Asia Pacific Journal of Medical Toxicology
Volume:4 Issue: 2, Spring 2015

Few methods have been introduced to assess the level of consciousness in critically-ill patients. This study was designed to evaluate how the Alert\Verbal\Painful\Unresponsive (AVPU) responsive scale corresponds with the Glasgow Coma Scale (GCS) and Richmond Agitation-Sedation Scale (RASS) scores in drug-poisoned patients and to devise an augmented AVPU scale. In this prospective study, patients with diagnosis of acute drug poisoning were included and their level of consciousness was assessed using GCS, RASS and AVPU scales. Overall, 165 poisoned patients (59% female) were studied. According to AVPU scale, 123 patients (74.5%) were graded as “alert”, 26 patients (15.8%) as “responsive to verbal stimulation”, 10 patients (6.1%) as “responsive to painful stimulation”, and 6 patients as “unresponsive” (3.6%). AVPU grades of "alert", "responsive to verbal stimulation", "responsive to painful stimulation" and "unresponsive" corresponded with median [IQR] GCS scores of 15 [15–15], 13 [12–13], 8 [7–10] and 6 [5–6], and median [IQR] RASS scores of -1 [-1 – +1], -2 [-3 – -1], -3 [-4 – -1], -5 [-5 – -5], respectively. By taking the median of RASS scores corresponding with each AVPU grade, an augmented AVPU scale for the assessment of consciousness was devised. The first proposed version of AVPU plus includes 14 qualitative grades of consciousness. By application of this scale, clinicians can evaluate both the alertness/attentiveness and arousal/excitability of poisoned and critical patients. The AVPU plus is a new scale designed for more detailed assessment of neurologic status of poisoned and critical patients. The prognostic-ability, reliability and validity of the scale should be investigated in future studies.

Poinsettia (Euphorbia pulcherrima), holly (Ilex opaca) and mistletoe (Phoradendron flavescens) adorn homes during the Christmas and New Year holiday season and create the potential for curious children to sample their colorful leaves and enticing berries. This study was aimed to review the American Association of Poison Control Centers National Poison Data System (AAPCC NPDS) to describe the epidemiologic profile of ingestion of these plants and to determine whether there was associated morbidity and mortality. All plant ingestion exposures reported to American poison centers (PCs) from 2000-2009 were analyzed to identify all exposures to E. pulcherrima, I. opaca and P. flavescens. The data analysis included ingestions by age, gender, patient management site, symptoms, intention and outcome. The AAPCC NPDS database included 668,111 plant ingestions during 2000 to 2009. E. pulcherrima (19,862; 3.0%), I. opaca (5,432; 0.8%) and P. flavescens (1,138; 0.2%) exposures accounted for 26,632 (4.0%) of all plant ingestion exposures. Children younger than six years were responsible for majority of ingestions (88.0%). Ingestions were more likely to occur unintentionally (P < 0.001). Most cases (96.1%) were asymptomatic. When clinical effects developed (1,046 cases), the most frequent reported signs were gastrointestinal in nature (59.8%) including abdominal pain, diarrhea and/or vomiting. Moreover, the development of gastrointestinal signs was higher in patients who ingested P. flavescens compared to the other two species. Most exposures (96.1%) were managed at home with the guidance from PC experts. When the outcome was known, the majority of exposures (89.2%) experienced no adverse effects. Moderate effects occurred in only 28 ingestions (0.1%), and one major effect was recorded in a patient who ingested poinsettia. These holiday plants were associated with extremely low morbidity and no mortality. Home management along with expert guidance can be adequate intervention in the majority of these exposures.

The anti-cancer effects of honey bee venom (BV) and chrysin might open a new window for treatment of chemo-resistant cancers. This study was designed to evaluate cytotoxic and pro-apoptotic effects of BV and chrysin on A2780cp cistplatin- resistant human ovarian cancer cells. As per the study objectives, A2780cp cells were categorized to 4 groups: 3 experiment groups (treated either with BV or chrysin or BV + chrysin) and 1 control group (untreated cells). Experiment group cells were cultured and treated by different concentrations of BV and chrysin for 24 hours. Then, experiment and control cells were studied with MTT assay, Annexin V-FITC, DAPI and Acridine Orange / Propidium Iodide statining, flow cytometry, caspase-3 and -9 assay, measurement of intracellular level of reactive oxygen species (ROS) and RT-PCR. MTT assay showed that 8 μg/mL BV, 40 µg/ml chrysin and 6 + 15 μg/mL BV + chrysin co-treatment induced 50% cell death on A2780cp cells compared with controls (P < 0.001). Morphological observations by inverted and fluorescent microscopy revealed ROS generation and apoptotic cell death under exposure to BV or chrysin or BV + chrysin co-treatment. Caspase-3 and -9 assay demonstrated that BV and chrysin triggered apoptosis through intrinsic pathway and RT-PCR demonstrated down-regulation of Bcl-2. Honey bee venom and chrysin are effective for destroying chemoresistant ovarian cancer cells through activation of intrinsic apoptosis, which propose them as potential candidates to be used in development of improved chemotherapeutic agents in the future.

