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Background: Organophosphorus compounds are widely used as pesticides in agriculture practicing countries like India. Since it is readily available and accessible, it is one of the most commonly used agents for suicidal poisoning. The current study was undertaken to evaluate the performance of the SOFA score (scoring system) and the serum lactate level (laboratory parameter) as a mortality predictor in organophosphorus poisoning. Material and Methods: This prospective observational study was conducted at AIIMS, Bhubaneswar, for 17 months. The study population included all patients with an alleged history of ingestion of organophosphorus (OP) compounds reporting to the casualty. The receiver operating characteristic (ROC) curve and the logistic regression analysis were used for the analysis. Results: In our study, 75 patients with OP poisoning were studied after satisfying the inclusion criteria. OP poisoning was commonly seen in married males aged 21–40 years. Twelve (16%) patients died during the process of treatment. There was a statistically significant difference in the mean SOFA score, serum lactate level, pH value, and mean duration of hospital stay between the discharged and the deceased patients. In the current study, the ROC curve analysis used to assess the predictor of the outcome of OP poisoning showed that the area under the curve for SOFA score and serum lactate level were 0.794 (95% CI 0.641–0.948) and 0.659 (95% CI 0.472–0.847), respectively. Conclusion: Sequential Organ Failure Assessment (SOFA) score is significantly associated with the outcome of organophosphate poisoning and can be utilized to predict mortality. [ABSTRACT FROM AUTHOR]

Objective: To ascertain the trend of poisoning cases admitted to the Government District Headquarters Hospital, a secondary care center in Udhagamandalam, Nilgiris District, Tamil Nadu, India, over a five-year period. Materials and Methods: The number of cases that presented to the hospital annually (incidence, mortality, and case fatality rates), socio-demographic pattern, and the nature of the poison were noted. Results: A total of 1860 poisoning cases (80 deaths) were reported during the period from October 2008 to September 2013. The incidence of poisoning was found to increase every year. The average incidence was 1.60 per 1000 population, while the average case fatality rate and mortality rates were 40.51 and 0.07, respectively. A total of 1148 (62%) were males. The majority of cases were seen in the 21-30 age group (41.24%). The poisonings were largely deliberate self-harm [n = 1,755; 94.35%), followed by accidental [n = 85; 4.57%). Agrochemicals were the main choice of poisoning agents and among these, organophosphates were the major cause. Conclusion: The data generated can help policy makers take decisions on the sale and availability of pesticides in this region. [ABSTRACT FROM AUTHOR]

Background Paraquat is an inexpensive herbicide used in agriculture because it is easily available and the cost of labour for manual clearance of weeds is prohibitive. Paraquat is toxic to human beings and is also used for committing suicide. We studied the reasons for under-reporting of paraquat poisoning including those related to the training of doctors. Methods In this mixed-methods study, we describe a series of patients with paraquat poisoning. We recorded their demographic data, clinical features, treatment and outcome with an intention to explore the reason for an initial misdiagnosis. We also explored whether deficiencies in curricula contributed to the misdiagnosis. Results The patients of paraquat poisoning (n=28) were mostly young illiterate men driven by impulsive behaviour rather than chronic depression. Paraquat was consumed by patients from non-agricultural background as well, implying easy access to the poison. Many patients could not name the agent and so initial treatment was directed at organophosphorus poisoning. The diagnostic signs included paraquat tongue, renal failure and jaundice. Most of the casualty medical officers and residents were unfamiliar with the symptoms and signs of paraquat poisoning as was evident by their answers to the questionnaire. Knowledge of medical students about paraquat poisoning was not assessed in the theory examinations and viva. Conclusion Factors contributing to the limitation in establishing the diagnosis are illiteracy and ignorance of the patients, lack of specific signs and lack of training of medical officers in treating patients with paraquat poisoning.

Background: Poisoning inflicts a considerable economic cost on the health sector. Few cases of poisoning may require intensive management in a critical care unit and thus add to the financial burden. In this study, our primary objective was to analyse the financial burden of poisoning on critical care facilities and the secondary objective was to analyse the critical care needs and treatment outcomes of patients with poisoning., Methods: We did this retrospective study of patients admitted with poisoning in the critical care unit of Government Medical College Hospital, Thiruvananthapuram, Kerala (12- bedded critical care unit of 2500-bedded medical college hospital) from January 2011 to December 2013. Patients <13 years of age were excluded. Cost was estimated using the hospital expenditure data., Results: A total of 118 patients, comprising 2.5% of the total critical care unit admissions, were included in the study. The average cost of providing critical care for cases of poisoning was ₹367 333 per annum. Organophosphorus poison was the most common agent (33.9%) with the highest cost per admission of approximately ₹1 8 500. The highest number of deaths was due to phosphide poisoning with a case fatality rate of 83%., Conclusions: Poisoning imposes a considerable burden on the limited critical care services. Organophosphorus was the most common substance consumed for poisoning and it led to the highest expenditure per admission., Competing Interests: None

