Liver Transplantation Society of India Guidelines for the Management of Acute Liver Injury Secondary to Yellow Phosphorus-Containing Rodenticide Poisoning Using the Modified Delphi Technique of Consensus Development.

BACKGROUND: Acute liver failure caused by the ingestion of yellow phosphorus-containing rodenticide has been increasing in incidence over the last decade and is a common indication for emergency liver transplantation in Southern and Western India and other countries. Clear guidelines for its management are necessary, given its unpredictable course, potential for rapid deterioration and variation in clinical practice. METHODS: A modified Delphi approach was used for developing consensus guidelines under the aegis of the Liver Transplantation Society of India. A detailed review of the published literature was performed. Recommendations for three areas of clinical practice, assessment and initial management, intensive care unit (ICU) management and liver transplantation, were developed. RESULTS: The expert panel consisted of 16 clinicians, 3 nonclinical specialists and 5 senior advisory members from 11 centres. Thirty-one recommendations with regard to criteria for hospital admission and discharge, role of medical therapies, ICU management, evidence for extracorporeal therapies such as renal replacement therapy and therapeutic plasma exchange, early predictors of need for liver transplantation and perioperative care were developed based on published evidence and combined clinical experience. CONCLUSION: Development of these guidelines should help standardise care for patients with yellow phosphorus poisoning and identify areas for collaborative research.

Estimating epidemiological and economic burden and community derived disability weights for snake bite in Kerala: a study protocol.

Background: In India, geographical variation, lack of data and underreporting on cases and deaths due to snakebite makes it difficult to estimate socio-economic burden of snakebites. Previous studies measuring economic burden of snakebite in low-and-middle-income countries (LMICs) using different approaches have been conducted, but none so far in India. The proposed study aims to provide evidence on disability weights, epidemiological and economic burden due to snakebites in Kerala state, India. Protocol: A cross-sectional community based study for estimating epidemiological and economic burden of snakebite, recruiting victims of snakebite occurring over a nine month period prior to start and over the three month period of the study, across Ernakulam district, Kerala state, India. For the community derived disability weights, 60 adult patients admitted and treated at Amrita Institute of Medical Sciences, Kochi or Little Flower Hospital, Angamaly would be interviewed. The sample size to determine the mortality rate is calculated at 108,458 persons in Ernakulam.The study will measure annual incidence, mortality, treatment cost of snakebites along with community-derived disability weights for snakebites. Standard methods for analysis and reporting of mortality, morbidity, years of lives lost, years lived with disability, disability weights, and costs of treatment will be calculated and presented. The study will be started in March 2021 and is expected to be completed by June 2021. Discussion: This protocol is the first published for estimating epidemiological, economic burden and community derived disability weights for snakebites in India. Besides, the Global Burden of Disease has not attached a particular disability weight to snakebite and this would be an attempt to do so.The protocol has been developed using guidelines for both cross-sectional studies and  for conducting community derived disability weights. The evidence generated will contribute to knowledge regarding epidemiology, economic burden and community-derived disability weights for snakebites in India and other LMICs.

Awareness of the Standard of Care for Snakebite Management Among Physicians in Kerala: A Cross-sectional Study.

Snakebite remains a largely neglected yet important cause of morbidity as well as mortality in Kerala. This study aimed to assess the knowledge about the standard of care for snakebite management among physicians in Kerala. This was a cross-sectional study using a questionnaire-based survey among 110 physicians from Kerala. The overall knowledge levels were assessed using a questionnaire with answers being scored as 0 for wrong answers and as 1 for correct answers. The total knowledge scores for all respondents were calculated, with a maximum possible score of 14 and a minimum possible score of 0. Comparisons were made between subsets of respondents. The questionnaire was administered to 110 physicians who fulfilled the predetermined criteria. The overall mean knowledge score during the study was 10.7 (standard deviation ± 2.9). However, there were certain pitfalls associated with the management of snakebite. In particular, questions about tourniquet use, bringing a dead snake to the physician, and the anti-snake venom test dose had high proportions of incorrect answers. Significantly higher knowledge levels were also observed in certain subgroups. There seems to be varying knowledge gaps associated with various aspects of snakebite management for certain subsets of respondents who are likely to benefit from specific training.