Paraquat (PQ) poisoning is highly fatal; and therefore, clinicians should be familiar with prompt approach to and poor prognostic features of this type of poisoning. Hence, in this study, clinical profile, management and outcome of a series of patients with PQ poisoning are presented. A retrospective review of medical records of patients poisoned with PQ who were treated at Clinical Toxicology Department of Razi Hospital in Ahwaz, Iran during 2005 to 2008 was performed. Forty-two patients (66.7% men) were studied. Majority of them (83.3%) were between 15-29 years of age. Most of PQ poisonings occurred following suicidal ideation (39 patients; 92.9%). The most common on-admission clinical findings of the patients were vomiting (69%) and respiratory distress (47.6%). Activated charcoal was given to 35 patients (83.3%). N-acetyl cysteine (100 mg/kg IV stat), vitamin E (100 IU daily IV) and vitamin C (500 mg daily IV) were given to all patients. Exploratory endoscopy for plausible mucosal ulcers was carried out for 23 patients (54.8%). Pantoprazole (40 mg twice daily) was given to all patients and for 7 patients with upper gastrointestinal (GI) irritation and GI bleeding, higher doses of pantoprazole (8 mg/hour) was administered. All patients received pulse therapy with methyl prednisolone (1g daily for three days) and cyclophosphamide (15 mg/kg daily for two days). Twenty patients died. Comparing death and survival, death was significantly higher in patients with respiratory distress (100 vs. 0.0 %, P < 0.001), renal dysfunction (85.0 vs. 9.1 %, P < 0.001) and hepatic dysfunction (75.0 vs. 4.5 %, P < 0.001). PQ poisoning creates a life-threatening clinical situation, which requires quick and proper treatment. Based on this research, mortality rate is greater in the presence of renal, hepatic and respiratory dysfunction.

Identification of regional pattern of poisoning is essential for health care authorities for proper planning on prevention programs and optimized management of antidote stockpiles. This study was designed to evaluate one-year epidemiologic pattern of acute poisoning cases treated at a tertiary care hospital in Thrissur, India. In this retrospective cross sectional study, medical records of patients with the diagnosis of acute pharmaceutical and chemical poisoning admitted to Jubilee Mission Hospital (JMH), during 1st October 2012 to 30th September 2013 were reviewed. During the study period, 168 poisoned patients (59.5% women) were treated at emergency department of JMH. Married patients outnumbered unmarried ones (55.4% vs. 44.6%). The highest number of patients aged 21 to 30 years (31.5%) followed by patients with 11-20 years of age (17.3%). Most of the poisonings occurred following suicidal ideation (72.6%). Familial disharmony (14.3%) was the most common reason behind suicidal ingestions, followed by mental disorders (11.3%). Drug poisoning made up the largest proportion of poisoning-related admissions (43.5%) followed by pesticide poisoning (37.5%). Among poisoning with pharmaceutical agents, most cases were due to paracetamol (13.7%) followed by anti-psychotics and sedatives (5.4%). In pesticide poisonings, the most common classes ingested by the patients were rodenticides and organophosphates. The most common household items ingested by the patients were petroleum products. The average length of hospital stay was 5.5 days. Seven patients (4.2%) died, of which 4 were due to organophosphates followed by 2 due to carbamates and one due to rodenticide ingestion. Pharmaceutical and pesticide products were identified as the main cause of poisoning. This finding warrants educational programs for adequate safety measures on storage and use of these substances.