Homicide by hanging is an extremely rare incident [1]. Very few cases have been reported in which a person is rendered senseless and then hanged to simulate suicidal death; though there are a lot of cases in wherein a homicide victim has been hung later. We report a case of homicidal hanging of a young Sikh individual found hanging in a well. It became evident from the results of forensic autopsy that the victim had first been given alcohol mixed with pesticides and then hanged by his turban from a well. The rare combination of lynching (homicidal hanging) and use of organo-phosporous pesticide poisoning as a means of homicide are discussed in this paper., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Organophosphate poisoning during pregnancy is rarely reported in the literature. In our retrospective study, we report the outcome of 21 cases of organophosphate poisoning during pregnancy. All patients received atropine injection until the tracheobronchial tree is cleared of the secretions and most secretions were dried. In addition, ventilatory care was needed in five women. Two patients (9.52%) died of the organophosphorus poisoning during the acute stage of poisoning and three patients were lost to follow-up. One woman had a spontaneous abortion. The remaining 15 women had no significant complication during pregnancy or labour and delivery. There was no congenital abnormality and no neurological deficit in any baby. However, long-term follow-up of neonates was lacking in our study population.

An autopsy based retrospective study was conducted from January 2000 to December 2006 at Manipal in Southern India, and a profile of the victims of poisoning was prepared. The study was done to understand the magnitude and pattern of all poisoning fatalities in relation to the manner of death in Manipal region of Southern India. The study included a total of 198 cases of fatal poisoning. Self-poisoning was reported in 92.9% cases. Fatal accidental poisoning was seen in 6.1% cases. Homicide by poisoning was not reported during the study period. Uncertainty regarding the manner of death due to poisoning was observed only in two cases. Males were predominantly affected (71.2%). The majority of the victims were in the 3rd decade (28.3%) of life. The age of the victims ranged from 2 to 82 years with a mean age of 38.4 years. While majority of the victims consumed poison during daytime, most of the poisoning fatalities were reported during summer months. Organophosphate compounds were implicated in 68.7% of the total poisoning related fatalities. Males in the 3rd to 5th decades were prone to self-poisoning with organophosphate compounds. Accidental poisoning deaths were uncommon and poisoning was not a preferred method of homicide in this region. Our approach to the study reveals that quantitative chemical (toxicological) analysis is required to further strengthen and improve the databases of epidemiology of poisoning in our region., (Copyright 2010 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Biochemical markers are one of the mainstays in the diagnosis of ill health. Plasma cholinesterase is one such marker of the ill health caused by acute organophosphorus pesticide poisoning. Organophosphorus pesticides are powerful inhibitors of plasma cholinesterase; consequently, the reduced level of this biochemical marker has been used in the diagnosis of cases of acute poisoning. But how dependable is this biochemical marker in the diagnosis of suspected organophosphorus pesticide poisoning without adequate clinical signs and symptoms? In the case reported here, the low level of plasma cholinesterase which was suspected to be due to organophosphorus poisoning was found to be caused by pulmonary Koch's and hepatitis B with associated malnutrition.

Sixty-five farmers reported on pesticide use and the signs and symptoms of acute pesticide poisoning when using two different plant protection strategies: in 2003 using chemical controls and in 2004 using an approach to Integrated Pest Management (IPM) based on an ecological analysis of the field conditions. Exposure to organophosphates was confirmed as a serious risk factor for occupational poisoning. The adoption of IPM reduced the use of pesticides and halved the incidence of acute pesticide poisoning. Overall, the pesticide use spectrum shifted towards lower WHO Hazard Classes. A reduction of adverse health effects was attained through a reduction in exposure to toxic pesticides and behavioural changes. Given that other strategies to reduce the rate of acute poisoning have proven ineffective, interventions aiming to minimize pesticide poisoning in India and in other developing countries with similar rural conditions should focus on restricting the use of highly toxic compounds and educating farmers on IPM.

