A study of the clinical profile of yellow oleander poisoning with special reference to electrocardiographic and biochemical abnormalities and outcome at GMKMCH, Salem

Introduction:Yellow oleander (Thevetia peruviana), which belongs to the Apocyanaceae family, is a common shrub seen throughout the tropics. All parts of the plant contain high concentrations of cardiac glycosides which are toxic to cardiac muscle and the autonomic nervous system. Here, we describe the clinical profile of patients with oleander poisoning and their outcomes.Methods and Materials:This retrospective study was conducted over a period of 12 months (March 2016 to February 2017). The data was extracted from the inpatient electronic medical records. Adult patients with a diagnosis of acute yellow oleander poisoning were included in the study. Descriptive statistics were obtained for all variables in the study and appropriate statistical tests were employed to ascertain their significance.Results:The study comprised 30 patients aged 30.77 ± 12.31 (mean ± SD) who presented at 12.29 ± 8.48 hours after consumption of yellow oleander. Vomiting (80%) was the most common presenting symptom. Metabolic abnormalities at presentation included hyperchloremia in 22 patients and metabolic acidosis (bicarbonate <24 mmol/L) in 29 patients. Fifteen (50%) patients had abnormal ECG, of which second-degree AV block was the commonest ECG abnormality seen in 4 (13.3%). Fifteen (50%) patients had transvenous temporary pacemaker insertion (TPI). Having a TPI significantly prolonged the duration of hospital stay (OR 1.85, 95% CI 1.06–3.21, P 0.03). The mortality in the cohort was 2 (6.7%).Conclusion:In patients with yellow oleander poisoning, dyselectrolytemia with ECG abnormalities was common. TPI prolonged the duration of hospital stay. Further studies are required to know the indication for and to ascertain the effect of temporary pacing on survival.

Cardiac toxicity after self-poisoning from ingestion of yellow oleander seeds is common in Sri Lanka. We studied all patients with yellow oleander poisoning (YOP) admitted to a secondary care hospital in north central Sri Lanka from May to August 1999, with the objective of determining the outcome of management using currently available treatment. Patients with bradyarrhythmias were treated with intravenous boluses of atropine and intravenous infusions of isoprenaline. Temporary cardiac pacing was done for those not responding to drug therapy. During the study period 168 patients with YOP were admitted to the hospital (male:female = 55:113). There were six deaths (2.4%), four had third-degree heart block and two died of undetermined causes. They died soon after delayed admission to the hospital before any definitive treatment could be instituted. Of the remaining 162 patients, 90 (55.6%) patients required treatment, and 80 were treated with only atropine and/or isoprenaline while 10 required cardiac pacing in addition. Twenty-five (14.8%) patients had arrhythmias that were considered life threatening (second-degree heart block type II, third-degree heart block and nodal bradycardia). All patients who were treated made a complete recovery. Only a small proportion of patients (17%) admitted with YOP developed life-threatening cardiac arrhythmias. Treatment with atropine and isoprenaline was safe and adequate in most cases.

