and management protocol of poisoning in patients diagnosed with acute poisoning. A retrospective analysis of cases diagnosed with acute poisoning and admitted to the emergency department of Al-Wattani governmental hospital during the year of 2008 was carried out. Data from patients' medical files were collected and then analysed using Statistical Package for Social Sciences (spss; SPSS Inc., Chicago, IL, USA), version 16. There were 674 cases diagnosed with acute poisoning in 2008 which accounted for 1.5% of the total admission to the hospital. The mean age of the cases was 21.8 ± 18.1 years. Approximately, 58% of poisoning cases occurred at home. Male to female ratio was 1.5:1. The maximum number of poisoning occurred during summer season. Poisoning cases were maximum in the age category >18 years. More than half (92%) of the cases were of unintentional type of poisoning. Unintentional poisoning was significantly more common among males (61.3%; p < 0.01), while intentional was more common among females (64.8%; p < 0.001). The causative agents encountered were mainly biological agents (77.4%), pharmaceuticals (11.6%), and other chemicals (10.9%). The most common route of poisoning was through stings (72.3%), followed by oral ingestion (23.5%) and inhalation (3.4%). The majority (91.1%) of cases did not undergo any decontamination methods. Of those who had decontamination procedure, gastric lavage was the most commonly used. This is the first study in Palestine that presents data on the pattern of acute poisoning. Awareness campaigns should be held about potentially toxic materials in the region, and methods of poison prevention should be spread among the public.

Triage vital signs predict in-hospital mortality among emergency department patients with acute poisoning: a case control study

BACKGROUND

To document the relationship between triage vital signs and in-hospital mortality among emergency department (ED) patients with acute poisoning.

METHODS

Poisoning patients who admitted to our emergency department during the study period were enrolled. Patient's demographic data were collected and odds ratios (OR) of triage vital signs to in-hospital mortality were assessed. Receiver operating characteristic curve was used to determine the proper cut-off value of vital signs that predict in-hospital mortality. Logistic regression analysis was performed to test the association of in-hospital mortality and vital signs after adjusting for different variables.

RESULTS

997 acute poisoning patients were enrolled, with 70 fatal cases (6.7%). A J-shaped relationship was found between triage vital signs and in-hospital mortality. ED triage vital signs exceed cut-off values independently predict in-hospital mortality after adjusting for variables were as follow: body temperature <36 or >37°C, p < 0.01, OR = 2.8; systolic blood pressure <100 or >150 mmHg, p < 0.01, OR: 2.5; heart rate <35 or >120 bpm, p < 0.01, OR: 3.1; respiratory rate <16 or >20 per minute, p = 0.38, OR: 1.4.

CONCLUSIONS

Triage vital signs could predict in-hospital mortality among ED patients with acute poisoning. A J-curve relationship was found between triage vital signs and in-hospital mortality. ED physicians should take note of the extreme initial vital signs in these patients.

Factors associated with the decline in suicide by pesticide poisoning in Taiwan: a time trend analysis, 1987-2010

OBJECTIVE

Pesticide self-poisoning accounts for one-third of suicides worldwide, but few studies have investigated the national epidemiology of pesticide suicide in countries where it is a commonly used method. We investigated trends in pesticide suicide, and factors associated with such trends, in Taiwan, a rapidly developing East Asian country.

METHODS

We conducted an ecological study using graphical approaches and Spearman's correlation coefficients to examine trends in pesticide suicide (1987-2010) in Taiwan in relation to pesticide sales, bans on selected pesticides, the proportion of the workforce involved in agriculture and unemployment. We compared pesticide products banned by the Taiwanese government with products that remained on the market and pesticides that accounted for the most poisoning deaths in Taiwan.

RESULTS

Age-standardised rates of pesticide suicide showed a 67% reduction from 7.7 per 100,000 (42% of all suicides) in 1987 to 2.5 per 100,000 (12% of all suicides) in 2010, in contrast to a 69% increase in suicide rates by other methods. Pesticide poisoning was the most commonly used method of suicide in 1987 but had become the third most common method by 2010. The reduction was paralleled by a 66% fall in the workforce involved in agriculture but there was no strong evidence for its association with trends in pesticide sales, bans on selected pesticide products or unemployment. The bans mostly post-dated the decline in pesticide suicides; furthermore, they did not include products (e.g. paraquat) that accounted for most deaths and were mainly restricted to selected high-strength formulated products whilst their equivalent low-strength products were not banned.

CONCLUSIONS

Access to pesticides, indicated by the size of agricultural workforce, appears to influence trends in pesticide suicide in Taiwan. Targeted bans on pesticides should focus on those products that account for most deaths.