Objective: The impact of long term exposure to cholinesterase (ChE)-inhibiting organophosphate (OP) and carbamate (C) pesticides on the respiratory health of agricultural workers in India was investigated., Methods: Three hundred and seventy-six nonsmoking agricultural workers (median age 41 yr) from eastern India who sprayed OP and C pesticides in the field and 348 age- and sex-matched control subjects with non-agricultural occupations from the same locality were enrolled. Prevalence of respiratory symptoms was obtained by questionnaire survey, and pulmonary function tests were carried out by spirometry. Chronic obstructive pulmonary disease (COPD) was diagnosed by the Global Obstructive Lung Disease (GOLD) criteria, and erythrocyte acetylcholinesterase (AChE) was measured by the Ellman method., Results: Agricultural workers had greater prevalences of upper and lower respiratory symptoms, and appreciable reduction in spirometric measurements. Overall, lung function reduction was noted in 48.9% of agricultural workers compared with 22.7% of control, and a restrictive type of deficit was predominant. COPD was diagnosed in 10.9% of agricultural workers compared with 3.4% of controls (p<0.05 in chi(2) test), and the severity of the disease was greater in agricultural workers. Red blood cell (RBC) AChE was lowered by 34.2% in agricultural workers, and the fall in AChE level was positively associated with respiratory symptoms, lung function decrement and COPD after controlling for education and income as potential confounders., Conclusions: Long-term exposure to cholinesterase-inhibiting agricultural pesticides currently in use in India is associated with a reduction in lung function, COPD and a rise in respiratory symptoms.

The aim of this study was to evaluate the pattern of acute organophosphorous (OP) poisoning cases including death, duration of hospitalization and time lapse before arrival at hospital. All OP poisoning cases admitted to the Emergency Department of MKCG Medical College Hospital and other fatal cases received at the mortuary between September 1999 and August 2001 were prospectively studied. Males outnumbered females and most OP poisoning occurred in the 21-30 year age group. In 68 (97.1%) cases the motive was suicide and more than 80% were from rural areas. Nearly one-third of cases occurred during the summer and in the later part of the day. Married females and unmarried males were most frequently affected. Most of the married females were housewives and the males were students or farmers. Fifty-four per cent of cases were admitted for treatment within three hours with a mean time lapse of 6.2 hours. The mean hospital stay for all OP poisoning cases was 5.1 days. Twenty-nine out of 66 admitted OP poisoning cases were fatal. There is a high incidence of OP poisoning with mortality in the region. OP compounds are readily available at low cost in the market. A time of stress and frustration can lead to their use as a common poison with which to commit suicide.

Around a million people commit suicide, and at least 10 times this number attempt suicide, worldwide every year. No nationwide epidemiological studies have been undertaken in India but a significant rise in suicides has been observed in Kashmir in recent years. This study was carried out on patients reporting to the Government SMHS Hospital in Srinagar with a history of suicidal poisoning.

Poisoning is an important health hazard and one of the leading causes of morbidity and mortality worldwide. Poisoning is one of the preferred means of committing suicide among males and females in India. A five year retrospective study from January 2000 to December 2004 was conducted at the Department of Forensic Medicine & Toxicology, Kasturba Medical College, Manipal, to understand the magnitude and pattern of suicidal poisoning deaths among males and females in Southern India. During this period, a total of 137 cases of suicidal poisoning related deaths were autopsied. Males were predominantly affected (male:female 2.8:1). Maximum victims of suicidal poisoning mortalities were in their 3rd decade. Mean age for males and females was 40.5 years and 34.4 years, respectively. 27.8% of females and 10.9% males were suffering from depression. Preference for organophosphates was relatively more in males when compared to females, who preferred zinc phosphide, carbamates and medicinal agents. Suicidal poisoning was commonly encountered during afternoon hours in females. Males usually consumed poison during evening and late night hours. Maximum male mortalities were noted during second quarter of the year in contrast to first quarter in females. This paper examines the difference in pattern of suicidal poisoning among males and females to identify population at risk, and understand the problem status among both genders.

Background: The role of oximes for the treatment of organophosphorus pesticide poisoning has not been conclusively established. We aimed to assess the effectiveness of a constant pralidoxime infusion compared with repeated bolus doses to treat patients with moderately severe poisoning from organophosphorus pesticides., Methods: 200 patients were recruited to our single-centre, open randomised controlled trial after moderately severe poisoning by anticholinesterase pesticide. All were given a 2 g loading dose of pralidoxime over 30 min. Patients were then randomly assigned to control and study groups. Controls were given a bolus dose of 1 g pralidoxime over 1 h every 4 h for 48 h. The study group had a constant infusion of 1 g over an hour every hour for 48 h. Thereafter, all patients were given 1 g every 4 h until they could be weaned from ventilators. Analysis was by intention to treat. Primary outcome measures were median atropine dose needed within 24 h, proportion of patients who needed intubation, and number of days on ventilation. The study is registered at http://www.clinicaltrials.gov with the identifier NCT00333944., Findings: 100 patients were assigned the high-dose regimen, and 100 the control regimen. There were no drop-outs. Patients receiving the high-dose pralidoxime regimen required less atropine during the first 24 h than controls (median 6 mg vs 30 mg; difference 24 mg [95% CI 24-26, p<0.0001]). 88 (88%) and 64 (64%) of controls and high-dose patients, respectively, needed intubation during admission to hospital (relative risk=0.72, 0.62-0.86, p=0.0001). Control patients required ventilatory support for longer (median 10 days vs 5 days; difference 5 days [5-6, p<0.0001])., Interpretation: A high-dose regimen of pralidoxime, consisting of a constant infusion of 1 g/h for 48 h after a 2 g loading dose, reduces morbidity and mortality in moderately severe cases of acute organophosphorus-pesticide poisoning.