Prescription drug suicide in non-abusers: A 6-year forensic survey.

BACKGROUND: Prescription drug suicide merits study to guide the development of strategies to reduce suicide risk. We examined prescription drug suicide specifically in non-abusers of prescription drugs; this is a relatively unexplored subject. METHODS: Six-year data on prescription drug suicide in non-abusers were extracted from the records of the Department of Forensic Medicine at the All India Institute of Medical Sciences, New Delhi. These records contained information obtained from the scene of the suicide, from interviews with relatives of the deceased, and from forensic toxicological analyses at two laboratories. RESULTS: There were 27 (8%) cases of prescription drug suicide in non-abusers out of 338 cases of suicidal poisoning. The mean age of this sample was 26 years. The sample was 74% male. Nearly half of the cases (44%) were students. A combination of dextropropoxyphene with dicyclomine, with or without paracetamol, was used by 41% of cases. Overdose was achieved through the ingestion of 10-40 (median, 30) tablets or by the injection of 2-3 (median, 2) vials of medication. In 52% of cases, it appeared that the drugs had been procured over the counter. CONCLUSIONS: It is reassuring that the absolute number of prescription drug suicides in non-abusers was small; the findings, however, are important because they could serve as a baseline for assessing time trends in future studies. For the present, we suggest that prescription drugs of potential abuse, especially those containing opioids and antispasmodics, should be prescribed and dispensed judiciously, especially to youth.

The utility of poison control centres in diagnosing and managing cases of poisoning and overdose.

The practice of establishing poison control centres is yet to catch on in a big way in India, even though most developed countries have this concept well in place. This has helped these countries in diagnosing and managing cases of poisoning and overdose much more effectively, thereby bringing down the morbidity and mortality, while India lags far behind with a staggering mortality rate, much of which is because of lack of access to latest methodologies of diagnosing and managing poisoning, as also the lack of facility to analyse body fluids and other samples for the presence and/or concentration of the toxic agent or its metabolites. Establishing properly equipped and staffed poison control centres would constitute a major step in ameliorating the situation, as exemplified by the Cochin (Kerala) experience, which has a fully equipped poison control centre in a major hospital that is recognised by the World Health Organisation.

Role of activated carbon fabric mask to prevent lead absorption--a short report.

An attempt was made to study the usefulness of activated carbon fabric (ACF) mask to prevent lead absorption. Indigenous ACF masks were provided to eight workers involved in the manufacture of batteries. Their blood lead levels were determined before and after using these masks. There was a substantial decrease in blood lead level after using the mask among those who were under treatment for high blood lead levels. Three workers who were not under treatment for lead also showed a decrease in blood lead level, after using this ACF mask, suggesting the usefulness of ACF in preventing further exposure. Such a study has not been reported anywhere in the available literature and similar such studies with more number of masks is necessary to evaluate its effectiveness.

Current views on antidotal therapy in managing cases of poisoning and overdose.

While it is an acknowledged dictum that in poisoning or overdose cases, the emphasis must be on general management comprising supportive measures than the use of specific antidotes in the vast majority of cases, it is nevertheless true that there are some instances where the timely use of a specific antidote or antagonist will dramatically reverse or at least halt the progression of toxicity. For this reason, and also because the indications and the exact manner in which antidotes must be used could be controversial or unfamiliar to the physician, an attempt has been made to review the current concepts on antidotal therapy of poisoning. There is enough evidence that the proper use of specific antidotes when combined with general supportive care does reduce the morbidity and mortality associated with severe poisonings. Common antidotes used in a hospital setting have been discussed in some detail.

Detection of Y STR markers of male fetal dna in maternal circulation.