Trends in poisoning hospitalization and mortality in Taiwan, 1999-2008: a retrospective analysis

Background

Subjects with non-fatal poisoning may be left with permanent, disabling sequelae, and the resultant long-term use of medical services smay be a burden on the public health care system. The objective of this study was to describe the epidemiology of poisoning in Taiwan from 1999 to 2008.

Methods

We analyzed poisoning-related data of mortality rates sourced from official Taiwanese vital statistics and of hospitalization from the National Health Insurance (NHI) Research Database. The data were age-adjusted to the year 2000 Standard Population to determine 10-year hospitalization and mortality rate trends, which we stratified according to gender, age, and poisoning agent. Poisson regression was used to investigate the trends.

Results

There were 20,260 deaths and 210,021 hospitalizations related to poisoning, with mortality and hospitalization rates of 8.21 per 100,000 and 86.30 per 100,000 population, respectively. Males exhibited higher rates of mortality and hospitalization as a result of poisoning, with the highest risk in those aged 65 years or older. Medicinal drugs followed by pesticides were the two most common agents of poisoning. There was an increasing trend of both poisoning-related mortality and hospitalization rates during the study period, with a greater increase occurring in the hospitalization rate than in the mortality rate.

Conclusions

We found the males aged 65 years or older were at highest risk of poisoning, with medicinal drugs being the leading cause. Hospitalization rates increased more than mortality rates over the 10-year period. Appropriate poisoning prevention programs need to be developed. We should strengthen case management and improve access to health services to increase survival in cases of poisoning.

Features and prognostic factors for elderly with acute poisoning in the emergency department

BACKGROUND

Elderly persons with acute poisoning in the emergency department (ED) and prognostic factors of outcomes have not been well addressed in previous research. This study aimed to investigate the characteristics of elderly patients with acute poisoning visiting the ED, and to identify the possible predictive factors of mortality.

METHODS

Patients aged > or = 65 years with acute poisoning who visited the ED in Taipei Veterans General Hospital from January 1, 2006 through to September 30, 2008 were enrolled in the study. We collected demographic information on underlying diseases, initial presentations, causes and toxic substances, complications, dispositions, and outcomes. Analyses were conducted among different groups categorized according to age, suicide attempt, and outcome. Multiple logistic regression was applied to identify possible predictive clinical factors influencing mortality in the elderly with acute poisoning.

RESULTS

A total of 250 patients were enrolled in the study, with a mean age of 77 years and male predominance. The most common cause of intoxication was unintentional poisoning. Medication accounted for 57.6% of poisonous substances, of which benzodiazepine was the most common drug, followed by warfarin. The overall mortality rate was 9.6%. The average length of stay in the ED increased significantly in the old (65-74 years), very old (75-84 years) and extremely old (> or = 85 years) groups. Suicide attempt patients experienced more complications including respiratory failure, aspiration pneumonia, hypotension and mortality. Three clinical predictive factors of mortality were identified: herbicide poisoning, hypotension and respiratory failure upon presentation.

CONCLUSION

Our results demonstrated that elderly patients with acute poisoning had a mortality rate of 9.6%. Suicide attempts resulted in more serious complications. The risk factors for mortality were herbicide intoxication, hypotension and respiratory failure.

'Hidden' suicides amongst deaths certified as undetermined intent, accident by pesticide poisoning and accident by suffocation in Taiwan

OBJECTIVE

To identify cause-of-death categories in which suicides might be misclassified in Taiwan.

METHODS

We plotted secular trends (1971-2007) in sex- and method-specific rates of deaths classified as suicide, undetermined intent and accident for the Taiwanese population aged 15+ and compared the sex, age and marital status profiles of deaths in these three categories by method of death.

RESULTS

The demographic profiles of registered suicides generally resembled those for deaths of undetermined intent and accidents by pesticide poisoning/suffocation but differed from those for accidents from non-pesticide poisoning/drowning/falling/poisoning by non-domestic gas. For the period 1990-2007, suicide rates based on suicides alone (14.8 per 100,000) would increase by 23, 7 and 1%, respectively, when including deaths of undetermined intent, accidental pesticide poisonings and accidental suffocations.

CONCLUSIONS

Suicide rates may be underestimated by more than 30% in Taiwan because some suicides are 'hidden' amongst deaths certified as due to other causes.