Background: The aim of this study was to characterize the poisoning cases admitted to the Government Wenlock Hospital (a teaching hospital of Kasturba Medical College) Mangalore, India., Study Design: All cases admitted to the emergency department of the hospital between January 2001 to May 2003 evaluated retrospectively. Data obtained from the hospital medical records and included the following factors: socio-demographic characteristics, agents and route of intake, and time of admission of the acutely poisoned patients., Results: Of the total 33,207 patients admitted in the hospital for treatment, 325 patients were for to acute poisoning. This was 1% of all emergency admissions. Of these 70% were males and 30% females. The majority (36%) cases were from age group of 21-30 years. Most (72%) poisonings were intentional and only 27% were unintentional. The most important agents of acute poisoning were agrochemical pesticides (49%) followed by drugs (17%), and alcohols (13%). Forty-eight (15%) patients died. The poisons responsible for most of the mortality were organophosphate pesticides (65%) and aluminium phosphide (15%). In summary, the prevention and treatment of poisoning due to organophosphate and aluminium phosphide should merit high priority in the health care of the indigenous population of South India (Dakshina Kannada district).

Unnatural deaths of married women amongst the total female deaths have been an increasing trend in Indian society during the recent past years. These unnatural deaths may be suicide, homicide or even accidents. But these suicides and homicides are currently more commonly associated with the dowry disputes. In India, dowries are a continuing series of gifts endowed before and after the marriage. When dowry expectations are not met, the young bride may be killed or compelled to commit suicide, either by burning, poisoning or by some other means. Here, in the study, the main objective is to present the different epidemiological and medicolegal aspects of poisoning deaths in the married women. In a cohort of 200 married female deaths, 35 (18%) were poisoning deaths and these were analyzed from both epidemiological and medicolegal aspects. In this series, most of the women consumed organophosphorus compound and died within 10 days. The majority of the affected wives due to dowry problems were below 35 years of age. Most incidents occurred either during morning hour or during daytime.

Objective: The aim of the study was to find whether continuous pralidoxime (2-PAM) infusion along with aggressive atropinisation improves the outcome in patients with severe organophosphate poisoning who require assisted ventilation., Methods: Sixteen patients admitted to the respiratory intensive care unit (RICU) with severe organophosphate poisoning and requiring assisted ventilation were included in the study. The compounds involved were phorate (six), dichlorvos (four), oxydimeton methyl (one), monocrotophos (one), methyl parathion (one) and in three it was unknown. After decontamination, they were given intravenous (iv) bolus atropine 5 mg at onset and then 2.5 mg every 5-10 min till atropinisation was achieved, and then maintained either by intermittent bolus doses or by continuous infusion if the required dose was large. They were also given continuous iv infusion of 2-PAM in dose of 7.5 mg/ kg body weight/h (maximum 500 mg/h) after an initial bolus dose of 2 g., Results: The mean (+/-S.D.) dose of atropine was 735.02 +/- 742.98 mg (range 85-3000 mg) with maximum dose on day 1. The mean (+/-S.D) duration of 2-PAM infusion was 96.4+/-49.4 h (range 10-216 h). The mean (+/-S.D) duration of mechanical ventilation (MV) was 131.5 +/- 95.65 h (range 4-336 h). Fourteen patients could be successfully extubated and two died of bronchopneumonia and sepsis (mortality 12.5%)., Conclusion: Continuous 2-PAM infusion along with aggressive atropinisation after initial decontamination improved the outcome but not the duration of MV in severely intoxicated patients with organophosphate compounds who required assisted ventilation in this case series.

Intermediate syndrome (IS) developed in 38 of 214 cases with organophosphorous compound poisoning (OPCP). Neck muscle weakness, motor cranial nerve palsy, respiratory muscle paralysis, proximal limb weakness were the chief neurological signs developed 16-120 hours after consumption of the insecticide. Two patients had pyramidal tract signs. Mean duration of IS was 9.26 (+/- 4.84) days. Electrophysiological study (EPS) was done in 21 patients. 18 patients showed decremental response to repetitive stimulation at 3Hz 5 pulses and absence of post tetanic facilitation. Motor conduction studies were abnormal in on (prolonged distal latency and reduced conduction velocity), 'F' responses were abnormal in, sensory nerve conduction was abnormal in two, and simple repetitive response were observed in 11 patients. 4 patients died. In IS neuromuscular junctional dysfunction is the predominant factor.