QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING
DISSERTATION SUBMITTED FOR M.D GENERAL MEDICINE
BRANCH – I APRIL 2020
REGISTRATION NUMBER - 201711119
THE TAMILNADU
DR.M.G.R. MEDICAL UNIVERSITY
CHENNAI, TAMILNADU, INDIA
CERTIFICATE FROM THE DEAN
This is to certify that this dissertation entitled “QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING” is the bonafide work of Dr.G.SHANTHOSH in partial fulfillment of the university regulations of the Tamil Nadu DR. M.G.R. Medical University, Chennai, for M.D General Medicine Branch I examination to be held in April 2020.
Dr.K.VANITHA, MD, DCH, The Dean,
Madurai Medical College, Madurai.
CERTIFICATE FROM THE HOD
This is to certify that this dissertation entitled “QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING” is the bonafide work of Dr.G.SHANTHOSH in partial fulfillment of the university regulations of the Tamil Nadu DR. M.G.R. Medical University, Chennai, for M.D General Medicine Branch I examination to be held in April 2020.
Dr. M. NATARAJAN, M.D., Professor and HOD,
Department Of General Medicine, Government Rajaji Hospital, Madurai Medical College, Madurai.
CERTIFICATE FROM THE GUIDE
This is to certify that this dissertation entitled “QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING” is the bonafide work of Dr.G.SHANTHOSH in partial fulfillment of the university regulations of the Tamil Nadu DR. M.G.R. Medical University, Chennai, for M.D., General Medicine Branch I examination to be held in April 2020.
Dr. J. SANGUMANI, M.D, D.DIAB, Professor of Medicine,
Department Of General Medicine, Government Rajaji Hospital, Madurai Medical College, Madurai.
DECLARATION BY THE CANDIDATE
I declare that, I carried out this work on “QTc PROLONGATION AS A PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING” at the Department of Medicine, Govt. Rajaji Hospital during the period FEBRUARY 2019 TO JULY 2019 under the guidance and supervision of Prof. Dr. J.SANGUMANI.M.D, D.DIAB,. I also declare that this bonafide work or a part of this work was not submitted by me or any others for any award, degree or diploma to any other University, Board either in India or abroad.
This dissertation is submitted to The Tamil Nadu DR. M.G.R. Medical University, Chennai in partial fulfillment of the rules and regulations for the award of M.D Degree General Medicine Branch- I; examination to be held in April 2020.
Place : Madurai Dr. G.SHANTHOSH,
Date : Post Graduate student, Department of General Medicine,
Madurai Medical College
ACKNOWLEDGEMENT
I would like to thank Dr. K. VANITHA, MD, DCH., Dean, Madurai Medical College, for permitting me to utilize the facilities of Madurai Medical College and Government Rajaji Hospital for this dissertation.
I wish to express my respect and sincere gratitude to my head of department, Prof. Dr. M. NATARAJAN M.D., Professor of Medicine for his valuable guidance and encouragement during the study and also throughout my course period.
I would like to express my deep sense of gratitude, respect and thanks to my beloved Unit Chief and Professor of Medicine Prof. Dr. J. SANGUMANI M.D, D.DIAB, for his valuable suggestions, guidance and support throughout the study and also throughout my course period.
I am greatly indebted to my beloved Professors Dr. G. BAGHYALAKSHMI M.D., Dr. C. DHARMARAJ, M.D.,
Dr. DAVID PRADEEP KUMAR M.D, DGM, MRCP., Dr. S.C. VIVEKANANTHAN M.D, DTCD., and Dr.K. SENTHIL M.D.,
for their valuable suggestions throughout the course of study.
I express my special thanks to Prof. Dr. M. NATARAJAN M.D, Professor and HOD Department of Medicine for permitting me to utilize the facilities in the Department, for the purpose of this study and guiding me with enthusiasm throughout the study period.
I am thankful to my Assistant Professors:
Dr. R. PALANI KUMAR M.D., Dr. P. SUDHA M.D.,
Dr. M. SURESH KUMAR M.D.,
for their valid comments and suggestions.
I sincerely thank all the staffs of Department of Medicine and Department of biochemistry for their timely help rendered to me, whenever and wherever needed.
I extend my love and express my gratitude to my family and friends for their constant support during my study period in times of need.
Finally, I thank all the patients, who form the most vital part of my work, for their extreme patience and co-operation without whom this project would have been a distant dream and I pray God, for their speedy recovery.
CONTENTS
S.NO
CONTENTS
PAGE NO1 INTRODUCTION 1
2 AIM OF STUDY 2
3 REVIEW OF LITERATURE 3 4 MATERIALS AND METHODS 60 5 RESULTS AND OBSERVATIONS 64
6 DISCUSSION 79
7 CONCLUSION 81
ANNEXURE BIBLIOGRAPHY PROFORMA ABBREVATIONS MASTER CHART
ETHICAL COMMITTEE APPROVAL LETTER ANTI PLAGIARISM CERTIFICATE
1
INTRODUCTION
Cleistanthus collinus is a shrub that grows in many areas in south India.
The shrub is also grows in Malaysia and Africa. It is called as Oduvanthalai in Tamil Nadu. Any part of the plant is toxic. It is commonly used as a homicidal agent and abortifacient. It can be ingestion by swallowing the crushed plant parts, chewing leaves or a decoction of the boiled leaves. The toxic compounds are arylnaphthalene lignan compounds like Cleistanthin A; B which are responsible for most of the clinical features. The other toxic compounds are Diphyllin and cleistanthin C and D. In the kidneys, it causes distal Renal Tubular Acidosis resulting in hypokalemia and also normal anion gap metabolic acidosis. Cardiac involvement results in arrhythmias.
Plant poisoning is a common method of self-harm in rural young women in South India. The most common plant poisons consumed in South India are Cleistanthus collinus and Thevetia peruviana. Women consume plant poisons because of easy availability or free access. Though the plant grows in other parts of the country, poisoning is confined mainly to the southern parts of the India.
2
AIM OF THE STUDY
TO STUDY THE INCIDENCE OF QTc PROLONGATION IN CLEISTANTHUS COLLINUS POISONING.
TO STUDY THE USEFULNESS OF QTc PROLONGATION AS A
PROGNOSTIC MARKER IN CLEISTANTHUS COLLINUS POISONING.
