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Ghonem MM, Abdelnoor AA, Hodeib AA. Shock and modified shock indices in predicting poisoning severity and outcomes in acute aluminum phosphide poisoned patients. Toxicol Res (Camb) 2024; 13:tfad124. [PMID: 38173544 PMCID: PMC10758595 DOI: 10.1093/toxres/tfad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 10/20/2023] [Accepted: 12/06/2023] [Indexed: 01/05/2024] Open
Abstract
Background Severe refractory hypotension and cardiogenic shock are the main contributors to death in acute aluminum phosphide (ALP) poisoning. Shock index (SI) and modified shock index (MSI) are easily obtained parameters that reflect shock at an early stage. Aim This study aimed to evaluate the role of SI and MSI in the prediction of the severity and outcomes of acute ALP poisoned patients. Patients and methods This cross sectional study was conducted on patients admitted to Tanta University Poison Control Centre with acute ALP poisoning from April 2022 to March 2023. Socio-demographics and toxicological data were taken, findings of clinical examination and laboratory investigations were recoded, SI was calculated by dividing heart rate over systolic blood pressure, and MSI was obtained by dividing heart rate over mean arterial pressure. Poisoning severity was assessed using poisoning severity score (PSS). Patients were divided into groups according to intensive care unit (ICU) admission and mortality. Results The study enrolled 94 patients. The median values of SI and MSI were significantly higher in ICU-admitted patients and non-survivors rather than their comparable groups. Significant positive correlations were observed between each of SI and MSI and PSS. At cut-off >1.14, SI conveyed fair performance to predict ICU admission and mortality (AUC = 0.710 and 0.739, respectively). Similarly, MSI had fair performance to predict ICU admission (AUC = 0.731) and mortality (AUC = 0.744) at cut-off >1.47 and >1.5, respectively. Conclusion Both SI and MSI could be considered simple bedside adjuncts to predict ICU admission and mortality in acute ALP poisoning.
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Affiliation(s)
- Mona M Ghonem
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta City 31527, Egypt
| | - Amira A Abdelnoor
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta City 31527, Egypt
| | - Aliaa A Hodeib
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Tanta University, Tanta City 31527, Egypt
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Chandel A, Dheeraj D, G J, Bairwa M. Bowel Gangrene Is a Rare but Dreaded Complication of Aluminum Phosphide Poisoning. Cureus 2022; 14:e27885. [PMID: 36127979 PMCID: PMC9481188 DOI: 10.7759/cureus.27885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2022] [Indexed: 11/29/2022] Open
Abstract
Poisoning is a significant contributor to mortality and morbidity throughout the world, and one of the most common pesticide poisonings is organophosphates, followed by phosphides. Ingestion of aluminum phosphide can induce severe gastrointestinal irritation leading to hemorrhage and ulcerations. Gastrointestinal ischemia, gangrene, and hemorrhage in the ileum secondary to aluminum phosphide poisoning have not been reported in the literature. The authors report a case of an 18-year-old man who had consumed 10 grams of Celphos, aluminum phosphide powder. The patient developed lower gastrointestinal ischemia and hemorrhage due to the direct effect of aluminum phosphide, leading to bowel gangrene. The gangrenous segment caused fecal peritonitis and sepsis, leading to multiorgan failure and death. This case report emphasizes the significance of the corrosive nature of aluminum phosphide; lower gastrointestinal hemorrhage is a rare but fatal complication of aluminum phosphide poisoning.
