Cognitive effects of

organophosphorus insecticide poisoning

studied using reaction time,
evoked potentials and
event-related potentials

Waidyaratne Dassanayake Mudiyanselage Tharaka Lagath

Dassanayake

Master of Philosophy

June 2007

Cognitive effects of
organophosphorus insecticide poisoning
studied using reaction time,
evoked potentials and
event-related potentials
Waidyaratne Dassanayake Mudiyanselage Tharaka Lagath
Dassanayake
MBBS (Sri Lanka)

Department of Physiology

A thesis submitted to the Faculty of Medicine in fulfilment of the

requirements for the Degree of

Master of Philosophy

of the

University of Peradeniya
Sri Lanka
June 2007

Declaration

I hereby certify that the work reported in this thesis was carried out by me under the
supervision of Dr. V. S. Weerasinghe, Dr. U. Dangahadeniya and Professor Nimal
Senanayake.

It describes the results obtained from my own research work except where due reference
has been made in the text. No part of this thesis has been presented for any other degree
in this or any other University.

Date:...................................

...................................................
Dr. W. D. M. T. L. Dassanayake

Certified by:
1.

Supervisor: Dr. V. S. Weerasinghe

Date: ..

2.

Supervisor: Dr. U. Dangahadeniya

Date: .

.
3.

Supervisor: Prof. N. Senanayake

...

Date: .

ii

Acknowledgements

Although this thesis presents my own research work, I would not be able to complete it
without the guidance and the support of many individuals and organisations to which I
must express my sincere gratitude.

I am very much obliged to my academic supervisor and Head of the Department of

Physiology Dr. Vajira Weerasinghe, for introducing me into scientific research and the
field of neurophysiology. He always encouraged me and rendered intellectual and
technical guidance from the day of inception of the thinking behind this work. Prof.
Nimal Senanayake sharpened my thinking by critically evaluating my work and giving
invaluable advice throughout the study. I am fortunate to have an exemplary researcher
like him to supervise my research degree. As an academic supervisor, Dr. Udaya
Dangahadeniya always welcomed me and provided prompt advice and guidance when I
was in need. I am much indebted to him.

I am thankful to my teachers and senior colleagues in the Department of Physiology;

Prof. Malini Udupihille, Prof. Premalatha Balasooriya, Dr. Jayantha Rajaratne, Dr.
Shamila Rajaratne, Dr. Anula Kariyawasam, Dr. Indu Nanayakkara, Dr. Anoja
Ariyasinghe and Dr. Sudheera Kalupahana for their encouraging me and sharing my
departmental commitments during the period of this study. Dr. Indu Nanayakkara and Dr.
Sudheera Kalupahana provided valuable suggestions in writing up the thesis.

iii

This project would not have been possible without the financial and intellectual support
of the South Asian Clinical Toxicology Collaboration (SACTRC). A very special thank
should go to Prof. Andrew Dawson, who provided numerous opportunities for me to
present my work in the scientific community. He was a great person to work with. I am
also thankful to all the colleagues of the SACTRC research team for supporting me in
many ways.

I must also acknowledge the Staff of the Poisoning Management Unit, the Neurology
Ward and the Medical Wards, Teaching Hospital, Peradeniya who supported me in many
ways in recruiting the study participants. I am especially grateful to Dr. Keerthi Kularatne
who advised and helped me in clinical assessment of the patients.

I greatly appreciate all the patients and the volunteers who consented to participate in the
study without any hesitation.

Finally, I deeply admire my wife Dewasmika and my mother who energized my work
with their understanding, encouragement and love.

iv

Abstract

Cognitive effects of organophosphorus insecticide poisoning studied using

reaction time, evoked potentials and event-related potentials
W. D. M. T. L. Dassanayake, Department of Physiology, Faculty of Medicine, University of Peradeniya
for the degree of
Master of Philosophy

Introduction: Research over last few decades suggests that acute organophosphorus
(OP) poisoning may lead to long-term cognitive impairment. However neurobehavioural
and symptomatic manifestations reported in previous studies show numerous
inconsistencies, highlighting the need for more objective and quantitative measures of
cognitive functions.
Objectives: The aim of the present study was to determine whether acute OP insecticide
poisoning leads to impairment of cognitive processing. The specific objectives were to
compare objective and quantitative psychophysiological parameters of cognitive
processing of visual information and auditory information, 1) between patients who
recovered from cholinergic phase of OP insecticide poisoning and matched controls and
2) between immediate post-cholinergic phase and six months after poisoning in the
patients.
Methodology: The first part of this research was a case-control study where patients
recovered from cholinergic phase of OP poisoning (n=44) were compared with two ageand sex-matched controls groups, viz. healthy controls (n=43) and patients with

paracetamol overdose (n=11). The second part was a prospective study where the OP
poisoned patients were followed up after six months of poisoning and the findings were
compared with their immediate post cholinergic phase measurements. The tests used to
assess visuomotor information processing were simple visual reaction time, recognition
visual reaction time, visual evoked potentials (VEP) and motor evoked potentials. The
term cognitive processing time (CPT) was used to denote the time taken from initial
cortical perception of a stimulus to initiation of descending motor impulses. CPT of each
type of visual reactions was calculated by subtracting the sum of the visual impulse
duration and the motor impulse duration from reaction time (CPT = Reaction time
(P100 VEP latency + total motor conduction time)). Auditory P300 cognitive eventrelated potential (ERP) was recorded, quantified and analysed to assess cognitive
processing of auditory information.
Results: Patients with OP insecticide poisoning showed significant delays in CPT of
simple visual reactions (CPTSVR) (p=0.037), CPT of recognition visual reactions
(CPTRVR) (p=0.024) and P300 latency (p=0.003) compared to healthy controls. The
patients also had a significant impairment in CPTSVR (p=0.017), CPTRVR (p=0.002) and
P300 latency (p=0.009) compared to the control group with paracetamol overdose.
Comparison of the initial and follow-up findings of the patients revealed that the
impairment in CPTSVR (p=0.527) and P300 latency (p=0.867) remained unchanged even
six months after poisoning. However, CPTRVR showed a significant improvement
(p=0.012). Visual and motor conduction latencies or P300 amplitude were similar
between the groups and between the two assessments of the patients with OP poisoning.

vi

Conclusions: OP insecticide poisoning appears to slow the cognitive processes involved

in visuomotor information processing and auditory stimulus evaluation. These effects
persist beyond the clinical recovery from the cholinergic phase, and the deficits in
auditory stimulus evaluation and cognitive processing in simple visual reactions appear to
be persistent even six months after exposure. These findings are compatible with the
cognitive deficits observed in some previous human studies. The neural substrates of the
affected cognitive processes are largely compatible with the topography of the
neuropathological lesions that have been observed in OP exposed experimental animals.

vii

Table of contents

Declaration ... i
Acknowledgements ... ii
Abstract . iv
List of tables ... xii
List of figures . xiii
List of abbreviations ... xvi

Section 1
INTRODUCTION .. 1
1.1. Organophosphorus insecticide poisoning ... 1
1.1.1. Epidemiology .. 1
1.1.2. Pathophysiology .. 3
1.2. Behaviour and cognition ... 5
1.3. Cognitive processing of sensory information and integration between
cortical areas . 8
1.3.1. Visual perception .. 12
1.3.2. Auditory perception .. 15
1.4. Measurement of information processing in human brain ... 17
1.4.1. Reaction time .... 17
1.4.2. Event-related potentials (ERPs) and P300 .... 21

viii

1.5. Delayed cognitive effects of acute OP poisoning: evidence from previous

studies and their limitations 25
1.6. Rationale, aims and objectives of the present study .. 29

Section 2
METHODOLOGY .... 31
2.1. Study design. 31
2.2. Ethical considerations . 32
2.3. Subjects ... 33
2.3.1. Test group ... 33
2.3.1.1.Inclusion criteria 33
2.3.1.2.Exclusion criteria ... 33
2.3.2. Healthy control group .. 34
2.3.2.1.Inclusion criteria 34
2.3.2.2.Exclusion criteria .. 34
2.3.3. Hospitalised control group ... 34
2.3.3.1.Inclusion criteria 34
2.3.3.2.Exclusion criteria ... 34
2.4. Background information . 35
2.4.1. Test group ... 35
2.4.2. Healthy controls ...... 36
2.4.3. Hospitalised controls .... 36

ix

2.5. Assessment of cognitive processing . 40

2.5.1. Basis of assessment paradigms .. 40
2.5.2. Equipment .. 42
2.5.3. Details of the techniques 44
2.5.4. Testing protocol . 53
2.6. Data analysis . 58
2.6.1. Calculated outcome variables . 58
2.6.2. Statistical analysis ... 59

Section 3
RESULTS .. 61
3.1. Data analysis .. 61
3.1.1. Test group ... 61
3.1.2. Healthy control group ..... 61
3.1.3. Hospitalised control group .. 62
3.2. Episode of poisoning, management measures and complications . 64
3.2.1. Test group ....... 64
3.2.2. Hospitalised control group .. 67
3.3. Intergroup comparison of measures of cognitive processing, visual and
motor components . 68
3.3.1. Visual reaction time 69
3.3.2. Components of visual reaction time ... 72

