PATTERN OF ACUTE POISONING AND GENDER COMPARISON AMONG CASES ADMITTED TO BENHA POISON CONTROL UNIT : A FIVE YEAR RETROSPECTIVE-DESCRIPTIVE STUDY ( 2011-2015 )

Background: Acute poisoning is a growing healthcare problem and an important cause of considerable morbidity and mortality worldwide, including Egypt. Its incidence and characteristics varies significantly between countries and different regions within the same country. Aim: This retrospective-descriptive study was conducted at Benha Poison Control Unit over a period of 5-year (2011-2015) to identify and analyze the characteristics of poisoned cases with special reference to comparison between gender. Research Methodology: Toxicological records were reviewed for socio-epidemiological, toxicological, implicated poisonous substances, clinical findings, and applied therapeutic modalities. Results: The study included 4372 case. The majority of overall cases were females (58.37%), under 18-year (67.86%), children <6-year (38.88%) and adults between 18-29-year (17.77%), unmarried (85.36%), rural residents (70.08%), of low economic (67.77%) and educational status (48.86%), and unemployed (54.19%). Most patients showed poisoning at homes (92.02%), a pre-hospitalization period for 3-hour (42.54%), hospitalized during afternoon (48.47%) and summer (35.18%) times as well as exposures via oral route (84.95%), unintentional manner (55.79%), and single agent (92.78%). Poisoning with non-medicinal (54.6%) predominated over medicinal (45.4%) products and the most common involved groups were, respectively, pesticides (25.14%) and corrosives (9.49%) and sedative-hypnotics (8.55%) and non-opioid analgesics (5.63%). The most frequently recorded clinical findings were mild toxidromes (77.13%), emergency room admission (70.31%), and hospitalization for ≤1-day (73.19%), complete recovery (97.71%) with low mortality rate (0.85%), and organophosphates were the chief cause of death (0.32%). Therapeutic interventions mostly involved internal decontamination (64.75%) by administration of activated charcoal (36.37%) and performance of gastric lavage (22.62%), followed by administration of specific antidotes (25.25%). The proportions of males were higher than females regarding age groups <18-year and children <6-year, low economic level, unintentional manner, medicinal preparations, mortality rate, death by organophosphates, management with internal decontamination, activated charcoal, gastric lavage, and specific antidotes. Whereas, the proportions of females were higher than males regarding age group between 18-29year, unmarried, rural residents, low educational level, poisoning at homes, afternoon and summer times, non-medicinal substances, pesticides and corrosives, non-opioid analgesics, mild toxidromes, emergency room admission, and complete recovery. There were statistically significant differences between genders regarding the Khodeary and Elkholy 176 Egypt J. Forensic Sci. Appli. Toxicol Vol 17 (1) June 2017 aforementioned variables. Conclusion: The current findings provide some data about the magnitude of acute poisoning in Benha region and its surrounding areas. Community education about the danger of poisonous substances and understanding the motivations behind this problem are recommended to reduce the incidence of poisoning.