Cardiac toxicity after self-poisoning from ingestion of yellow oleander seeds is common in Eastern Sri Lanka. To determine the clinical manifestations, cardiac arrhythmias, electrolytes abnormalities and outcome of management using currently available treatment, Poisoning Unit, Tertiary Care Hospital in Eastern Sri Lanka. We studied 65 patients [Mean age : 23(± 0.43)yrs], (Male: Female=27:38) with yellow oleander poisoning (YOP) admitted to a Poisoning Unit, Tertiary Care Hospital in Eastern Sri Lanka from January to December 2011. Most patients are symptomatic who presented with classical symptoms of vomiting, abdominal pain and diarrhea. Cardiac dysrhythmias such as bradycardia or an irregular pulse are the most common findings on examination. Most symptomatic patients had conduction defects affecting the sinus node, the atrioventricular (AV) node, or both. Patients showing cardiac arrhythmias that required transfer for specialised management had significantly higher serum potassium concentrations. Almost all patients were treated with multiple activated charcoal even late presentation. Patients with brad arrhythmias were treated with intravenous boluses of atropine and intravenous infusions of isoprenaline. Temporary cardiac pacing was done for those not responding to drug therapy. There were two deaths (3.07%), both had third-degree heart block. They died even definitive treatment could be instituted. Of the remaining 63 patients, 54 (83.1%) patients required treatment, and 29 were treated with only atropine and/or isoprenaline while one required cardiac pacing in addition. 12 (18.4%) patients had arrhythmias that were considered life threatening (second-degree heart block type II, third-degree heart block and nodal bradycardia). They had good recovery even though they had developed cardiac toxicity. YOP are common among young females. The cardiac toxicity develops within 24 hrs of ingestion of YO seeds. The risk of toxicity has negative correlation with number of seeds. Most patients have nonspecific symptoms. AV conduction defects are common. Multiple activated charcoals alone were safe and adequate in most cases even late presentation.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA G.S. Y, Honest P, Subramanian A, et al. Characteristics, types and causes of chest pain in an urban family practice secondary care center in South India. Family Medicine & Primary Care Review. 2017;19(4):377-381. doi:10.5114/fmpcr.2017.70810. APA G.S., Y., Honest, P., Subramanian, A., Abraham, R., Velaga, S., & Pricilla, R. et al. (2017). Characteristics, types and causes of chest pain in an urban family practice secondary care center in South India. Family Medicine & Primary Care Review, 19(4), 377-381. https://doi.org/10.5114/fmpcr.2017.70810 Chicago G.S., Yeshvanth Kumar, Prince Christopher Rajkumar Honest, Apoorva Subramanian, Ranjit Abraham, Saran Teja Velaga, Ruby Angeline Pricilla, and Kirubah Vasandhi David et al. 2017. "Characteristics, types and causes of chest pain in an urban family practice secondary care center in South India". Family Medicine & Primary Care Review 19 (4): 377-381. doi:10.5114/fmpcr.2017.70810. Harvard G.S., Y., Honest, P., Subramanian, A., Abraham, R., Velaga, S., Pricilla, R., David, K., and Abraham, S. (2017). Characteristics, types and causes of chest pain in an urban family practice secondary care center in South India. Family Medicine & Primary Care Review, 19(4), pp.377-381. https://doi.org/10.5114/fmpcr.2017.70810 MLA G.S., Yeshvanth Kumar et al. "Characteristics, types and causes of chest pain in an urban family practice secondary care center in South India." Family Medicine & Primary Care Review, vol. 19, no. 4, 2017, pp. 377-381. doi:10.5114/fmpcr.2017.70810. Vancouver G.S. Y, Honest P, Subramanian A, Abraham R, Velaga S, Pricilla R et al. Characteristics, types and causes of chest pain in an urban family practice secondary care center in South India. Family Medicine & Primary Care Review. 2017;19(4):377-381. doi:10.5114/fmpcr.2017.70810.