3.3.2.1.Visual conduction . 72
3.3.2.2.Motor component .. 73
3.3.2.3.CPT of visual reactions . 76
3.3.2.3.1. CPT(SVR) 76
3.3.2.3.2. CPT(RVR) 76
3.3.3. P300 ERP 78
3.3.4. Summary of intergroup comparison of measures of information
processing ... 81
3.3.5. Correlation between measures of cognitive processing .. 84
3.4. Follow up assessment of the patients with OP insecticide poisoning 86
3.4.1. Visual reaction time . 86
3.4.2. Components of visual reaction time 87
3.4.2.1.Visual conduction .. 87
3.4.2.2.Motor component .. 88
3.4.2.3.CPT of visual reactions . 89
3.4.3. P300 ERP . 90
3.4.4. Summary of the comparison of initial and follow up assessment of the
parameters of cognitive processing, afferent and efferent conduction .... 92

Section 4
DISCUSSION 94
4.1. Effects of OP on visual reaction time .. 95

xi

4.2. Importance of analysis of individual components of visual reactions ......... 96

4.3. Cognitive processes and the flow of information in visuomotor reactions .......... 97
4.4. Long-term effects of OP pesticide poisoning on visuomotor information
processing ... 101
4.5. Effects of OP poisoning on P300 event-related potential ... 106
4.6. OP induced brain damage: corroborating evidence from human studies
and animal experiments .. 109
4.7. Limitations of the study ......... 111

Section 5
CONCLUSIONS AND FUTURE DIRECTIONS 114

List of references ... 116

Appendices 138

xii

List of tables

3.1. Comparison of age: Test group and healthy control group . 62

3.2. Age distribution of organophosphorus poisoned patients, matched hospitalised
control group and healthy controls 63
3.3. The type of organophosphorus (OP) insecticide ingested by patients ... 65
3.4. Numbers of subjects whose measurements were taken in tests of information
processing .. 69
3.5. Comparison of the measures of information processing: test group (initial
assessment) vs. healthy controls 82
3.6. Comparison of the measures of information processing: hospitalised controls
vs. matched test group subjects and healthy controls 83
3.7. Correlation between parameters of cognitive processing in all study participants.. 84
3.8. Comparison of parameters of information processing of the test group patients
in the initial post-cholinergic phase and the follow up .. 93

4.1. Neuropsychological findings of the epidemiological studies on chronic effects

of acute OP pesticide poisoning 103

xiii

List of figures

1.1. Chemical structure of organophosphorus compounds . 4

1.2. Neuropsychological classification of dimensions of behaviour and cognition ... 6
1.3. Generic scheme of information processing in sensory pathways 9

2.1. Selection and comparison of study samples ... 39

2.2. Calculation of cognitive processing time 41
2.3. Magstim Model 200TM magnetic stimulator with circular 90mm coil ... 43
2.4. Signal averaging machines 43
2.5. Electrode placement in VEP recording .. 46
2.6. A normal VEP waveform 47
2.7. Magnetic field and the induced current produced by the current flowing
through the coil of the magnetic stimulator 49
2.8. A standard MEP waveform 50
2.9. Electrode placement in recording P300 component of ERPs 52
2.10. A normal P300 ERP waveform 53
2.11. Reaction time test . 55
2.12. Recording auditory P300 event-related potential .... 55
2.13. Recording pattern reversal visual evoked potentials .. 57
2.14. Transcranial magnetic stimulation and motor evoked potential recording 57

xiv

3.1. Age distribution of the test group and healthy controls .. 62

3.2. Number of patients that showed each cholinergic feature . 67
3.3. VRT in the test group and healthy controls ....... 71
3.4. VRT in the test subjects, matched hospitalised controls and healthy controls .. 71
3.5. VEPs of a patient with OP poisoning 72
3.6. Distribution of P100 latency .. 73
3.7. MEPs in a patient with OP poisoning 74
3.8. Motor conduction times in patients and healthy controls .. 75
3.9. Motor conduction times in test subjects, matched hospitalised controls
and matched healthy controls . 75
3.10. CPT(SVR) and CPT(RVR) in the test group and healthy control group ... 77
3.11. CPT(SVR) and CPT(RVR): test subjects, matched hospitalised controls and
healthy controls .. 78
3.12. Grand average ERP waveforms for target tones . 79
3.13. Distribution of P300 latencies . 80
3.14. Distribution of P300 amplitudes . 81
3.15. Correlation between CPT(SVR) and CPT(RVR) ... 85
3.16. Correlation between CPT(RVR) and P300 latency 85
3.17. Changes in VRT from initial post-cholinergic phase assessment to the
follow up assessment . 87
3.18. Changes in P100 VEP latency from initial post-cholinergic phase
assessment to the follow up assessment . 88

xv

3.19. Measures of motor conduction in the first assessment and the follow up in the
patients with OP poisoning 89
3.20. CPT of visual reactions in the patients in the first assessment and
the follow up assessment ... 90
3.21. Grand average ERP waveforms of the first assessment and the follow up
assessment of the patients with OP poisoning ... 91
3.22. P300 ERP changes in patients with OP poisoning: first assessment vs.
follow up assessment . 92

xvi

List of abbreviations

AChE acetylcholinesterase
ACh acetylcholine
CI confidence intervals
CMCT central motor conduction time
CPT cognitive processing time
CPTRVR cognitive processing time of recognition visual reactions
CPTSVR cognitive processing time of simple visual reactions
dB decibels
EP evoked potential
ERP cognitive event-related potential
FDS Flexor digitorum superficialis
Hz Hertz
IQR inter-quartile range
M magnocellular
MEP motor evoked potential
ms milliseconds
MT movement time
n number of subjects
OP organophosphorus

xvii

P parvocellular
PET - positron emission tomography
PMCT peripheral motor conduction time
r Pearsons correlation coefficient
RAS - reticular activating system
RRT recognition reaction time
RT reaction time
RVRT recognition visual reaction time
SE standard error of the mean
SRT simple reaction time
SVRT simple visual reaction time
TMCT total motor conduction time
TMS transcranial magnetic stimulation
V1 primary visual cortex
V2 secondary visual cortex
VEP visual evoked potential
WHO World Health Organisation
V microvolt

Section 1
INTRODUCTION

1.1.

Organophosphorus insecticide poisoning

1.1.1. Epidemiology

Production of synthetic pesticide formulations has a history of over half-a-century.

In year 2000 the global production was 3.75 million metric tons (Tilman et al., 2001).
About one-fourth of formulated pesticides are used in the developing countries
(Jeyaratnam, 1984). Organophosphorus (OP) compounds have been the principal means
of agricultural pest control throughout the world since 1980s (Stephens, 1995).

In 1992, World Health Organization (WHO) reported that roughly three million
pesticide poisonings occur annually resulting in 220,000 deaths worldwide. Poisonings
are far more frequent in the developing world in comparison to the developed countries.
Ninety-nine per cent of more than 200,000 pesticide-related deaths occur in the
developing world (Jeyaratnam, 1990). Ingestion of pesticides, particularly OP

compounds, is a widely prevalent method of deliberate self-harm in agricultural

communities across Asia. According to WHO reports in 2002, the estimated annual death
rate from self-harm in the Asian region is half-a-million (World Health Organisation
2002). Of these, ingestion of pesticides accounts for 300,000 deaths (Eddleston, 2000).
About two-thirds of the instances (i.e. 200,000 deaths) the causative pesticide is an OP
insecticide (Eddleston, 2000; Eddleston and Phillips, 2004).

Like in many other Asian countries, pesticide poisoning is a major clinical and
public health problem in Sri Lanka (Jeyaratnam et al., 1982; Eddleston et al., 1998; Van
der Hoek et al., 1998; Fernando & Hewagalage, 1999). According to the Annual Health
Bulletin year 2000, pesticide poisoning is the leading cause of death in many agricultural
districts (Ministry of Health, 2001). Although pesticides are widely used in agricultural
communities, most clinically documented acute poisonings in Sri Lanka are not due to
occupational overexposure, but episodes of deliberate ingestion. In a study carried out in
North-Central province, out of 526 pesticide-related poisonings 68% cases were selfinflicted, 19% were spraying-related and 13% were accidental (Van der Hoek et al.,
1998). Young adults form the major proportion of deliberate self-poisoning victims (de
Alwis, 1988; Van der Hoek et al., 1998). Occupational exposure leading to intoxication
through inhalation and skin contact is also seen in agricultural communities. Pesticide
sprayers who do not use protective gear are particularly at risk.

Following the common pattern of the Asian region (Eddleston, 2000; Eddleston and
Phillips, 2004), OP insecticides are responsible for the majority of pesticide poisonings in
Sri Lanka. By late 1970s and early 80s, OP compounds became the main causative agents
in pesticide poisoning associated hospital admissions in many parts of Sri Lanka
[Colombo 1976: 26 out of 46 (55%), Peradeniya 1984/85: 92 out of 117 (79%) and Jaffna
259 (89%) out of 291] (Senanayake, 1986). In the following decade the islandwide
hospital statistics showed that about 75% of poisoning related admissions and 85% of
deaths from poisoning were caused by OP insecticides (Senanayake, 1998).

1.1.2. Pathophysiology

All OP compounds share a common chemical structure (figure 1.1). The basic
components include a phosphorus atom that forms a double bond with either oxygen (P =
O) or sulphur (P = S), and three side chains. Group X differs widely in individual OP
agents and to a great extent determines the physical and chemical characteristics of the
compounds (Erdman, 2004). The R1 and R2 side chains are typically alkoxy groups, but
may be aliphatic or aromatic hydrocarbons. The biological action of OP depends on the
phosphorylating ability of the OP, which in turn is determined by the electrophilicity of
the phosphorus atom. Electrophilicity is mostly determined by the substituent groups in
the OP molecule. In vivo activity of the OP depends also on the lipid solubility of the OP
compound. Highly lipid soluble OP compounds can cross the biological membranes and
the blood brain barrier, to reach the neural tissues where the OP can exert its main action.

