DELIBERATE SELF-POISONING IN SOUTH ODISHA: STUDY OF ITS CLINICAL PROFILE AND OUTCOME

Objective: Deliberate self-poisoning is a serious global issue that contributes to significant morbidity and mortality all over the world. The present study was conducted with an objective to identify the common agents used for self-poisoning prevalent in South Odisha and to determine the common clinical features and outcome of such cases. Methods: This cross-sectional observational study was conducted on 200 patients with deliberate self-poisoning belonging to the age group of 15–70 years over a period of 2 years from August 2017 to September 2019 in Maharaja Krishna Chandra Gajapati Medical College and Hospital, Berhampur, Odisha, India. All the above-mentioned patients admitted to the hospital, were treated with specific antidotes according to the poison ingested. Results were analyzed using appropriate standard statistical methods such as mean, standard deviation, and percentage. Results: Out of 200 patients, majority were female (65%, n=130) and 35% (n=70) were male; mean age was 38.9 (±16.8) years. Organophosphates, aluminum phosphide, glyphosate, organochlorines, and carbamates were the most common pesticides used as poisoning agents (74.5%, n=149) followed by plant poisons (7%, n=14) which included yellow oleander seed. Overall mortality in our study was 12.5%. Conclusion: Pesticides and plant poisons were the common agents used in our study for deliberate self-poisoning. Young persons, illiterates, and housewives were commonly involved in suicide attempts. Organophosphate caused majority of deaths. synapses.


INTRODUCTION
Deliberate self-poisoning and suicides are serious global health issue in many developing and underdeveloped countries including India, where the toxicity of available poisons and sparse medical facilities contributes to significant morbidity and mortality.
It is also observed that suicide attempts by females are 3 times more common than males [1]. In India, social and economic reasons are the major cause of suicidal death in men while emotional and personal problems are the causes in women [2].
Profile of patients and their choice of agents depend on the local availability of the substances and the socioeconomic and cultural backgrounds. It is seen to vary in different regions [3].
Acute pesticide poisoning is a major issue in developing countries of the Asia-Pacific region and organophosphates are considered the most important cause of death from acute poisoning worldwide. In developed countries, however, the incidence of severe pesticide poisoning is relatively very low where drugs play the predominant role. According to data available from National Poison Information Centre, India, suicidal poisoning with pesticides is the most common modality of poisoning since it is cheap, highly toxic, and capable of being taken along with food or drink and above all easily available [4].
The WHO estimates that deliberate ingestion of pesticides causes 370,000 deaths each year which is one-fifth of the total world's suicidal deaths. The number of these deaths can be reduced by limiting the availability of and access to, highly toxic pesticides.

Aims and objectives
The aim of the present study was to determine the clinical profile and outcome of deliberate self-poisoning in South Odisha.
The objectives were: • To study the demographic details of the patients of poisoning, • To identify the common agents used for poisoning and, • To determine the common clinical features, complications, and outcomes of the patients treated. The types of poison were confirmed from patient's detailed history, signs and symptoms, reliable information, either from the patients or from his/her relatives, and the container of the poison produced.

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Data regarding demographic profiles including age, sex, educational level, socioeconomic status, and premorbid conditions were recorded from them.

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Gastric lavage was done in most of the cases and gastric content samples were preserved and sent to forensic laboratory for chemical analysis, for medicolegal purpose.
All patients were investigated with routine and specific laboratory tests including baseline investigations such as complete blood count, serum urea, serum creatinine, random blood sugar, liver function tests, arterial blood gas analysis, electrocardiography (ECG), X-ray chest and plasma cholinesterase level, and other relevant tests at the time of admission.
Necessary therapeutic intervention was started as per standard protocol initially in the emergency ward. The patients requiring ICU care were shifted to medical ICU. Complications developed by the patients were recorded and were followed up until recovery or death. All the recovered deliberate self-poisoning patients were sent for psychiatric consultation and evaluation before their discharge from the hospital.

Patients' selection criteria
Patients with a history of deliberate self-poisoning of either sex and above 14 years of age admitted to the hospital were included in this study.

Exclusion criteria
Accidental exposure/ingestion of poison, drink spiking poisoning, psychiatric illness, snake bite, insect bite, food poisoning, and allergic reaction to drugs were excluded from this study.

