CERTIFICATE FROM THE HEAD OF THE DEPARTMENT

A STUDY ON GLYCEMIC CHANGES AS A PROGNOSTIC TOOL IN ORGANOPHOSPHATES POISONING PATIENTS

ADMITTED TO M.G.M.G.H.,TRICHY

Dissertation submitted to

THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY

In partial fulfilment of the regulations for the award of the degree of

M.D. GENERAL MEDICINE – [BRANCH - 1]

DEPARTMENT OF GENERAL MEDICINE

K.A.P.VISWANATHAM GOVERNMENT MEDICAL COLLEGE

&

M.G.M. GOVERNMENT HOSPITAL, TIRUCHIRAPALLI

THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY CHENNAI

MAY 2020

CERTIFICATE FROM THE DEAN

This is to certify that the dissertation titled “A STUDY ON GLYCEMIC CHANGES AS A PROGNOSTIC TOOL IN ORGANOPHOSPHATE POISONING PATIENTS ADMITTED TO M.G.M.G.H.,TRICHY” is a bonafide research work of Dr. S.KUMARESH under the guidance of Dr.U.B.PADMANABAN DCH., M.D., in partial fulfilment of the requirements of M.D. General Medicine [Branch-1]

examination of The Tamilnadu Dr.M.G.R Medical University to be held in May 2020.

Prof.Dr.A.ARSHIYA BEGUM M.D., DEAN,

K.A.P.V.Govt. Medical College &

M.G.M Govt. Hospital, Tiruchirappalli.

CERTIFICATE FROM THE HEAD OF THE DEPARTMENT

This is to certify that this dissertation in “A STUDY ON GLYCEMIC CHANGES AS A PROGNOSTIC TOOL IN ORGANOPHOSPHATE POISONING PATIENTS ADMITTED TO M.G.M.G.H.,TRICHY” is a bonafide research work done by Dr.S.KUMARESH, under the guidance and supervision of Dr.U.B.PADMANABAN DCH.,M.D., in partial fulfillment of the award of M.D.Degree in General Medicine (Branch-I) by The Tamil Nadu Dr.M.G.R Medical University ,Chennai -600 032.

DR.D.NEHRU MD., DMRD., Professor & Head of Department Department of General Medicine K.A.P.V.Govt. Medical College &

M.G.M Govt. Hospital, Tiruchirappalli.

CERTIFICATE FROM THE GUIDE

This is to certify that the dissertation titled “A STUDY ON GLYCEMIC CHANGES IN ORGANOPHOSPHATE POISONING PATIENTS ADMITTED AT MGMGH, TRICHY” is a bonafide research work done by Dr.S.KUMARESH under my direct supervision and guidance, in partial fulfilment of the requirements for the award of M.D. GENERAL MEDICINE degree of The Tamilnadu Dr.M.G.R. Medical University, to be held in May 2020.

Date: Prof.Dr.U.B.PADMANABAN DCH., M.D.,

Department of General Medicine

Place: K.A.P.V.Govt. Medical College &

M.G.M Govt. Hospital, Tiruchirappalli.

DECLARATION

I solemnly declare that the dissertation titled “A STUDY ON GLYCEMIC CHANGES IN ORGANOPHOSPHATE POISONING PATIENTS ADMITTED TO M.G.M.G.H.,TRICHY” is done by me at K.A.P.VISWANATHAM GOVTMEDICAL COLLEGE, TIRUCHIRAPALLI- 1 under the guidance and supervision of Prof.Dr U.B.PADMANABAN, DCH, M.D. This dissertation is submitted to The Tamil Nadu Dr. M.G.R.

Medical University towards the partial fulfilment of the requirements for the award of M.D. Degree [Branch-1] in General Medicine.

Place: TIRUCHIRAPALLI Dr.S.KUMARESH,

Date: Postgraduate student,

M.D. General medicine K.A.P.V Government Medical college, M.G.M.G.H, Tiruchirappalli.

PLAGIARISM CERTIFICATE

This is to certify that this dissertation work titled “STUDY ON GLYCEMIC VALUES IN ORGANOPHOSPHATE POISONING PATIENTS ADMITTED TO M.G.M.G.H., TRICHY” of the candidate Dr.S.KUMARESH with registration Number 201711555 for the award of M.D. DEGREE in the branch of General Medicine. I personally verified the urkund.com website for the purpose of plagiarism Check. I found that the uploaded thesis file contains from introduction to conclusion pages and the result shows 8(EIGHT) percentage of plagiarism in the dissertation.

Guide & Supervisor sign with Seal.

ACKNOWLEDGEMENT

I express my sincere gratitude to the Prof. Dr.A. ARSHIYA BEGUM M.D., DEAN, K.A.P.V. Government Medical College, Tiruchirappalli for allowing me to undertake this study in this prestigious institution.

I am extremely grateful to Dr.D.NEHRU DMRD., M.D., Professor and Head of the Department of General medicine, K.A.P.V. Govt Medical College and Hospital for permitting me to carry out this study and for his constant encouragement and guidance.

I am extremely grateful to Dr.U.B.PADMANABAN DCH., M.D., our unit chief and my thesis guide in constant support and encouraging in the study, throughout my work.

I thank my unit Assistant Professors Dr. P.BHARATHIRAJA DLO., M.D., Dr. M.RAMESH M.D., for their continuous motivation and valuable guidance throughout my work. I sincerely thank all the Assistant Professors of the Department of General Medicine for their co-operation and guidance.

I whole heartedly thank, colleagues, friends and staff of our hospital for their support for this work.

I owe my sincere thanks to all the patients for their kind co-operation throughout the study.

CONTENT

S. NO TITLE PAGE

NO.