INTRODUCTION
Acute poisoning by vast numbers of various poisonous substances is an extremely significant, widespread, and growing dilemma all over the world (Srivastava et al., 2005 Hassan and Siam, 2014).The costs of medical management can be substantial, leading to considerable negative implications on the medico-social services that expend or reduce their valuable resources besides adding further massive economic burden on the community (Afshari et al., 2004;Rajapakse et al., 2014).
This global issue can be attributed to the exponential growth in the number and types of new substances production as a result of rapid industrialization and technological advancement in the fields of agriculture, industrial technology, and medical pharmacy.Hence, extensive availability and progressive flooding of the global markets with such enormous substances can increase the risk of human exposure to poisons (Shadnia et al., 2007;Ahmadi et al., 2010).Toxic substances are plenty and involve synthetic toxicants such as pharmaceutical or medicinal products and non-pharmaceutical or chemical compounds (pesticides, household cleaning substances, fertilizers, petroleum distillates) and natural toxins (venomous animals, toxic plants, pathologic food contaminants, poisonous fish) as well as ayurvedic and homeopathic products (Lall et al., 2003;Mowry et al., 2015).Therefore, identification of hazardous substances may not be straightforward and can add more burdens on the healthcare providers.
Acute poisoning is not only one of the most important reasons of emergency hospital visits and/or admissions (Tüfekçi et al., 2004;Ahmadi et al., 2010) According to the Global Burden of Disease study of the World Health Organization, in 2004 an estimated 346000 individuals died globally from unintentional poisoning and about 91% of these deaths occurred in low-and medium-income countries.Based on the disability-adjusted life years, poisoning is responsible for loss of over 7.4 million years of healthy life (Mathers et al., 2008).In the United States, unintentional and intentional exposures to poisons resulted in 1173 human fatalities in the year 2014 (Mowry et al., 2015), while in Egypt 2011, the recorded mortality rate due to poisoning was 0.3% (61 cases) in the year 2011 (El Masry and Tawfik, 2013).Also, the Iranian study of Hassanian-Moghaddamet al. (2014) showed 2109 deceased cases due to poisoning between the years 2006 to 2011.Despite this, the overall incidences of the acute poisoning can be higher because it is remarkably difficult to determine the exact number of poisoning associated morbidity and mortality due to either underestimated and unreported cases or lack of Poison Control Center consultation and surveillance (Shadnia et al., 2007;Obeidat et al., 2010), even in countries with advanced health care systems for data collection (Mowry et al., 2015).
The incidence and characteristics of acute poisoning varies widely between countries and depends on several diverse and complicated factors such as industrialized and urbanized levels, agriculture style, the availability of diagnostic and therapeutic healthcare facilities and expertise consultations (Lall et al., 2003), accessibility and availability of potentially poisonous substances, socio-economic conditions, cultural background and faith/religious beliefs (Afshari et al., 2004; El Masry and Tawfik, 2013), and legal reprisal or liability (Hatzitolios et al., 2001).
Authoritative data regarding the pattern of poisoning in Benha (the capital of Al-Qalyubia province, north of Cairo, Egypt) and surrounding areas are sparse and incomplete.Based on the acute poisoning admissions to Benha Poison Control Unit, this five-year (2011)(2012)(2013)(2014)(2015) retrospective-descriptive study was conducted to identify and analyze the pattern of acute poisoning and gender differences of the overall cases in order to understand the magnitude of this problem that may help in minimizing exposure to poisonous agents and to establish an appropriate strategy for early diagnosis and treatment of poisoned patients, which in turn may lead to reduction of poisoning associated morbidity and mortality.

Benha
Poison Control Unit {BPCU}, a part of Benha University Hospitals, Benha, Al-Qalyubia, Egypt, is under supervision of medical staff of Forensic Medicine and Clinical Toxicology Department as well as paramedical high nurses who runs the unit 24 hours per day, 7 days per week.This five-year retrospective study (1 st of January 2011 to the 31 th of December 2015) was designated to compile and analyze socio-epidemiological, toxicological, implicated poisonous substances, clinical findings, and applied therapeutic data of poisoned cases who admitted to BPCU.The data were obtained by reviewing toxicological medical records of the unit and each item was described separately (i.e.no correlations were carried out between the overall recorded parameters).The study was approved by the Ethics Committee of Scientific Research, Faculty of Medicine, Benha University, Egypt.
Inclusion criteria: All poisoned cases who had admitted to BPCU due to poisoning by medicinal and nonmedicinal compounds were included.Exclusion criteria: Poisoned patients as a result of pathogenic food poisoning (food contaminated with various infectious organisms such as bacteria, parasites, or viruses) were excluded from the study.
The collected data were organized, tabulated, and analyzed.Microsoft Excel (2000 Microsoft Corporation, USA) was used to perform descriptive statistics, while 2-sample z-test (an online EpiTools ® epidemiological calculator) was used to compare proportions between genders.A calculated two-tailed P-values at or less than 0.05 (<0.05) were considered as statistically significant.