Figure 1.1: Chemical structure of organophosphorus compounds.

OP insecticides inhibit acetylcholinesterase (AChE), the enzyme which degrades

the neurotransmitter acetylcholine (ACh) released by cholinergic nerve endings.
Resulting accumulation of ACh leads to different effects depending on the site. It causes
depolarisation block of the nicotinic cholinergic receptors at the neuromuscular junction.
Cholinergic overactivity in the autonomic nervous system principally causes
parasympathetic stimulation through muscarinic cholinergic receptors. Accumulation of
ACh also affects the cholinergic neural circuits in the central nervous system. Classically,
three main syndromes of acute OP poisoning have been identified, viz. acute cholinergic
crisis, intermediate syndrome and delayed polyneuropathy. The latter two are seen only
in a proportion of the victims who develop acute cholinergic crisis. To a large extent, the
amount and the type of the OP compound determines the occurrence of intermediate
syndrome and delayed polyneuropathy.

In addition to these manifestations, research over last few decades suggests the
possibility of delayed sequelae of OP on higher functions of the nervous system. The

observations have variously referred in literature as neurobehavioural effects,

neuropsychological abnormalities or neuropsychiatric changes (Abou-donia, 2003).
Particularly, the cognitive sequelae have drawn attention of researchers engaged in
toxicology as well as in many other fields including neurology, neuropsychology and
psychophysiology.

1.2.

Behaviour and cognition

Behaviour can be conceptualised in three dimensions, viz. cognition, emotionality

and executive functions (Figure 1.2) (Lezak, 1995).
1. Cognition is defined as the information handling aspect of behaviour. In general
terms, cognition is described as knowing, perceiving or conceiving as a faculty
distinct from emotion and volition (Oxford Dictionary, 1994).
2. Emotionality concerns with feelings and motivation.
3. Executive functions deal with the ways in which the mental operations are
executed. The observable motor activity comes under this domain.

Cognitive functions may be studied under four faculties (Figure 1.2):

1. Receptive functions encompass abilities to select, acquire and integrate
information. Major part of sensory information perception falls into this category.

2. Memory and learning refers to encoding, storage, mental representations and

retrieval of information.
3. Thinking, at least in a neuropsychological perspective, can be classified under the
dimension of cognition. It involves voluntary mental organisation and
reorganisation of information. In this view, any cognitive operation that relates
two or more bits of information explicitly (e.g. adding two numbers) or implicitly
(e.g. judging an action as good or bad) can be regarded as a thinking process.
4.

Expressive functions encompass the mental operations dealing with means

through which information is communicated or acted upon (e.g. speech, writing
and drawing, gestures and manipulating). Thus, the expressive aspect of cognition
forms the immediate mental substrate for executive functions of behaviour.

Figure 1.2: Neuropsychological classification of dimensions of behaviour and cognition.

However, the mental tasks cannot be strictly compartmentalised in any one of these
functional subdivisions of cognition. Even in simple tasks such as face-recognition,
many of them operate in unison. The initial cortical processing involves analysis of
perceptual properties of the visual stimulus such as lines, colour of the face and the
spatial relationship of its parts. This mainly demands receptive functional resources. At a
higher level of recognition, stored memory traces are retrieved to match the perceptual
representations of the face. These latter stages of processing attribute a semantic value for
initial visual signals (Gazzaniga et al., 1998). Therefore, visual recognition necessitates
two facets of cognition (viz. receptive functions and memory) to work in harmony.
Nevertheless this classification of behaviour and cognition permits easier practical
observation, measurement and description of normal and abnormal behaviour, and
constitutes a framework for organisation of behavioural data.

Activity variables determine the efficiency of the above dimensions of behaviour.

Some neuropsychologists categorise consciousness and attention under activity variables
(Lezak, 1995). For instance, solving an arithmetic problem involves numerous
interactions between receptive functions, memory and thinking. When a person is fully
conscious and directs maximum attention towards the task, he can integrate the above
dimension of cognition and solve the problem more accurately and faster than when he is
less attentive. Activity variables do not have any specific behavioural outcomes or end
products of their own. Thus there are no pure behavioural tests to measure activity
variables. Behavioural correlates of activity variables are always assessed through

performance of a task related to other behavioural domains mentioned earlier. Thus, a

given cognitive process involves activation of one or more faculties of cognition, the rate
of the process being influenced by activity variables.

1.3.

Cognitive processing of sensory information and integration between cortical

areas

Information processed during cognitive operations are either retrieved from

memory stores, or acquired from the external environment as sensory inputs. Sensory
signals generated by external stimuli are carried to brain via afferent neuronal pathways.
These signals cross several synapses and reach the cerebral cortex. Synaptic transmission
permits the afferent signals to be modified to a certain extent by pre- and/or post-synaptic
influences. Thalamus, with its specific sensory nuclei, plays a major role as a multimodal
relay station where sensory perception occurs at an elementary level. On their way to
cortical areas, sensory pathways send inputs to the reticular activating system (RAS) of
the brain stem. RAS is involved in maintaining the arousal state of the individual.
Thalamocortical fibres project to primary sensory cortical areas. Higher-order perceptual
processing begins in these modality-specific (vision, hearing, somatic sensations etc.)
primary cortical areas. An abstract schematic representation of this initial information
processing is illustrated in figure 1.3.

Figure 1.3: Generic scheme of information processing in sensory pathways. (RAS:

reticular activating system).

Primary sensory areas are found in different parts of the cerebral cortex, depending
on the sensory modality they subserve:

Primary visual area: striate cortex of the occipital lobe

Primary auditory area: superior temporal gyrus

Primary somatosensory cortex: postcentral gyrus

10

Billions of neurons in primary sensory cortical areas register raw sensory

information in the form of a map. These representations per se do not have a semantic
value. Primary sensory cortical representations are transmitted to adjacent secondary
association areas which integrate these raw perceptions, increasing the complexity of
sensory information. The cells in secondary association areas are also modality specific.
Only a stimulus of the appropriate modality can fire neurons in secondary association
areas.

Tertiary association areas are considered responsible for integration of mental

representations of more than one modality (Lezak, 1995). Posterior association cortex is a
main area where this supramodal integration of perceptual functions takes place.
Therefore it is also called heteromodal or multimodal cortex. Having a parieto-temporooccipital distribution, it is in close proximity with somatosensory, auditory and visual
cortical regions. Inputs from many sensory organs can fire the neuronal populations of
posterior association cortex. Patients with lesions in posterior parietal cortex may develop
constructional disorders where multimodal integration of visuospatial information is
deficient (Black & Bernard, 1984). Transfer of impulses between cortical regions is not
unidirectional. Feedback loops from secondary and tertiary association areas backinnervate more elementary sensory areas. The association areas also have numerous
connections with subcortical structures.

11

As information moves from one stage to the next, the cortical representations
become perceptually elaborate and semantically sophisticated. Findings of single cell
recording experiments support this. For example, a simple flash of light can stimulate
primary visual cortical neurons. In contrast, cells of the association areas of inferior
temporal cortex do not fire on exposure to simple lines or spots of light. Rather, they
respond to complex stimuli such as an elaborate drawing of a hand (Desimone et al.,
1990). Thus, visual association areas in the inferior temporal cortex appear to play a role
is object recognition rather than simple perception of a quantum of light.

Multimodal representations synthesised in association areas are transmitted to

limbic and frontal association areas, to be activated into feelings, thoughts and actions
(Pandya & Yeterian, 1985, 1990). Prefrontal division of the frontal lobe receives
information about the external environment from postcentral structures. According to one
estimate, around 60% of these neuronal pathways come from tertiary association areas
and 25% from secondary association areas (Strub & Black, 1988). Prefrontal cortex also
receives inputs form limbic system about the internal status of the body. Convergence of
many types of information from multiple sources (memory storage, visceral arousal
centres, sensory association areas etc.) enables the prefrontal cortex to process and
integrate information at the highest order or greatest complexity. The prefrontal division
interacts with the secondary motor association area in the premotor division and
subsequently with the primary motor cortex, to bring about executive functions of
behaviour such as movements, gestures, speech etc.

12

As discussed earlier, receptive functions do not operate in isolation. There are

numerous complex interactions with memory systems occupying multiple loci including
the diencephalon, hippocampus, striatum, amygdala and many parts of the neocortex.
Two-way information transfer nourishes both these faculties of cognition. Retrieval of
information from the memory stores helps higher order semantic interpretation of
perceptual cues, whilst perceptual processing enables encoding and consolidation of new
external information to strengthen memory networks. In humans, visual and auditory
perception provide large amount of external information for higher-order processing.

1.3.1.

Visual perception

Visual stimuli evoke sensory neural impulses that travel through afferent visual
pathways to lateral geniculate nuclei and then to the primary visual cortex in the occipital
lobes. Cerebral neural networks process these signals further to identify their perceptual
and semantic properties. In the present study, processing of the visual representations
beyond the primary visual cortex is regarded as cognitive processing of visual
information.

