Asia Pacific Journal of Medical Toxicology
Volume:3 Issue: 1, Winter 2014

In the past decade, high attention has been given to the Disability-Adjusted Live Year (DALY) metric. One DALY is one lost year of «healthy» life. DALYs for a disease or a health condition are measured by the sum of (a) the Years of Life Lost (YLL) because of premature death occurred in the target population and (b) the Years Lost due to Disability (YLD) for those living with that condition or its consequences. YLL corresponds to the number of deaths multiply by the standard life expectancy at the age and gender at which death occurs. YLD is estimated by multiplying the number of incidents by the average duration of the disease to a weight factor that reflects the severity of the disease (disability weight or DW). DW is reported on a scale from 0 (perfect health) to 1 (dead). The DWs could be measured by several utility measurement techniques (1). The sum of these DALYs across a population is assumed as the burden of that disease. This is the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of that disease and disability. In a study undertaken by the World Health Organization, it was found that poisoning in individuals was scored 0. 611-0. 608 while stroke for example was scored 0. 920 and cretinism was scored 0. 804. On the other side of the spectrum, otitis media, pharyngitis and mild upper respiratory infection were scored 0. 023, 0. 07 and 0. 00 respectively (2). Poisoning in general, therefore, has been considered as a highly disabling condition. Poisoning can be intentional, accidental or criminal (3). Its burden includes physical as well as mental disabilities. While the medical burden of intentional and accidental poisonings seems to be equal for similar severe cases, intentional poisoning often occurs in patients with depression or coping difficulties and may need extra psychological, familial or social attention. It has been shown that burden of suicide (including suicidal poisonings) puts it at 21st rank in the list of most important diseases. Suicide and nonfatal attempted suicide together climb the position to 11th in this ranking of diseases (4). Furthermore, adding the mental suffering from suicidal thoughts will rank suicidal behaviors among the most important diseases (4). In poisonings, type of medication or toxic agent used, dose, route of administration, chronic use, addiction and racial differences as well as health infrastructure, pre-hospital care and availability of antidotes may affect the outcome. Unlike overdose with multivitamins, low dose oral consumption of aluminum phosphide may lead to critical condition and death. In addition, some poisonings such as opioid overdose are easily treatable due to the presence of effective antidotes. These variables may drastically change the weights in different regions. Experts who establish disability weights from pairwise comparisons (5), ranking and person trade off methods should be extra careful in medical toxicology. Extra caution should be given in interpretation of the DW in poisonings. Accidental poisoning should also be considered independently. Perhaps, the burden of each toxic agent should be calculated and interpreted separately in different regions.

Poisoning remains a major cause of hospital admission into the emergency department and intensive care unit. Proper diagnosis is the cornerstone for optimal management of poisoned patients. Since the definitive analytical confirmation of the nature of the toxicant involved in the poisoning cannot be rapidly obtained in the majority of healthcare facilities, diagnosis relies on the medical history and the rigorous clinical examination of the patients well as results of the routine biological tests and the electrocardiogram. Identification of the toxidromes addresses not only the correct diagnosis but also rules out other differential diagnoses. Despite no definitive predictive value, this clinical approach facilitates making decision on empirical treatments and emergent antidotes. Pharmacodynamic tests using specific antidotes including naloxone for opioids and flumazenil for benzodiazepines and its analogues are also helpful to assess the final diagnosis in comatose patients. The objective of this article is to review the toxidrome-based approach to common poisonings before toxicological analysis enables the confirmation of the initially suspected toxic etiology.

Hydrogen sulfide (H2S) suicides have been frequent in Japan in recent years. This study was performed to describe the epidemiologic profile of an outbreak of H2S suicides in Japan. In September 2008, questionnaires about patients involved in H2S suicides were sent to 250 hospitals in Japan. Data collected from each patient included gender, age, clinical manifestations, date of event, location of suicide, source of H2S, treatments and neurological outcome. A total of 90 subjects (60 men, 30 women) were enrolled in this study. In this outbreak, the first case was reported in September 2006 and subsequent cases reached a peak in April 2008. There were 60 cases of attempted suicide by generating H2S gas (suicide group) and 30 cases of secondary exposure (secondary exposure group). The suicide group included mostly subjects in their twenties. Cardiopulmonary arrest at the scene was reported in 39 cases (65%). Clinical features of the suicide group inpatients included coma (14 cases), convulsion (1 case), and lung edema (1 case). Patients in suicide group were significantly younger than secondary exposure group (P < 0.001). The development of cardiopulmonary arrest was significantly higher in suicide group (65% vs. 10%; P < 0.001). Death was more frequent in suicide group (70% vs. 10%; P < 0.001) and patients with secondary exposure were discharged with better neurological outcomes (Table 1). Suicide with H2S poisoning has recently been a serious social problem especially in younger generation in Japan. There is extensive information on H2S suicide methods on the internet. Management of access to websites describing suicide methods is an immediate necessity together with counseling for suicide prevention.