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 3

3 MATERIALS AND METHODS 4

4 REVIEW OF LITERATURE 7

5 STATISTICS 46

6 DISCUSSION 73

7 CONCLUSION 76

8 LIMITATIONS 77

9 BIBLIOGRAPHY 78

10 ANNEXURES

a. Data collection Proforma 96

b. Consent and Patient Information letter 97 c. Ethical committee clearance certificate 99

d. Plagiarism Report 100

e. Master Chart 101

1

HYPERGLYCEMIA IN OPC POISONING

INTRODUCTION

Organo phosphorous poisoning is an indication for hospital admission. Organo phosphates used as pesticides, herbicides ,chemical warfare agents . OP inhibits the enzyme choline esterase. It leads to accumulation of acetylcholine at synapses and myoneural junction resulting in cholinergic over activity.

Most common cause of death due to OP poisoning is respiratory failure. To improve the survival early recognition and ventilatory support is essential. At the initial examination identify the clinical features and criteria to predict the need for ventilator support.

The clinical sequence can be of three types: type 1 syndrome (acute poisoning) in which clinical features appears within a day of exposure to OP.

cholinergic symptoms are tachycardia or bradycardia, diarrhea , vomiting , sweating , salivation, micturition , fasciculations .These cholinergic symptoms are treated with atropine. Type 2 syndrome or intermediate syndrome follows the intense cholinergic crises of OP poisoning. Their symptoms manifest 24-96 hours of after the poisoning on recovery from the

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cholinergic crises and include muscular weakness, it mostly affecting the proximal limb muscles and neck flexors. This syndrome carries a risk due to respiratory depression. Type 3 syndrome induced by organophosphate esters, it cause distal dying back axonopathy characterized by cramping muscle pain in the legs, paresthesia and motor shortcoming beginning 10 days to three weeks after the initial exposure. Sensory symptoms may be present but it predominantly a motor neuropathy. Diagnosis based on history of OP poisoning , clinical findings , electromyography and nerve conduction studies which show typical denervation pattern . OP poisoning in addition to its cholinergic symptoms shows metabolic derangements leading to hyperglycemia.

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AIMS AND OBJECTIVES

Aims

To assess the blood sugar values in OPC poisoning and correlate the severity of opc poisoning based on the blood sugar values.

Objectives of the study

This study was undertaken to assess the blood sugar values in OPC poisoning. . Random blood sugar values may be used a simple bed side test for assessing the patients in need of mechanical ventilation. They may be used along with POP scale.

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MATERIALS AND METHODS

Source of Data

A Total of 100 patients admitted in MGMGH TRICHY with alleged history of consumption of OPC poisoning .

Study Period

June 2017 to June 2018 Study Design

Observational prospective study.

Consent

A preinfomed well written consent obtained from patients or relatives.

Sample Size 100

Ethical Committee Clearance

Approval was obtained from the Institutional ethics committee.

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Inclusion Criteria

1. Patients within the age group of 18 to 40.

2. Patients with confirmed history of OPC poisoning( compound available)

3. patients with admission time 6 hrs to 12 hrs after the consumption of OPC poison

4. Patients with written consent.

Exclusion Criteria

1. Patients less than 18 and above 40 were excluded.

2. Patients with a H/O DM/SHTN/CKD were excluded.

3. Patients under alcohol intoxication were excluded.

4. Patients presentation time more than 12 hrs were excluded.

Sample Collection

Patients with alleged history of OP poisoning , after getting consent from the Patients Blood sugar values were collected at < 6hrs. Second sample of Blood sugar values were collected at < 12 hrs. 2ml of blood sample were collected in plain test tube under aseptic precautions.

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Data Collection and Methods

Patients with history of OP compound poisoning with reliable history of compound name/ time of admission were selected and blood samples taken at 6 and 12 hrs. Severity of the patient assessed using POP scale at 6 and 12 hrs. Patients were followed up for need for mechanical ventilation/

recovery / complications such as Rhabdomyolysis/AKI/VAP.

Statistical Analysis

After obtaining these data the results were transcribed into bar charts/tabulations/statistical analysis were performed. Tests of significance were used wherever required appropriately.

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REVIEW OF LITERATURE

OP exposure is a major toxicological threat to that may affect human and animal health because of their various toxicities such as neurotoxicity , endocrine toxicity, immunotoxicity, reproductive toxicity , genotoxicity and ability to induce organ damage, alterations in cellular oxidative balance and disrupt glucose homeostasis¹. Extremes and fluctuations in the glycemic status is a most important parameter affecting the outcomes in critical illness. All variesties of glycemic changes from hypoglycemia to hyperglycemia and ketoacidosis in OP poisoning ⁴

History of Organophosphates

The organophosphates was first synthesized in 1850. For the treatment of glaucoma physostigmine was used. For skeletal muscle and autonomic disorders synthetic cholinesterase inhibitors used⁶. It also tried in the treatment of parkinsonism. Adolf hitler used Nerve gases such sarin, sabu in second world war. It was released for clinical use in 1993. Rivastigmine which is a new drug is now available¹⁰. Most common adverse effect are nausea and vomiting with resultant weight loss because of increase in cholinegic activity. It is used in mild to moderately severe Alzheimer’s diseases.

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TABUN / SARIN USED IN SECOND WORLD WAR BY GERMANY

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STRUCTURE OF ORGANOPHOSPHATES

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WHO reported about 3 million cases of OPC exposure and 40,000 deaths annually. Majority of poisoning cases were under the age of thirty.

Males were exposed more than females. Estimates from the WHO indicate that each year 1 million accidental poisonings and 2 million suicide attempts involving pesticides were happen worldwide. Ingestion is the most common route of exposure followed by inhalational route¹⁰.

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Classification and their structure¹²

Acephate Asataf,orthene,starthene

Chlorpyrifos Dursban,duemet, lorsban

Dichlorvas Noovan

Dimethoate Rogar, tara 909, fosfamid

Fenitrothian Surmunion ,nitrophos

Fenthion Baycid, baytex

Malathion Cythion , chemathion

Methyl parathion Metacid , folitav

Monocrotophos Monocron , nuvacron , luphos

Phorate Thimet , pempart

Parathion Folidol , ekatox

Phosphomidan Dimecron , famfos

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Organophosphorus compound classification Older classification :

Most commonly used.