Visual perception involves concurrent, parallel analysis of various attributes of the

stimulus (colour, shape, orientation, motion etc.) through different subsystems
(Gazzaniga et al., 1998). This parallel processing begins in the lateral geniculate nuclei,

13

where magnocellular (M) neurons and parvocellular (P) neurons analyse different
features of the stimulus. This M-P distinction is maintained at primary (V1 or
Brodmanns area 17) and secondary (V2 or Broadmanns area 18) visual cortical regions
as demonstrated by histological studies (Bear et al., 1996). M pathways are sensitive to
changes in contrast and motion. As shown in cytochrome oxidase histological staining
techniques, P pathway has two subsystems viz. blobs and interblobs in V1, which
correspond to thin strips and interstrips respectively, in V2. Blobs and thin strips in P
pathway are mainly sensitive to colour. Interblobs and interstrips are mainly sensitive to
location and orientation of the stimulus. Additional evidence for parallel processing in
visual perception comes from single cell recording studies (Hubel & Wiesel, 1968;
Maunsell & Van Essen, 1983), visual search task experiments (Treisman & Gelade,
1980), and more recently, from positron emission tomography (PET) studies (Zeki,
1993).

The specialisation hypothesis of visual perception is based on the above

observations. It suggests that in a given moment, there are many maps of the same image
in many visual areas. But each map differs according to the type of information (e.g.
colour, shape, orientation etc.) they represent. Higher level visual processing engage
subcortical pathways extending form V1 to adjacent parietal and temporal cortices.
Superior longitudinal fasciculus (occipito-parietal pathway) contains axons extending to
posterior parietal cortex. Inferior longitudinal fasciculus (occipito-temporal pathway)
contains axons terminating in inferior temporal cortex.

14

Mishkin and Ungerleider first proposed a functional model involving these two
pathways, to explain extraction of two fundamentally different properties of visual
information (Mishkin et al., 1982a; 1982b; 1983). According to them, the ventral,
occipito-temporal pathway is involved in recognising what we are looking at (i.e. object
recognition), and hence called what pathway. Dorsal, occipito-parietal tracts are
specialised in spatial perception where we identify the location of an object and the
spatial relationship of objects in the visual field. Therefore the original researchers called
it where pathway. This what where dichotomy of visual perception is supported by
electrophysiological evidence (Robinson et al.,1978; Desimone, 1991; Ito et al. 1995),
behavioural experiments on animals (Pohl, 1973) and PET studies of normal human brain
(Haxby et al., 1994).

The purpose of the analysis of individual visual features is to recognise the objects
in the visual field. According to the Warringtons two-stage model, analysis of visual
features helps categorisation of the object we see according to its physical properties (i.e.
colour, shape etc.), and it is called perceptual categorisation. Patients who are unable to
perform this perceptual categorisation are incapable of recognising an object as the same
one when viewed under different lighting conditions or from different viewpoints
(Gazzaniga et al., 1998). This condition is called appreciative agnosia. At a higher level
of processing, the perceptual representation of the object undergoes semantic
categorisation, where the perceptual representation is given a meaningful functional
value. Those who are unable to perform this semantic categorisation suffer from

15

associative agnosia. When they are shown a set of objects and asked to choose two
objects which are similar in terms of their function they tend to select two which are
similar in physical appearance (Warrington & Taylor, 1978).

At these higher levels of visual information processing where the demands are to
recognise the object, perceptual representations interact with long-term memory traces of
the known objects. In other words, multiple dimensions of cognition (figure 1.2) viz.
receptive functions, memory and learning and even thinking, begin to interact strongly
with one another.

1.3.2.

Auditory perception

Auditory afferents enter the brainstem via cochlear nerves. Forming synapses in
cochlear nuclei, superior olivary nucleus, inferior colliculus and medial geniculate
nucleus, the neuronal pathways reach the primary auditory cortex (Brodmanns area 41)
in the superior temporal gyrus. Secondary auditory cortex occupies the Brodmanns areas
42 and 43. Neurons in the auditory areas are arranged to form a tonotopic map. For
instance, cells in a given area of the primary auditory cortex are maximally sensitive to a
particular frequency. The frequency of maximal sensitivity changes little by little from
one cell to the adjacent ones, so that one can map the auditory area into a frequency
gradient. Therefore the receptive field of a neuron involved in auditory processing is

16

expressed as a frequency range (in contrast to a visual cortical cell, of which the receptive
field encompasses a specific area of the visual field, which can be expressed in spatial
dimensions).

Basilar membrane near the base of the cochlea is maximally sensitive to high
frequency sounds, whilst low frequency sounds mainly activate the apex of the cochlea.
The tuning specificity of auditory receptive fields becomes more refined as the stimulus
moves through the system. For instance, a cell in cochlea that is maximally sensitive to
5000Hz stimulus, responds to stimuli ranging from 2000Hz to 10000Hz. A cell in
auditory cortex that responds maximally to a stimulus of 5000Hz may respond to stimuli
of 4000Hz to 6000Hz, which is a much narrower range.

The computational goals of audition are similar to those of vision. The two goals
are to recognize the nature of the sound (what?) and the location of the sound source
(where?). Scientific evidence on mechanisms of auditory information processing is
much scarce in comparison to those of visual information processing. Auditory cortex is
involved in determining the nature of the auditory stimulus (what is the stimulus?) as
well as direction from which sound emanates. However evidence based on the
experimental animal model barn owl, suggests that to a certain extent, the question
where is the stimulus? is solved at the level of brain stem and the auditory cortex
(Konishi, 1993). Medial superior olivary nucleus plays a major role in detecting the time
lag between acoustic signals entering the two ears.

17

1.4.

Measurement of information processing in human brain

The rapidity of human information processing and scarcity of knowledge on the

neural correlates of higher-order information processing makes studying the neural
processes of cognition difficult. However, the discipline of mental chronometry, which
has origins that date back to more than a century, seeks to measure the time-course of
mental operations in the human brain. Mental chronometric tasks have been used
extensively in cognitive neuroscience to elucidate mechanisms underlying cognitive
processing. From late 1800s to 1950s, assessment of temporal nature of information
processing was built almost entirely around a single behavioural method: measuring and
comparing reaction times during simple cognitive tasks. Later, with the development of
electrophysiological techniques, evoked potentials (EPs) and cognitive event-related
potentials (ERPs) started to contribute to elucidation of the time-course of information
processing in the nervous system. Present study uses visual reaction time (VRT) tests, EP
and ERP techniques to quantitatively assess the cognitive processing of visual and
auditory information processing in victims of OP poisoning.

1.4.1. Reaction time

Reaction time (RT) is defined as the time that passes from arousal of a sensory
organ to a motor reaction. Depending on task requirements and complexity, RT tests are
widely used to evaluate the time-course of various cognitive processes (Gazzaniga et al.,

18

1998). All types of reaction tasks demand analysis of certain perceptual and/or semantic
properties of a presented stimulus (e.g. colour, shape, position in space, tone, meaning of
a word etc.), and execution of an appropriate motor response. The analysis of perceptual
and semantic properties of the stimulus involves receptive functions, memory updating
and thinking, whereas selection and execution of motor response involve expressive
functions of cognition.

In simple reaction time (SRT) experiments, there is only one stimulus (e.g. white
flash) and one response (e.g. pressing a button). Therefore the responder does not have to
concentrate on specific characteristics of the stimulus (e.g. whether it is a white flash or a
red flash) and just need to respond to the stimulus as quickly as possible. If the stimulus
is of visual modality the test is a simple visual reaction time (SVRT) test.
Neuropsychologists use SRT as a measure of attention (Lezak, 1995).

In recognition reaction time (RRT) experiments, there are some stimuli that should
be responded to, and others that should get no response. For example, in a recognition
visual reaction time (RVRT) test, either a white flash or a red flash may appear
randomly, and the requirement is to respond only to white flashes as soon as possible.
Thus there is still only one correct response. Before responding the individual has to
detect the stimulus and also discriminate the target stimulus (i.e. white flash) from the
distracting stimulus (i.e. red flash).

19

Pioneer RT studies were those of F.C. Donders in 1868. He showed that SRT is
shorter than RRT. Laming (1968) in his studies, determined that SRT averaged 220ms
and RRT averaged 384ms. According to Bellis (1933), pressing a key in response to a
light (i.e. SVRT) is around 220ms in males, and about 260ms in females (Kosinski,
2000). This is in line with many studies that concluded that complex stimulation
paradigms, as in RRT experiments, elicit slower RTs (Brebner, 1980, Teichner et al.,
1974). Over the last century, RT has been used to assess psychomotor speed in variety of
neurological and psychiatric illnesses (e.g. mental retardation, dementias, depression,
schizophrenia, drug dependence) and in performance oriented groups (e.g. sportsmen).

Being a behavioural test, RT includes not only cognitive processing of information

but also sensory and motor components of the task. Welford (1968) defined three
components of a psychomotor reaction: first, the time taken by the stimulus to activate
the sense organ and for impulses to travel from it to the brain; second, the central
processes concerned with identifying the signal and initiating a response to it; and third,
the time required to energize the muscles and to produce an overt recorded response
(Danev et al., 1971). With invent of electrophysiological techniques, there are direct
ways to assess the sensory and motor components.

1. Sensory Component:
This can be visual, auditory etc., depending on the modality of the stimulus. The
duration of this component is the time period between stimulation of the sensory

20

receptors and arrival of the afferent neuronal impulse to the primary sensory (visual,
auditory or somatosensory) cortex. If the stimulus is visual, the light strikes the retina,
stimulates photoreceptors and initiates the afferent nerve impulses that reach the primary
visual cortex. Transmission of impulses along the visual pathways can be studied using
visual evoked potential (VEP) techniques. In VEP recordings P100 component is a
waveform that peaks around a latency of 100ms. Research evidence suggests that it is
generated by the neuronal activity of the striate cortex when a visual impulse reaches the
occipital cortex (Seki et al. 1996). Thus, P100 latency can substitute the duration of
afferent component of a visual reaction.

