الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Cholinesterase inhibitors insecticides poisoning (especially organophosphorus) is still a global problem especially in the developing countries like Egypt. Organophosphorus compounds are widely used as pesticides in agriculture and also as domestic insecticides. Patients may be exposed to organophosphorus compounds through inhalation, ingestion or dermal exposure.
The easy availability of these compounds and their wide spread usage makes self-pining by organophosphorus compounds a common way for suicidal attacks especially in the young age group or by accidental ingestion especially in agricultural workers.
Organophosphorus compounds act mainly by inhibition of acetyl cholinesterase enzyme leading to accumulation of acetylcholine and the occurrence of the characteristic signs and symptoms the form of muscarinic, nicotinic and CNS manifestations.
Serious complications may occur from OP poisoning, one of them, is the intermediate syndrome which is characterized by muscle weakness and may result in respiratory failure and hence the need for respiratory support in the form of mechanical ventilation.
Diagnosis of OP poisoning can be done by history taken from the patient or his relatives and the characteristic clinical picture.
Since the clinical picture alone is not enough to create a sufficient assessment of the patient’s toxic status and severity, hence, the need for sufficient investigations has become mandatory during the past few decades especially with the increase in the number of cases of poisoning with CEIs.
The aim of this study was to investigate the validity of acyl-peptide hydrolase (APH) enzyme as a probable marker of severity in cases of poisoning by cholinesterase enzyme inhibitor (CEIs) insecticides. The present work was carried out on eighty patients suffering from acute cholinesterase enzyme inhibitors insecticides poisoning admitted to the department of Emergency Medicine or Poison Unit, at the Main Alexandria University Hospital during the period from the 1st of June 2014 till the 30th of November 2014, after agreement and signing of informed consent. Another 15 healthy volunteers were included as a control group.
A clinical sheet was used to assess the patients, including The following:personal history:name,address (residency), age, gender, education, route of poisoning and circumstances of poisoning. Clinical examination: vital signs (pulse, blood pressure, respiratory rate and temperature), clinical examination (pupil size & reaction, muscarinic manifestations, nicotinic manifestations, central nervous system manifestations and level of consciousness). Investigations: ECG, serum cholinesterase level, serum acyl-peptide hydrolase level, arterial blood gases & electrolytes (pH, PCO2, HCO3, PO2, Na+, K, O2 saturation) and treatment received by the patients.
Regarding the demographic data, the mean age for the studied patients (n=80) was 27.53 ± 10.58 years, with a minimum age of 13 years and a maximum age of 57 years old. 48 patients were males (60 %) and 32 patients were females (40 %). 25 patients (31.3 %) were students, 23 patients (28.8%) were farmers, 17 patients (21.3 %) had no work and 15 patients (18.8 %) were housewives. The main route of poisoning was the oral route, which accounted for 57 cases 71.3 % (25 males 52.1 % and 32 females 100%), while the non oral route (inhalation and transdermal), which accounted for 23 patients (28.8%), all of them were males (23 males 42.9 %). Almost all of the patients were intentionally subjected to the poisoning compounds (suicidal attempts) (54 patients, 67.5 %; 22 males 45.8 %and 32 females 100%),however,only 26 patients(32.5%)were subjected accidentally to the poisoning compounds,all of them were males (26males;54.2 %).
Clinical examination of the studied patients showed that, the most prevalent signs and symptoms in the studied patients were muscarinic manifestations: vomiting (40 patients 50 %), miosis (35 patients 43.8 %), followed by fasciculation (31 patients 38.8 %). The least represented symptoms were bradycardia (8 patients 10 %) and tachypnea (8 patients 10%). 70 patients (87.5 %) were categorized as mild, 6 patients (7.5 %) were categorized as moderate and 4 patients (5 %) were categorized as severe (according to Peradenya Organophosphorus Poisoning (POP) scale ).
Regarding the laboratory findings of the studied patients, the total sample had a mean serum acyl-peptide hydrolase level of 14.16±22.53 pg/ml, which is within the normal range (5 – 220 pg/ml). The total sample had a mean serum acetyl cholinesterase level of 3556.0 ± 2815.66 U/L, which is lower than the normal range (4900 – 11900 U/L).
As regards to the arterial blood gases & electrolytes analysis, the total sample had a mean pH level of 7.42 ± 0.06. The sample had a mean partial carbon dioxide tension (PCO2) of 35.03 ± 6.29 mmHg. The mean bicarbonate (HCO3) level of the total sample was 23.72±6.25 mEq/L. The mean partial oxygen tension (PO2) of the total sample was 97.18 ± 17.87 mmHg. The total sample had a mean sodium (Na+) of 150.18 ± 15.13 mEq/L, while they had a mean potassium (K+) level of 3.37 ± 0.28 mEq/L, and a mean oxygen saturation (O2 saturation) of 96.05 ± 4.26 %.
Clinical interventions to the studied patients varied between general measures, with or without atropine and toxogonine (oximes), till the final clinical outcome was calculated for each patient.
There was a high degree of negative correlation, and a highly significant P value of < 0.001, between the serum acetyl cholinesterase level and the POP score and high degree of positive correlation, and a highly significant P value of 0.003, between the serum acetyl cholinesterase level and bicarbonate (HCO3) and PCO2 with P value of < 0.001. There was no significant correlation, no significant P value of 0.096, between the serum acyl-peptide hydrolase level and the POP score, and between the serum acyl-peptide hydrolase and the serum acetyl cholinesterase with P value of 0.665.
Although, there was a progressive decrease in serum acyl-peptide hydrolase(APH)activity proportional to increase to severity in poisoning and APH correlates best and effectively with clinical severity. Thus, it may be stand as an alternative, sensitive and specific biochemical marker to PchE in investigation, diagnosis and prognosis of CEIs insecticides poisoning cases.