Alkylphosphates - TEPP, HETP, OMPA, malathion, systox, DFP arylphosphates - parathion, EPN, chlorthios, diazinon, demeton Classification based on pharmacological and toxicological interest by Holmstedt. Compounds divided into 5 depending on thedifferent X in the structure of OP compound.

Group A :

X- halogen, cyanide, thiocyanate SOMAN, SARIN, DFP

Group B :

X- alkyl, alkoxy, aryloxy DDVP, forstenon, pyrazoxon

Group C :

X – thiol or thiophosphorus

Parathion, malathion, azethion, diazinon, dementon

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Group D :

Pyrophosphates and related compounds TEPP, DPDA, OMPA

Group E :

Quaternary ammonium compound Phospholin

Highly toxic organophosphates

 Phosphomidan

 Ethyl parathion

 Chlorthiophos

 Demeton s methyl

 Carbophenothion

 Methyl parathion

 Dichlorvas

Moderately toxic organophosphates

 Fenthion

 Formothion

 Malathion

 Fenitrothion

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 Diazinon

 Chlorpyriphos

 Temephos

Others

 Edephenophos

 Phosphenidone

 Triazophos

 Monocrotophos

 Dimethoate

 Quinalphos

 Primiphos

Medical application of organophosphates and carbamates Reversal of neuromuscular blockade

 Neostigmine

 Pyridostigmine

 Edrophonium

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Treatment of glaucoma , myasthenia gravis and alzeimer’s disease

 Echothiopate

 Pyridostigmine

 Tacrine

 Donepezil

Structural features of organophosphates

The basic structure consists of phosphorus which is bound to oxygen by a double bond. R1 and R2 may be alkyl, alkoxy, aryloxy, amido, mercaptan or other groups. “X” represents the leaving group , it found as a halide, cyanide, thiocyanate, phenoxy, thiocholine or carboxylate group. ¹⁸ Kinetics

Kinetics depends on the many factors like route of administration ,distance from target organs , local versus systemic metabolism and activation route of elimination²³. After absorption the chemicals are equally distributed in all tissues. Most of the compounds absorbed in liver and the kidney. Metabolism occurs by three ways namely oxidation , hydrolysis, within 48 hours 80% to 90% of the drug eliminated via urinary and faecal excretion²⁵ .

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Common causes of OP poisoning Accidental poisoning

Self poisoning

1. Inhalation – airborne inhalation of insecticides while spraying 2. Ingestion – eating fruits and vegetables without washing 3. Drinking water contaminated with pesticides

4. Absorption – unwashed hands after handling pesticides²⁸

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ACETYL CHOLINE IN NEUROMUSCULAR JUNCTION

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Mechanism of action

Acetylcholine is the neurotransmitter released in all postganglionic parasympathetic nerve endings and at all the synapses of both sympathethic and parasympathetic ganglia³². It also released in skeletal muscle myoneural junction . acetyl choline is hydrolysed by acetylcholine esterase enzyme.

Two forms of acetylcholine esterase true and pseudo choline esterase.

True acetycholine esterase present in the tissues and erythrocytes.

pseudocholine esterase which is found in serum and liver⁴⁰.

Phosphorylation of choline esterase enzyme resulting in inactivation of the enzyme. Spontaneous reactivation of the enzyme may occur. Oximes enhancing the reactivation of the enzyme by hydrolysis⁴². Response to reactivating agent is decline with time because of ageing of the inhibited enzymes. Ageing is due to loss of one alkyl or alkoxy group⁴⁶. After the ageing reactivation of the enzymes by oximes cannot occur.

Acetylcholine accumulation leads to overstimulation of muscarinic and nicotinic receptors. It disrupts the nerve impulse transmission in both central and peripheral nervous system.⁴⁹ Phosphorylation of choline esterase by organophosphorus compounds.

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Three independent reactions determine the speed of onset and severity of poisoning.

Ageing

Organophosphorus compounds divides into alkyl phosphates and arylphosphates. Alkyl phosphates are direct inhibitors like malathion.

Arylphosphates are indirect inhibitors like parathion⁵⁰.

A specific acetylcholinesterase (true choline esterase) and nonspecific butrylcholine esterase (pseudo cholinesterase) are present in the body⁵⁴. Acetylcholine

Acetylcholine synthesized in the cytosol of terminal nerve fibre. Golgi apparatus forms small vesicles containing acetylcholine which is about 40nm in the cell body of motor neuron at spinal cord⁵⁶. These vesicles transported from the central body of spinal cord to neuromuscular junction⁵⁸. Synthesis, storage and release of acetylcholine

When an nerve impulse arrives at nerve terminal it cause release of acetylcholine into the synaptic space. Acetylcholine is hydrolyzed by acetyl choline esterase. Acetylcholine is reabsorbed into neural terminal and reused in formation of new acetylcholine. ⁶⁰

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Once its function in the synapse is over, acetyl choline esterase breaks it into acetate anions and choline. Hydrolysis of acetylcholine takes less than millisecond.

Acetate goes back into krebs cycle. Choline reuptake through Na/Cl dependent transporter⁶². Choline reuptake is the rate limiting step.

Acetylcholine estearse

It present in three forms in human body.

Brain acetylcholine esterase

In brain it is seen as tetramer and monomer form.

RBC acetylcholine esterase

Specific or true acetylcholine esterase Red cell, nervous tissue, skeletal muscle.

Plasma acetylcholine esterase

Butryl or pseudocholine esterase Plasma, liver, heart, pancreas, brain.

Each molecule of the enzyme is able to bind and hydrolyze several molecules of acetylcholine.

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Organophosphates attack acetylcholine esterase

Effects of OP compounds due to accumulation of endogenous acetylcholine at sites of cholinergic transmission⁶⁴. Acetylcholine esterase progressively phosphorylated by covalent bonding a process normally takes 24-48 hours. This process is called “ageing”. This period is known as the

“critical interval”. Once the ageing is completed the enzyme cannot be reactivated⁷².