3
REVIEW OF LITERATURE
India is a tropical country, and so, it is host to a rich array of thousands of plants, some of them are extremely poisonous. Most people in rural areas depend for their food, on plants grown in their own farms. Cases of accidental poisoning occur frequently due to careless ingestion of toxic plant products or contamination of food items. Some cases are due to, consumption of harmful home remedies or traditional treatment. A substantial number of patients are children, for whom plants are accessible easily. In few Western population, most of the human exposures reported to poison, are involving plants. In India, if rural population is taken in isolation, the percentage of consumption of plant poisons will be very high.
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Cleistanthus collinus poisoning
The shrub is also called, Oduvanthalai or Nillipalai in Tamilnadu and Pondicherry, Kadishe in Andhra Pradesh, Karlajuri in West Bengal, Garari in northern states of India
Its botanical name is Cleistanthus collinus.
Cleistanthus collinus belongs to family Phyllanthaceae and grows wild in dry hills of India from Himachal Pradesh to Bihar and also in southern parts, upto peninsular India.
It is a small, deciduous tree with spreading and smooth branches. Leaves are orbicular or broadly oval or elliptical and has rounded tips.
Flowers look like borne in small axillary clusters.
The fruit capsule is large, looks trigonous, woody, dark- brown and appears shiny and wrinkled when dried.
Seeds look globose and chestnut to brown in colour.
5
Toxic parts of the plant include all parts of the plant, which are equally poisonous.
Extract of the various parts of the plant yield a number of compounds.
Of these, glycosides, arylnaphthalene lignan lactones are highly toxic.
The lignan lactones including cleistanthin A and B, collinusin and diphyllin, are called collectively as “oduvin”.
Clinical features include 1. Vomiting
2. epigastric pain 3. breathlessness
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4. visual disturbances, giddiness and drowsiness 5. fever, tachycardia, hypotension or
6. respiratory arrest
7. survivors are usually asymptomatic or transiently symptomatic with abdominal pain, giddiness or visual symptoms.
Neuromuscular weakness may be documented.
Distal renal tubular acidosis and shock occurs due to inappropriate vasodilatation.
Diagnosed by
1. ECG changes like QTc prolongation and non-specific ST-T changes.
2. Blood investigations may reveal hypo-kalaemia, hypo-natraemia, hyper- bilirubinaemia, hypo-calcemia and elevated urea levels.
3. Arterial blood analysis, may show metabolic acidosis, hypoxia with a widened alveolar- arterial O2 gradient, especially in those with respiratory failure.
Treatment can be given by,
1. Correction of metabolic acidosis with soda bicarbonate.
2. Correction of hypokalaemia with intra-venous potassium chloride.
3. N-acetylcysteine in the form of i.v., given as 150 mg/kg i.v. over 1 hour, followed by 50 mg/kg i.v. over 4 hours and 100mg/kg i.v. over the next 16 hours.
7
8
9
Castor poisoning
It is commonly known as, mole bean or moy bean or palma christi.
Its botanical name is Ricinus communis.
The plant belonging to family Euphorbiaceae, which is a perennial, erect, branched plant, native to India. It is also encountered even in temperate and tropical climates.
Dwarf forms of the plant are typically 2 metres in height, however most plants become tree-like with stout roots and soft stems reaching a height of 7 to 8 metres.
Stems and branches are red or maroon.
Leaves have long, green or reddish stalks and are quite large, which are generally notched into several palmate lobes with toothed margins.
Clusters of greenish-white coloured flowers form at the end of the branches, on long upright stems. Male and female flowers are separate, but on the same plant.
The fruit (seed pod) has a prickly capsule.
The fruit contains three shiny, mottled, hard-coated, greyish-brown seeds.
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Seed pods are green or red, an inch long, and holds elliptical, glossy seeds, which may be mottled with black, brown, white colours, and are 1.5cm in length.
Used as an ornamental plant.
Oil extracted from the seeds is used medicinally as a purgative and as a lubricant oil for engines.
Castor beans have found use, both systemically and topically.
Used in stimulating breast milk production in many countries.
11
Ricin is being used as a chemical warfare agent and also as a reagent for pepsin and trypsin
Toxic parts of the plant are seeds
The toxic principle is the phytotoxin ricin which is a toxalbumen.
Toxalbumen is not present in castor oil, contains a milder irritant, ricinoleic acid. Ricin is a supertoxic poison of plant origin.
Toxalbumens cause severe gastrointestinal irritation, especially of the oropharynx, oesophagus, or stomach when exposed.
Although clinically similar to alkaline caustic burns, they are usually delayed for few hours after exposure.
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Delayed complications occur from the cytotoxic effects on the liver, central nervous sytem, kidney, and adrenal glands, typically 2 to 4 days after exposure.
The patient may be asymptomatic initially.
The seeds are harmless when ingested whole, since the outer coating resists digestion.
But, if the seeds are crushed or chewed before swallowing, toxicity results due to the release of ricin.
Poisoning is severe, when ricin is injected parenterally.
Ricin has two polypeptide chains held together by a single disulphide bond with a molecular weight of 66,000.
Chain B is a lectin that binds to the surface of the cell, facilitating toxin entry into the cell.
Chain A disrupts protein synthesis by activating the 60S ribosome.
Sensitisation to castor bean may occur, with the main allergen being a storage albumin. Both Type 1 (immediate) and Type IV (delayed) reactions have been reported.
Haemagglutination is almost never seen in actual poisonings.
13
It is now believed that the haemagglutinating agent is not ricin, but another lectin, ricine.
The pulp of the seed contains allergic glycoproteins which cause allergic dermatitis, rhinitis and asthma in some individuals.
Clinical features
1. There is a delay of several hours before manifestations begin.
2. There is a burning sensation in the GI tract which is followed by colicky abdominal pain, vomiting and diarrhoea.
3. Frequent stools, including bloody diarrhoea and tenesmus, can occur.
4. There is haemorrhagic gastritis and dehydration.
5. Blood Urea Nitrogen, amino acid hydrogen, and inorganic phosphate levels are elevated.
6. CNS toxicity can occur, involving the cranial nerves. Optic nerve damage is been reported with ricin.
7. Renal manifestations include acute renal failure and haematuria . Serum creatinine is usually elevated.
8. Liver damage may occur in higher doses.
9. Alterations in glucose metabolism has to occured in experimental ricin intoxication. GI absorption of glucose decreases and glucose concentrations fall.