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Elgazzar FM, Shama MA, Shoeib O, Hafez ASAF. The Role of Echocardiographic Findings in Estimating Survival Probability of Intensive Care Unit Admitted Aluminum Phosphide Poisoned Patients. J Med Toxicol 2022; 18:128-138. [PMID: 35083735 PMCID: PMC8938530 DOI: 10.1007/s13181-021-00868-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Cardiotoxicity represents the primary cause of death in acute aluminum phosphide (AlP) poisoning. Prompt supportive care can improve patient survival. This study assessed the role of echocardiography in estimating the survival probability of AlP-poisoned patients admitted to the intensive care unit. METHODS A prospective cohort study of symptomatic acute AlP poisoned patients was conducted between September 2019 and December 2020. Patients were subjected to history taking, clinical examination, To be included, patient evaluation needed to include electrocardiographic (ECG) and echocardiographic studies. The statistical analysis assessed the association between patient survival and relevant factors. Survival analysis was performed using the Kaplan-Meier survival curve and Cox proportional hazard regression. RESULTS A total of 90 patients met inclusion criteria. Electrocardiographic abnormalities were detected in 38.1% of survivors and 82.6% of non-survivors (p < 0.001). Survivors had a higher mean left ventricle ejection fraction (LVEF) (50.86 ± 6.30% vs. 26.52 ± 7.64%, respectively, p < 0.001) and a lower percentage of global LV hypokinesia (4.8% vs. 94.2%, p < 0.001). The mean survival time was higher among patients with LVEF ≥ 50% than those with LVEF = 41-49% and ≤ 40% (p = 0.014 and 0.001, respectively). The hazard of death was 4.42 and 5.40 times greater in patients with LVEF ≤ 40% or with global LV hypokinesia, respectively. Regression revealed that the global LV hypokinesia, ECG abnormalities, and decreased LVEF and oxygen saturation were significantly associated with the risk of death (hazard ratios: 4.382, 3.348, 0.957, and 0.971, respectively). CONCLUSIONS Echocardiography represents a valuable diagnostic tool to assess cardiac function in acute AlP poisoning. Both LVEF and global LV hypokinesia significantly impact the survival of AlP-poisoned patients. Echocardiography was superior to ECG changes in terms of accuracy for the prediction of mortality.
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Affiliation(s)
- Fatma M. Elgazzar
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Medical Collages Complex, Tanta University, Al-Geesh Street, Tanta, 31527 Egypt
| | - Mohamed A. Shama
- Emergency Medicine and Traumatology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Osama Shoeib
- Cardiology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amal S. A. F. Hafez
- Forensic Medicine and Clinical Toxicology Department, Faculty of Medicine, Medical Collages Complex, Tanta University, Al-Geesh Street, Tanta, 31527 Egypt
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Pannu AK, Jhuria L, Bhalla A, Sharma N. OUP accepted manuscript. Toxicol Res (Camb) 2022; 11:361-366. [PMID: 35510238 PMCID: PMC9052320 DOI: 10.1093/toxres/tfac015] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 11/14/2022] Open
Abstract
Introduction We recently derived a simplified 3-point PGI score (representing blood pH < 7.25, Glasgow coma scale [GCS] score < 13, and impaired systolic blood pressure [SBP] < 90 mm Hg), which accurately predicted in-hospital case fatality ratio (CFR) in acute aluminum phosphide poisoning. The present study aimed to validate the PGI score and compare it with Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) II score, Sequential Organ Failure Assessment score (SOFA), and Simplified Acute Physiology Score (SAPS) II scores. Patients and Methods We performed a prospective cohort study in adult patients with aluminum phosphide ingestion admitted in PGIMER, Chandigarh (India), from April 2013 to August 2014. A univariant analysis detected the association of various baseline variables with CFR. Correlation of the PGI score with SOFA, SAPS-II, and APACHE-II scores was performed using Spearman's correlation (rs , range -1 to +1) and scatter plots. Results Seventy-six patients were enrolled (mean age, 28.3 years; 41 males). CFR was 60.5%. PGI score variables-pH, GCS, and impaired SBP predicted CFR (P-value <0.001). Among patients with a total PGI score of 3 or 2, 100% died, compared with 50% in score 1 and 10.7% in score 0. Baseline PGI, SOFA, SAPS-II, and APACHE-II scores predicted CFR (P-value <0.001). There was a positive correlation between the PGI score and SOFA score (rs , 0.855), SAPS-II score (rs , 0.861), and APACHE-II score (rs , 0.883). The P-value for all rs values was <0.001. Conclusion The PGI score is a validated toxidrome-specific and simplified risk-stratification tool. Validation in other populations is warranted to confirm its routine use.