In order to describe the patients and evaluate the effectiveness of treatments for widow spider envenomation, investigators require a reliable assessment tool. In this paper, the development of a clinical index for measuring the widow spider bite severity, Latrodectus Envenomation Severity Score (LESS), is described. According to the valid methods for index development, a Delphi group process was applied. A panel of 13 experienced medical toxicologists and physician experts in treatment of black widow spider bites was assembled in December 2013. The participants were asked to score clinical manifestations of Latrodectus envenomation based on their importance on the severity and patients’ prognosis. Hence, an initial draft of the severity index was developed and in the second phase of study, the draft was discussed in a focus group of experts to finally comment on each variable and vote about the final scores. The proposed version of LESS comprises of 34 clinical items categorized in 8 organ systems. The index includes definition of each clinical variable to help users of the index how to ascertain or rule out the clinical finding. The maximum theoretical score according to LESS is 87. Acute renal failure, myocarditis, pulmonary edema and ileus received the highest scores in this index. The LESS is a new assessment tool that is designed to more objectively evaluate the severity and progression of envenomation in victims of widow spider bite. The prognostic-ability, reliability and sensitivity to change of the index should be investigated in future studies.

Acute poisoning with organophosphorus (OP) pesticides is a common method of suicide and entails considerable mortality in Bangladesh. The objective of this study was to evaluate the effects and outcomes of a protocol for treatment of OP poisoning that included titrated incremental atropine as loading dose and slow infusion for maintenance. In this prospective descriptive case series, definitive OP poisoned patients were enrolled in an adult medicine unit of Dhaka Medical College Hospital from April 2006 to April 2007. Clinical examinations were done as soon as the patient entered the ward. Patient’s demographics, comorbid conditions and the occurrence of specific clinical outcomes including death, need for assisted ventilation and clinical complications were recorded. The patients were treated according to the protocol. A total of 56 patients were enrolled over the study period. The median age of the study population was 22.5 years. Most patients were men (67.8%). The most common clinical presentation was miosis (58.9%). In total, 11 patients died (19.6%). Intermediate syndrome developed in 12 patients (21.4%) and 6 of them died. Assisted ventilation was required in 16 cases (28.5). Patients with diastolic blood pressure ≤ 70 mmHg and/or GCS ≤ 10 were significantly less likely to survive (P = 0.02, 0.006, respectively). Moreover, early respiratory failure (P < 0.001) and the need for assisted ventilation (P < 0.001) were significantly higher among deceased cases. The mortality rate in this study was similar to previous studies. The frequency of atropine toxicity in the present study (1.8%) was considerably lower than conventional regimen used in previous studies. Using the new protocol, lower rate of atropine toxicity developed in victims. Hence, the new protocol appears to be safer and its effectiveness should be further evaluated in case control studies in Bangladesh.

Addiction is multi-dimensional medical problem and psychologic defects have a major role on its establishment. This study was designed to determine the effect of emotional quotient (EQ) on the rate of addiction relapse after quitting. This was a prospective cross-sectional study on 22 to 51 year old subjects who were being treated at chemical dependency rehabilitation centers in Mashhad, Iran, during December 2012 to May 2013. For assessment of EQ, the Persian version of Bar-On EQ questionnaire was employed at first visit of each patient. During the rehabilitation therapy, the subjects were visited monthly. The data of patients were collected during the first 6 months post-quitting. One-hundred sixty subjects were studied which 87% of them were men. Mean (SD) score of patients'' EQ was 11.9 (2.8). The mean number of addiction relapses was 2.1 (2.8). Data analysis showed that there was a significant inverse correlation between EQ score and the number of relapses (r = -0.82, P = 0.05). In addition, it was found that the EQ score had a direct significant relationship with age (r = 0.33, P = 0.05). No significant correlation between type of abused substance and the number of relapses was found. EQ has a positive impact on preventing addiction relapse. Increasing EQ through educational programs can be used as a preventive measure for treating addict persons.