Plasma acetylcholine esterase recovers within four weeks. Red cell AchE takes longer time to recover and may not be restored⁷⁴. Restoration of acetylcholine esterase activity occurs by denovo synthesis of free enzyme and also by spontaneous dephosphorylation of the inhibited enzyme⁷⁶.

Ageing has an important effect on toxicity and treatment outcome.noximes cannot reactivate aged phosphorylated enzyme. ⁷⁸

Changes in AchE levels during poisoning and treatment

Enzyme inhibition is proceeded till a steady state is reached and spontaneous reactivation is achieved¹⁴. choline esterase activity of red cells is instantly and completely restored and long lasting. Return of activity of serum choline esterase is transient and variable after oximes³². There is

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correlation between ingestion and serum choline esterase activity. Longer the interval of ingestion, lowers the activity. ⁴³

Serum choline esterase is sharply reduced in acute myocardial infarction. And below normal level is seen in dermatomyositis. In nephrotic syndrome high level of serum choline esterse is seen⁵⁴.

Disadvantages of serum choline esterase estimation

Following pralidoxime administration true choline esterase levels indicate the effectiveness of PAM, serum choline esterase levels indicates prior presence of cholinesterase inhibition even after recovery of true choline esterse activity by PAM⁸⁰. So latter cannot be used to assess the effectiveness of PAM therapy.

Clinical features Muscarinic symptoms

Excessive salivation Constricted pupils Lacrimation

Wheezing, crackles, pulmonary edema Cramps, vomiting, diaarhea, tenesmus Bradycardia, hypotension

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Blurring of vision Urinary incontinence Nicotinic symptoms

Fasciculations, cramps, weakness, twitching Hypertension, tachycardia

Clinical features⁶⁴

Symptoms appear within 30 minutes to 3 hours. Mostly history given by the patients is accidental or intentional ingestion of organophosphates.

Usually signs and symptoms are non specific. Patients presents with vomiting, diarrhea, abdominal pain, others may be unconscious at the time of arrival at the hospital. High index of suspicion is needed for diagnosis. In early stage patients presents with parasympathetic overactivity and a characteristic garlic smell⁴⁶. Respiratory, gastro intestinal, cardiovascular, nervous and skeletal system also involved. Other organs and metabolic effects such as hypo or hyperglycemia. Most the fatalities occur within 24 hours⁹⁸. Those patients who recover usually do so within 10 days.

Three well defined clinical phases – initial cholinergic phase, the intermediate syndrome, delayed polyneuropathy.

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Cholinergic phase:

Increased secretion because of organophosphate poisoning due to accumulation of acetylcholine at muscarinic sites. It resulting in salivation, bronchorrhea, tearing, sweating. Other features includes bronchoconstriction, bradycardia, vomiting and increase in gastrointestinal motility³⁷. It cause miosis in the eyes resulting in blurring of vision. It act on nicotinic sites and cause muscle fasciculations and flaccid paralysis due to depolarization block⁵⁹. Acetylcholine esterase inhibition in the brain leads to headache, insomnia, confusion, giddiness. Severe exposure cause respiratory depression, convulsions and coma. Death due to effect on heart, respiration and brain⁸⁶. This phase lasts for 1 -2 days. Treatment in intensive care unit is necessary.

Intermediate syndrome:

This syndrome includes onset of muscle weakness and cranial nerve palsies. Death usually due to respiratory failure⁹⁹. This phase sets in approximately 1-4 days after poisoning. Following adequate ventilator care recovery occurs within 4-21 days.⁹⁰

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Delayed polyneuropathy:

Usually occurs in 14- 28 days following exposure to organophosphates. symmetrical peripheral muscle weakness and disturbance in sensation⁸⁴.

They are two types of organophosphate agents one is neurotoxic and the other is neuropathic agents.

Difference between intermediate syndrome and delayed polyneuropathy⁷⁶ Intermediate

syndrome

Delayed polyneuropathy

Latent period 1-4 days 2-3 weeks

Site of weakness Proximal Distal

Limb muscle Involved Not involved

Neck muscle Involved Not involved

Cranial nerve Yes No

Respiratory muscle Involved Not involved

Electromyogram Tetanic fade Denervation

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Rebound phenomenon

Patients those who appear to recover in the level of consciousness and pulmonary edema, again fall back into terminal phase. It includes toxic myocarditis, intestinal reabsorption⁶⁵. This effect is due to binding of OP compounds with fat and their sudden release cause rebound phenomenon¹⁰⁰.

Other system involvement:

Effect on immune system

Reason for severe cholinergic stimulation are direct action or may be secondary to toxic chemical stress⁵⁶. It cause impairment of neutrophil chemotaxis. Increased frequency of upper respiratory tract infections.

Alteration in metabolism

Changes in glucose metabolism and in the diurnal pattern of plasma ACTH may occur. Nonketotic hyperglycemia and glycosuria is present⁷⁶. Effect on endocrine system

T3 and T4 concentrations decreased and TSH level increased⁴¹.

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Effect on cardiac function

Cardiac complications includes hypotension, hypertension, arrhythmias, cardiac arrest. These complications due to hypoxia, metabolic acidosis, electrolyte changes. ⁹²

Effect on reproductive system

Exposure to organophosphate poisoning at the third month of pregnancy, abortion has been performed²¹. Because continuation of pregnancy is hazardous.

Miscellaneous effects

Vocal cord paralysis is also reported in some cases. Isolated bilateral recurrent laryngeal nerve paralysis hs also been reported⁵².

Exposure to organophosphate pesticides associated with arthritis.

Cerebellar disorder ataxia developed about five weeks after acute exposure⁷⁶.

OP poisoning in children

Most of the symptoms in children is related to severe CNS depression, coma, stupor, dyspnea, flaccidity. Miosis, excessive salivation, sweaty cold skin, gastrointestinal symptoms were less frequent³⁸.

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Modified dresisbach clinical criteria Grade 1

Mild symptoms related to portal of entry Nausea, vomiting in case of ingestion Cough, burning sensation in the chest.