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Affiliation(s)
| | | | | | - N Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Bagherian F, Kalani N, Rahmanian F, Abiri S, Hatami N, Foroughian M, Mehramiz NJ, Shahi B. Aluminum Phosphide Poisoning Mortality Rate in Iran; a Systematic Review and Meta-Analysis. Arch Acad Emerg Med 2021; 9:e66. [PMID: 34870232 PMCID: PMC8628645 DOI: 10.22037/aaem.v9i1.1396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Introduction: According to statistics provided by the forensic medicine facility of Iran, there are a high number of Aluminum phosphide (ALP) poisoning-related deaths in the country; while the mortality rate varies in different studies. This study aimed to determine a pooled estimate of ALP poisoning mortality rate in Iran. Methods: The present study was a systematic review and meta-analysis of the mortality rate of ALP poisoning in Iran. Through the quarry of Persian and English databases, using “aluminum phosphide”, “phosphine”, “rice pills”, “poisoning”, and “Iran” as keywords, and no time restrictions, studies reporting mortality rate in ALP poisoning cases were collected. The random-effects model was used to pool the proportions of mortality and age of survivors versus non-survivors. Results: 21 studies with 3432 cases of ALP poisoning were included in this meta-analysis. The pooled mortality rate of ALP poisoning in Iran was 39.6%, (95% CI: 31.5%-47.9%; I2 = 95%). Since there was significant publication bias, the trim-and-fill correction was conducted and the corrected pooled mortality rate was estimated to be 27.3% (95% CI: 18.9%- 36.5%), which is the rate that should be considered for clinical guidance. Morality rate in male and female patients was 62.3% (95% CI: 53.5%-70.8%) and 37.7% (95% CI: 29.2%-46.5%), respectively (p < 0.01). Survivors had significantly lower mean age than non-survivors (SMD: -0.26 (95% CI: -0.37 to -0.15); p < 0.01; I2=0%). Conclusion: According to this report, the Mortality rate of ALP poisoning in Iranian population is about 27%, with men having a higher fatality rate than women. Poisoning at a younger age is associated with better results.
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Affiliation(s)
- Farhad Bagherian
- Department of Emergency Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Navid Kalani
- Research center for social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Fatemeh Rahmanian
- Department of Emergency Medicine, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Samaneh Abiri
- Department of Emergency Medicine, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Naser Hatami
- Student Research Committee, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Mahdi Foroughian
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Neema John Mehramiz
- Department of Psychiatry Neurology, Banner university medical center, Tucson, AZ, USA
| | - Behzad Shahi
- Department of Emergency Medicine, Faculty of Medicine, Zahedan University of Medical Sciences, Zahedan, Iran
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Mu Y, Hu B, Gao N, Pang L. Prognostic value of the neutrophil-to-lymphocyte ratio in acute organophosphorus pesticide poisoning. Open Life Sci 2021; 16:703-710. [PMID: 34307885 PMCID: PMC8284330 DOI: 10.1515/biol-2021-0069] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 06/03/2021] [Accepted: 06/03/2021] [Indexed: 11/15/2022] Open
Abstract
This study investigates the ability of blood neutrophil-to-lymphocyte ratio (NLR) to predict acute organophosphorus pesticide poisoning (AOPP). Clinical data of 385 patients with AOPP were obtained within 24 h of admission, and NLR values were calculated based on neutrophil and lymphocyte counts. The patients were divided into two groups - good and poor - based on prognosis. Poor prognosis included in-hospital death and severe poisoning. The factors affecting prognosis were analyzed by logistic regression analysis, and the prognostic value of NLR was evaluated using the area under the receiver operating characteristic curve (AUC). Univariate logistic regression analysis showed that NLR levels, serum cholinesterase, and creatinine levels were good predictors of AOPP. Multivariate logistic regression analysis showed that high NLR was an independent risk factor for severe poisoning (adjusted odds ratio [AOR], 1.13; 95% CI, 1.10-1.17; p < 0.05) and in-hospital mortality (AOR, 1.07; 95% CI, 1.03-1.11; p < 0.05). NLR values >13 and >17 had a moderate ability to predict severe poisoning and in-hospital mortality, respectively (AUC of 0.782 [95% CI, 0.74-0.824] and 0.714 [95% CI, 0.626-0.803], respectively). Our results show that high NLR at admission is an independent indicator of poor prognosis in AOPP and can be used to optimize treatment and manage patients.