Chemical exposure is a major health problem globally. Poison control centers (PCCs) play a leading role both in developed and developing countries in the prevention and control of poisonous chemical exposures. In this study, we aimed to assess the current state of PCCs in Pakistan and highlight capacity building needs in these centers. A cross-sectional survey of the two registered PCCs was done during August – December 2011. Necessary services of the PCCs were evaluated and the data were recorded on a predesigned checklist. Both PCCs are affiliated to a tertiary care hospital. Clinical services to poisoned patients were available 24 hours a day / 7 days a week. Information on common local products was available to poison center staff. Both centers were involved in undergraduate and post graduate teaching. Telephone poison information service was not available in either of centers. There was a limited capacity for qualitative and analytical toxicology. Common antidotes were available. There were limited surveillance activities to capture toxic risks existing in the community and also a deficiency was observed in chemical disaster planning. PCCs in Pakistan need capacity building for specialized training in toxicology, toxicovigilance, chemical disaster planning, analytical laboratory tests and telephone service for consultation in poisoning cases.

Periodic epidemiological studies are necessary to understand the pattern of poisoning in each region. This study was designed to evaluate the pattern of acute poisoning cases treated in a tertiary care hospital in Navi Mumbai, India. This cross sectional study was conducted at Dr. D. Y. Patil Medical College, Hospital and Research Centre during July 2012 to July 2013. All cases of poisoning admitted to the hospital were included in this study. The patients’ data were obtained from medical records and were documented on a pre-structured proforma. A total of 74 cases of acute poisoning were studied, of which 51.4% were men. Most of the patients aged 20 to 29 years (44.6%). In majority of cases, the route of exposure to poison was oral (86.5%). Most of the patients reside in urban areas (52.7%). Most of the patients were Hindus (85.1%) followed by Muslims (14.9%). The exposure mostly occurred between 6:00 pm to 12:00 am (30% of cases). The majority of poisonings (44.6%) was due to consumption of household products followed by pesticides (14.9%) and pharmaceutical agents (13.5%). Neurologic manifestations were the most common clinical findings (64.8%) followed by gastrointestinal manifestations (37%). All patients were treated successfully with no mortality. There was a significant correlation between gender and intention of poisoning (P < 0.001), as the suicidal attempts were higher in women (69.4%). Moreover, a significant relationship existed between marital status and intention of poisoning (P = 0.016) as the suicidal poisonings were most common among married individuals (45.7%). The trend in poisoning is never static. Household products were identified as the main cause of poisoning in urban areas of India. Educational programs with more emphasis on preventive measures are necessary to create awareness among the general public.

Wasp stings are quite commonly observed in Bangladesh though they are under reported. However, rhabdomyolysis following multiple wasp stings is a rare entity. Case report: A middle aged physician was stung by a swarm of wasps at multiple sites of the body. He felt severe pain at the sites of the stings and was primarily treated with intravenous hydrocortisone and chlorpheniramine. Within few hours he developed oliguria with dark color. The dipstick urine test was positive for myoglobin and negative for red blood cell. His serum creatinine was 1.65 mg/dl, and creatine phosphokinase was 3963 IU/L, on admission. Subsequently, creatinine increased for the next three days. He was given forced diuresis with furosemide for three days and other supportive treatments. Clinical and biochemical picture started to improve including urine output and color and normalized on 6th day post-admission. The species Vespa affinis was confirmed by a zoologist as the offending insect. Wasp sting usually results in pain and allergic reactions, though severe anaphylaxis may occasionally occur. Mass envenomation can cause systemic reactions and organ dysfunction including rhabdomyolysis, hemolysis, coagulopathy, and hepatic, renal, cardiac and neurological complications. Rhabdomyolysis is a distinguished cause of acute kidney injury in patients with wasp sting. Vespa affinis is the species commonly found in this region which can bring catastrophe. Multiple wasp stings may cause rhabdomyolysis followed by renal failure. Immediate supportive treatment (including copious hydration and sodium bicarbonate) is the mainstay to reduce morbidity and mortality in such cases.