14
Fatal dose is believed to be the ingestion of a single castor seed, whereas actually 8 to 10 seeds are required to result in death.
However, even a single seed can occasionally cause death resulting from anaphylaxis.
Parenteral injection of ricin is fatal with a dose as low as 1 mg/kg predicted body weight.
However, ricin is a poorly absorbed substance, and it may take up to 5 days for toxic effects to manifest completely.
Treatment in the latent period between exposure and systemic symptoms requires observation for 8 hours following exposure to ricin.
Decontamination procedures include stomach wash, activated charcoal and catharsis.
Supportive measures consist of i.v. fluids, monitoring for hypoglycaemia, haemolysis and complications of hypovolaemia.
Alkalinisation of urine prevents crystallisation of haemoglobin and it should be considered in severe poisonings.
Many antidotes have been suggested, but no specific treatments are available for toxalbumen exposures.
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Croton poisoning
The botanical name is, Croton tiglium.
The plant belonging to family Euphorbiaceae, found in, Assam, Bengal, and the Western Ghats.
It’s a small tree with ovate or elliptic leaves which are narrow-pointed, toothed, and 2 to 3 inches long, varying from metallic green to bronze, orange or yellow.
Seeds are oval, smooth, 2 cm long, and brownish in colour.
The seed, oil, and root extract are used as a laxative.
Toxic parts of the plant include, 1. Stem,
2. leaves, 3. seeds.
Toxic principle is Crotin or toxalbumen and Crotonoside which is a glycoside.
Clinical features include,
Plants in this family contain irritant contains diterpene esters that are strongly irritative.
Rubbing the latex of these plants on face or chewing on the stem results in erythema, swelling, and blistering.
16
Initial symptoms of reddening and swelling occur in 8 hours, with vesicle and blister formation peaking in 4 to 12 hours.
Severity depends on the amount of latex and the duration of contact.
Ingestion results in burning pain in the upper GI tract, vomiting, tenesmus, watery or blood-stained diarrhoea.
Severe diarrhoea results in hypotension, collapse, coma, and death.
Treatment includes,
1. Decontamination with gastric lavage.
2. Treatment of shock with i.v. fluids and vasopressors.
3. Administration of cold milk may alleviate the GI irritation.
17
Glory Lily Poisoning
Botanical name of the plant is Gloriosa superba
Other common names include, 1. Climbing lily
2. Superb lily.
The plant belongs to family Liliaceae, which is a large, herbaceous, climbing annual.
It has a slender vine with a thick tuberous root, resembling that of a sweet potato.
The leaves terminate in tendril-like, long, curling tips.
It’s flowers are large, solitary, yellow or red, crinkled, and long-stalked.
They appear to be “upside-down”, with the stamens and pistils pointing downwards.
It’s uses are,
1. The juice from the leaves is used as a pediculoside.
2. The root is used to treat various ailments in traditional medicine.
Toxic parts of the plant are leaves and root.
18
Toxic principles are,
The roots containing colchicine and gloriosine.
The tubers contain an estimated 6 mg/10 gm of tuber of colchicine, along with gloriosine, which is a related alkaloid.
Clinical features include,
1. Acute poisoning with the root results in severe vomiting, diarrhoea, tachycardia, chest and abdominal pain.
2. Hypotension, bradycardia.
3. Seizures.
4. Bone marrow suppression.
5. Coagulopathy.
6. ECG changes, respiratory failure and death have been reported.
Acute colchicine overdose results in severe toxicity which may be delayed for 12 hours post ingestion.
Toxic effects occur in three phases.
Early Phase upto 24 hours,
1. Severe GI symptoms like nausea, vomiting, abdominal pain, haemorrhagic gastroenteritis along with electrolyte abnormalities, volume depletion, and hypotension.
2. Ingestion causes numbness of the lips, tongue and throat.
19
Second phase extends up to 72hours.
1. Multisystem organ failure, with fever and neurological features like, confusion, coma and ascending peripheral neuropathy.
2. Pulmonary, renal, hepatic, haematological and cardiovascular toxicity.
3. Seizures have been reported in children.
4. Death may occur from respiratory failure, cardiovascular collapse, or sudden cardiac death.
5. Sepsis is the most common cause of death between 3 to 7 days.
Third phase extends up to 7 to 10 days.
Phase of recovery is characterised by a rebound leukocytosis and reversible alopecia.
The fatal dose used is, estimated fatal dose of pure colchicine being 7 to 60 mg.
The colchicine content of tubers of Gloriosa superba is approximately 0.4%.
A potentially lethal amount would therefore be contained in about 5 grams of tuber.
Radioimmunoassay and enzyme linked immune-sorbent assays have also been developed for detecting colchicine.
20
Treatment includes,
1. Following an ingestion, the patient should be observed for at least 12 hours due to an asymptomatic period, which can last up to 12 hours.
2. Decontamination involes activated charcoal therapy.
3. Colchicine is believed to undergo enterohepatic circulation.
4. Activated charcoal may interrupt enterohepatic recirculation, though there is no clinical evidence that this decreases toxicity.
5. Symptomatic and supportive measures like fluid and electrolyte management
6. Potassium levels, should be followed closely, while administration of appropriate IV fluids.
7. A complete blood count should be done daily, monitoring for bone marrow depression.
8. Patients suffering from bone marrow depression should be isolated to prevent the patient developing infection.
9. Analgesics or opiates with an anticholinergic drug, if necessary may be used to control abdominal pain.
10. Ascending paralysis with respiratory involvement requires mechanical ventilation.
21
Figure - The Gloriosa superba plant with presence of flowers.
22
Marking Nut poisoning
The botanical name is Semecarpus anacardium.
This tree belongs to the family of Anacardiaceae.
It grows well in many parts of the country, and bears oblong leaves rounded at the tip, ash grey in colour, with cartilaginous margins.
The fruit is also called “marking nut”.
It is blackish in colour and is vaguely heart-shaped. The juice of the nut being oily and black.
The juice of the nut is used to mark washed laundry and hence the name marking nut.
The nut is used to treat various ailments in folk medicine.
The bruised nut is sometimes used as an abortifacient, by inserting it into the vagina.