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Affiliation(s)
- Yuhang Mu
- Department of Emergency, First Hospital of Jilin University, No. 1 Xinmin Road, Changchun, 130021, China
| | - Boqi Hu
- Department of Radiology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Nan Gao
- Department of Emergency, Third Clinical Hospital of Changchun Traditional Chinese Medicine University, Changchun, 130117, China
| | - Li Pang
- Department of Emergency, First Hospital of Jilin University, No. 1 Xinmin Road, Changchun, 130021, China
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Golaghaei A, Hassanian-Moghaddam H, Shadnia S, Zamani N, Amraei F. Potential prognostic roles of serum lactate and Creatine kinase levels in poisoned patients. BMC Emerg Med 2020; 20:32. [PMID: 32349695 PMCID: PMC7191820 DOI: 10.1186/s12873-020-00326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 04/22/2020] [Indexed: 11/25/2022] Open
Abstract
Background Examination of serum lactate level and its changes, as an indicator of tissue oxygenation, as well as level of creatine kinase (CK) inhibitors, as a factor of mortality which partially expresses heart, brain, and muscle damage, may be considered as tools to determine prognosis in critically ill patients. We aimed to evaluate these two factors as potential prognostic factors in critically poisoned patients admitted to our toxicology ICU. Method This is a cross-sectional descriptive-analytic study that was performed on poisoned patients referred to emergency department of Loghman Hakim Hospital. One-hundred critically poisoned patients who had been admitted to ICU were conveniently chosen using a random number table and included into the study after obtaining consent forms from their next of kin. Their serum lactate and CK levels were checked on admission. These levels were compared subsequently between survivors and non-survivors to seek for their potential prognostic role. Results In a total of 100 patients enrolled, 61 were male. Serum level of lactate (with a cut off of 26 mg/dL) and serum CK with a cutoff point of 169 U/L could have prognosticated death with sensitivity and specificity of 78 and 77% (for lactate) and 74 and 62% (for serum CK), respectively. Conclusions In poisoned patients, serum lactate and CK can be used as possible prognostic factors because they rapidly increase in the serum and are easily detectable.
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Affiliation(s)
| | - Hossein Hassanian-Moghaddam
- Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahin Shadnia
- Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasim Zamani
- Department of Clinical Toxicology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. .,Toxicological Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Dong N, Liu J, Wang Z, Gao N, Pang L, Xing J. Development of a practical prediction scoring system for severe acute organophosphate poisoning. J Appl Toxicol 2020; 40:889-896. [PMID: 32030807 DOI: 10.1002/jat.3950] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 11/07/2022]
Abstract
Acute organophosphorus poisoning (AOPP) is a serious public health issue, especially in the rural areas. This study was designed to establish a scoring system to assess the risk of cases with severe AOPP. A retrospective cohort study was conducted at two independent hospitals. The derivation cohort included 444 patients with AOPP and the validation cohort included 274 patients. A risk score for patients with severe AOPP was developed. The rates of severe AOPP cases were 20.7% and 20.1% in the derivation and validation cohorts, respectively. A scoring system for severe AOPP risk was developed that included: (1) age >50 years, (2) white blood cell count of >15 × 109 /L, (3) plasma cholinesterase of <360 U/L, (4) plasma albumin of <35 g/L, (5) blood pH <7.3, and (6) lactic acid >3.0 mmol/L. The predicted score in severe cases of AOPP had good accuracy in both the derivation (area under the receiver operating characteristic curve [AUC] 0.88, 95% confidence interval [CI], 0.85-0.92) and validation cohorts (AUC 0.83, 95% CI, 0.77-0.90). A practical bedside prediction scoring system was developed for patients with severe AOPP. The routine use of this scoring system could rapidly assist in identifying patients at higher risk who require more intensive care or transfer to a larger better-equipped hospital.
