Journal of The Korean Society of Clinical Toxicology

Volume 14(2); December 2016

Clinical Characteristics of Patients after Aryloxyphenoxy Propionate Herbicide Ingestion: Junyeong Lim, Jeongmi Moon, Byeongjo Chun; J Korean Soc Clin Toxicol. 2016;14(2):71-77. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.71

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Abstract PDF: Purpose: No studies have been conducted to investigate the acute toxicity of aryloxyphenoxypropionate herbicides in humans following ingestion. Therefore, this study was conducted to investigate the clinical characteristics of aryloxyphenoxypropionate herbicide poisoning and provide guidance for physicians treating patients who have ingested these types of herbicides. Methods: A retrospective observational case series was conducted using ten patients with history of aryloxyphenoxy propionate herbicide. Data were collected for clinical manifestation, management and final outcome. Results: The most common symptoms were gastrointestinal irritation and an altered mental state (Glasgow Coma Scale<15). An elevated lactate level was a common laboratory abnormality, and prolonged QTc interval was commonly observed. These clinical features normalized within one day of supportive treatment. Conclusion: The acute toxicity of aryloxyphenoxypropionate herbicides in humans is manageable with supportive treatment. However, physicians should take into account depressed consciousness, the possibility of arrhythmia, and an elevated lactate level when planning their treatment strategy.

In vitro Effects of Epigallocatechin Gallate on Sister Chromatid Exchange in the Lymphocytes Exposed to Glyphosate: Jung-Min Park, Woo-Ik Choi, Sang-Chan Jin, Jae-Ho Lee, In-Jang Choi; J Korean Soc Clin Toxicol. 2016;14(2):78-82. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.78

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Abstract PDF: Purpose: Green tea is known as a potent anti-oxidant, anti-carcinogen, and genetic protector. Glyphosate (N-phosphonomethyl glycine) is a widely used non-selective herbicide that causes DNA damage. The present study was conducted to investigate the protective effects of green tea in human blood lymphocytes exposed to glyphosate using the Sister Chromatid Exchange (SCE) frequency method. Methods: Peripheral blood was obtained from 10 volunteers and cultured through four different conditions. Four groups were divided into control, glyphosate only (300 ng/mL), glyphosate and low ($20{mu}m$) concentrations of epigallocatechin gallate (EGCG) and glyphosate and high ($100{mu}m$) concentrations of EGCG. Results: The glyphosate exposed groups had a higher mean SCE frequency ($10.33{pm}2.50$) than the control group ($6.38{pm}2.28$, p<0.001). The low concentrations of EGCG groups had a lower mean SCE frequency ($9.91{pm}1.93$) than the glyphosate-only group, although this difference was not significant (p=0.219). However, the high concentration group ($9.49{pm}1.85$) had a significantly lower SCE frequency than the glyphosate-only group (p=0.001). Conclusion: EGCG has a gene protective effect in human lymphocytes exposed to the genotoxicity of glyphosate in the case of high concentrations.

The Incidence, Associated Factors and Clinical Impact of Hyperamylasemia in Self-poisoning Patients: Min Gu Seo, Sang Hoon Oh, Jee Yong Lim, Han Joon Kim, Se Min Choi; J Korean Soc Clin Toxicol. 2016;14(2):83-91. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.83

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Abstract PDF: Purpose: This study was conducted to investigate the incidence, associated factors and clinical impact of hyperamylasemia in self-poisoning patients. Methods: This study was based on a toxicology case registry of patients treated from 2009 to 2013 at a tertiary care university hospital. We retrospectively investigated the demographics, clinical variables, laboratory variables and intoxicants. Hyperamylasemia was defined as an elevation in serum amylase level to above the upper normal limit within 24 hours after admission. We analyzed the predisposing factors and clinical outcomes of patients in the hyperamylasemia group. Results: Hyperamylasemia was identified in 49 (13.3%) of the 369 patients. Using multivariate logistic regression, the odds ratios for HA were 3.384 (95% confidence interval, 1.142-8.013, p=0.014), 3.261 (95% confidence interval, 1.163-9.143, p=0.025) and 0.351 (95% confidence interval, 0.154-0.802, p=0.013) for pesticides, multi-drug use and sedatives, respectively. In the hyperamylasemia group, the peak amylase levels during 72 hours were correlated with the peak lipase levels (r=0.469, p=0.002) and peak aspartate aminotransferase levels (r=0.352, p=0.013). Finally, none of these patients had confirmed acute pancreatitis. Conclusion: Hyperamylasemia occurred rarely in these self-poisoning patients, and pesticide and multi-drug use were independent predictors of hyperamylasemia. Peak amylase levels were correlated with the peak lipase and aspartate aminotransferase levels.