Toxic principles include 1. Semecarpol
2. Bhilawanol.
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Clinical features include,
1. Skin contact with the acrid juice results in irritation, vesication and ulceration.
2. Ingestion produces GI distress with blister formation in and around the mouth.
3. Severe poisoning results in vomiting, abdominal pain, diarrhoea, hypotension, tachycardia, delirium, and coma.
4. Pupils may be dilated.
Fatal dose is 5 to 8 seeds, or 10 grams.
Treatment comprises of,
1. Wash contaminated skin with soap and water, and treat lesions with help of a dermatologist.
2. Decontamination, if taken orally, with activated charcoal and laxative.
3. Milk may be useful in ameliorating the GI distress.
4. Supportive and symptomatic measures.
24
Mayapple (May Apple) Poisoning
Common name of the plant is American Mandrake.
Botanical plants include, 1. Podophyllum peltatum, 2. Podophyllum hexandrum.
This plant belonging to family Podophylaceae grows well in the hilly regions of Sikkim, Uttar Pradesh, Punjab, Himachal Pradesh, and Kashmir.
It is a towering herb with a root stock with deeply lobed leaves having toothed margins.
Flowers are usually single, cup-shaped and white or pink in colour.
Fruits are generally ovoid and bright scarlet.
Toxic Part include leaves and rhizomes.
Toxic Principle is podophyllin
Podophyllin or the purified form, podophyllotoxin is an amorphous caustic powder which is light brown to greenish- yellow or brownish-grey in colour having a characteristic odour and is a mixture of compounds divided into two groups: lignans (wood extracts) and avonols.
It is present in the rhizomes and roots of the plant, and contains podophyllotoxin.
25
Commercial preparations usually contain 25% podophyllum resin as tincture of benzoi or 10% benzoin and isopropanol.
Both podophyllum and podophyllotoxin, have a colchicine-like and vinblastine-like effect, resulting in the chemical effects of,
1. Antimitosis, which is arrest of mitosis in metaphase.
2. Negative effect on axoplasmic transport.
3. Inhibition of protein, RNA and DNA synthesis.
4. Blocking of oxidation enzymes in tricarboxylic acid cycle.
26
Uses of the plant includes,
1. Podophyllum and its resin, used as keratolytic agents whose caustic action is thought to be caused by the arrest of mitosis in metaphase.
2. Topical treatment of venereal warts.
3. Podophyllum is also used in Homoeopathy.
Clinical features have a varied presentation,
1. Ingestion or dermal application, both result in toxicity.
2. The toxicity associated with podophyllum are colchicine-like, arresting cellular mitosis.
3. Symptoms usually begin 30 minutes to several hours following ingestion and 24 hours following dermal absorption.
4. Exposure of eyes to podophyllum powder causes intense irritation with conjunctivitis, keratitis, corneal ulceration and iridocyclitis.
5. Ingestion results in nausea, abdominal pain, vomiting, and diarrhoea, followed by fever, tachypnoea, peripheral neuropathy,
6. Severe poisoning resulting in tachycardia, hypotension, ataxia, dizziness, lethargy, confusion, and altered sensorium.
7. Seizures may occur.
8. Polyneuropathy generally appears in a week and progresses for 2 to 3 months.
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9. After a few days, pancytopenia and hepatic dysfunction may occur, which generally resolves in 2 to 3 weeks.
10. Cardiotoxicity, ileus, coma and hallucinations may occur.
11. Autonomic dysfunction, including sinus tachycardia, urinary retention, paralytic ileus, and orthostatic hypotension may persist for several months.
12. Oliguria, anuria, and renal failure are rare complications.
13. Consumption of Chinese herbal products containing extracts of podophyllum have caused neuropathy and encephalopathy.
It has been suggested that podophyllum should not be used during pregnancy for the treatment of genital warts due to the potential for severe myelotoxicity and neurotoxicity in the mother.
There are indications that podophyllum may be teratogenic and carcinogenic.
Squamous cell carcinoma- like changes have been reported following the dermal use of podophyllum in humans.
Treatment comprises of
1. Baseline investigations including, CBC, Sr. electrolytes, Sr. calcium, renal function test and liver function test.
2. Gastric decontamination with induced emesis is not indicated, although activated charcoal might help.
3. Symptomatic and supportive measures.
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4. For hypotension, Infuse 10 to 20 ml/kg of isotonic fluid.
5. If hypotension persists, administer dopamine or noradrenaline.
6. Monitor electromyography and nerve conduction studies in all patients with symptoms of peripheral neuropathy.
7. Patients generally recover from thrombocytopenia and leukopenia within a month.
8. Granulocyte colony-stimulating factor- filgrastim may be effective in accelerating recovery from neutropenia following podophyllum poisoning.
9. Due to the large molecular weight of the compound it is unlikely that haemodialysis would be effective, for the removal of podophyllum.
10. Early haemoperfusion has been suggested by some, to be useful in facilitating neurological recovery in some patients. But there is no conclusive data regarding its usefulness.
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Rosary pea poisoning
Common names of the plant include, Jequirity bean, Indian bead, Buddhist rosary bead, Rosary pea, Seminole bead, Prayer bead, Jungle bead, Crab’s eye, Weather plant, Love bean, Lucky bean, Ojo de pajaro and Indian liquorice.
The botanical name is Abrus precatorius.
Physical appearance shows,
The green vine belongs to family Leguminosae and is a tropical, ornamental, twining, woody vine which grows to a height of 20 feet when supported by other plants.
It has slender, tough branches with 10 cm long compound leaves bearing 10–20 pairs of leaflets.
Leaves are alternate, opposite, pinnately divided with small oblong leaflets. Leaflets appear in 8 to 15 pairs and are about half inch long.
Stems are green but later develops grey bark as the plant matures.
Flowers are pink, purple or white and borne in clusters. They appear in the leaf axils along the stems.
The distinctive part of the plant is the seed which is oval and has an attractive hard glossy outer shell that is usually scarlet red with a black centre.
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The seeds are present inside fruit pods, each containing many seeds. The pods split-open when ripe.
The pod is a legume (pea-shaped pod) and is about 3 cm long.
The seeds are often used in rosary beads, necklaces, and folk jewellery.
Jewellers in India, sometimes use the seeds as a measure for weighing gold or precious stones.
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Quacks use extracts of various parts of the plant, for the treatment of a wide variety of ailments.