Statistical analysis
Results were analyzed using appropriate standard statistical method such as mean (±standard deviation [SD]), and percentage.
Among pesticide poisoning cases, 91 were of organophosphates, 25 were of aluminum phosphide, 13 were of cypermethrin, 2 were of carbamate, and 4 were of organochlorine cases.
Nicotinic features such as fasciculation and tachycardia muscle weakness leading paralysis were seen. Central nervous system (CNS) features observed were altered sensorium and seizure.
The signs, symptoms, and complications of this cholinergic insecticide group with their number and percentage found in our study are shown in Table 5.
Organophosphate poisoning accounted for the majority of deaths (n=19, 82.60%), among the pesticide groups where total deaths due to pesticide were 23 (Table 4).

Aluminum phosphide poisoning
As there is no specific antidote for aluminum phosphide poisoning, patients were treated conservatively providing symptomatic and supportive aid.

Yellow oleander (Thevetia peruviana) poisoning
Out of 4 paraphenylenediamine poisoning cases, 3 (75%) patients were presented with symptoms of difficulty in swallowing. Three patients (75%) with facial puffiness and edema of lips and 3 patients (75%) with stridor and difficulty in speaking were found with this poisoning. In this study of other poisonings, there were no deaths found.

Outcome
The mortality in the present study was 12.5% (25 deaths with 17 males and 8 females).
All the above cases belonged to pesticide groups where 19 were due to organophosphate poisoning, 2 with glyphosate poisoning, 2 with aluminum phosphide poisoning, and one each with cypermethrin and norbormide poisoning (Table 4).