Grade 2

Moderate systemic intoxication

Abdominal pain and diarrhea in case of ingestion

Chest tightness, difficulty in breathing in case of inhalation

Salivation, lacrimation, sweating, pupillary changes, bradycardia, confusion, tremor, restlessness.

Grade 3

Severe systemic intoxication

Respiratory depression, generalized weakness Cyanosis, peripheral circulatory failure

Convulsion, coma

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Diagnostic criteria Investigation modalities

Organophosphates toxicity is a clinical diagnoisis. choline esterase activity estimation is done to confirm the diagnosis⁴³. RBC choline esterse level better correlates with CNS acetyl choline esterase, is more useful marker of organophosphate poisoning⁶⁷.

Measurement of RBC and plasma choline esterase levels prior to treatment with pralidoxime. Monitoring serial levels used to determine response to treatment⁸⁴.

RBC acetylcholine esterase represents AchE found on RBC membranes which is similar to that found in neuronal tissue. Measurement reflects nervous system OP AchE inhibition¹⁰².

Plasma choline esterase is a liver acute phase protein which is circulates in blood plasma.

RBC cholinesterase is the more accurate measurement. Plasma cholinesterase is easier to assay and is more readily available.

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These levels do not always correlate with severity of illness.

Neonates and infants have baseline levels that are lower than adults⁵⁷. Falsely depressed levels of plasma cholinesterase are observed in liver dysfunction, neoplasia, low protein conditions, hypersensitivity reactions and genetic deficiencies⁶⁸.

Falsely depressed levels of erythrocyte choline esterase are observed in pernicious anemia, haemoglobinopathies⁷⁹.

Other laboratory findings include leukocytosis, hemoconcentration ,metabolic acidosis, hyperglycemia, hypokalemia, hypomagnesemia⁴⁸.

Imaging studies

Features of pulmonary edema is present in chest radiograph. ECG findings are prolonged Q-Tc intervals, elevation of ST segment, inverted T waves, prolonged PR interval³⁶.

Cardiac toxicity following OP poisoning⁹

Phase 1 : a brief period of increased sympathetic tone.

Phase 2 : a prolonged period of parasympathetic activity including AV nodal blockade.

Phase 3 : Q-T prolongation followed by torsades de pointes. Ventricular tachycardia and ventricular fibrillation.

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According to patel et al

Signs and symptoms Points

Nausea,vomiting,diarrhea, sweating 1

Lacrimation,salivation,miosis,fasciculations 2

Seizures, incontinence, apnea, areflexia 3

ARDS, proximal muscle weakness 4

Coma 5

Respiratory paralysis 8

Sennayake N. proposed POP scale for grading the severity

Points Grade

<6 Mild

7-10 Moderate

11-16 Moderately severe

>16 Severe

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PERADONEYA ORGANOPHOSPHATE POISONING SCALE

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Paradeniya organophosphorus poisoning scale (POP)

Parameter Score

Miosis

Pupil size >2mm <2mm

Pinpoint pupil

0 1 2

Fasciculations None Present

Generalized continuous fasciculations with central cyanosis

0 1 2

Respiration

RR <20 min RR >20 min

RR>20 min with central cyanosis

0 1 2

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Bradycardia

PR >60/min PR 41-60/min PR <40 / min

0 1 2 Level of consciousness

Conscious and rational

Impaired but responds to oral commands

Impaired but no response to oral commands

0 1

2

Total 11

Score Grade

<4 Mild

4-7 Moderate

>7 Severe

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Therapeutic considerations:

Intubations may be necessary in cases of respiratory distress due to laryngospasm, bronchospasm, bronchorrhea, seizures. Use of atropine immediately may eliminate the need for intubation²⁵.

Succinylcholine should be avoided which is degraded by acetylcholinesterase. It resulting in prolonged paralysis⁸⁷.

Continuous cardiac monitoring and vitals monitoring is important.

ECG should be taken. Action of intravenous magnesium sulphate may include acetylcholine antagonism or ventricular membrane stabilization, it has been reported beneficial for organophosphate toxicity⁵⁵.

Remove all clothing and cleanse the patient with soap and water because organophosphates are hydrolyzed readily in aqueous solutions with high ph³⁴.

Neoprene or nitrile gloves and gowns used for personal protection.

Use charcoal cartridge masks for respiratory protection while decontaminating patients.

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Eyes irrigation using isotonic saline. If ingestion occurs within 30-60 minutes, nasogastric tube placement and activated charcoal administration in a dose of 1g/kg orally⁷⁶.

Atropine administration 3-5mg rapid intravenous to reach effective atropinisation³⁸.

5 parameters is used to check adequate atropinisation:

 Pulse rate >85/min

 Systolic blood pressure >80mmhg

 Absence of lung crackles

 Dry axilla

 No constricted pupils

If the parameter are not attained within 3-5 minutes double the initial dosing. To get adequate atropinisation atropine should be given in doubling dose pattern⁴⁴.

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Maintenance of atropinisation

10-20% of the bolus in 100ml normal saline is given. Parameters are assessed every 15 minutes. Superimposed bolus dose of about 3-5 mg is given if there is inadequate atropinisation⁵⁸. Atropine should be tailored down hourly for 6 hours and then every 2-3 hours for the next 24 hours.

Features of atropine toxicity includes agitation, confusion, bladder retention, hyperthermia, ileus and tachycardia⁶⁸. Glycopyrrolate can be used instead of atropine which does not increase the heart rate.

Oximes – pralidoxime

These are nucleophilic agents. It reactivate the phosphorylated acetyl cholinesterase by binding to organophosphate compounds⁵⁴.

Actions of pralidoxime

- Direct action converting the organophosphate to harmless compound

- A transient reaction protecting the enzyme from further inhibition.

- Reactivation of inhibited alkyl phosphorylated enzyme to free the active unit.

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The reactivating action of pralidoxime most marked at the nicotinic skeletal neuromuscular junction³⁹. It should be started as early as possible to prevent permanent binding of organophosphate to acetyl cholinesterase.

Once this has occurred receptor regeneration is required to allow recovery.