Flumazenil administration in suspected patients with acute hypnotics and sedatives poisoning: risk-benefit re-evaluation: Jae Hong Huh, Sang Chun Choi, Yong Gyun Lim, Samsun Lampotang, Eung Jung Park; J Korean Soc Clin Toxicol. 2016;14(2):92-99. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.92

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Abstract PDF: Purpose: The use of flumazenil administration in the emergency department is still controversial because of concerns about adverse effects. The present study was conducted to re-evaluate the risk-benefit ratio associated with flumazenil administration to patients suspected of having acute hypnotics and sedatives poisoning in the emergency department. Methods: A retrospective chart review study was conducted for patients whose final diagnoses were "poisoning" and "benzodiazepine" or "sedatives-hypnotics" from Mar. 2006 to Feb. 2015. The basal characteristics of the patients, including past medical history, ingredients and dose of ingested drug and co-ingested drugs were investigated. For patients administered flumazenil, responsiveness and time from admission to flumazenil administration were investigated with supplement. All collected data were analyzed in aspect terms of risk/benefit. Results: A total of 678 patients were included in our study. Benzodiazepine was the most common sedative/hypnotic drug prescribed, and the frequency of prescription continuously increased. The proportion of TCA as co-ingestion decreased from 13.1% to 3.9% in patients with acute sedative/hypnotic poisoning. Flumazenil was administered to 55 patients (8.1%), of which 29 patients (52.7%) were applied to contraindications. Fifty-three patients (96.4%) showed positive responsiveness, including partial responsiveness after flumazenil administration. No severe adverse events were identified. Conclusion: Based on the current trends in prescription patterns for sedative/hypnotic drugs, increased use of non-TCA antidepressants, and responsiveness to administration of flumazenil, benefit seemed weighted more in this study, although the observed benefits were based on limited results. Further prospective multicenter studies will be needed to optimize benefit-risk ratio.

The Intoxication of Beta Blocker with Psychiatric Drugs Focused on the Cardiovascular Adverse Effects: Sung Woo Joo, Young-Gi Min, Sang-Cheon Choi, Eun Jung Park; J Korean Soc Clin Toxicol. 2016;14(2):100-106. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.100

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Abstract PDF: Purpose: Beta blocker (BB) has been prescribed for anxiety and panic disorder. Patients intoxicated by psychiatric drugs have often been exposed to BB. Moreover, BB overdose has adverse effects including cardiovascular effects, which can be life-threatening. This study was conducted to identify the characteristics of BB intoxication with psychiatric drugs and the adverse effects on the cardiovascular system. Methods: A single center, retrospective study was performed from January 2010 to December 2015. A total of 4,192 patients visited the emergency department (ED) with intoxication, and 69 with BB intoxication were enrolled. Results: Overall, 64 patients (92.8%) of enrolled patients were intoxicated with drugs prescribed for the purpose of psychiatric disorders. Propranolol was the most common BB (62 cases, 96.2%), and the median dose was 140.0 mg (25%-75% 80.0-260.0). Twenty-four patients (37.5%) had experienced cardiovascular events, and these patients tended to have decreased mentality, hypotension and coingestion with quetiapine. An initial mean arterial pressure (MAP) below 65 mmHg (odds ratio 10.069, 95% confidence interval 1.572-64.481, p=0.015) was identified as a factor of cardiovascular event upon multiple logistic regression analysis. Conclusion: Initial MAP below 65 mmHg was a factor of cardiovascular adverse effect in patients of BB intoxication with psychiatric drugs.