Toxic parts include, Seeds, root and leaves.
The toxic principles are,
1. Abrin, abric acid, glycyrrhizin and N-methyl tryptophan.
2. The main active principle is abrin, which is a toxalbumen very similar to ricin.
3. It is a lectin composed of two polypeptide chains, A and B that are connected by a disulphide bridge.
4. The basic structure of two peptide chains linked by a single disulphide chain is similar to that of botulinum toxin, tetanus toxin, cholera toxin, diphtheria toxin and insulin.
5. Like castor, the seeds of abrus are harmless when ingested whole, since the hard outer shell resists digestion.
6. However, crushing of the seed before swallowing will enable the toxins to be released.
7. Abrin is a powerful gastrointestinal toxin and one of its polypeptide chains (B) binds to the intestinal cell membrane, while the other chain, (A) enters the cytoplasm.
8. Once inside the cell, the A chain acts on the 60S ribosomal sub-unit, prevents binding of elongation factor 2, thus inhibiting protein synthesis and leading to cell death.
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Clinical features include,
1. Dermal contact causes redness and rash.
2. Ocular exposure causes redness, swelling and blindness.
3. Ingestion causes, burning pain in the mouth and throat; severe vomiting;
abdominal pain and bloody diarrhoea.
4. Cardiac arrhythmias
5. CNS manifestations like headache, convulsion and CNS depression.
6. Elevations of liver enzymes.
Usual fatal dose is about 1 to 2 seeds.
There have been cases of ingestion of large amounts of seeds, which have resulted in minimal clinical effects. This may represent variations in toxicity, and GI absorption.
If the seeds of these plants are swallowed as a whole, symptoms are less likely to occur.
Treatment includes,
1. Gastric decontamination in the form of lavage or activated charcoal.
2. Whole bowel irrigation is said to be helpful, according to some investigators.
3. Supportive measures, with special emphasis on i.v. fluids.
33
Sweet Pea Poisoning
Common names of the plant are, Chickling pea, Indian pea, Grass pea and Guaya. Botanical name is Lathyrus sativus.
The plant belongs to a family of Leguminosae, which grows well in Madhya Pradesh, Bihar, Uttar Pradesh, West Bengal and Punjab.
The seeds also called kesari dal, are used as a substitute for lentils by the rural folk in these states.
Toxic principles are,
1. Beta-N-oxalyl-amino-L-alanine (BOAA).
2. Beta- N-oxalyl-alpha-beta-diaminopropionic-acid.
Clinical features are,
Chronic intake of kesari dal leads to the development of lathyrism, characterised by progressive bilateral spastic paraparesis.
There may be prodromal manifestations such as cramps, prickling sensation, and nocturnal calf pain.
Tendon reflexes are usually exaggerated and plantar response is extensor.
Treatment -Exclusion of kesari dal from diet and symptomatic measures.
34
Figure - Lathyrus sativus
35
QT interval
36
The QT interval is measured, from the beginning of the QRS complex to the end of the T wave.
The ACC / AHA/ Heart Rhythm Society recommend that the QT interval should be measured using at least three different leads and should be the longest QT interval that can be measured in the 12-lead ECG.
The duration of the QT interval is affected by heart rate (HR).
Thus, the QT interval corrected for heart rate known as the QTc.
The QTc is calculated using the Bazett formula.
The normal QTc is longer in women than in men.
The QTc interval, should not exceed 0.44 seconds (440 milliseconds) in women and 0.42 seconds (420 milliseconds) in men.
A prolonged QT interval is defined as a QTc >0.44 seconds (440 milliseconds) in men and >0.46 seconds (460 milliseconds) in women and children.
If bundle branch block or intraventricular conduction defect of >0.12 seconds is present, the QTc is prolonged if it measures >0.50 seconds (500 milliseconds).
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A prolonged QTc interval can be either, acquired or inherited.
It predisposes to the occurrence of, a ventricular arrhythmia called torsades de pointes which is a Polymorphic VT.
A prolonged QTc, either acquired or inherited, should always be identified because it can be lethal.
The difference between the longest and shortest QT interval, when the QT intervals are measured in all leads in a 12- lead ECG, is called QT dispersion.
Wide QT dispersion of >100 milliseconds predicts a patient who is prone to ventricular arrhythmias.
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Bazett's formula
The most commonly used QT correction formula is the Bazett's formula, named after physiologist, Henry Cuthbert Bazett, calculating the heart rate corrected QT interval (QTc).
Bazett's formula is based on observations from his study, in 1920.
Bazett's formula is given in a form that returns QTc in dimensionally suspect units, square root of seconds. The mathematically form of Bazett's formula is,
Where, QTc is the QT interval corrected for heart rate, and RR is the interval from the onset of one QRS complex to the onset of the next QRS complex.
This mathematically correct formula returns the QTc in the same units as QT, which is in milliseconds.
In this formula, it is assumed that QT is measured in milliseconds and that RR is measured in seconds, often derived from the heart rate (HR) as 60/Heart Rate.
39
Therefore, the result will be given in seconds per square root of milliseconds. However, reporting QTc using this formula creates a requirement regarding the units in which the original QT and RR are measured.
In either form, Bazett's non-linear QT correction formula is generally not considered accurate, as it over-corrects at high heart rates and under- corrects at low heart rates.
Bazett's correction formula is one of the most suitable QT correction formulae for neonates.
Once corrected, a QTc > 440msec in males and > 460msec in females is considered prolonged.
40
Acquired Long QT syndrome
Drugs – Ketoconazole, tetracycline, erythromycin.
Neurogenic.
Severe hypothermia.
Hypokalemia.
Hypocalcemia.
Coronary contrast injection.
Class 1A and class 3 anti-arrythmic drugs.
Hypothyroidism.
Severe bradycardia.
Advanced AV block.
Myocardial ischemia.
Unexplained.
41
Congenital Long QT syndrome
Familial prolongation of the QT interval associated with, congenital deafness and sudden cardiac death due to ventricular arrhythmia was first reported by Jervell and Lange-Nielsen.
This condition is autosomal recessive.
Romano-Ward syndrome is an autosomal-dominant congenital long QT syndrome, associated with sudden death and normal hearing.
The disorder has incomplete penetrance, the appearance of symptoms is sporadic, and the duration of the QT interval shows marked variations.
