Importance of pesticides for lethal poisoning in India during 1999 to 2018: a systematic review

BACKGROUND: Poisoning is a major problem in India. However, there is little systematic information on the key poisons responsible for most deaths by geographical area and over time. We aimed to review the literature to identify the poison classes causing the greatest number of deaths in India over the last 20 years. METHODS: We performed a systematic literature review in Medline, Embase and Google Scholar (1999–2018), and Indian online medical journals, to find papers that reported deaths from all forms of poisoning in India, with last search 20 April 2020. We included epidemiological studies, observational studies, randomised trials, interventional studies, and case series published from 1999 to 2018 that showed the number of deaths and autopsy studies indicating the specific poisons or poison classes. Studies providing the case fatality for specific poisons or classes, which enabled calculation of the number of deaths, were also included. We excluded deaths due to animal bites and stings, ethanol or methanol poisoning, and gas inhalation as well as papers reporting a single death (case study of single patient). We grouped the papers into 5-year intervals and identified the two most common poison classes in each paper. We used descriptive statistics to summarise the findings over time based on the causative poison and the location of the study. RESULTS: We identified 186 papers reporting 16,659 poisoning deaths between 1999 and 2018. The number of publications per 5-year interval showed no clear trend over the period (48, 38, 67, and 36 for consecutive periods). Half of the deaths (n = 8338, 50.0%) were reported during the first 5 years of the study (1999–2003), the number of deaths declining thereafter (to n = 1714 in 2014–2018). Deaths due to pesticide poisoning (94.5%) were dominant across the study period compared to other classes of poison [hair dye paraphenylenediamine poisoning (2.6%), medicine overdose (1.4%) or plant poisoning (1.0%)]. Among the pesticides, aluminium phosphide was the most important lethal poison during the first 10 years before declining markedly; organophosphorus insecticides were important throughout the period, becoming dominant in the last decade as aluminium phosphide cases declined. Unfortunately, few papers identified the specific organophosphorus insecticide responsible for deaths. CONCLUSION: Use of the published literature to better understand the epidemiology of lethal poisoning in India has clear limitations, including secular variation in publishing practices and interest in poisoning. Unfortunately, there are no long-term detailed, combination hospital and community studies from India to provide this information. In their absence, our review indicates that pesticides are the most important poison in India, with organophosphorus insecticides replacing aluminium phosphide as the key lethal poison after government regulatory changes in 2001 reduced the latter’s lethality. Plant and hair dye poisoning and medicines overdose caused few deaths. Aluminium phosphide deaths mostly occurred in northern Indian states, whereas deaths from organophosphorus insecticide poisoning occurred throughout India. Paraquat poisoning has become a clinical problem in the last 10 years. Lethal pesticide poisoning remains alarmingly common, emphasising the need for additional regulatory interventions to curtail the burden of pesticide poisoning deaths in India. More detailed reporting about the specific pesticide involved in lethal poisoning will be helpful to guide regulatory decisions

Comparison of risk factor profile, severity and outcome between lacunar strokes & other ischaemic stroke subtypes

Objective: Lacunar infarcts are a frequent type of stroke caused mainly by cerebral small-vessel disease.  Because of this, lacunar infarcts are likely to behave differently from other ischaemic stroke subtypes and may require a different approach in their management. Objective was to describe the differences in risk factor profile, severity and outcome between lacunar and other ischaemic stroke subtypes as this aspect had not been studied in Srilankan patients. Methods: This prospective descriptive study included 70 patients with acute ischaemic strokes admited to Colombo South Teaching Hospital during 01/06/2012 to 10/09/2012. Severity of the stroke was assessed by using The National Institutes of Health Stroke Scale (NIHSS). Assessment of the outcome was done by estimating disability using Modified Rankin Scale (MRS) by contacting the patient via telephone after one month of hospital discharge. Results: In this period of time 46 patients with lacunar strokes and 26 with other types of ischaemic stroke were evaluated. Hypertension (58.7% Vs 54.2%) and Diabetes mellitus (45.7% Vs 45.8%) were equally common in lacunar and non lacunar stroke. Hypercholesterolemia (32.6% Vs 12.5%) was more frequent in lacunar stroke and chronic atrial fibrillation (4.2% Vs 2.2%) was more frequent in non lacunar stroke patients. Regarding severity, 56.5% of lacunar stroke patients had minor stroke (NIH stroke scale 1-4) while 62.5% of non lacunar patients had moderate stroke (NIH stroke scale 5-15)(P value = 0.02). With regard to outcome following stroke, 63% of lacunar strokes and 45.8% of non lacunar strokes were independent (MRS<3) after one month. Conclusion: Lacunar strokes appear to cause less disability and their outcome too is better.  Risk factors did not show a significant difference, but a larger study is needed to confirm this