Utility of the APACHE II Score as a Neurologic Prognostic Factor for Glufosinate Intoxicated Patients: Dae Han Yoo, Jung Won Lee, Jae Hyung Choi, Dong Kil Jeong, Dong Wook Lee, Young Joo Lee, Young Shin Cho, Joon Bum Park, Hae Jin Chung, Hyung Jun Moon; J Korean Soc Clin Toxicol. 2016;14(2):107-114. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.107

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Abstract PDF: Purpose: The incidence of glufosinate poisoning is gradually increasing, and it can be fatal if severe poisoning occurs. However, factors useful for predicting the post-discharge neurological prognosis of patients who have ingested glufosinate have yet to be identified. Our objective was to evaluate the utility of the acute physiology and chronic health evaluation (APACHE) II score measured in the emergency department for predicting the neurological prognosis. Methods: From April 2012 to August 2014, we conducted a retrospective study of patients who had ingested glufosinate. The outcome of the patients at discharge was defined by the Cerebral Performance Category Score (CPC). The patients were divided into a good prognosis group (CPC 1, 2) and a poor prognosis group (CPC 3, 4, 5), after which the APACHE II scores were compared. The Hosmer-Lemeshow test and the area under the receiver operating characteristic (ROC) curve from patients determined calibration and discrimination. Results: A total of 76 patients were enrolled (good prognosis group: 67 vs poor prognosis group: 9). The cut-off value for the APACHE II score was 12 and the area under the curve value was 0.891. The Hosmer and Lemeshow C statistic x2 was 7.414 (p=0.387), indicating good calibration for APACHE II. Conclusion: The APACHE II score is useful at predicting the neurological prognosis of patients who have ingested glufosinate.

Incidence and Features of Cognitive Dysfunction Identified by Using Mini-mental State Examination at the Emergency Department among Carbon Monoxide-poisoned Patients with an Alert Mental Status: Hyun Youk, Yong Sung Cha, Hyun Kim, Sung Hoon Kim, Ji Hyun Kim, Oh Hyun Kim, Hyung Il Kim, Kyoung Chul Cha, Kang Hyun Lee, Sung Oh Hwang; J Korean Soc Clin Toxicol. 2016;14(2):115-121. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.115

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Abstract PDF: Purpose: Because carbon monoxide (CO)-intoxicated patients with an alert mental status and only mild cognitive dysfunction may be inadequately assessed by traditional bedside neurologic examination in the emergency department (ED), they may not receive appropriate treatment. Methods: We retrospectively investigated the incidence and features of cognitive dysfunction using the Korean version of the Mini-Mental State Examination (MMSE-K) in ED patients with CO poisoning with alert mental status. We conducted a retrospective review of 43 consecutive mild CO poisoned patients with a Glasgow Coma Scale score of 15 based on documentation by the treating emergency physician in the ED between July 2014 and August 2015. Results: Cognitive dysfunction, defined as a score of less than 24 in the MMSE-K, was diagnosed in six patients (14%) in the ED. In the MMSE-K, orientation to time, memory recall, and concentration/calculation showed greater impairments. The mean age was significantly older in the cognitive dysfunction group than the non-cognitive dysfunction group (45.3 yrs vs. 66.5 yrs, p<0.001). Among the initial symptoms, experience of a transient change in mental status before ED arrival was significantly more common in the cognitive dysfunction group (32.4% vs. 100%, p=0.003). Conclusion: Patients with CO poisoning and an alert mental status may experience cognitive dysfunction as assessed using the MMSE-K during the early stages of evaluation in the ED. In the MMSE-K, orientation to time, memory recall, and concentration/calculation showed the greatest impairment.

Epidemiologic Characteristics of Carbon Monoxide Poisoning: Emergency Department Based Injury In-depth Surveillance of Twenty Hospitals: Sohyun Bae, Jisook Lee, Kyunghwan Kim, Junseok Park, Dongwun Shin, Hyunjong Kim, Joonmin Park, Hoon Kim, Woochan Jeon; J Korean Soc Clin Toxicol. 2016;14(2):122-128. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.122