Syncope and sudden death are provoked by sympathetic stimulation and emotional stress, such as fright or startling noises.
Prolongation of the QT interval is precipitated by noxious stimuli, followed by concomitant appearance of VPC’s and ventricular tachycardia degenerating into ventricular fibrillation.
Evidence for autonomic dysfunction in patients with long QT syndrome include an inability to increase the heart rate appropriately with exercise and inappropriate adjustment of the QT interval to tachycardia induced by exercise.
Polymorphic VT (torsade de pointes) or ventricular fibrillation, occur in the setting of large dispersion of ventricular repolarization and are precipitated usually by a VPC interrupting the T wave.
42
Congenital long QT syndrome (LQTS) is an abnormality of ion channel, that can be, K+ channel block or prolonged inactivation of the Na+
channel.
Mutations in two genes where common in some affected families, both encoded cardiac channels in families linked to chromosomes 3 and 7.
Congenital LQTS is primarily a channelopathy with genetic heterogeneity.
The Jervell and Lange-Nielsen syndrome is caused by two genes that encode the slowly activating delayed rectifier potassium channel KCNQ1 and KCNEI.
The Romano-Ward syndrome is caused by mutations in eight different genes,
1. KCNQI (LQTI), 2. KCNH2(LQT2),
3. SCN5A (sodium channel-LQT3),
4. ANKB (protein ankyrin involved in anchoring calcium and sodium channel to the cellular membrane (LQT4),
5. KCNEI (mink syndrome, LQT5), 6. KCNE 2 (LQT6),
7. KCNJ2(LQT7, Andersen’s syndrome) and 8. CACNAIC (LQT8, Timothy syndrome).
43
The long QT in LQTI and LQT2 is caused mostly by T wave lengthening, whereas in patients with LQT3 lengthening of QT is due to prolongation of the ST segment.
Certain types of the T and U abnormalities, such as prolonged terminal portion of T wave down- slope and wide T-U junction, have been seen in Andersen-Tawil syndrome (LQT7).
44
Hypokalemia
45
46
Hypokalemia has prominent effects on cardiac, skeletal and intestinal muscle cells.
Hypokalemia predisposes to digoxin toxicity by a number of mechanisms, including reduced competition between K+ and digoxin for shared binding sites on cardiac Na+/K+-ATPase subunits.
ECG changes in hypokalemia include broad flat T waves, ST depression, U waves, and QT prolongation which are most marked when serum K+ is
<2.5 mmol/L.
Hypokalemia also results in hyperpolarization of skeletal muscle, impairing the capacity to depolarize and contract; resulting in weakness and even paralysis.
It also causes a skeletal myopathy and predisposes to rhabdomyolysis.
Finally, the paralytic effects of hypokalemia on intestinal smooth muscle results in intestinal ileus.
The effects of hypokalemia on the kidney can include Na+, Cl– and HCO3– retention, polyuria, phosphaturia, hypocitraturia, and an activation of renal ammoniagenesis.
Bicarbonate retention and other acid-base effects of hypokalemia can contribute to metabolic alkalosis.
47
Hypokalemic polyuria is due to a combination of central polydipsia and an ADH-resistant renal concentrating defect.
Structural changes in the kidney due to hypokalemia include a relatively specific injury to proximal tubular cells, interstitial nephritis and renal cysts.
Hypokalemia also predisposes to AKI and can lead to end-stage renal disease in patients with long- standing hypokalemia due to eating disorders and/or laxative abuse.
Hypokalemia and/or reduced dietary K+ are involved in the pathophysiology and progression of hypertension, heart failure and stroke.
Correction of hypokalemia is important in hypertensive patients treated with diuretics, in whom BP improves with the establishment of normokalemia.
The goals of therapy in hypokalemia are to prevent life-threatening consequences, to replace the associated K+ deficit, and to correct the underlying cause and/or mitigate future hypokalemia.
The urgency of therapy depends on the severity of hypokalemia, associated clinical factors and the rate of decline in serum K+.
48
Patients with a prolonged QT interval and other risk factors for arrhythmia should be monitored during repletion.
Urgent and cautious K+ replacement should be considered, in patients with severe redistributive hypokalemia (plasma K+ concentration < 2.5mmol/l), or when serious complications occur.
When sympathetic nervous system is thought to result in redistributive hypokalemia, as in theophylline overdose, and head injury, high-dose propranolol (3 mg/kg) should be considered; as this nonspecific - adrenergic blocker will correct hypokalemia, without the risk of rebound hyperkalemia.
Oral replacement with KCl is the mainstay of therapy in hypokalemia.
Potassium phosphate, oral or IV, may be used in patients with combined hypokalemia and hypophosphatemia.
Potassium bicarbonate or potassium citrate should be considered in patients with hypokalemia and metabolic acidosis.
Hypomagnesemic patients are refractory to K+ replacement alone, such that concomitant Mg2+ deficiency should always be corrected with oral or intravenous repletion.
49
In the absence of abnormal K+ redistribution, the total deficit relates to serum K+, such that serum K+ drops by approximately 0.27 mM for every 100-mmol reduction in total-body stores.
Loss of 400–800 mmol of total-body K+, results in a reduction in serum K+ by approximately 2.0 mM.
This deficit must be replaced gradually over 24-48 h, with frequent monitoring of plasma K+ concentration to avoid transient overrepletion and rebound hyperkalemia.
The use of i.v. administration should be limited to patients unable to use the enteral route or in the setting of severe complications like paralysis and arrhythmia.
Intravenous KCl should always be administered in saline containing solutions, rather than dextrose, because the dextrose-induced increase in insulin can acutely exacerbate the hypokalemia.
The peripheral intravenous dose is usually 20–40 mmol of KCl per liter, because higher concentrations can cause local pain from chemical phlebitis, irritation, and/or sclerosis.
If hypokalemia is severe (<2.5 mmol/L) or critically symptomatic, intravenous KCl can be administered through a central vein, with cardiac monitoring in an ICU setting, at rates of 10–20 mmol/h.
50
Higher rates should be administered for acutely life-threatening complications.
The absolute amount of administered K+ should be restricted, to about 20 mmol in 100 mL of saline solution, to prevent inadvertent infusion of a large dose.
Femoral veins are preferable, because i.v. infusion through IJV or subclavian central lines can acutely increase the local concentration of K+
and hence, affect cardiac conduction.