Dose required to treat the organophosphate poisoning is 500 mg/hr infusion for the first 48 hours⁴². Followed by 1 gm iv tds for another 3 days. It should be continued till the adequate spontaneous ventilation is achieved by the patient. Effective plasma concentration is 4mg/litre and the patient should show signs of improvement 10-40 mins after administration. During treatment monitor plasma and psudo cholinesterase levels⁸⁰. Side effects of pralidoxime includes drowsiness, visual disturbance, nausea, tachycardia, muscle weakness.

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Treatment with pralidoxime is reserved for potentially fatal patients.

In the management of organophosphate poisoning fresh frozen plasma can also be used.

Prevention and education

Improved regulation of pesticides availability, strict regulation of vendors, modifications in packaging of pesticides may all help to reduce use of OP. public should have the awareness regarding the OP poisoning³⁴. Drugs and antidotes which is used for the management of OP poisoning should be easily available. Establishment of poison information centers will facilitate in reducing the morbidity and mortality⁹. To prevent accidental poisoning it should be kept out of reach of children. Precautions should be taken during agricultural spraying, to prevent inhalation²³.

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Moon JM et al conducted studies on the association between blood sugar values and the severity of opc poisoning. There are various causes for the elevation of blood sugar value in opc poisoning⁴³.

Montgomery et al suggested a positive correlation between chlorpyrifos and the increased blood sugar values⁶⁶.

Gustavson et al suggested inhibition of AChE by OPC at neuroeffector sites in the adrenal medulla causes increase in the secretion of adrenaline. Adrenaline increases blood glucose value by induction of gluconeogenesis and stimulating glycogenolysis³².

Duttaroy et al showed pancreatic B cells have acetylcholine receptor involved in insulin production dependent on blood glucose level. I n animal studies OP pesticide acted as an inhibiter of acetylcholinesterase which caused accumulation of acetyl choline and decrease in insulin production⁷⁶.

42

SYMPATHETIC/PARASYMPATHETIC SYSTEM

43 MUSCARINIC RECEPTOR IN PANCREAS

44

TYPES PF MUSCARINIC/NICOTINIC RECEPTORS

45

46

OBSERVATION RESULTS

Distribution of study population according to age group TABLE 1

Age group Number Frequency

≤20 6 6

21-30 65 65

31-40 29 29

Total 100 100

Majority of the study population (around 65%) are between the age group of 21-30 years.

47

FIGURE 1

Distribution of Study population according to Gender TABLE 2

Sex Number Frequency

Male 51 51

Female 49 49

Total 100 100

Males and females are more or less equally distributed in the study population

0 10 20 30 40 50 60 70

≤20 21-30 31-40

6

65

29

48 FIGURE 2

51 49

Male Female

49

Distribution of study population according to the chemical composition of the poison

TABLE 3

Chemical composition Number Frequency

Carbofuran 5 5

Chlorpyrifos 34 34

Diazinion 1 1

Malathion 27 27

Parathion 33 33

Total 100 100

Around 34 % of study population consumed chlorpyrifor, another 33% consumed Parathion, and another 27 % consumed Malathion.

0 5 10 15 20 25 30 35

Carbofuran Chlorpyrifos Diazinion Malathion Parathion 5

34

1

27

33

50

Distribution of Study population according to HbA1C levels TABLE 4

HbA1c levels Number Frequency

<6 92 92

6-6.5 8 8

>6.5 0 0

Total 100 100

92% of the population have a HbA1c <6

51

FIGURE 4

92

8

0 10 20 30 40 50 60 70 80 90 100

<6 6-6.5

<6 6-6.5

52

Distribution of study population according to POP Score taken within 6 hrs of consumption

TABLE 5

POP score Number Frequency

3 14 14

4 18 18

5 7 7

6 38 38

7 11 11

8 11 11

9 1 1

Total 100 100

53

Distribution of study population according to POP Score taken within 6 hrs of consumption

FIGURE 5

0 5 10 15 20 25 30 35 40

score 3 score 4 score 5 score 6 score 7 score 8 score 9 14

18

7

38

11 11

1

54

Distribution of study population according to POP-score taken within 12 hrs of consumption

TABLE 6

POP Score Number Frequency

3 5 5

4 11 11

5 3 3

6 13 13

7 8 8

8 26 26

9 24 24

10 10 10

Total 100 100

55

Distribution of study population according to POP-score taken within 12 hrs of consumption

FIGURE 6

0 5 10 15 20 25 30

score 3 score 4 score 5 score 6 score 7 score 8 score 9 score 10 5

11

3

13

8

26

24

10

56

Distribution of Study population according to the need for mechanical ventilator

TABLE 7

Mechanical ventilator Number Frequency

Needed 70 70

Not needed 30 30

Total 100 100

70 30

Needed Not needed

57

Distribution of Study population according to Recovery of the patients TABLE 8

Outcome Number Frequency

Recovered 90 90

Death 10 10

Total 100 100

0 10 20 30 40 50 60 70 80 90

Recovered Death

90

10

58

Distribution of Study population according to Complications TABLE 9

Outcome Number Frequency

No complications 89 89

Polyneuropathy 1 1

VAP 10 10

Total 100 100

59

As our primary objective is to find out the effect of hyperglycaemia in the outcome of the patients. The study group is henceforth divided as two groups

Group 1 – Random blood sugar value less than 200 Group 2 – Random blood sugar value more than 200

(Since we have taken only non-diabetic patients as our study population, glycaemic index was not used for dividing the groups)

0 10 20 30 40 50 60 70 80 90

No complications Polyneuropathy VAP

89

1 10

60

Distribution of Study Population according to Gender TABLE 10

Gender

RBS< 200mg/dl RBS>200mg/dl Chisquare

Value Significance

No % No %

0.446 0.542

Male 21 55.26 30 48.38

Female 17 44.74 32 51.62

Males and females are equally distributed in both groups. The results are statistically significant. The groups are homogeneous or alike before the start of the study- sample selection is correctly done.

