Journal of The Korean Society of Clinical Toxicology

Original Article

Utility of the APACHE II score as a neurological prognostic factor for glufosinate-intoxicated patients with alert mental status: Rok Lee, Tae Yong Shin, Hyung Jun Moon, Hyun Jung Lee, Dongkil Jeong, Dongwook Lee, Sun In Hong, Hyun Joon Kim; J Korean Soc Clin Toxicol. 2023;21(2):135-142. Published online December 29, 2023; DOI: https://doi.org/10.22537/jksct.2023.00018

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Abstract PDF: Purpose: In patients with glufosinate poisoning, severe neurological symptoms may be closely related to a poor prognosis, but their appearance may be delayed. Therefore, this study aimed to determine whether the Acute Physiology and Chronic Health Evaluation II (APACHE II) score could predict the neurological prognosis in patients with glufosinate poisoning who present to the emergency room with alert mental status.
Methods
This study was conducted retrospectively through a chart review for patients over 18 years who presented to a single emergency medical center from January 2018 to December 2022 due to glufosinate poisoning. Patients were divided into groups with a good neurological prognosis (Cerebral Performance Category [CPC] Scale 1 or 2) and a poor prognosis (CPC Scale 3, 4, or 5) to identify whether any variables showed significant differences between the two groups.
Results
There were 66 patients (67.3%) with good neurological prognoses and 32 (32.8%) with poor prognoses. In the multivariate logistic analysis, the APACHE II score, serum amylase, and co-ingestion of alcohol showed significant results, with odds ratios of 1.387 (95% confidence interval [CI], 1.027–1.844), 1.017 (95% CI, 1.002–1.032), and 0.196 (95% CI, 0.040–0.948), respectively. With an APACHE II score cutoff of 6.5, the AUC was 0.826 (95% CI, 0.746–0.912). The cutoff of serum amylase was 75.5 U/L, with an AUC was 0.761 (95% CI, 0.652–0.844), and the AUC of no co-ingestion with alcohol was 0.629 (95% CI, 0.527–0.722).
Conclusion
The APACHE II score could be a useful indicator for predicting the neurological prognosis of patients with glufosinate poisoning who have alert mental status.

Predicting Factors Associated with Large Amounts of Glyphosate Intoxication in the Early-Stage Emergency Department: QTc Interval Prolongation: Dong-Soo Kyung, Jae-Cheon Jeon, Woo Ik Choi, Sang-Hun Lee; J Korean Soc Clin Toxicol. 2020;18(2):130-135. Published online December 31, 2020; DOI: https://doi.org/10.22537/jksct.2020.18.2.130

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Abstract PDF: Purpose: Taking large amounts of glyphosate is life-threatening, but the amounts of glyphosate taken by patients for suicide are not known precisely. The purpose of this study was to find the predictors of large amounts of glyphosate ingestion. Methods: This retrospective study analyzed patients presenting to an emergency department with glyphosate intoxication between 2010 and 2019, in a single tertiary hospital. The variables associated with the intake amounts were investigated. The parameters were analyzed by multivariate variate logistic regression analyses and the receiver operating characteristic (ROC) curve. Results: Of the 28 patients with glyphosate intoxication, 15 (53.6%) were in the large amounts group. Univariate analysis showed that metabolic acidosis, lactic acid, and corrected QT (QTc) interval were significant factors. In contrast, multivariate analysis presented the QTc interval as the only independent factor with intoxication from large amounts of glyphosate. (odds ratio, 95% confidence interval: 1.073, 1.011-1.139; p=0.020) The area under the ROC curve of the QTc interval was 0.838. Conclusion: The QTc interval is associated significantly with patients who visit the emergency department after being intoxicated by large amounts of glyphosate. These conclusions will help in the initial triage of patients with glyphosate intoxication.

Characteristics of Acute Herbicide Poisoning: Focused on Chlorophenoxy Herbicide: Hakyoon Song, Sangchun Choi, Yoon Seok Jung, Eunjung Park, Hyukhoon Kim; J Korean Soc Clin Toxicol. 2019;17(2):126-131. Published online December 31, 2019; DOI: https://doi.org/10.22537/jksct.2019.17.2.126

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Abstract PDF

Purpose: Herbicide-related mortality has decreased since the complete ban of paraquat product sales in 2012, but there still have been other herbicides intoxications with relatively severe complications. Glyphosate and glufosinate herbicides are used widely, and considerable research has been conducted. Chlorophenoxy herbicide is another major herbicide that has shown poor outcomes and mortality without proper management, but research in this area is lacking. Therefore, this study compared the clinical features of chlorophenoxy herbicide with those of other herbicides. Methods: The medical records of patients exposed to herbicides at a tertiary academic university hospital in Korea from May 2014 to April 2019 were reviewed retrospectively. The demographic and clinical data of 135 patients were then analyzed to identify the recent herbicides intoxication trends after the paraquat sales ban, focusing mainly on chlorophenoxy herbicide poisoning. Results: Of the 135 patients, 13 patients (9.6%) had chlorophenoxy herbicide poisoning. No significant differences in all the variables were observed between the chlorophenoxy herbicide poisoning group and non-chlorophenoxy herbicides poisoning groups. Toxic symptoms after poisoning varied from nothing noticeable to confusion; none of the patients had severe complications after their treatments. Conclusion: Acute chlorophenoxy poisoning is relatively less severe, with lower mortality rates than glyphosate and glufosinate poisoning.