2. Cognitive Processing:
This comprises the processes that occur in between stimulation of the
corresponding sensory (visual/auditory) cortex and initiation of the motor signal in the
area of the primary motor cortex that control the responding part of the body (e.g. hand,
finger etc.). In this process, more meaningful mental representations of the stimulus are
linked with neural generators of the appropriate motor response. Thus perception of the
sensory stimulus comes under receptive functions of cognition whereas selection of the
appropriate response can be categorised under thinking and expressive functions of
cognition. In comparison to simple reactions, cognitive processing takes a longer time in
recognition reactions because the brain needs to discriminate between two or more types
of stimuli and decide on the appropriate motor response.

21

3. Motor component:
Once the desired motor response (e.g. flexion of the index finger to press a response
button) is planned, corresponding area of the primary motor cortex is stimulated. The
efferent signals travel along the corticospinal tracts and stimulate the corresponding
anterior horn cells and then transmit along the peripheral nerve to generate the endplate
potentials at the fibres of the target muscles. The time taken for this motor conduction
can be measured with motor evoked potential (MEP) studies, where the primary motor
cortex is stimulated and the MEPs are recorded at the skeletal muscles. The duration
between motor cortical stimulation and the onset of MEP denotes the duration of the
motor component of the psychomotor reaction. Motor cortical stimulation can be
performed by transcranial magnetic stimulation (TMS) which is a safe and non-invasive
procedure (Barker et al., 1985).

The sensory and motor components involve the same neuronal pathways and their
durations are expected to be the same in all types of RT tests. This implies that the
differences in RTs are due to differences in cognitive component (Miller, 2001).

1.4.2. Event-related potentials (ERPs) and P300

Recording the average event-related electrical potentials from scalp electrodes

became a research tool in the 1960s with the advent of analogue and then digital

22

computers to accomplish the recording and averaging. The principal use of ERPs is to
determine the time course of cognitive processes in the human brain (Bressler, 2002).

The physiological basis of the cortical ERPs lies in fields of potential generated by
interacting neurons. Activity of the neural circuits of the brain generates electrical fields
which can be recorded over the scalp as potential differences on a time scale. The
potential at a given site over the scalp changes every millisecond, reflecting the everchanging activity of underlying neural circuits. This electrical activity is contributed to by
numerous mental processes which cannot be identified in isolation. Thus, in order to
observe the neural activity related to a particular cognitive process two main
requirements have to be fulfilled.

First, the electrical potentials related to the cognitive process of interest, should be
captured during the short time duration it occurs. In ERP tests this is done by applying an
external event, the properties of which are analysed by the brain. For example, if the tone
of a presented auditory stimulus needs to be analysed, this stimulus evaluation process
generates electrical activity in cerebral neural circuits within the next fraction of a
second. Thus if acquisition of the electrical activity begins at the onset of the stimulus
and continue for next second or so, the electrical potentials related to the mental process
of stimulus evaluation can be captured. In other words, in order to capture a particular
brain process, the recording epoch has to be time-locked with the stimulus that evokes the
cognitive process. However, there are so many unrelated neural activities going on even

23

during this small time span, and this noise (as labelled in electrophysiology), may mask
the captured mental process of interest.

Thus, secondly, the captured mental process needs to be highlighted or isolated.

This highlighting is done through averaging many time-locked epochs. Unrelated
electrical activity, having no fixed temporal relationship with the stimulus and the
recorded time epoch, cancels out with repeated averaging, retaining the potentials of the
mental process of interest in the recording.

ERP components could be systematically related to sensory and motor stages of

information processing. Present study focuses on the auditory ERP waveform P300,
which is generated in analysing auditory stimuli. P300 was first demonstrated by Sutton
and colleagues in 1965 (Sutton, et al., 1965). It is a positive ERP deflection which peaks
around a latency of 300 - 600ms, when a person is exposed to randomly timed two
different stimuli of the same modality, and required to respond to the infrequent (rare)
stimulus (also called the target stimulus). Thus the paradigm that is used to elicit P300 is
called the oddball paradigm. The response to the target stimulus need not necessarily be
a motor response. Even mentally counting the target stimuli evoke P300.

Behavioural correlates of P300 indicate that it reflects a consequence of orienting

and attending to task-relevant events. Therefore P300 latency is considered a measure of

24

stimulus evaluation time, that is independent of selection of the response (Kutas et al.,
1977; McCarthy and Donchin, 1981).

P300 latency was found to have good test-retest reliability in normal individuals, so
that it has the stability required for clinical and research applications (Polich, 1986;
Sclare et al., 1984). However, P300 latency is affected by aging. Older subjects were
found to have longer P300 latencies than young (Marsh & Thompson, 1972; Pfefferbaum
et al., 1979, 1980a, 1980b; Ford et al., 1979, 1982a, 1982b; Beck et al., 1980).
Assessment of P300 latencies over a continuous age range have demonstrated that this
increase in latency begins at puberty and extends into the eighth decade (Brown et al.,
1983).

ERP amplitude variation is considered to reflect the variation in intensity of

activation of neural structures in the brain by the task variables (Kok, 1990). In
experimental settings that apply the simple oddball paradigm, P300 amplitude also
depends on the probability of the target stimulus; rarer the target, greater the amplitude of
the P300 it elicits (Coles, 1995).

25

1.5.

Delayed cognitive effects of acute OP poisoning: evidence from previous

studies and their limitations

The first reports of chronic neurobehavioural manifestations of OP poisoning date

back to 1960s. They mainly reported symptoms such as poor memory, confusion,
anxiety, drowsiness, fatigue, depression and irritability in patients heavily exposed to OP
compounds (Dille & Smith, 1964; Gerson & Shaw, 1961; Metcalf & Homes, 1969;
Durham et al., 1965). Although these studies were of little help to reach conclusions, they
have, for the first time, highlighted the possibility of development of chronic OPinduced neuropsychiatric disorders (Jamal, 1997). After these early studies, research on
long-term neurobehavioural effects of OP compounds pursued along two lines:
1. The occurrence of chronic neurobehavioural impairment as a consequence of an
acute OP poisoning (Savage et al., 1988; Rosenstock et al., 1991; Steenland et al.,
1994; Wesseling, et al., 2002, Stallones & Beseler, 2002)
2. The occurrence of neurobehavioural changes as a consequence of prolonged
exposure without preceding episodes of acute poisoning. Changes with chronic
low-level exposure were studied in many occupational groups including farmers
(Fiedler et al., 1997; Stallones & Beseler, 2002), farm-workers (Daniell et al.,
1992; London et al., 1997), sheep-dippers (Stephens et al., 1995) and termiticide
applicators (Steenland et al., 2000).

26

Present study focuses on delayed cognitive effects of acute OP poisoning. Other

than initial case studies, only few large scale analytical epidemiological studies have
assessed the chronic neurological sequelae of acute OP poisoning (Savage et al., 1988;
Rosenstock et al., 1991; Steenland et al., 1994, Wesseling et al., 2002).

However, there are several methodological limitations and inconsistencies of the

findings in the early case studies (Gerson & Shaw, 1961; Dille & Smith, 1964; Durham et
al., 1965; Metcalf & Homes, 1969) as well as recent case-control studies (Savage et al.,
1988; Rosenstock et al., 1991; Steenland et al., 1994, Wesseling et al., 2002):
1. All these were cross-sectional studies where patients were assessed once, usually
months to years after poisoning. The large scale epidemiological studies on
delayed effects of acute poisoning (Savage et al., 1988; Rosenstock et al., 1991;
Steenland et al., 1994, Wesseling et al., 2002) present little information about the
acute clinical picture: the type and amount of OP, cholinergic manifestations and
complications.
2. All the investigators have used symptom inquiry and/or neuropsychological
testing tools to assess cognitive functions. However, all neuropsychological tests
require the subjects to perform a particular motor task. Thus the behavioural test
performance depends largely on cognitive functions as well as executive
functions. In other words, standard neurobehavioural tests (e.g. RT) cannot assess
the cognitive component in isolation, as the neurobehavioural task duration
includes the sensory and motor conduction. When these behavioural experiments

27

are used to deduce conclusions on cognitive functions, it is assumed that patients

sensory and motor conduction are normal. However normal variations and
pathological deviations in sensory or motor conduction can affect the behavioural
test outcome, particularly in those where the speed of the performance is tested
(e.g. RT tests). In this respect, OP induced delayed neuropathy is a major
confounding factor. Delayed polyneuropathy manifests after 1-4 weeks of acute
OP poisoning, causing slowed sensory and motor conduction (Lotti & Moretto,
2005; Glynn, 2006).
3. Techniques such as electrophysiology and functional neuroimaging, which assess
brain function at a more fundamental level, were hardly ever used in the previous
studies to elicit chronic cognitive effects of acute OP pesticide poisoning except
in few, where EEG recordings were analyzed (Metcalf & Holmes, 1969; Savage
et al., 1988). So far, OP related ERP changes have been reported only in three
studies: two of them evaluated ERP changes in chronic subclinical exposure in
pesticide applicators (Teo et al., 1987; Misra et al., 1994) and the other one
assessed ERP in victims of OP warfare agent sarin (Murata et al., 1997). There
are no studies that evaluated the delayed effects of acute OP insecticide poisoning
on ERP.
4. Cognitive processing test performance depends on many long-term/stable (e.g.
age, sex, alcohol abuse etc.) confounding factors, and short-term modifying
factors (level of arousal, recent alcohol/tobacco intake, sleep deprivation etc.)
(International Programme on Chemical Safety, 2001). In the previous research

28

reports, authors have described the long-term confounding factors. However,

information is insufficient to ascertain whether the investigators have taken steps
to minimise the influence of short-term modifying factors before testing the
subjects.
5. Patients have complained more neuropsychiatric symptoms than controls in all
four epidemiological analytical studies (Savage et al., 1988; Rosenstock et al.,
1991; Steenland et al., 1994, Wesseling et al., 2002). However neurological
examination did not reveal any abnormalities in poisoned subjects. Reviewers
have questioned the validity of the positive symptomatology, suggesting that it
may be due to recall bias: patients who were exposed to pesticides are more
motivated to recall or report symptoms (Kamel & Hoppin, 2004).
6. Findings of neuropsychological tests are also inconsistent among different
studies. On one hand, the ambiguity of the results of these studies may be
attributed to variations in sampling criteria and methodological differences from
one study to another. On the other hand, some subsequent authors have
questioned the objectivity of the testing methods and the sensitivity of the existing
objective testing tools in identifying any subtle impairment in higher brain
functions (Steenland et al., 2000; Kamel & Hoppin, 2004). However, one
common feature is that all studies have revealed abnormalities in at least one
aspect of visual information processing.