BACKGROUND: Circulating fetal cells and cell free DNA in the maternal blood has been shown to help in prenatal diagnosis of genetic disorders without relying on invasive procedures leading to significant risk of pregnancy loss. AIM: The current study was undertaken to detect the male fetal population using Y STR markers DYS 19, DYS 385 and DYS 392 and also to study the extent of persistence of fetal DNA in the mother following delivery. MATERIALS AND METHODS: Blinded study was conducted on 50 mothers delivering male and female babies. Cellular and cell free DNA was extracted from maternal and fetal cord blood and amplified for Y STR markers by PCR. RESULTS: The amplification sensitivity of Y specific STR, DYS19 was 100% (22/22) in the male fetal DNA samples. The incidence of other STRs, i.e., DYS385 and DYS392 were 91% (20/22) each. Analysis of results revealed that thirteen of the twenty six women had detectable male fetal DNA at the time of delivery. However fetal DNA was not detectable twenty four hours after delivery. CONCLUSION: Preliminary results show that the separation of fetal cell-free DNA in the maternal circulation is a good low-cost approach for the future development of novel strategies to provide non-invasive techniques for early prenatal diagnosis.

Clinical manifestations of lead workers of Mangalore, India.

OBJECTIVE: To correlate blood lead levels and clinical manifestations. PARTICIPANTS: Battery workers and painters (occupationally exposed to lead in and around Mangalore, India) and occupationally unexposed controls. MAIN OUTCOME MEASURES: We measured the blood lead levels by anodic stripping voltammetry, and a clinical examination was carried out on all participants. RESULTS: There was a statistically significant difference between the lead-exposed group and controls with respect to clinical manifestations. The prominent findings among the lead-exposed group were fatigue, abdominal colic, abdominal discomfort, backache, muscular exhaustability, myalgia and paresthesia, at a blood lead level ranging from 0.4 to 116.6 microg/dL. CONCLUSIONS: Such a study on battery workers and painters has not been reported in India. Several attempts have been made over the years to relate blood lead levels to adverse health effects. It was not possible to determine a precise blood lead level below which symptoms never occur or a blood lead level at which symptoms are always reported.

Poisoning due to white seed variety of Abrus precatorius.

We report an unusual case of poisoning involving the white seed variety of Abrus precatorius that caused serious manifestations in a middle-aged male who had consumed the seeds on the advice of a folk medicine practitioner. He recovered after a prolonged duration of hospital treatment without any subsequent complications or sequelae. The case is being reported on account of its rarity.

Portable lead analyzer to locate source of lead.

OBJECTIVE: To investigate the sources of lead in the environment in children with elevated blood, with the help of a Field Portable X-Ray Fluorescence Analyzer. METHODS: One hundred and seven school children were chosen for this study on a random basis, from Mangalore and Karnataka. Their blood lead was analyzed. Of the cases analyzed, 10 students whose blood lead level was more than 40 microg/dl were investigated using a field portable X-Ray Fluorescence Analyzer. This is the first time such a device has been available for this purpose in India. RESULTS: The 'likely' source of lead exposure could be determined in eight cases which was from the immediate environment of the children like 'lead-based' paint on surfaces in the house, on playground and other exterior equipment; lead storage batteries, contaminated dust and soil and other lead-containing substances. CONCLUSION: The use of an X-Ray Fluorescence Analyser appeared to be useful in determining the source of lead.

Estimation of fetal age by histological study of kidney.

An attempt has been made to correlate the gestational age of a fetus with a histological study of the sequential development of nephrons in the kidneys. One hundred and eighteen dead fetuses aged between 14 and 40 weeks of gestation were examined. In each case, paraffin sections from the kidneys were studied microscopically and the number of glomerular generations present was counted and correlated with the reported period of gestation based on obstetric calculations. The results were analysed and statistically confirmed a high degree of correlation, indicating that this could be a reliable method of estimating fetal age in forensic situations, such as infanticide and criminal abortion.