RESULTS
A total of 4708 intoxicated cases were admitted to BPCU during the fiveyear study period (2011)(2012)(2013)(2014)(2015).However, a total of 336 (7.14%) cases were excluded from the study (199 cases accounted for 4.23%; 115 males and 84 females; had incomplete data or referred to other Poison Control Centers in Egypt and 137 cases accounted for 3.14%; 51 males and 86 females; had pathogenic food poisoning), leaving a study sample of 4372 patients (an annual average of about 875 cases per year) with sufficient information.
Table (4) represents the distribution pattern of the most common involved medicinal and non-medicinal substances based on the ICD-10 classification.The most commonly involved causative agents among the overall non-medicinal and medicinal groups were organophosphate and carbamates compounds (20.24%;T60-0) and benzodiazepine derivatives (6.15%; T42-4), respectively.
Table ( 5) exhibits the distribution pattern of the clinical findings.The majority of cases were mildly intoxicated (77.13%;Grade 1), admitted to the emergency room of the unit (70.31%), hospitalized for ≤1 day (73.19%), and recovered completely without any sequelae (97.71%).Meanwhile, the proportions of nonfatal sequelae (1.44%) and mortality rate (0.85%) were considerably low with organophosphates (0.32%) were the predominant cause of death.
Among the overall cases, administration of activated charcoal (36.37%, a local adsorbent antidote that effectively decreases the systemic absorption of most xenobiotics) was the most frequently used method, followed in order of frequency by performance of gastric lavage to remove stomach contents (22.62%), induction of emesis with syrup of ipecac to evacuate the stomach (14.14%), and oral administration of demulcents (2.79%; milk and/or egg white to sooth the gastric wall in corrosive poisoning).Administration of activated charcoal alone (22.26%) was the most commonly applied single method, followed by gastric lavage (16.08%), and syrup of ipecac (9.52%).Additionally, concomitant use of gastric lavage and activated charcoal (6.54%) was greater than combined use of syrup of ipecac and activated charcoal (4.62%) or activated charcoal with cathartic sorbitol (2.95%).
Utilizations of all specific antidotes (37.86%), atropine alone (21.76%), atropine plus obidoxime chloride (5.55%), naloxone (2.20%), and polyvalent snake antivenom (0.71%) as well as symptomatic treatment (29.12%) and emergent and supportive measures (15.88%) were more commonly required in treatment of males than females.There were statistically significant differences between genders in terms of the aforementioned variables (P<0.05).The present study has some limitations.This was a hospital-based retrospective study done at BPCU.Therefore, the study will not reflect the overall pattern of poisoning in the country.Also, cases deceased before reaching the hospital, seeking primary and secondary healthcare centers, and transferred to other poison control centers were not included.Moreover, lack of information about stressful events, incomplete data in some medical records, inability to identify some causative agents, and inability to follow up some cases after hospital discharge were noticed.Suicide is a legal offence in Egypt and some patients or attendants might deny suicidal intent to avoid legal repercussions.Thus, it is quite possible that some patients who were recorded as unintentional were actually attempted suicides.
In conclusion, the current study provides important information about the pattern of poisoning in Benha city and its surrounding areas.The majority of cases were females, under 18-year, unmarried, rural residents, of low economic and educational status, unemployed, and previously healthy.Also, pre-school children and young adults were the most vulnerable groups.Poisoning at homes, a prehospitalization period for 3-hour, and hospital admission during afternoon shift and summer season as well as exposures via oral route, unintentional manner, and single agent were mostly reported.A predominance of poisoning with substances listed in non-medicinal group was found.Among them, pesticides (particularly organophosphate and carbamates), followed by corrosives (particularly alkalis), and organic solvents (particularly kerosene) were the most common implicated causative agents.While, among the medicinalrelated poisoning, sedative-hypnotics (especially benzodiazepines), followed by non-opioid analgesics (especially acetaminophen and NSAIDs), and narcotics and hallucinogens (especially tramadol and cannabis) were the most common involved causative agents.The most frequently recorded clinical findings were mild toxidromes, emergency room admission, hospitalization for ≤1-day, and complete recovery.Organophosphates were the chief cause of death.The vast majority of cases received different internal decontamination procedures followed by administration of specific antidotes, symptomatic treatment, and finally emergent and supportive measures.Comparison between genders revealed statically significant differences regarding some of the studied variables. Concerning

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Table ( 1
): The percentage of the distribution pattern of socio-epidemiological data regarding overall cases and both genders.

Table ( 2
): The percentage of distribution pattern of toxicological data regarding overall cases and both genders.

Table ( 3
): The percentage of distribution pattern of implicated medicinal and nonmedicinal groups regarding overall cases and both genders based on the ICD-10 classification.

Table ( 4
): The percentage distribution pattern of the most common involved medicinal and non-medicinal causative agents regarding overall cases and both genders based on the ICD-10 classification.

Table ( 5
): The percentage of distribution pattern of the clinical findings regarding overall cases and both genders.

Table ( 6
): The percentage of distribution pattern of the most common therapeutic interventions regarding overall cases and both genders.

.A. and Siam, M.G. (2014):
the present study, some suggestions are recommended.Restricted attention and supervision are needed for children.Patients with suicidal poisoning must undergo psychiatric consultation.Afternoon hours are very busy periods; hence, relief hours for medical staffs should be better during early evening hours.Strict regulation and control regarding the sale of pesticides and central nervous system drugs are crucial.Continuous health education and adequate information concerning hazardous effects of pesticides should be conducted.Potentially toxic drugs must not be sold without the prescription.To reduce morbidity and mortality associated poisoning, considerations must be given to establishing treatment guidelines, training healthcare providers, and ensuring sufficient stocks of the antidotes, especially atropine and toxogonin.The underlying causes of