29

1.6.

Rationale, aims and objectives of the present study

Present study was designed hypothesising that acute OP insecticide poisoning

impairs cognitive processing of visual and auditory stimuli, even after recovery form the
cholinergic phase of poisoning. In contrast to cross-sectional studies conducted by
previous researchers on patients several months after exposure, we enrolled the patients
during the acute stage of poisoning. Initial assessment was done in the immediate postcholinergic phase and a follow up assessment was done six moths after poisoning.
Furthermore, selection criteria and study protocols were designed to minimize the effects
of long-term confounding factors and short-term modifying factors that affect cognitive
performance. The effect of age and sex on the measures of cognitive processing was
particularly considered and hence the patients were individually matched with the control
groups for age and sex.

Particular attention was given to the psychophysiological indicators of cognitive

processing of visual and auditory information. We aimed at isolating the cognitive
component of visual reactions, which is not possible with standard RT measurements.
The term Cognitive Processing Time (CPT) is used in this study to specify the duration
of the cognitive component of a visual reaction. This component of psychomotor function
has not been studied to date. As the sensory and the motor components are outside the
cognitive domain and vary even among healthy individuals, CPT is a more refined and
accurate measure (in comparison to RT itself) of cognitive processing of information. We

30

used ERPs to assess cognitive processing of auditory information. With more refined and
quantitative tests which closely correlate with actual neuronal processes (viz. cognitive
processing time in RT tasks, EPs and ERPs), main concerns were to maximize the
objectivity of the findings and to identify the exact mental processes affected.

Objectives:
Specific objectives of this study were to compare the psychophysiological measures
of cognitive processing of visual information (viz. cognitive processing time of simple
visual reactions and cognitive processing time of recognition visual reactions) and
cognitive processing of auditory information (viz. P300 latency and amplitude),
1. between patients with OP insecticide poisoning (on recovery from the cholinergic
phase) and matched controls
2. between immediate post-cholinergic phase and six months after poisoning in the
patients.

31

Section 2
METHODOLOGY

2.1.

Study design

This study consisted of two parts.

First part was a case-control study where parameters of cognitive processing were
compared in patients with OP insecticide poisoning and matched control groups. This
phase included three groups: the test group and two control groups.
1. Test group: These were the patients with acute OP poisoning. They were tested twice:
initially in the immediate post-cholinergic stage of poisoning, and then six months after
poisoning.
2. Healthy controls: Healthy individuals from the community, who did not have any
exposure to OP compounds.
3. Hospitalised controls: This control group consisted of patients hospitalised with
paracetamol overdose. This second group was added to match the general wellbeing and
the psychological status of the test and the control groups at the time of
neurophysiological assessment. The drug paracetamol was chosen as it has no known
direct action on cognitive functions.

32

The second part was a follow up study where the patients with OP poisoning were
tested six months after poisoning. The follow up results of the patients were compared
with their initial values.

The study was carried out in medical wards, poisoning management unit and the
clinical neurophysiology laboratory, Teaching Hospital, Peradeniya. Data were collected
over a period of 31 months, from July 2004 to February 2007. Patients admitted to the
medical wards and the poisoning management unit during this period were assessed for
eligibility for the study.

2.2.

Ethical considerations

The study design and protocols complied with the World Medical Association
Declaration of Helsinki. Informed written consent was obtained from all participants (see
appendix 1 for patient information sheet and the consent form). Ethical clearance was
granted by Research and Ethical Review Subcommittee, Faculty of Medicine, University
of Peradeniya, Sri Lanka, on 18/06/2004.

33

2.3.

Subjects

2.3.1. Test group

All patients admitted to the hospital with suspected OP poisoning were assessed for
eligibility.

2.3.1.1. Inclusion criteria:

1) Reliable history of OP exposure
2) Any of the clinical features of cholinergic over-activity: fasciculation, miosis,
bradycardia, excessive sweating / salivation, dyspnoea/lung signs, impaired
consciousness
2.3.1.2. Exclusion criteria:
1) Chronic exposure to OP compounds (e.g. occupational exposure in farmers, pesticide
applicators etc.)
2) Other pre-existing (diagnosed) neurological illnesses, which can affect cognitive or
motor functions
3) Gross visual or hearing impairment where the patient is unable to identify visual and
auditory stimuli
4) Long-term intake of medications which have the potential to alter cognitive functions
5) Consumption of alcohol: more than the upper limit of the safe range (men >
21units/wk, women > 14units/wk. One unit = equivalent of 8 grams of alcohol)

34

2.3.2. Healthy control group

2.3.2.1. Inclusion criteria:

1) Age- and sex-matched individuals with similar social background: For the social and
educational factors to be comparable, patients were instructed to bring a relative or a
friend of the same age and sex, on attending cognitive function tests. In the instances they
were unable to do that, appropriate volunteers were tested. The age of the matched
control was within 3 years of the age of the test group subject.
2.3.2.2. Exclusion criteria:
1) Past history of OP poisoning
2) All the exclusion criteria applied for the test group (criteria 1 to 5 under 2.3.1.2.)

2.3.3. Hospitalised controls

2.3.3.1. Inclusion criteria:

1) Age- and sex-matched individuals hospitalised with paracetamol overdose. The age of
the matched control was within 3 years of the age of the test group subject.
2.3.3.2. Exclusion criteria:
1) Clinical features of hepatic encephalopathy
2) Past history of OP poisoning
3) All the exclusion criteria applied for the patient group (criteria 1 to 5 under 2.3.1.2.)

35

2.4.

Background information

Before selecting the participants for cognitive tests, background information were
collected using structured data sheets (see appendix 2). This aimed at assessing the
eligibility (criteria under 3.3 above) for the study, finding out the details of poisoning,
and identifying any confounding factors.

2.4.1. Test group

Clinical interview, examination and inward assessment targeted the information

related to following areas (see appendix 2.1):
1. Personal details: Name, sex, age, postal address, occupation, educational status and
computer familiarity
2. Details of the episode acute poisoning: type of OP, amount, route of exposure, mode
(intentional/accidental)
3. Signs characteristic of OP poisoning: on admission and during hospital-stay
4. Management measures: gastric lavage, atropine, pralidoxime, intensive care and other
supportive treatment
5. Any major complications: e.g. respiratory/cardiac arrest, seizures, shock etc.
6. Probable confounding factors and other performance modifying factors:

prediagnosed visual/neurological/cognitive impairment

pre-diagnosed psychiatric illnesses

36

alcohol, tobacco and other addictive drug use: duration, regularity, amount per
day/week

2.4.2. Healthy controls

Background information included personal details and probable confounding

factors and other performance modifying factors stated under the information of the test
group (areas 1 and 6 above) ( Appendix 2.2).

2.4.3. Hospitalised controls

Background information collected was similar to those of the test group:

1. Personal details: Name, sex, age, postal address, occupation, educational status and
computer familiarity.
2. Details of paracetamol overdose: amount, mode (intentional/accidental) if intentional,
the reason
3. Clinical features: on admission and during hospital-stay
4. Management measures: antidotes (N-acetylcysteine), supportive treatment, intensive
care
5. Any major complications: e.g. liver failure, hepatic encephaolpathy
6. Probable confounding factors and other performance modifying factors stated above
under information of the test group (see appendix 2.3).

37

All the patients with intentional poisoning were referred to the hospital psychiatrist.
The psychiatric assessment and the diagnosis were also included in the record.

After assessment of background information, the eligible subjects were selected to

perform tests of cognitive functions. Numbers of recruited subjects and the design of
inter-group comparison are illustrated in figure 2.1. From July 2004 to September 2006,
67 patients admitted to Teaching Hospital, Peradeniya with a history of OP poisoning
were assessed for eligibility for the study. Of these, nine did not meet the inclusion
criteria either because the evidence of OP exposure was unreliable or because they did
not show clinical features of intoxication. Of the 58 who fulfilled the inclusion criteria,
two were excluded due to chronic occupational exposure to OP and seven were excluded
due to excessive intake of alcohol. These nine patients were males. Of the remaining 49,
five could not be tested as they left the hospital prematurely. Accordingly, 44 patients (28
males and 16 females) were assessed after recovery form cholinergic phase (i.e. 1st visit),
usually on the day of discharge from the hospital. Recovery from acute poisoning was
considered complete when the patients were free of all signs and symptoms of the acute
cholinergic syndrome, and free of medication such as atropine. There was at least 24hour gap between the last dose of atropine/benzodiazepines and cognitive function tests.
The median duration between exposure and cognitive testing was of 10.5 days (Range: 3
to 47 days).