Strategies to minimize K+ losses should also be considered including, 1. minimizing the dose of non-K+ sparing diuretics,
2. restricting Na+ intake,
3. using clinically appropriate combinations of non-K+-sparing and K+- sparing medications like e.g., loop diuretics with angiotensin-converting enzyme inhibitors.
51
Metabolic Acidosis
Metabolic acidosis is defined as, a low arterial blood pH in association with a reduced serum HCO3−.
Respiratory compensation results in a decrease in arterial carbon dioxide tension i.e., PaCO2.
A low Sr. HCO3− alone is not diagnostic of metabolic acidosis, because it also results from, renal compensation to chronic respiratory alkalosis.
Measurement of the arterial pH differentiates between these two entities.
After the diagnosis of metabolic acidosis is made, the first step in the evaluation of the patient is to calculate the serum anion gap.
Anion is the difference between the plasma concentrations of the major
cation, sodium ([Na+]), and the major measured anions, chloride and bicarbonate ([Cl−] and [HCO3−]), given by the following formula,
Anion gap = [Na
+] − ([Cl
−] + [HCO
3−])
52
Causes of Metabolic Acidosis
53
54
Hypocalcemia
The causes of hypocalcemia can be differentiated based to whether serum PTH levels are low i.e., hypoparathyroidism or high i.e., secondary hyperparathyroidism.
Impaired PTH production and impaired vitamin D production are the most common cause of hypocalcemia.
PTH is the only defence against hypocalcemia, and hence, disorders associated with deficient PTH production may be associated with
profound hypocalcemia.
Hypoparathyroidism commonly results from, inadvertent damage to all four glands during thyroidectomy or parathyroid gland surgeries.
Hypoparathyroidism can also be seen in autoimmune endocrinopathies.
Hypocalcemia may be associated with infiltrative diseases like sarcoidosis.
Impaired PTH secretion may be secondary to magnesium deficiency or due to activating mutations in the CaSR or in the G-proteins that mediate CaSR signals.
Vitamin D deficiency, impaired 1,25(OH)2VIT D production or vitamin D resistance also cause hypocalcemia.
55
Hypocalcemia in these disorders, is not like that seen with hypoparathyroidism because the parathyroid glands are able to mount a compensatory increase in PTH secretion.
Hypocalcemia may also occur, in conditions associated with severe tissue injury like burns, rhabdomyolysis, tumor lysis syndrome or pancreatitis.
The cause of hypocalcemia includes, a combination of low albumin, hyperphosphatemia, tissue deposition of Ca and impaired PTH secretion.
Patients with hypocalcemia may be asymptomatic, if the decrease in serum Ca is relatively mild and chronic but they may present, with life- threatening complications.
Moderate to severe hypocalcemia is associated with paraesthesia, usually of the fingers, toes, and circumoral regions which is caused by increased neuromuscular irritation.
On examination, a Chvostek’s sign i.e., twitching of the circumoral muscles in response to gentle tapping of the facial nerve just anterior to the ear may be seen, although it is also seen in normal individuals.
Carpal spasm may be induced by inflation of a blood pressure cuff to 20 mmHg above the patient’s systolic blood pressure for 3 min i.e., Trousseau’s sign.
56
Severe hypocalcemia can cause, seizures, carpopedal spasm, bronchospasm, laryngospasm and a prolonged QT interval.
Evaluation of a patient with hypocalcemia includes measurement of, 1. Sr. calcium,
2. Sr. albumin, 3. Sr. phosphorus, 4. Sr. magnesium, and 5. Sr. PTH level.
A suppressed PTH level in the setting of hypocalcemia establishes, hypoparathyroidism as the cause of the hypocalcemia.
Elevated PTH level i.e., secondary hyper-parathyroidism, should direct attention to the vitamin D deficiency as the cause of hypocalcemia.
Vitamin D deficiency is identified by, measuring serum 25- hydroxyvitamin D levels, which reflects vitamin D stores.
In the setting of renal insufficiency or vitamin D resistance, Sr. 1,25(OH)2
VIT D levels are informative.
57
The treatment depends on the severity of the hypocalcemia and the rapidity with which hypocalcemia occurs, and the associated complications like, seizures and laryngospasm.
Acute or symptomatic hypocalcemia is managed with calcium gluconate, 10 mL 10% wt/vol given i.v. diluted in 50 mL of 5% dextrose or 0.9%
sodium chloride, given intravenously over 10 min.
If hypocalcemia persists, it often requires a constant i.v. infusion, typically 10 ampules of calcium gluconate, or 900 mg of calcium in 1 L of 5%
dextrose or 0.9% sodium chloride, being administered over 24 h.
Hypomagnesemia, if it is present, should be treated with appropriate Mg supplementation.
Chronic hypocalcemia due to hypoparathyroidism is treated with calcium supplements i.e., 1000–1500 mg/d elemental calcium in divided doses and either vitamin D2 or D3 i.e., 25,000–100,000 U/day or calcitriol i.e.,1,25(OH)2D, 0.25–2 μg/day.
Other vitamin D metabolites like, dihydrotachysterol, alfacalcidiol are not used nowadays.
58
Vitamin D deficiency, however, is treated best using vitamin D supplementation, generally responds to low doses of vitamin D i.e., 50,000 U, 2–3 times per week for several months.
Vitamin D deficiency due to malabsorption may require much higher doses i.e., 100,000 U/d or higher.
The treatment goal, is to bring serum calcium into the low normal range and to avoid hypercalciuria as it may lead on to nephrolithiasis.
59
60
MATERIALS AND METHODS
STUDY POPULATION
The study will be conducted on 50 patients admitted to Government Rajaji Hospital & Madurai Medical College during the study period from February 2019 to July 2019.
INCLUSION CRITERIA
Patients with history of Cleistanthus collinus poisoning within 48hrs.
EXCLUSION CRITERIA Age < 18 years
Drug history- Quinidine, procainamide, TCA’s, bisphosphonates Chronic kidney disease
Acute pancreatitis
Acute myocardial infarction Advanced or complete AV block
61
ANTICIPATED OUTCOME
Increased incidence of mortality in Cleistanthus collinus poisoning patients with prolonged QTc interval.
DATA COLLECTION
Informed consent will be obtained from all patients to be enrolled for the study. In all the patients, relevant information will be collected in a predesigned proforma.