DISCUSSION
The objective of this study was to describe the demographic features, identifying the common agents used for deliberate self-poisoning, and assessment of common clinical features with outcomes.
This study shows the high incidence of deliberate self-poisoning among females, which is similar to studies done internationally [5][6][7][8] [11] in India in which the incidence was high among males.
Maximum number of cases were in the age group of 18-40 years (n=146, 73%) which can be explained by the fact that the persons of this age group were victims of modern lifestyle, failure in love, family problems, nuclear family concept, etc. This result differs from a United States study where the rate was found to be higher in the age group of adolescents [6]. However, similar results were found in the United Kingdom [5] where the majority of deliberate self-poisoning patients were in their thirties.
The majority of patients of suicidal poisoning were housewives (n=85, 42.5%) followed by students (n=57, 28.5%) and farmers (n=24, 12%) followed by businessmen (n=18.9%) ( Table 2). It could be due to domestic problems in case of housewives, whereas in case of students, stress of modern lifestyle, failure in love, and family pressure might be the cause. Poverty was the main cause of suicidal attempts in case of farmers, whereas business failure led the business men to attempt the same.
Educational status shows that maximum number of suicidal poisoning cases were from the groups of illiterates (n=77, 38.5%), whereas primary educated accounted for 28.5% (n=57). Thirty-seven (18.5%) patients were secondary and 15 (7.5%) patients were higher secondary educated. Only 7% (n=14) of patients were graduates. This result differs from other study groups like Singh et al. [12]. This study shows that pesticides were the most common agents used for deliberate selfpoisoning followed by plant poison, and in all the cases, the route of ingestion was oral. A similar study had been carried out by Madhavan et al. in South India [13].
Among pesticides, organophosphates were the common agents (61.07%) unlike the other studies where carbamates were common, which may be due to regional variation [13]. A study from All India Institute of Medical Sciences, New Delhi, also showed a predominance of carbamates among pesticide group, but poisoning due to drugs predominated that study [14]. Organophosphate compounds inactivate acetylcholinesterase (AChE), resulting in the accumulation of acetylcholine (ACh) and uncontrolled activation of cholinergic In our study, we found cholinergic symptoms of both muscarinic and nicotinic features such as diarrhea, miosis, bradycardia, bronchorrhea, bronchoconstriction, emesis, salivation, hypotension, and fasciculation.
Standard treatment was given to reduce absorption with gastric lavage and/or activated charcoal and continued with administration of atropine and pralidoxime. Atropine works at muscarinic synapses leading to reversal of ACh excess which reverses the clinical effects of cholinergic excess at parasympathetic end organs. High dose of atropine was given which is well established. Pralidoxime which is recommended by the WHO was given whose main action is to reactivate AChE that has not undergone aging because aged enzyme cannot be reactivated by oximes, thereby recovering neuromuscular transmission at nicotinic synapses.
Gastrointestinal symptoms were most prevalent in our study. We did not find any case of mydriasis. This shows similarity with the study of Madhavan et al. [13]. The mortality rate in the present study is 20.87%, which is much higher in the study conducted by Kora et al. [15], where it was found to be 4.72%. The mortality rate directly depended on the time at which the patient received the treatment and in one study, it was 47%, because in that study, the treatment was given late [16].
Aluminum phosphide was the second most pesticide poisoning group in our study (n=25). This is used as rodenticide and pesticide in grain storage facilities. It produces phosphine gas which results in mitochondrial poisoning. There is no specific antidote for this poisoning.
The patients admitted in our hospital were presented with the features of severe hypotension, dizziness, fatigue, tightness in the chest, nausea, vomiting, and headache. Two patients died in our study one due to acute respiratory distress syndrome and the other from profound shock and multiorgan failure. The delay in arrival might be the cause of their death. Although all the patients were treated with MgSO 4 and antacid after gastric lavage with KMnO 4 , 23 patients survived. This study agrees with the study conducted by Singh et al. (1997) [17].
Cypermethrin is a synthetic pyrethroid used as an insecticide in largescale agricultural application as well as for domestic purposes. In large doses, it may produce neurotoxicity such as tremor, fasciculation, convulsion, coma, and even respiratory failure [18]. It causes type 1 hypersensitivity reaction like anaphylaxis when exposed to the mouth, lips, eyes, or skin. ECG may show ST-T changes, sinus tachycardia, and ventricular premature beats [19]. It also causes increased salivation, upper gastrointestinal bleeding, and rarely renal failure.
In our study, the patients were presented with the symptoms of facial burning and tingling, dizziness, nausea, and headache. One patient died with seizure.
Glyphosate is a non-selective herbicide which is absorbed from the gastrointestinal tract. Multiorgan dysfunction including hypotension, kidney or liver dysfunction, pulmonary edema or pneumonitis, altered level of consciousness, and/or metabolic acidosis is associated with severe glyphosate poisoning [20]. This study observed symptoms of nausea, vomiting, erosion of gastrointestinal tract, dehydration, hypotension, pneumonitis, altered level of consciousness, hyperkalemia, and dysrhythmia in patients of glyphosate poisoning. Two out of 10 patients died of this poisoning, both with multiorgan failure. Patients developing acute kidney injuries, hyperkalemia, pulmonary edema, and metabolic acidosis are more likely to die [21].
Oleander poisoning patients brought to our hospital showed the clinical features of vomiting, abdominal pain, drowsiness, dizziness, syncope, palpitation, bradycardia, and hypotension with 4 asymptomatic cases. ECG findings showed sinus bradycardia in eight patients and first degree AV block in six patients with no other abnormalities. All of them responded to atropine and orciprenaline. No casualties were found in our study. Mild ingestion and early intervention might be the cause of above result.
The symptoms of benzodiazepine poisoning may include drowsiness, slurred speech, nystagmus, hypotension, ataxia, coma, respiratory depression, and cardiorespiratory arrest [22]. All the patients in our study exhibited the above features except nystagmus, coma, and cardiorespiratory arrest with zero casualties. Drugs were mainly used by males and were not taken in fatal doses.
Two patients with kerosene (paraffin) poisoning were admitted in our hospital, one was asymptomatic while the other was presented with nausea, vomiting, and cough. No casualties were there. However, in the study of Reed et al. [23] and Wolfe et al. [24], kerosene produces CNS excitation in low doses and depression in high doses. Other effects include nausea, vomiting, abdominal pain, hepatitis, acute hepatic or renal failure, and rhabdomyolysis.
Overall mortality rate was 12.5% in our study with a total number of 25 deaths out of which 19 were from organophosphate poisoning and 3 from rodenticide (aluminum phosphide and norbormide) poisoning and 2 from herbicide (glyphosate) poisoning; thus, all deaths were due to pesticide poisoning. This shows the similarity with the study made by Santosh et al. [3], where the mortality was 8.7% which was little less than our study with a total of 21 deaths of whom 19 were due to organophosphate poisoning and 2 due to rodenticide poisoning.

CONCLUSION
This study showed that the most common agents used for deliberate self-poisoning were pesticides followed by plant poison. Among pesticides, organophosphate was the most common poisoning agent followed by aluminum phosphide. The occurrence was mostly among young persons, housewives, and illiterates. Since a large number of deliberate self-poisoning are made with pesticides, due to their easy accessibility, bringing down the morbidity and mortality associated with the same needs legal changes regarding the sale of pesticides.