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Purpose: This study was conducted to describe the characteristics of patients with carbon monoxide (CO) poisoning. Methods: We retrospectively surveyed data from the Emergency Department based Injury In-depth Surveillance of 20 hospitals (2011-2014). We included patients whose mechanism of injury was acute CO poisoning caused by inhalation of gases from charcoal or briquettes. We surveyed the annual frequency, gender, age, result of emergency treatment, rate of intensive care unit (ICU) admission, result of admission, association with alcohol, and place of accident. We also surveyed the cause and experience of past suicide attempts by intentional poisoning. Results: A total of 3,405 patients were included (2,015 (59.2%) and 1,390 (40.8%) males and females, respectively) with a mean age of $39.83{pm}18.51$ year old. The results revealed that the annual frequency of CO poisoning had increased and the frequency of unintentional CO poisoning was higher than that of intentional CO poisoning in January, February and December. The mean age of intentional CO poisoning was younger than that of unintentional CO poisoning ($38.41{pm}13.03$ vs $40.95{pm}21.83$) (p<0.001). The rates of discharge against medical advice (DAMA), ICU care and alcohol association for intentional CO poisoning were higher than for unintentional CO poisoning (36.4% vs 14.0%, 17.8% vs 4.7%, 45.2% vs 5.6%) (p<0.001). The most common place of CO poisoning was in one's residence. Conclusion: The annual frequency of total CO poisoning has increased, and unintentional CO poisoning showed seasonal variation. DAMA, ICU care, and alcohol association of intentional CO poisoning were higher than those of unintentional CO poisoning.

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Prevalence of Carbon Monoxide Poisoning and Hyperbaric Oxygen Therapy in Korea: Analysis of National Claims Data in 2010–2019
Eunah Han, Gina Yu, Hye Sun Lee, Goeun Park, Sung Phil Chung
Journal of Korean Medical Science.2023;[Epub] CrossRef

Comparison of Epidemiology and Outcomes of Patients with Intentional Poisoning by Age Groups: Single Center Observation Study: Jin Hyun Kim, Jin Seong Cho, Jin Joo Kim, Yong Su Lim, Hyuk Jun Yang, Geun Lee; J Korean Soc Clin Toxicol. 2016;14(2):129-135. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.129

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Purpose: This study was conducted to compare demographic and characteristic differences in self-poisoned patients by age groups using a comprehensive trauma database. Methods: This study included 1,823 patients who were admitted to the emergency room following self-poisoning. Three age groups were defined: young patients (less than 19 years), adult patients (19 to 64 years) and elderly patients (65 years and old). From January 2011 to December 2015, data were obtained from in a single emergency medical center. We investigated the materials of poisoning, ingestion time, GCS, systolic blood pressure, heart rate, and outcomes of patients. Results: A total of 1,823 self-poisoned patients visited the hospital during 5 years. Among these, 130 (7.1%) were categorized as young, 1,460 (80.1%) were adults and 233 (12.8%) were elderly. The most common drug of self-poisoning substances was antipyretics (50.0%) for those in the young group, sedative drugs (45.0%) for adults, and pesticides (41.2%) for the elderly. Mortality was 2.7% in the adult group and 14.6% in the elderly group. After adjusting for all factors related to mortality, the odds ratio (OR) of mortality was 2.63 in the elderly group (95% confidence interval [CI]: 1.44-4.81). Conclusion: There were definite differences in the characteristics of three groups. The younger patients used drugs that could be easily obtained while older patients used more lethal drugs.

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Clinical features of adolescents with suicide attempt and the factors associated with their outcomes: poisoning versus non-poisoning
Myoung Hoon Lee, Jae Ho Jang, Jin-Seong Cho, Woo Sung Choi, Jea Yeon Choi
Pediatric Emergency Medicine Journal.2020; 7(2): 85. CrossRef

General Characteristics for Poisoning-Induced Transient or Sustained Hyperammonemia: Soo Hyung Lee, Hong In Park, Michael Sung Choe, Dong Wook Je, Woo Young Nho, Seong Hun Kim, Mi Jin Lee, Jae Yun Ahn, Sung Bae Moon, Dong Eun Lee, Jung Bae Park; J Korean Soc Clin Toxicol. 2016;14(2):136-143. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.136