The patients are selected based on history, ECG and biochemical tests.
The incidence of QTc prolongation is assessed. In those with prolonged QTc interval, the outcome is assessed in the form of mortality or discharge from the hospital.
LABORATORY INVESTIGATIONS Complete blood count
Blood sugar test.
Renal function test Liver function test Sr. electrolytes Sr. amylase Sr. Calcium
Electrocardiography
62
DESIGN OF STUDY Prospective study.
PERIOD OF STUDY
6 MONTHS (February 2019 to July 2019) COLLABORATING DEPARTMENTS:
DEPARTMENT OF BIOCHEMISTRY ETHICAL CLEARANCE: Applied for
CONSENT: Individual written and informed consent
ANALYSIS: Statistical analysis will be performed using appropriate tests required according to data
CONFLICT OF INTEREST: Nil FINANCIAL SUPPORT: Self
PARTICIPANTS: 50 Cleistanthus collinus poisoning patients at Government Rajaji Hospital, Madurai
63
OBSERVATION
Statistical analysis
Statistical analysis was done using SPSS version 16(SPSS Inc., Chicago, IL).
The results were presented as mean, Standard error and Standard deviation for continuous data and as percentages for categorical data.
Distribution of the computed data was analysed using shapirowilks test.
The clinical, laboratory variables were compared among survivors and expired in the study population.
Comparisons of the continuous data between the groups were performed by Student’s t-test.
Qualitative differences between the groups were analyzed by the Chi- square test or Fisher’s exact test.
A p-value < 0.05 were considered to indicate statistical significance.
64
RESULTS
Distribution of clinical profile and laboratory profile among study population
Variables Mean
Std.
Deviation
Minimum Maximum Median IQR
Age in yrs 27.22 6.42 18 41 26 9.25
Serum calcium 9.236 0.75 7.4 10.6 9.25 0.72
Serum potassium 3.576 0.70 1.6 4.7 3.6 0.7
QTc interval 424.6 35.29 380 510 420 0
Serum pH 7.36 0.54 7.24 7.49 7.365 0.8
27.22
9.236
3.576
7.36
0 5 10 15 20 25 30
Age in yrs Serum calcium Serum potassium Serum pH
Mean distribution of age and laboratory profile among study population
Age in yrs Serum calcium Serum potassium Serum pH
65
Comparison of the laboratory profile and clinical profile among expired and survivors of the study population
Survivors (N=44) Expired (N=6)
Mean Std.
Deviation
Std. Error
Mean Mean Std.
Deviation
Std. Error Mean
p value
Age in years 27.05 6.23 0.94 28.5 8.26 3.374 0.608
serum calcium 9.42 0.548 0.082 7.85 0.59 0.24 0.001*
* serum
potassium 3.74 0.51 0.078 2.33 0.63 0.25 0.001*
*
QTc interval 415.68 25.73 3.88 490 26.077 10.64 0.001*
*
serum pH 7.37 0.04 0.006 7.26 0.01 0.007 0.001*
*
Student t test; **shows (p<0.001)
0 5 10 15 20 25 30
Age in years serum calcium serum potassium
serum pH 27.05
9.42
3.74
7.26 28.5
7.85
2.33
7.37
Comparison of the laboratory profile among expired and survivors of the study population
Survivors Expired
66
QTc interval
The average QTc interval among survivors is 415 msec.
The average QTc interval among expired is 490 msec.
The QTc interval significantly identifies patients with a high chance of poor outcomes.
The significance of QTc is explained by the hypokalemia and hypocalcemia caused by toxic effects of the plant.
360 380 400 420 440 460 480 500
Survivors Expired
415.68
490
Comparison of QTc interval among expired and survivors of the study population
Survivors Expired
67
Age Distribution
The incidence of Cleistanthus collinus poisoning is significantly higher in younger age groups.
It is due to the ease of availability.
The plant is seen all over southern states of the nation.
26 26.5 27 27.5 28 28.5
Survivors Expired
27.05
28.5
Comparison of age among expired and survivors of the study population
Survivors Expired
68
Serum Calcium
Serum calcium levels are significantly reduced among expired, as compared to survivors.
The mean Sr. calcium among expired is 7.85.
It is in part due to renal involvement in patients with Cleistanthus collinus poisoning.
0 1 2 3 4 5 6 7 8 9 10
Survivors Expired
9.42
7.85
Comparison of serum calcium among expired and survivors of the study population
Survivors Expired
69
Serum Potassium
Serum potassium is significantly reduced in patients who expired as compared to survivors.
Even in survivors the serum potassium levels are in the low normal levels.
The observation is similar to the previous studies.
0 0.5 1 1.5 2 2.5 3 3.5 4
Survivors Expired
3.74
2.33
Comparison of serum potassium among expired and survivors of the study population
Survivors Expired
70
Acid-Base Balance
pH is an important prognostic marker in Cleistanthus collinus poisoning.
The mean pH among expired is 7.26.
Hence, ABG is an important initial investigation in assessing prognosis.
7.2 7.22 7.24 7.26 7.28 7.3 7.32 7.34 7.36 7.38
Survivors Expired
7.37
7.26
Comparison of serum pH among expired and survivors of the study population
Survivors Expired
71
GENDER DISTRIBUTION
Gender wise distribution among expired and survivors of the study population
Outcome
Total
Sex Survivors Expired P value
Male
Count (N) 6 1 7
0.616
% within sex 85.7% 14.3% 100.0%
Female
Count (N) 38 5 43
% within sex 88.4% 11.6% 100.0%
Fisher's Exact Test; Not significant
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Survivors Expired
85.70%
14.30%
88.40%
11.60%
Gender wise distribution among expired and survivors of the study population
Male Female
72
85.70%
14.30%
Male
Survivors Expired
88.40%
11.60%
Female
Survivors Expired
73
Distribution of categorical parameters among the study population
Parameters Frequency (N) Percent (%)
Gender Male 7 14
female 43 86
ST-T interval Abnormal 41 82
normal 9 18
Dyspnoea Absent 46 92
present 4 8
Elevation of
SGOT present 40 80
Absent 10 20
74
Gender Distribution
The consumption of Cleistanthus collinus is very high among females as compared to males.
It is attributable to easy availability.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Male female
Genderwise distribution of study population
Male female