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Association between continuous renal replacement therapy and mortality after acute herbicide (glyphosate and/or glufosinate) intoxication: propensity score matching approach
Seung Woo Lee, Won-joon Jeong, Seung Ryu, Yongchul Cho, Yeonho You, Jung Soo Park, Changshin Kang, Hong Joon Ahn, So Young Jeon, Jinwoong Lee
Journal of The Korean Society of Clinical Toxicology.2023; 21(1): 17. CrossRef

Comparison of Clinical Characteristics and Severity of Glyphosate and Glufosinate Herbicide Poisoning Patients: Hyung Sun Joo, Tae Ho Yoo, Soo Hyung Cho; J Korean Soc Clin Toxicol. 2018;16(2):124-130. Published online December 31, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.2.124

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Abstract PDF: Purpose: The number of glyphosate and glufosinate intoxication cases are increasing in Korea. This study was undertaken is to compare the clinical manifestations of poisoning by these two herbicides and to document severities and clinical outcomes. Methods: We retrospectively evaluated cases of glyphosate or glufosinate intoxication among patients that visited our emergency department between January 1, 2013, and December 31, 2017. Incidences of intoxications were analyzed over this five year period, and underlying diseases, transportation, mental state, shock occurrence, inotropics, gastric lavage, charcoal administration, intubation and ventilator therapy, and hemodialysis were investigated. In addition, we included transfer to the intensive care unit, incidences of pneumonia and of other complications, death, and hopeless discharge. Results: There were 119 cases of glyphosate intoxication and 42 of glufosinate intoxication. Levels of consciousness were lower for glufosinate and vasopressor usage was higher due to a high shock rate (p=0.019). In addition, many patients were referred to the ICU for intubation and ventilation. The incidences of pneumonia and of other complications were significantly higher for glufosinate. Conclusion: Overall glufosinate intoxication was found to be more severe than glyphosate intoxication as determined by complication and ICU admission rates.

Relationship between Serum Neuron Specific Enolase Level and Seizure in Patients with Acute Glufosinate Ammonium Poisoning: Gyo Jin An, Yoonsuk Lee, Yong Sung Chan, Hyun Kim; J Korean Soc Clin Toxicol. 2018;16(1):49-56. Published online June 30, 2018; DOI: https://doi.org/10.22537/jksct.2018.16.1.49

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Abstract PDF: Purpose: Glufosinate ammonium poisoning can cause seizures, even after a symptom-free period. This study was conducted to evaluate the relationship between serum neuron specific enolase (NSE) level and the occurrence of seizures in patients with acute glufosinate ammonium poisoning. Methods: For this retrospective observational study, data from patients diagnosed with acute glufosinate ammonium poisoning were collected between January 2016 and June 2016. Serum NSE was measured within 2 hours of arrival at the emergency department. The patients were divided into a seizure group and a non-seizure group. Results: The seizure group included eight of the 15 total patients (53.3%). The serum NSE level was significantly higher in the seizure group than in the non-seizure group ($32.4{pm}11.9ng/mL$ vs. $19.5{pm}5ng/mL$, p=0.019). The amount of glufosinate ingested and initial and peak serum ammonia levels were significantly higher in the seizure group than in the non-seizure group. There was no significant difference in the area under the curve of the serum NSE level or the initial and peak serum ammonia levels in terms of predicting the occurrence of seizures. Conclusion: In acute glufosinate poisoning, initial serum NSE levels may help in prediction of seizures.

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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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.

Citations

Citations to this article as recorded by

Association between continuous renal replacement therapy and mortality after acute herbicide (glyphosate and/or glufosinate) intoxication: propensity score matching approach
Seung Woo Lee, Won-joon Jeong, Seung Ryu, Yongchul Cho, Yeonho You, Jung Soo Park, Changshin Kang, Hong Joon Ahn, So Young Jeon, Jinwoong Lee
Journal of The Korean Society of Clinical Toxicology.2023; 21(1): 17. CrossRef
Utility of the APACHE II score as a neurological prognostic factor for glufosinate-intoxicated patients with alert mental status
Rok Lee, Tae Yong Shin, Hyung Jun Moon, Hyun Jung Lee, Dongkil Jeong, Dongwook Lee, Sun In Hong, Hyun Joon Kim
Journal of The Korean Society of Clinical Toxicology.2023; 21(2): 135. CrossRef