The epidemiology of glyphosate-surfactant herbicide poisoning in Taiwan, 1986-2007: a poison center study

BACKGROUND

Glyphosate-surfactant herbicide (GlySH) is widely used in agriculture and has been associated with numerous toxicities following oral ingestion. However, there are many controversies with regard to the exact causes and determinants of developing severe/death outcome after exposure to GlySH.

METHODS

We conducted an analysis of all GlySH exposures reported to the Taiwan National Poison Control Center between 1986 and 2007. Patients' baseline characteristics and clinical data were reviewed and analyzed.

RESULTS

A total of 2,186 patients were eligible for analysis. Most of the exposures were related to oral ingestion (n = 2,023, 92.5%) and attempted suicide (n = 1,631, 74.6%). The mean age of exposure was 42.8 +/- 18.6 years. One hundred patients developed severe effects and 146 patients died following oral GlySH exposure, resulting in a case fatality rate of 7.2%. Shock (n = 85, 58.2%) and respiratory failure (n = 34, 23.3%) accounted for most fatalities. Four out of eight patients with injection exposure manifested severe (n = 3) or fatal outcome (n = 1). In a multivariate logistic regression analysis, increasing age, larger amount of exposure, longer elapsed time to presentation, attempted suicide, receipt of atropine therapy, and being exposed in certain calendar years were positively associated with the severity of poisoning following oral GlySH exposure.

CONCLUSION

Age, ingested amount, delayed presentation, and reason for exposure were likely to be determinants of the severity of GlySH exposure. Because shock is the major cause of death and usually develops early after GlySH exposure, prompt fluid replacement therapy seems critical in the initial management of such exposures. Patients' airway should also be secured to avoid aspiration and subsequent respiratory failure.

Neonicotinoid insecticides: an emerging cause of acute pesticide poisoning

INTRODUCTION

Neonicotinoids are a relatively new class of insecticides. They exhibit agonistic effects at postsynaptic nicotinic receptors in insects and are believed to have low toxicity in humans.

METHODS

We conducted a retrospective analysis of all neonicotinoid exposures reported to the Taiwan National Poison Center to better understand the toxicity profile of neonicotinoid insecticides.

RESULTS

A total of 70 patients were analyzed. Most exposures involved suicidal ingestions of imidacloprid alone. Clinical manifestations of neonicotinoid insecticide toxicity bear some resemblance to those of acute nicotine poisoning. Although most exposures were of mild-to-moderate severity, eight patients developed major effects and two died. Aspiration pneumonia and respiratory failure were the main cause of severe toxicity.

CONCLUSION

Significant toxicity of neonicotinoids can occur following large amount of oral ingestion. Poisoned patients may present with cholinergic syndrome, and judicious use of atropine seems justified. Symptomatic treatment, especially ventilator support, remains most important in clinical management.

Acute hemolysis caused by incidental trichlorfon exposure

Trichlorfon (o-o-dimethyl-2,2,2-trichloro-hydroxyethylphosphate), an organophosphate, has a moderately potent anticholinesterase activity. Organophosphate poisoning is well known for its characteristic symptoms and signs, but acute hemolysis caused by trichlorfon is rarely reported. We present a patient who developed acute hemolysis and renal function impairment after percutaneous trichlorfon exposure. A 54-year-old man applied trichlorfon powder to his dog to kill its parasites. Half an hour later, the dog was suspected to die of cholinergic crisis and the patient felt abdominal cramping pain. Later, he developed severe nausea, vomiting, chills, high fever, and cold sweat. Laboratory work-up disclosed a picture of acute hemolysis, jaundice, renal function impairment and leukocytosis. However, there were no clinical features of acute cholinergic syndrome except gastrointestinal symptoms, and blood cholinesterase activities were also normal. He eventually had a full recovery. Trichlorfon should be added to the toxins known to cause acute hemolysis.

Epidemiology of organophosphate pesticide poisoning in Taiwan

INTRODUCTION

The nationwide epidemiology of organophosphate pesticide (OP) poisoning has never been reported in detail for Taiwan.

METHODS

This study retrospectively reviewed all human OP exposures reported to Taiwan's Poison Control Centers (PCCs) from July 1985 through December 2006.

RESULTS

There were 4799 OP exposures. Most OP exposures were acute (98.37%) ingestions (74.50%) of a single OP (80.37%) to attempt suicide (64.72%) in adults (93.25%). Males were the most common gender (64.95%). Most patients (61.97%) received atropine and/or pralidoxime. The mortality rate for all 4799 OP exposures was 12.71%. Exposures to single OPs without co-intoxicants caused 524 deaths; of these, 63.36% were due to dimethyl OPs.

CONCLUSION

Dimethyl OPs cause the majority of deaths in Taiwan.