Background. Poisoning due to deliberate self-harm with the seeds of yellow oleander (Thevetia peruviana) results in significant morbidity and mortality each year in South Asia. Yellow oleander seeds contain highly toxic cardiac glycosides including thevetins A and B and neriifolin. A wide variety of bradyarrhythmias and tachyarrhythmias occur following ingestion. Important epidemiological and clinical differences exist between poisoning due to yellow oleander and digoxin; yellow oleander poisoning is commonly seen in younger patients without preexisting illness or comorbidity. Assessment and initial management. Initial assessment and management is similar to other poisonings. No definite criteria are available for risk stratification. Continuous ECG monitoring for at least 24 h is necessary to detect arrhythmias; longer monitoring is appropriate in patients with severe poisoning. Supportive care. Correction of dehydration with normal saline is necessary, and antiemetics are used to control severe vomiting. Electrolytes. Hypokalemia worsens toxicity due to digitalis glycosides, and hyperkalemia is life-threatening. Both must be corrected. Hyperkalemia is due to extracellular shift of potassium rather than an increase in total body potassium and is best treated with insulin-dextrose infusion. Intravenous calcium increases the risk of cardiac arrhythmias and is not recommended in treating hyperkalemia. Oral or rectal administration of sodium polystyrene sulfonate resin may result in hypokalemia when used together with digoxin-specific antibody fragments. Unlike digoxin toxicity, serum magnesium concentrations are less likely to be affected in yellow oleander poisoning. The effect of magnesium concentrations on toxicity and outcome is not known. Hypomagnesaemia should be corrected as it can worsen cardiac glycoside toxicity. Gastric decontamination. The place of emesis induction and gastric lavage has not been investigated, although they are used in practice. Gastric decontamination by the use of single dose and multiple doses of activated charcoal has been evaluated in two randomized controlled trials, with contradictory results. Methodological differences (severity of poisoning in recruited patients, duration of treatment, compliance) between the two trials, together with differences in mortality rates in control groups, have led to much controversy. No firm recommendation for or against the use of multiple doses of activated charcoal can be made at present, and further studies are needed. Single-dose activated charcoal is probably beneficial. Activated charcoal is clearly safe. Arrhythmia management. Bradyarrhythmias are commonly managed with atropine, isoprenaline, and temporary cardiac pacing in severe cases, although without trial evidence of survival benefit, or adequate evaluation of possible risks. Accelerating the heart rate with atropine or β-adrenergic agents theoretically increases the risk of tachyarrhythmias, and it has been claimed that atropine increases tachyarrhythmic deaths. Further studies are required. Tachyarrhythmias have a poor prognosis and are more difficult to treat. Lidocaine is the preferred antiarrhythmic; the role of intravenous magnesium is uncertain. Digoxin-specific antibody fragments. Digoxin-specific antibody fragments are effective in reverting life-threatening cardiac arrhythmias; prospective observational studies show a beneficial effect on mortality. High cost and lack of availability limit the widespread use of digoxin-specific antibody fragments in developing countries. Conclusions. Digoxin-specific antibody fragments remain the only proven therapy for yellow oleander poisoning. Further studies are needed to determine the place of activated charcoal, the benefits or risks of atropine and isoprenaline, the place and choice of antiarrhythmics, and the effect of intravenous magnesium in yellow oleander poisoning.

The human heart beats 2.5 billion times during a normal lifespan, a feat accomplished by cells of the cardiac conduction system (CCS). The functional components of the CCS can be broadly divided into the impulse-generating nodes and the impulse-propagating His-Purkinje system. Human diseases of the conduction system have been identified that alter impulse generation, impulse propagation, or both. CCS dysfunction is primarily due to acquired conditions such as myocardial ischemia/infarct, age-related degeneration, procedural complications, and drug toxicity. Inherited forms of CCS disease are rare, but each new mutation provides invaluable insight into the molecular mechanisms governing CCS development and function. Applying a multidisciplinary approach, which includes human genetic screening, biophysical analysis, and transgenic mouse technology, has yielded a broad array of gene families involved in maintaining normal CCS physiology (Figure 1). In this review, we discuss gene families that have been implicated in human CCS diseases of rhythm, conduction block, accessory conduction, and development (Table). We also investigate evolving therapeutic strategies that may serve as adjuvant or replacement therapy to current implantable pacemakers. Figure 1. Cardiac conduction system cell. Genes identified in human cardiac conduction system disease are highlighted. View this table: Table. Genetic Basis of Conduction System Disease The human sinoatrial node (SAN) is a crescent-shaped, intramural structure with its head located subepicardially at the junction of the right atrium and the superior vena cava and its tail extending 10 to 20 mm along the crista terminalis.26 The SAN has complex 3-dimensional tissue architecture with central and peripheral components made up of distinct ion channel and gap junction expression profiles.27 Central and peripheral cells have different action potential characteristics and conduction properties (Figure 2).27 Experimental and computational models have demonstrated that SAN heterogeneity is necessary to maintain normal automaticity and impulse conduction.28,–,30 Figure 2. Electrophysiological heterogeneity of the …