The Clinical Feature and Prognostic Factor of Glyphosate Intoxication Patients: Hee Min Eun, Jin Hui Paik, Joo Hyun Suh, Jin Hee Jung, Eun Kyung Eo, Hyung-Keun Roh; J Korean Soc Clin Toxicol. 2013;11(2):89-95. Published online December 31, 2013

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Abstract PDF: Purpose: Glyphosate is widely used and its toxic exposures are not rare. Occasionally, glyphosate intoxication can lead to death. The aim of this study is to analyze clinical findings and fatality in glyphosate intoxication. Methods: Clinical data on acute glyphosate intoxication were prospectively collected at 28 hospitals nationwide between August 2005 and July 2006. The patients' clinical symptoms and characteristics of fatalities were investigated and statistical analysis was performed. Results: Among 105 patients who were finally included, gastrointestinal symptoms(59%) were the most common. A significant difference in the amount ingested was observed between patients with higher systolic blood pressure and those with systolic blood pressure less than or equal to 80 mmHg (p<0.001). The more the patients ingested, the more aggravated their mental status became (p=0.004). Seven patients(6.7%) died, and all of them had ingested greater than or equal to 200 ml. Patients who died had ingested greater amounts than the survivors (p<0.001), and their mental status was worse (p<0.001), and systolic blood pressure was lower (p<0.001). According to the result of logistic regression analysis, relative risk was 24.1-fold higher in the 'poor' mental status group compared with 'good'. Conclusion: Patients who ingested large amounts of glyphosate showed poor mental status and lower blood pressure. Statistical difference in amount ingested, mental status, and systolic blood pressure was observed between survivors and patients who died. Ingested amounts and mental status were the most important factor of the prognosis of glyphosate intoxication.

Epidemiology and Clinical Analysis of Poisoning of Glufosinate Herbicide - Multicenter Study -: Sung-Woo Lee, Yun-Sik Hong, Woon-Yong Kwon, Joon-Seok Park, Eun-Kyung Eo, Bum-Jin Oh, Mi-Jin Lee, Joo-Hyun Suh, Hyung-Keun Roh; J Korean Soc Clin Toxicol. 2007;5(1):36-42. Published online June 30, 2007

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Abstract PDF: Purpose: To assess the epidemiology and the clinical features of Glufosinate herbicide in Korea. Methods: Data was prospectively collected during 1 year since August 2005 from 38 hospital in Korea. We analyzed the epidemiologic characters and clinical manifestations of Glufosinate poisoning. In addition, the characteristics of patients with severe central nervous system toxicity were separately analyzed to find poor prognosis relating factors. Results: During study periods, there were 715 persons of poisoning of herbicides and insecticides. 6.3% (45 persons) of the agricultural chemicals poisoning had Glufosinate poisoning. There were 36 cases of suicide attempts and 7 cases of accidental exposure, The major of poisoning route was oral ingestion (44 cases). 28.9 % of the study patients had not toxic symptoms. The most common symptoms were gastrointestinal symptoms relating surfactant irritation. 67.7% of central nervous symptoms occurred lately. 10 persons showed severe central nervous system toxicity. 4 persons of them showed poor outcomes (1 death, 3 hopeless discharged). Complications of respiratory failure and renal failure related with poor outcome. Conclusion: Majority of patients ingested Glufosinate for suicide attempt. 22.2% of patients with Glufosinate poisoning showed delayed serious central nervous system toxicity. Early supportive care of altered mentality may prevent late respiratory complications and improve the outcomes.

Analysis of 2002 year's Pesticides Poisoning Deaths' data of Korea National Statistical Office and Counterplan to Prevent Deaths Due to Herbicides Poisoning: Uk Jin Kim, Hyo Yun Kim, Seung Hwan Kim, Sun Wook Kim, Young Soon Cho, Sung Pil Chung, Hahn Shick Lee; J Korean Soc Clin Toxicol. 2004;2(2):77-82. Published online December 31, 2004

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Abstract PDF: Background
s: Deaths from pesticides poisoning has increased annually, but no studies have been reported. Especially paraquat is suspected to be a major material in pesticide poisoning deaths. In Korea, simple epidemiology of pesticides poisoning is not well known. So, there is no effective method to prevent pesticides poisoning. We tried to investigate the present status of pesticides poisoning with data from Korea National Statistical Office and suggest an effective counterplan. Methods: We analysed death cause data derived from Korean Statistical association, deaths causes being pesticides poisoning in the year 2002. Also, we investigated data from internet, mainly from Korea National Statistical Office home page. Results: Total 2,875 persons died after pesticides poisoning in 2002 year. Average age is 54.2 year, standard deviation being 17.7 year. Many victims (about $41\%$) died during the herbicides' non-necessary period (JanuaryMarch, October-December) Conclusion: Herbicides sale should be restricted only during herbicides' necessary period, and so called a pesticides safety supervisor system shall effectively prevent herbicides poisoning.

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