0 20 40 60 80 100

RBS< 200mg/dl RBS>200mg/dl 55.26

48.38 44.74

51.62

Female Male

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Distribution of Study Population according to age group TABLE 11

AGE group

in yrs

RBS< 200mg/dl RBS>200mg/dl Chisquare

Value Significance

No % No %

2.277 0.352

<20 4 10.5 2 3.2

21-30 24 63.2 41 66.1

31-40 10 26.3 19 30.6

There is no statistical difference in both groups with respect to age.

0 10 20 30 40 50 60 70

<20 21-30 31-40

10.5

63.2

26.3

3.2

66.1

30.6 RBS< 200mg/dl RBS>200mg/dl

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Distribution of Study Population according to chemical compound Consumed

TABLE 12

Chemical compound

RBS< 200mg/dl RBS>200mg/dl Chisquare

Value Significance

No % No %

3.994 0.409

Carbofuran 2 5.3 3 4.8

Chlorpyrifos 9 23.7 25 40.37

Diazinion 0 0 1 1.6

Malathion 13 34.2 14 22.3

Parathion 14 36.8 19 30.6

There is no statistical difference in both groups with respect to chemical composition consumed.

63

Distribution of Study Population according to chemical compound consumed

FIGURE 12

0 5 10 15 20 25 30 35 40 45

Carbofuran Chlorpyrifos Diazinion Malathion Parathion 5.3

23.7

0

34.2

36.8

4.8

40.37

1.6

22.3

30.6

RBS< 200mg/dl RBS>200mg/dl

64

From the last three tables we infer that there is no statistical significance between the study subjects with respect to age group. Gender and chemical composition consumed. Hence its very clear that both the groups are comparable. In other words , the sampling technique has been followed perfectly so that both the groups are similar in composition before the start of the study enabling us to compare the difference in both groups effectively.

65

Association between need for mechanical ventilation and both groups.

TABLE 13 Need for

Mechanical ventilation

RBS< 200mg/dl RBS>200mg/dl

Chi square Value

Significance

No % No %

49.231 0.000

Needed 11 28.9 59 95.2

Not needed 27 71.1 3 4.8

Around 95% of the study population in the group two(RBS > 200) needed mechanical ventilation support while only 29 % of the study population needed mechanical ventilation support. The results are statistically significant. Thus it is obvious that the need for mechanical ventilation is very high in non-diabetics who have RBS level >200 while admission.

66

Association between need for mechanical ventilation and both groups.

FIGURE 13

0 10 20 30 40 50 60 70 80 90 100

RBS< 200mg/dl RBS>200mg/dl

28.9

95.2

71.1

4.8

Needed Not needed

67

Association between recovery status and both groups TABLE 14

Recovery

status RBS< 200mg/dl RBS>200mg/dl

Fischer exact Value

Significance

No % No %

8.332 0.040

Recovered 38 100 52 83.8

Died 0 0 10 16.2

Around 16% of the study population died in Group 2, while there is no death in group one. Concurrently the recovery percentage is comparatively good in group 1(97.37% vs 80.6%). The results are statistically significant. Hence the recovery percentage is better in those who had initial blood sugar value of less than 200mg/dl

68

Association between recovery status and both groups FIGURE 14

0 10 20 30 40 50 60 70 80 90 100

RBS< 200mg/dl RBS>200mg/dl 100

83.8

0

16.2

Recovered Died

69

Association between both groups and the post admission complications TABLE 15

Complications RBS< 200mg/dl RBS>200mg/dl Chisquare

Value Significance

No % No %

12.15 0.016 No

complications 38 100 51 75

Poly

neuropathy 0 0 1 1.61

VAP 0 0 10 23.39

There is no complication encountered in those who had an initial blood sugar value of 200mg /dl and the results are statistically significant.

FIGURE 15

0 10 20 30 40 50 60 70 80 90 100

No complications Poly neuropathy VAP 100

0 0

75

1.61

23.39

RBS< 200mg/dl RBS>200mg/dl

70

Association between POP score within 6 hrs vs POP within 12 hrs in patients with RBS< 200mg/dl

POP score with 6 hrs

POP score within 12 hrs Chisquare

Value Significance Mild Moderate Severe

14.325 0.001

Mild 5 7 0

Moderate 0 19 7

Severe 0 0 0

Association between POP score within 6 hrs vs POP within 12 hrs in patients with RBS> 200mg/dl

POP score with 6 hrs

POP score within 12 hrs Chisquare

Value Significance Mild Moderate Severe

13.816 0.007

Mild 0 2 0

Moderate 0 7 41

Severe 0 0 12

From the above two tables, we can infer that the deterioration from moderate to severe is around 27 % in RBS < 200 mg/dl group while it is more than 85 % in group 2. The results are statistically significant when comparing POP score taken within 6 hrs with POP score taken with 12 hrs,

71

Further the difference in POP score and Difference in RBS values between POP score taken within 6 hrs with POP score taken with 12 hrs was measured and correlation between both were also measured. There is a non significant very weak correlation(r = 0.016) between both in RBS >

200mg/dl.

Association between type of compound consumed and the POP/RBS difference was analysed with the outcome. There is no statistically significant difference in outcome with respect to the chemical composition of the poison

72

Association between outcome and complications TABLE 18

Outcome

Complications

Fischer exact Value

Significance No

complications Polyneuropathy VAP

18.024 0.008

Recovered 42 1 9

Died 9 0 1

Only 10 % of those who had VAP died while the rest 90% recovered.

Around 90 % who died had no complications. The results are statistically significant. Hence it is inferred that VAP is not the reason for death in opc poisoning.

73

DISCUSSION

OPC poisoning is one of the common and fatal poisoning encountered in India. The number of cases encountered in rural areas are almost as twice as the urban population. Trichy MGMGH is located in heart of the city and almost all cases of OPC poisoning in and around Trichy are referred to Trichy. Since OPC are the compounds easily available , making them the most common poisoning.