This review was performed to evaluate the trend of alcohol use, characteristics of consumers, alcohol use disorders and toxic alcohol intoxications in Bangladesh. In addition, sources and sales figures of alcoholic beverages, and number of legal permits issued for alcohol consumption are reported and analyzed. A narrative search was performed on available medical literature in online medical databases including Medline, Embase, Google Scholar and Bangladesh Journal online (Banglajol) to obtain articles related to alcohol use and related disorders in Bangladesh. Governmental legislations and reports related to alcohol use were also collected and reviewed. The main estimates are based on the data reported during 2006 to 2011. Estimated frequency of alcohol users in general population of Bangladesh is about 1.9% (CI 1.7-2.1). Prevalence of alcohol consumption is 3.6% (CI 3.3-4.1) among men and 0.3% (CI 0.2-0.5) among women. The majority of alcohol consumers are within 25 to 44 years of age (76.3%). Total number of alcohol use permits has increased by 49.0% during 2006 to 2011. In total, 80637 permits have been issued up to 2011, and therefore it can be estimated that 79/100,000 people are legal alcohol consumers in Bangladesh. The estimate of alcohol use prevalence (1.9%) is approximately 24 times higher than estimated legal consumers (0.08%). There is a growing trend over alcohol use in Bangladesh, as alcohol per capital consumption has increased by about 100 times during 1973 to 2010. Heavy episodic drinking has been reported in 20.2% (CI 16.3-24.8) of Bangladeshi drinkers. Alcohol dependence was estimated to be 0.7% in general population. Alcohol use is on the rise in Bangladesh and it is particularly higher among some specific populations. Targeted intervention programs may help stop this increasing trend.

Pyrethroids are generally of low toxicity to humans, but in suicidal poisonings which are usually associated with ingestion of high doses, they lead to severe systemic effects. Case Report: A 30-year old woman presented to emergency department with a history of intentional ingestion of about 15 mL of prallethrin around 3 days earlier. She complained of shortness of breath along with chest pain for the last 2 days. She reported no vomiting or stomach pain prior to presentation to hospital. On chest auscultation, breath sounds were mildly decreased in bilateral infrascapular areas with generalized crepitation. Arterial blood gas analysis revealed respiratory alkalosis. Chest X ray and computed tomography of thorax revealed widespread confluent areas of consolidation with interlobular septal thickening involving bilateral parahilar regions suggestive of acute respiratory distress syndrome (ARDS). The patient did not respond to broad spectrum antibiotic coverage, diuretics and oxygen inhalation. Intravenous methylprednisolone (2 mg/kg/day divided 6 hourly) was started and slowly tapered off during the next days. The patient discharged after 3 weeks in good health. As pyrethroids can affect sodium channels, the osmotic gradient of alveolar epithelium probably disrupts and therefore, alveolar infiltrations gradually spread over lungs. In addition, there is a possibility of hypersensitivity reactions to pyrethroids, which can cause progressive inflammation and involve respiratory tract in severe cases. Pyrethroid poisoning can lead to ARDS. Steroid therapy may help such patients tide over the pulmonary crisis.

Iranian medical universities choose their best researchers in each field annually. The protocols of this process have been modified quite often, but the changes were not fundamental and did not lead to all-inclusive evaluation tools. The recent article in Asia Pacific Journal of Medical Toxicology, which proposes a scoring scale for evaluation of scientist's impact called "360-degree researcher evaluation score" (1), not only opens a new window for detailed evaluation of researcher's products and creations, but also provides a basic platform for promoting the research. In community medicine, there is a strict view to primarily address upstream causes of health problems while we look for solutions for downstream ones (2). It seems that this view has been considered in the designing process of this new scale, as for example, some neglected criteria which build capacity for science production (upstream causes of low science production) are taken into account. We really appreciate the holistic view of the scale, but we believe that following suggestions would help to improve its utility: In "science development" domain: It seems that the parameter of "number of downloads of articles" is not an appropriate criterion, because some journals do not report this measure. Besides, its value in scholarly communication is still under debate and it can be easily manipulated by the researcher himself (3). In calculating scores for journal articles, the calculation method is based on dividing impact factor (IF) by 30. Many journals have low IFs of just 0.1 or 0.2 and this calculation can make too many decimals. However, the good news is that with this method of calculation, there is more emphasis on the design of the study than the IF of the publishing journal. In "economic impact" domain: The measurement method is based on "ranking in institution". As some parameters only receives 1 score at maximum and there may be several staff members in one department, the acquired score for one person may be too small and calculation of the score of several persons by comparing them with each other can be difficult. Cost benefit and cost effectiveness are not two distinct concepts, they are just two different approaches to a unique comparison analysis (4). Therefore, it seems that taking both of them as two different citeria for evaluation of a research will overestimate a single effect in the total score. In "societal impact" domain: Although, we declare that considering the recommended parameters in this domain for evaluation of research impacts will have enormous effects on guiding the global projects to more efficient ones, these parameters are not clearly and objectively defined. How can somebody, for example, determine the amount of increased life expectancy from a single specific research? It seems that the four-fold score for international versus national conferences is a bit underestimating the value of national ones. Taken together, the proposed scale is a well-designed protocol for considering the most important dimensions of research. However, ensuring the reliability and validity of this tool requires further studies.