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Affiliation(s)
- Ning Dong
- Department of Emergency, the Fist Hospital of Jilin University, Changchun, China
| | - Junlan Liu
- Department of Emergency, the Fist Hospital of Jilin University, Changchun, China
| | - Zhihao Wang
- Department of Geriatrics, the Fist Hospital of Jilin University, Changchun, China
| | - Nan Gao
- Department of Emergency, the Third Clinical Hospital of Changchun Traditional Chinese Medicine University, Changchun, China
| | - Li Pang
- Department of Emergency, the Fist Hospital of Jilin University, Changchun, China
| | - Jihong Xing
- Department of Emergency, the Fist Hospital of Jilin University, Changchun, China
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Affiliation(s)
- Omid Mehrpour
- a Rocky Mountain Poison and Drug Safety, Denver Health , Denver , CO , USA
| | - Natalie Neumann
- a Rocky Mountain Poison and Drug Safety, Denver Health , Denver , CO , USA
| | - Patrick Ng
- a Rocky Mountain Poison and Drug Safety, Denver Health , Denver , CO , USA
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Malic A, Ntrivalas E, Dubois J. Clinical Performance and Utility of Point-of-Care Lactate Technology in Patient Care Pathways. ACTA ACUST UNITED AC 2019; 18:62-5. [DOI: 10.1097/poc.0000000000000185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Farzaneh E, Ghobadi H, Akbarifard M, Nakhaee S, Amirabadizadeh A, Akhavanakbari G, Keyler DE, Mehrpour O. Prognostic Factors in Acute Aluminium Phosphide Poisoning: A Risk-Prediction Nomogram Approach. Basic Clin Pharmacol Toxicol 2018. [PMID: 29527823 DOI: 10.1111/bcpt.13005] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Aluminium phosphide (AlP) is a toxic agent associated with a high mortality rate following acute exposure from various routes. The aim of this study was to determine the clinical and laboratory findings useful for predicting the medical outcome of AlP-poisoned patients using established scoring systems. This is a prospective study of AlP-poisoned patients from 2010 to 2015 in Ardabil, Iran. All patients that presented with a confirmed diagnosis of acute AlP poisoning in the study interval were included in the study. Clinical and laboratory data, using Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Simplified Acute Physiology Score II (SAPS II) scoring systems, were compared for their predictive value in determining differences between survived and non-survived patients. Univariate analysis (Mann-Whitney or t-test), multiple logistic regression analysis, receiver operating characteristic (ROC) curve analysis and the Pearson correlation test were performed using STATA/SE 13.0 and the Nomolog Software. A total of 68 AlP-poisoned patients with confirmed acute AlP poisoning were included for evaluation. Of these, 36 were non-survived. Multiple logistic regression analysis was performed using parameters and values derived from patient clinical and laboratory data, and revealed that four factors were significant for predicting mortality: Glasgow coma score (GCS); systolic blood pressure (SBP); urinary output (UOP); and serum HCO3 . A four-variable, risk-prediction nomogram was developed for identifying high-risk patients and predicting the risk of mortality. Study results showed that SBP of <92.5 mmHg (p = 0.006); HCO3- < 12.9 mEq/L (p = 0.01), UOP < 1725 mL/day (p = 0.04); and GCS < 14.5 (p = 0.003) were significant predictors of AlP mortality. Scoring systems analysis showed SAPS II score >24.5, APACHE II score >8.5 and SOFA score >7.5 were predictive of non-survival patients. The results of our study showed that SBP, GCS, UOP and serum HCO3 levels are the best prognostic factors for predicting mortality in AlP-poisoned patients. According to the area under the ROC curve of the APACHE II score, when compared with SOFA and SAPS II scores, the APACHE II score can more effectively discriminate between non-survivors and survived patients.
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Affiliation(s)
- Esmaeil Farzaneh
- Department of Forensic Medicine and Toxicology, Faculty of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Hassan Ghobadi
- Department of Internal Medicine, Faculty of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mahdieh Akbarifard
- Department of Internal Medicine, Faculty of Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Samaneh Nakhaee
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran
| | - Alireza Amirabadizadeh
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran
| | | | - Daniel E Keyler
- Department of Experimental & Clinical Pharmacology, University of Minnesota, Minneapolis, MN, USA
| | - Omid Mehrpour
- Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences, Birjand, Iran
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