Intentional self-poisonings with seeds from the yellow oleander tree (Thevetia peruviana) are widely reported. Activated charcoal has been suggested to benefit patients with yellow oleander poisoning by reducing absorption and/or facilitating elimination. Two recent randomized controlled trials (RCTs) assessing the efficacy of activated charcoal yielded conflicting outcomes in terms of mortality. The effect of activated charcoal on the pharmacokinetics of Thevetia cardenolides has not been assessed. This information may be useful for determining whether further studies are necessary. Serial blood samples were obtained from patients enrolled in an RCT assessing the relative efficacy of single-dose and multiple-dose activated charcoal (SDAC and MDAC, respectively) compared with no activated charcoal (NoAC). The concentration of Thevetia cardenolides was estimated with a digoxin immunoassay. The effect of activated charcoal on cardenolide pharmacokinetics was compared between treatment groups by determining the area under the curve for each patient in the 24 hours following admission, the 24-hour mean residence time, and regression lines obtained from serial concentration points, adjusted for exposure. Erratic and prolonged absorption patterns were noted in each patient group. The apparent terminal half-life was highly variable, with a median time of 42.9 hours. There was a reduction in 24-hour mean residence time and in the apparent terminal half-life estimated from linear regression in patients administered activated charcoal, versus the control group (NoAC). This effect was approximately equal in patients administered MDAC or SDAC. Activated charcoal appears to favorably influence the pharmacokinetic profile of Thevetia cardenolides in patients with acute self-poisoning and may have clinical benefits. Given the conflicting clinical outcomes noted in previous RCTs, these mechanistic data support the need for further studies to determine whether a particular subgroup of patients (eg, those presenting soon after poisoning) will benefit from activated charcoal.

POSTER PRESENTATIONS

Considerable advances in the diagnosis and treatment of cancer have made a huge impact on morbidity and mortality from neoplastic diseases. However, cancer remains the leading cause of death across the world. This is a retrospective study carried out at a tertiary cancer care centre (Kidwai Memorial Institute of Oncology, Bangalore) in South India. Case records of all cancer patients who died while receiving inpatient treatment between January 2022 and December 2022 under the Department of Medical Oncology were reviewed and studied. There was a total of 240 deaths. Out of these, the majority of deaths 147 (61.25%) were patients with haematological malignancies while the remaining 93 (38.75%) were patients with solid tumours. In patients with solid tumours, the majority 49 (52.7%) were in the age group of 40 to 60 years while only 18 (19.35%) patients were less than 40 years. The majority of patients weremale sex i.e. 55(59.1%) and undergoing treatment with palliative intent 81 (87%). The most common organ was the lung in 21 patients (22.6%) followed by the breast while the most common system involved was the gastrointestinal tract in 28 (30.1%) patients. The most frequent cause of death was progressive disease in 72 (77.4%) while sepsis (11 patients; 11.8%) was the second most frequent cause of death in solid tumours. In haematological malignancies, also a significant number of 57 (38.8%) patients were in the age group of 40 to 60 years. Fifty-two (35.3%) patients were in the age group of 22 to 40 years. The majority weremale sex (79 patients; 53.7%). About the phase of treatment, the majority of deaths 45 (30.6%) were during induction and under evaluation. Those with relapse/refractorydisease were 38 (25.9%). A substantial number of patients had acute myeloid leukaemia47 (32%) and five (3.4%) deaths were acute promyelocytic leukaemiapatients. Twenty-three patients (15.6%) hadacute lymphoblastic leukaemia. The most common cause of death was sepsis in 76 patients (51.7%) whileintracranial bleeding was in 34 patients (23.1%). In some patients, there were multiple causes leading to death. Mortality audits are important to evaluate the services being provided at any centre. One can appreciate the lacunae in handling a particular disease or flaws in a treatment protocol or the staff delivering the treatment. Sepsis is the leading cause of death in patients with haematological malignancy; even in solid malignancy sepsis accounts for a substantial proportion of deaths and should be handled aggressively to save lives.

ABSTRACTBackground: Poisoning occurs following the ingestion of crushed seeds or fruits of yellow oleander. Objectives of the study were to investigate various arrhythmias and electrolyte abnormalities seen in patients with yellow oleander poisoning and to find out the correlation between various arrhythmias, duration and form of exposure of oleander.Methods: Fifty patients from the toxicology ward in the Institute of Internal Medicine, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, who fulfilled the eligibility criteria, were enrolled for this prospective and observational study among the patients admitted for the ingestion of yellow oleander.Results: Oleander seed poison was most prevalent in the 21-40 years of age. Incidence was more among the young males. Mortality was independent of the number of seeds consumed. More the crushed seeds consumed and delay to admission to the hospital, poorer was the outcome. ECG abnormalities were found in majority of the individuals. Electrolyte disturbances (hyperkalemia and hypermagnesemia) were found in significant proportion of the patients.Conclusions: Prognosis was poor among those who presented with bradycardia, electrolyte disturbances and complex arrhythmias. The arrhythmias produced by this poisoning might range from sinus bradycardia to complete heart block and ventricular tachycardia. Sinus bradycardia was the most common arrhythmia seen in this study. As there are no standard guidelines at present to recommend the indications for temporary pacemaker in the management of oleander induced arrhythmias, uniform guidelines have to be formulated.