38

The healthy control group that comprised 43 individuals matched for age and sex
with the patients on one-to-one basis (healthy control number-64 was matched with the
patient number-18 and number-26). Healthy controls were tested on an appointment
basis.

Recruitment of the hospitalised control group (i.e. patients with paracetamol

poisoning) was started in April 2006. Patients admitted to the hospital with paracetamol
poisoning were enrolled in the hospitalised control group only if the patient could be
matched for sex and age (to nearest 3 years) with a member of the test group.
Accordingly, the hospitalised control group comprised 11 subjects (three males and nine
females) who could be matched individually for age and sex with 11 patients in the test
group. The hospitalised control group was also compared with 11 healthy individuals
matched with the 11 OP poisoned patients drawn from the test group. This helped to
determine whether psychological conditions associated with self harm and hospitalisation
(which was present in patients with paracetamol overdose, but absent in healthy
individuals) affects the test performance. Hospitalised control group was tested after
recovery from the acute stage, on the day of discharge from the ward. The median
duration between ingestion and testing was 5 days (range: 3 to 6 days).

39

67 patients with suspected OP

poisoning assessed for eligibility

58 fulfilled
inclusion criteria
9 excluded:
2: chronic occupational exposure
7: excessive alcohol intake
49 eligible patients
5 did not participate

44 assessed for
cognitive functions
on recovery from
cholinergic phase

Age-and-sexmatched

11 patients drawn
from test group

43 healthy
controls
Age-and-sexmatched

14 loss of follow up

30 assessed for
cognitive fuctions
after 6 months

Figure 2.1: Selection and comparison of study samples.

11 hospitalised
controls

40

The subjects were instructed and made to stick to the following criteria before
attending the cognitive function tests, so that it was possible to minimize the short-term
factors modifying the cognitive processing speed (International Programme on Chemical
Safety, 2001):
1. Abstain from alcohol on the day of testing and the day before
2. Abstain from smoking and drinking coffee on the day of the test
3. Having a sleep of at least 6 hours in the night before the test

Subjects were inquired for contraindications for magnetic stimulation (intracranial

metal implants, cardiac pacemakers) but none had any contraindication. A neurological
examination and a visual acuity test were performed on the day of cognitive assessment.

2.5.

Assessment of cognitive processing

After neurological examination, subjects participated in the test battery devised to

assess cognitive processing of visual information and auditory information.

2.5.1. Basis of the assessment paradigms

Visual information processing: Studying the cognitive processing of visual information

was based on measurement of the cognitive component of visual reactions. We denoted
the cognitive component of visual reactions as cognitive processing time (CPT), and

41

quantified the CPT using combined VRT test and EP studies. The collective duration of
the sensory component, cognitive component and the motor component of the visual
reaction was measured using VRT tests. VEPs were used to measure the afferent
conduction time of the visual stimulus, and MEPs to measure the motor component of the
reaction time. P100 VEP latency was considered the sensory component. We stimulated
motor cortical neurons using transcranial magnetic stimulation (TMS) and recorded the
MEPs of the muscle that responds in the visual reaction. Then we measured the duration
between cortical stimulation and the onset of MEPs, which is the total motor conduction
time (TMCT). This was considered the length of the motor component of the visual
reaction. Then CPT of the visual reaction was calculated by subtracting the sum of the
sensory component and the motor component from the VRT (figure 2.2).

Figure 2.2: Calculation of cognitive processing time (CPT). VRT: visual reaction time.
TMCT: total motor conduction time.

42

Auditory information processing: Assessment of cognitive processing of auditory

information was based on findings of ERPs which are electrophysiological correlates of
cognition. Applying the auditory oddball paradigm, we recorded ERPs that reflect the
auditory stimulus evaluation process of the neural circuits.

2.5.2. Equipment

1. A computer-based test (SermionTM) was used to measure SVRT and RVRT. Visual
stimuli were displayed on a 14-inch colour monitor.
2. A Magstim Model 200TM magnetic stimulator with a circular 90mm coil (Type 9784)
was used for TMS and spinal stimulation (figure 2.3).
3. Medtronic Keypoint signal averaging machines were used to record and average EPs
and ERPs (figures 2.4A & 2.4B). MEPs were recorded with pre-gelled surface
electrodes. 10mm gold-plated cup electrodes were used for VEP and ERP recording.

43

Figure 2.3: Magstim Model 200TM magnetic stimulator with circular 90mm coil.

Figure 2.4: Signal averaging machines: (A) Medtronic KeypointTM (used to record visual
evoked potentials and motor evoked potentials). (B) Medtronic Keypoint PortableTM
(used to record ERPs).

44

2.5.3. Details of the techniques

1. Visual reaction time tests:

Two types of VRTs (viz. SVRT and RVRT) were measured using a computerbased RT test (SermionTM). Visual stimuli for the reactions were displayed on a 14-inch
colour monitor. The brightness and the contrast of the screen were fixed throughout the
study in order to keep the stimulus intensity constant. The Ctrl key on the right side of
the computer keyboard was the response button for right-handed subjects, while that on
the left side was the response button for the left-handers. The computer calculated the
interval between appearance of the stimulus and the response (i.e. VRT), to the closest
millisecond and displayed the result.

In SVRT tests, the stimulus was a randomly-timed white flash appearing on the
screen and the subject had to react to as quickly as possible by pressing the
response button. If the subject did not respond to a stimulus, it was counted as an
omission.

In RVRT tests, the stimulus appearing on the screen was either a white or a red
flash. Both the timing and colour of the flashes were random. The subject had to
recognize and respond only to the white flashes as quickly as possible. Each
response to a red flash (non-target stimuli) was counted as an error, and each
instance where there was no response to a white flash (i.e. target stimulus) was
counted as an omission. The importance of the correct response (accuracy

45

instructions) as well as the reaction speed (speed instructions) was emphasised to

the participants, the accuracy being the primary requirement.

2. Visual evoked potentials:

To evaluate the afferent component of the VRT, VEPs were recorded using the
Medtronic Keypoint signal averaging machine. The recording technique conformed to
the International Federation of Clinical Neurophysiology guidelines (Celesia & Brigell,
1999). Black and white checkerboard pattern reversal stimulus was presented at a
reversal frequency of 2Hz, on a 14-inch video screen. Recording electrodes were placed
conforming to the international 10-20 scalp electrode placement standards which are
based on landmarks of the skull (figure 2.5). Initially, the distance between the nasion
and inion was measured along the midline over the vertex. Based on this distance, the
recording electrodes were placed on the following positions:

Active electrode: Oz position (10% of the distance, above the inion)

Reference electrode: Fp position (10% of the distance, above the nasion)

Ground electrode: Cz position (at the midpoint between nasion and inion)

Electrode impedance was maintained below 5kOhm.

The recording settings were as following:

High frequency filter: 50Hz

Low frequency filter: 1 Hz

Time-base (recording epoch): 200ms

Sensitivity: 10V per division

46

Hundred recordings were averaged to acquire the VEP waveform. The P100 latency
was measured from the onset of the recording epoch to the point of maximum positivity
of the waveform (figure 2.6). The P100 amplitude was measured form the peak of the
preceding negative waveform (which is called N75 wave) to the peak of the P100
waveform.

Figure 2.5: Electrode placement in VEP recording.

47

5V
20ms

Figure 2.6: A normal VEP waveform (N75 and P100 components are marked).

3. Magnetic stimulation and motor evoked potentials

TMS and MEP techniques were performed conforming to the International
Federation of Clinical Neurophysiology guidelines (Rothwell et al., 1999). The motor
response in the VRT tests was flexion of the index finger of the dominant hand. This
involved contraction of the flexor digitorum superficialis (FDS) muscle. Thus, to evaluate
the motor conduction of the VRT task, MEPs of the FDS muscle were analysed.
Magnetic stimulation technique was used in this study to generate MEPs. A Magstim
Model 200TM magnetic stimulator with a circular 90mm coil (Type 9784) was used for
magnetic stimulation.

48

Magnetic stimulation involves transmission of a pulse of electric current through

the coil and resulting in a magnetic field around the coil, which peaks around 150s and
decays over next millisecond. This magnetic field in turn generates an electric current to
the opposite direction, in a conducting medium located within the magnetic field (figure
2.7). In stimulating the upper limb muscles using transcranial magnetic stimulation, this
coil is placed tangentially over the scalp aligning the centre of the coil over the Cz
position (international 10-20 electrode placement system). The magnetic filed creates an
electric current in the brain tissue, depolarising the motor cortical neurones. Cortical
stimulation is maximal when the induced current flows in postero-anterior direction
(Mills, 2002). Thus in right-handed subjects a counter-clockwise current in the coil (as
viewed from above) was used to optimally stimulate the left motor cortex. A clockwise
current in the coil was used in left-handers to maximally stimulate the right motor cortex.
The motor impulse descends along the corticospinal tracts and then along the motor
neurones to generate MEPs in the flexor digitorum superficialis (FDS) muscle. The
duration between cortical depolarisation and the onset of the MEP is denoted total motor
conduction time (TMCT) which represents the motor component of the visual reaction.

Spinal magnetic stimulation can stimulate the spinal motor roots innervating the
muscles. The spinal roots are stimulated placing the centre of the coil over the spinous
processes. The duration between spinal root depolarisation and the onset of the MEP is
named peripheral motor conduction time (PMCT). In the present study motor roots to
FDS were stimulated placing the coil over the C8 spinous process. The difference

49

between TMCT and PMCT is the central motor conduction time (CMCT) and it
represents the motor conduction along the corticospinal tracts and the most proximal
parts of the motor neurones (Mills, 2002).