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Abstract PDF: Purpose: In patients with altered mentality caused by drugs or unknown causes, ammonia is checked to facilitate differential diagnosis or diagnose hepatic coma. This helps early prevention and treatment of brain damage due to hyperammonemia. This study was conducted to evaluate clinical characteristics of intoxicated adult patients with hyperammonemia. Methods: We evaluated 95 patients with hyperammonemia among intoxicated patients above the age of 15 who visited our ED from January 2013 to December 2015. We analyzed the demographic characteristics and type of poisoning substance, reason for ingestion, toxicological characteristics such as elapsed time from ingestion to hospital visit, lab, clinical progression and complications. Data were evaluated using the student's t test or Mann-Whitney U test for continuous variables, and Chi-square test and Fisher's exact test for frequency analysis of categorical variables. Results: When compared to healthy individuals, patients with hyperammonemia showed statistical significance on their SOFA score (p=0.016) and poison severity score (p<0.001). Additionally, patients with hyperammonemia showed significantly different initial serum AST level (p=0.012) and maximum serum AST level during the hospital stay (p=0.026) when compared to healthy individuals. Moreover, individuals with sustained hyperammonemia compared to transient hyperammonemia showed clinically significant SOFA scores (p<0.001), poison severity scores (p=0.007), mortality rates in the ICU (p=0.021), as well as different duration of hospital stay (p=0.037), serum creatinine level (p=0.002), erythrocyte sedimentation rate (p=0.025), and serum myoglobin (p=0.015). Conclusion: Most poisoning-induced hyperammonemia cases were transient and recovered without special treatment. Therefore, hyperammonemia is almost non-specific among poisoning patients.

Genoprotective Effect of Melatonin Against to the Genotoxicity of Glyphosate on Human Blood Lymphocytes: Jung-Gyu Kim, Woo-Ik Choi, Jae-Ho Lee, In-Jang Choi, Sang-Chan Jin; J Korean Soc Clin Toxicol. 2016;14(2):144-150. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.144

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Abstract PDF: Purpose: Glyphosate is a widely used non-selective herbicide. Previous studies have shown that glyphosate has genotoxicity, and that even low-doses of glyphosate can cause DNA damage. Melatonin is a hormone produced and secreted by the pineal gland that is known to be a potent anti-carcinogen, anti-oxidant, and genetic protector. This study was conducted to investigate the genoprotective effect of melatonin against glyphosate in human blood lymphocytes. Methods: Human peripheral blood was obtained from 15 young, healthy volunteers and cultured under four different toxicologic conditions. The four groups consisted of a control group, glyphosate only group (300 ng/mL), glyphosate with low level of melatonin group ($50{mu}M$), and glyphosate with high level of melatonin group ($200{mu}M$). The mean Sister Chromatid Exchange (SCE) frequency of each group was then analyzed. Results: Glyphosate exposed groups had a higher mean SCE frequency ($10.33{pm}2.50$) than the control group ($6.78{pm}2.31$, p<0.001). Interestingly, the group that received a low-level of melatonin had a lower mean SCE frequency ($8.67{pm}2.58$) than the glyphosate-only group, while the group that received a high level of melatonin had a much lower mean SCE frequency ($8.06{pm}2.50$) than the glyphosate-only group. There was statistical significance. Conclusion: Melatonin exerted a potent gene protective effect against the genotoxicity of glyphosate on human blood lymphocytes in a dose-dependent fashion.

Low Plasma Insulin Level Prolonged Hypoglycemia after High dose Insulin Lispro Injection: Jeong Ho Kang, Hyun Soo Park; J Korean Soc Clin Toxicol. 2016;14(2):151-154. Published online December 31, 2016; DOI: https://doi.org/10.22537/jksct.2016.14.2.151

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Abstract PDF: Increased plasma insulin levels are often observed in exogenous insulin overdose patients. However, plasma insulin level may decrease with time. We report a case of low plasma insulin level hypoglycemia after insulin lispro overdose. The patient was a 37-year-old man with no previous medical history who suspected insulin lispro overdose. Upon arrival, his Glasgow coma scale was 3 points and his blood sugar level (BSL) was 24 mg/dl. We found five humalog-quick-pen (insulin lispro) in his bag. There was no elevation of glucose level, despite an initial 50 ml bolus of 50% glucose and 150 cc/hr of 10% dextrose continuous intravenous infusion. He also suffered from generalized tonic-clonic seizure, which was treated with lorazepam and phenytoin. We conducted endotracheal intubation, after which he was admitted to the intensive care unit (ICU). There were recurrent events of hypoglycemia below BSL<50 mg/dl after admission. We repeatedly infused 50 ml 50% glucose 10 times and administered 1 mg of glucagon two times. The plasma insulin level was 0.2 uU/ml on initial blood sampling and 0.2 uU/ml after 5 hours. After 13 hours, his BSL stabilized but his mental status had not recovered. Diffuse brain injury was observed upon magnetic resonance imaging (MRI) and severe diffuse cerebral dysfunction was found on electroencephalography (EEG). Despite 35 days of ICU care, he died from ventilator associated pneumonia.

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