2021 PACES Expert Consensus Statement on the Indications and Management of Cardiovascular Implantable Electronic Devices in Pediatric Patients: Executive Summary.

Background: Yellow oleander/Cerebra thevetia/Pila kaner a plant widely cultivated in the plains in india is highlypoisonous. Kernels of the seeds contain glycosides thevetin, thevetoxin, cerberin, and peruvoside. Poisoningusually leads to gastrointestinal and cardiac toxicity.Aims and Objectives: Our aim was to determine the clinical profile of yellow oleander poisoning with specialemphasis on cardiac toxicity, neurotoxicity if any and outcome of management using currently available treatment.Materials and Methods: We studied 60 patients with yellow oleander poisoning prospectively admitted inHospital. A 12 lead electrocardiogram 3 min rhythm ECG strip and blood sample for measurement of electrolytes,Serum calcium, urea and creatinine and liver function tests were taken before treatment. ECG was also done inevery patient on 2nd day of admission and at the time of discharge. Serum cardiac glycosides could not be donedue to lack of facilities.Results: Toxic manifestations included were Gastrointestinal, cardiac toxicity in the form of cardiac arrhythmia butSome patients developed neurological symptoms in the form of tremor (6 patients -10%), ataxia( 8 patients-13.33%)at the end of first week, and focal seizure (only four patients-6.66%).Conclusion: In our study we found gastrointestinal symptoms(vomitting, loose motion with dehydration) andcardiological symptoms (sinus tachycardia, sinus bradycardia, AV block and nodal rhythm, ventricular ectopicsare more commonly present in Yellow oleander poisoning. Moreover we have found some Neurological symptomsin our study in the form of tremor,ataxia and focal seizures.

Multiple-dose activated charcoal for treatment of yellow oleander poisoning: a single-blind, randomised, placebo-controlled trial

ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities

Background: Uterine mesenchymal tumors have been conventionally classified into two broad categories; Smooth Muscle Tumors (SMT) and Endometrial Stromal Tumors (EST). Most common being Smooth muscle tumors, its accurate categorization by light microscopic examination is important and at times can be challenging. Here we discuss Institutional experience of Uterine mesenchymal tumors for 1 year in a tertiary care centre in South India. Aim: To determine the various histomorphological types of Uterine Mesenchymal Tumors and to study its correlation with Clinico-Pathological findings. Materials and Methods: It is a descriptive record based study. Study was carried out in a tertiary care centre in South India. All the consecutive hysterectomy and myomectomy cases received in the department of Pathology were studied. Cases from women aged between 20-80 years, received from January 2019 to December 2019 and diagnosed as mesenchymal tumors of the uterus were retrieved and reviewed. Results: In our study period of 12 months, a total of 246 cases were noted. There were 212 Hysterectomy specimens and 34 Myomectomy specimens. Average size of the lesions was 4.9 cm and average age at presentation was 45yrs. Benign tumors were more common compared to malignant tumors. Out of total number of 246 cases, 243 were Leiomyoma and its variants. Typical leiomyoma were 179 cases and variants included Leiomyoma with hyaline change 34 cases, which was commonest followed by adenomyoma 11 cases, cellular leiomyoma 8 cases, leiomyoma with myxoid change 4 cases, lipoleiomyoma 2 cases, atypical leiomyoma 2 cases and leiomyoma with red degeneration and leiomyoma with amianthoid fibers 1 case each. Among malignant tumors 1 case was Leiomyosarcoma (LMS) and 2 were Endometrial Stromal Sarcoma (ESS). Conclusion: It is important to differentiate benign and malignant mesenchymal tumors due to differences in their clinical outcome. Most common being Smooth muscle tumors, its accurate categorization by light microscopic examination is important and at times can be challenging. Role of surgical pathologist in making this distinction, especially in difficult cases cannot be underestimated. Although Immunohistochemical stains are helpful in establishing the final diagnosis, the morphologic features are superior to all the other ancillary techniques for this group of neoplasms.Recent application of molecular techniques has identified numerous lesions with distinctive genetic abnormalities and clinicopathological characteristics.