The manifestations of OPC poisoning are 1. Acute cholinergic crises

2. Intermediate syndrome 3. Delayed polyneuropathy

There are various other complications that may be expected in OPC poisoning

 Acute kidney injury

 Rhabdomyolysis

 Ventilator associated Pneumonia

Though there are various severity scoring scales are available for OPC poisoning , a simple bedside biochemical investigation for severity would be useful.

74

Random blood sugar values may give clue in assessing the severity of the patient. Based on the blood sugar values , it will be easy to assess the prognosis and clinical spectrum of the patient.

There various factors attributed for hyperglycemia

 Stress

 Acute pancreatitis

 oxidative stress

 Renal tubular damage

 stimulation of adrenals

 Release of Catecholamines

In our study of 100 patients there was no gender discrimination ,male and female patients were almost equal.male 51% and female 49%.Majority of the study population were in the age group 21-30 (65%).Around 34% of the study population consumed chlorpyrifos 33%parathion 27% malathion.

92% of the study population had a HbA1C <6.

The severity of the patients were assessed using POP scale at 6hrs and 12hrs, with their corresponding blood sugar values at 6 and 12 hrs.The deterioration from moderate to severe in POP scale is around 27% in RBS<200 while it is more than 85% in RBS >200.

75

There is no statistical difference in the prognosis of the patient with respect to age/gender/type of compound.

95% in the study population in group 2(RBS>200) needed mechanical ventilation while in group 1 only 29% needed mechanical ventilation. The results were statistically significant ( chi square value 49.23)The study by pendkar et all showed incidence of complications as 73%(group 2) and 27%(group1)

16% of the study population in study group 2 died, while there is no death in group 1.The number of deaths in Ali mohammad sabzghabee et al was 13% in group1 and 15% in group2.The results were statically significant(fischer exact value 8.32)

There are no complications in the study group 1 with RBS<200mg/dl.

only 10% of those who had VAP died while the rest 90% recovered. Around 90% who died has no complications such as VAP.

76

CONCLUSION

Hyperglyemia is definitely a simple bed side test that may be used to assess the prognosis and recovery in patients taking organophosphorous compounds.

Hereby conclude that the study conducted in Trichy MGMGH in pts with OPC POISONING proved to be statistically significant that hyperglycemia is poor prognostic factor.

77

LIMITATIONS

 The sample size is minimal (100)

 The duration of study is small

 Quantity of the amount of poison consumed cannot be estimated.

78

BIBLIOGRAPHY

1. Abdollahi, M., Donyavi, M., Pournourmohammadi, S., & Saadat M.

(2004a). Hyperglycemia associated with increased hepatic glycogen phosphorylase and phosphoenol pyruvate carboxykinase in rats following sub-chronic exposure to malathion. Comparative Biochemistry & Physiology (C), 137, 343-347.

2. Abdollahi, M., Ranjbar, A., Shadnia, S., et al. (2004b). Pesticides and oxidative stress; review. Medical Science Monitor, 10, 141-147.

3. Abou-Donia, M. (2003). Organophosphorus Ester-Induced Chronic Neurotoxicity. Archives of Environmental Health, 58, 484-497.

4. Akhgari, M., Abdollahi, M., Kebryaeezadeh, A., et al. (2003).

Biochemical evidence for free radical-induced lipid peroxidation as a mechanism for sub chronic toxicity of malathion in blood and liver of rats. Human & Experimental Toxicology, 22, 205-211.

5. Andrews, RC., & Walker, BR. (1999). Glucocorticoids and insulin resistance: old hormones, new targets. Clinical Science, 96, 513-523.

6. Argaud. D., Zhang, Q., Malatra, S., et al. (1996). Regulation of rat liver glucose-6- phosphatase gene expression in different nutritional and hormonal states. Diabetes, 45, 1563-1571.

79

7. Banerjee, BD., Seth, V., & Ahmed, RS. (2001). Pesticide-induced oxidative stress: perspective and trends. Reviews on Environmental Health, 16, 1-40.

8. Begum, K, & Rajini, PS. (2011a). Monocrotophos augments the early alterations in lipid profile and organ toxicity associated with experimental diabetes in rats. Pesticide Biochemistry & Physiology, 99, 33-38.

9. Begum, K & Rajini, PS. (2011b). Augmentation of hepatic and renal oxidative stress and disrupted glucose homeostasis by monocrotophos in streptozotocin-induced diabetic rats. Chemico Biological Interactions, (In press).

10. Bradbury, MWB., Burden, J., Hillhouse, EW., & Jones, MT. (1974).

Stimulation electrically and by acetylcholine of the rat hypothalamus in vitro. Journal of Physiology, 239, 269–83.

11. Brodeur, J., & DuBois, KP. (1964). Studies on the mechanism of acquired tolerance by rats O, O-diethyl S-2- (ehylthio) ethyl phosphorodithioate (Di-syston). Archives of International Pharmacodynamics, 149, 560-570.

80

12. Bugajski, J., Gadek-Michalska, A., & Bugajski, AJ. (2002). Effect of constitutive- and inducible-cyclooxygenase in the carbachol-induced pituitary-adrenocortical response during social stress. Journal of Physiology & Pharmacology, 53, 453-462.

13. Calogero AE, Kamilaris TC, Gomez MT, et al. (1989). The muscarinic cholinergic agonist arecoline stimulates the rat hypothalamic-pituitary-adrenal axis through a centrally-mediated corticotropin-releasing hormone-dependent mechanism.

Endocrinology, 125, 2445-2453.

14. Calogero, AE., Gallucci, WT., Bernardini, R., et al. (1988). Effect of cholinergic agonists and antagonists on rat hypothalamic corticotropin-releasing hormone secretion in vitro.

Neuroendocrinology. 47, 303-308.

15. Costa, LG., Schwab, BW., & Murphy, SD. (1982a). Differential alterations of cholinergic muscarinic receptors during chronic and acute tolerance to organophosphorus insecticides. Biochemical Pharmacology, 31, 3407-3413

16. Costa, LG., Schwab, BW., & Murphy, SD. (1982b). Tolerance to anticholinesterase compounds in mammals. Toxicology, 25, 79-97.