Figure 2.7: Magnetic field and the induced current produced by the current flowing
through the coil of the magnetic stimulator.

The MEPs were recorded in a Medtronic Keypoint signal averaging machine. The
electrodes were connected to the signal averaging machine in a belly-tendon montage,
with the following placements:

Active electrode: Over the flexor digitorum superficialis muscle, at the junction
between proximal 2/3 and distal 1/3 of the forearm of the dominant arm

Reference electrode: 3cm distal to the active electrode

Ground electrode: On the anterior surface of the other forearm

50

Recording settings were as following:

High frequency filter: 5kHz

Low frequency filter: 2Hz

Time-base (recording epoch): 50ms

Sensitivity: 2mV per division

In all MEP recordings, latencies were measured from the beginning of the recording
epoch to the beginning of the MEP waveform (figure 2.8).

MEP latency

Figure 2.8: A standard MEP waveform.

4. Event-related potentials
The auditory oddball paradigm was applied to record P300 ERP. Task variable
properties were as following:

Standard stimulus: low frequency (1000Hz) click; probability 80%

51

Target stimulus: high frequency (2000Hz) pip; probability 20% (i.e. the oddball)

Stimulus intensity: 70dB

The auditory stimuli were applied binaurally through a pair of headphones. The

interval between two successive stimuli varied randomly between one to two seconds.
The type of the stimulus (target/standard) at a given moment was also random. Each
session included to 250 stimuli (standard ~ 200, target ~ 50). The subjects were required
to mentally count the target stimuli while ignoring the standard ones.

ERP responses to the standard and target stimuli were averaged and recorded
separately by Medtronic Keypoint Portable signal averaging machine. Electrode
placement (international 10-20 scalp electrode placement standards) (figure 2.9):

Active electrode: Cz position of the scalp

Reference electrodes: bilaterally over mastoid processes (combined inputs to

the signal avarager)

Ground: Fp position of the scalp

Electrode impedance was maintained below 5kOhm.

Recording settings:

High frequency filter: 20Hz

Low frequency filter: 0.2 Hz

Time- base: 1000ms

Sensitivity (gain): 10V per division

52

Figure 2.9: Electrode placement in recording P300 component of ERPs.

At the end of signal acquisition, the peak of the first positive ERP wave between
250ms and 900 ms was marked as P300 of which the latency was measured. The peak of
the preceding negative component (N2 wave) was marked and the difference between N2
and the P300 along the vertical axis was measured to obtain the P300 amplitude (figure
2.10).

53

10V
100ms

Figure 2.10: A normal P300 ERP waveform.

2.5.4. Testing protocol

The tests that require cognitive operations and attention (i.e. VRT, ERPs) were
applied first, in order to minimise possible performance variations in case the subjects get
bored by testing over a period of an hour or so. Test of sensory and motor conduction
(VEPs and MEPs) were performed during the latter part of the session. Subjects
performed all the tests in sitting position. Background noise and distractions were
minimised. In VRT and VEP experiments surrounding light was cut off to maintain a
uniform background luminance. In all EP and ERP tests the subjects were instructed to
minimise body movements. The sequential test-protocol was as following:

54

I. SVRT: The subject was seated, lightly touching the response button with the index
finger of the dominant hand (figure 2.11). He had to concentrate on the stimulus
display screen, respond to the randomly timed stimuli as soon as possible. Initially
all subjects were given a practice session of 10 RT trials to familiarise with the
procedure. Thereafter each subject performed 30 RTs, and the average SVRT was
calculated.

II. RVRT: The seating arrangement, finger position of the subject and the visual
display background were similar to those of the SVRT test. Before the test the
subjects were observed whether they can differentiate the two stimuli. Similar to
SVRT, a practice session was provided for the subject to get familiarised with the
test. Each subject performed 30 RTs which were averaged to calculate the RVRT.

III. Auditory ERPs (figures 2.12): In a pre-test exposure to the stimuli, it was ensured
that the subjects can differentiate the target stimulus from the standard stimulus.
Then each subject was exposed to 250 stimuli (~50n targets and ~200 standard
stimuli) asking them to mentally count the number of targets. At the end of the
session average P300 latency and the amplitude were measured.

55

Figure 2.11: Reaction time test.

Figure 2.12: Recording auditory P300 event-related potential.

56

IV. VEPs (figure 2.13): Standard checkerboard type pattern reversal VEPs were
recorded with minimal surrounding illumination. One eye was stimulated at a time;
right eye followed by the left. The subjects kept the eye fixed on a target on the
middle of the screen, while keeping the opposite eye closed. After averaging 100
VEP waveforms P100 latency was measured. The P100 latencies of two eyes were
averaged and used for further analysis.

V. TMS and MEPs (figure 2.14): TMS was applied first to generate MEPs and
measure TMCT. Next, spinal magnetic stimulation was done to elicit MEPs which
used to measure PMCT. In all the instances magnetic stimulation was performed
with facilitation, where the subject kept the index finger of the dominant hand
flexed (at metacarpophalangeal and interphalangeal joints) against a moderate
resistance. Six MEPs were recorded with TMS and six were recorded with spinal
magnetic stimulation. Of the six recordings, the shortest latency was taken as the
TMCT (with TMS) / PMCT (with spinal stimulation).

57

Figure 2.13: Recording pattern reversal visual evoked potentials.

Figure 2.14: Transcranial magnetic stimulation and motor evoked potential recording.

58

When a subject was found to have any medical condition that needs further
management, he/she was explained about the condition, and was referred to appropriate
treatment units. The test group underwent the above test procedure twice: initially during
immediate post-cholinergic phase and then six months after poisoning. All control
subjects were tested once.

2.6.

Data analysis

2.6.1. Calculated outcome variables

The readings obtained at the end of a testing session were SVRT, RVRT, P100
latency, P100 amplitude, TMCT, PMCT, auditory P300 latency and P300 amplitude.
CMCT was calculated by subtracting PMCT from TMCT:
CMCT = TMCT - PMCT
As VRT is the sum of the afferent visual impulse duration (i.e. P100 latency), the motor
impulse duration (i.e. TMCT) and CPT, the CPT was calculated by subtracting the sum
of P100 latency and TMCT by VRT:
CPT = VRT - (P100 latency + TMCT)
Thus,
CPT of simple visual reactions (CPTSVR) = SVRT - (P100 latency + TMCT)
CPT of recognition visual reactions (CPTRVR) = RVRT - (P100 latency + TMCT)
As VRT varies with the test, CPT is different in simple and recognition VRT tests.

59

2.6.2. Statistical analysis

All the outcome variables (SVRT, CPTSVR, RVRT, CPTRVR, P100 latency, P100
amplitude, TMCT, PMCT, CMCT, P300 latency and P300 amplitude) were compared
between the groups. Follow up measurements of the test group were compared with their
initial values. The data were analysed using Statistical Package for the Social Sciences
(SPSS) for Windows Version 10.0.

Continuous variables with normal distributions (viz. age, SVRT, RVRT, CPTSVR,
CPTRVR, P100 latency, TMCT, PMCT, CMCT and P300 latency) were presented as
mean " standard error of the mean (SE) values. These variables of cognitive processing
and peripheral conduction were compared between the test group and the controls with
non-paired t-test. The two sets of normally distributed measurements of the OP poisoned
patients were compared with paired t-test. In comparing these normally distributed
variables, Levenes test was applied to check the equality of variances between the
corresponding parameters between groups. In the instances where there were significant
differences in the variances, p values related to unequal variances were taken to assess
the significance of the differences between the data sets. P300 amplitudes were not
normally distributed so that they were presented as medians and inter-quartile ranges
(IQR). Non-parametric tests were used to compare P300 amplitudes between different
data sets. P300 amplitudes between groups were compared with Mann-Whitney U test,
whilst the patients initial and follow-up P100 and P300 amplitude data were analysed

60

with Wilcoxon signed rank test. Correlations were calculated using Pearsons correlation
coefficient (r). All tests were two-sided and assessed at 5% significance level.

61

Section 3
RESULTS

3.1. Sample characteristics

3.1.1. Test group

Test group comprised 44 patients (28 males and 16 females) with acute OP
poisoning. Age of these patients was 24.1 " 1.1 years and ranged from 14 years to 50
years (figure 3.1).

3.1.2. Healthy control group

This group consisted of 43 individuals. These controls were individually matched

with the patients with OP poisoning so that the sex distribution was the same in both
groups. The age of healthy controls was 24.6 " 1.3 years, ranging from 15 to 52 years.
With one-to-one matching for the age, its distribution in this group was similar (p =
0.797) to that of the test group (figure 3.1 and table 3.1).

62

Healthy control group

18

Number of controls

Number of subjects

Test group

16
14
12

18
16
14
12

10

10

2
0

0
15 20 25 30 35 40 45 50

15 20 25 30 35 40 45 50

Age (years)

Age (years)

Figure 3.1: Age distribution of the test group and healthy controls.

Table 3.1: Comparison of age: Test group and healthy control group.
Mean age (SE) (Years)
Test group
(n = 44)
24.1 (1.1)

Healthy controls
(n = 43)
24.6 (1.3)

Significance
(p value)

Mean difference (95%

confidence intervals)
(years)

0.797

-0.5 (-3.9 3.0)

3.1.3. Hospitalised control group

This group consisted of 11 patients (three males and nine females) hospitalised with
paracetamol overdose. The age of this group was 19.7 " 1.2 years and ranged from 14 to

63

27 years. Age of the hospitalised control group is compared with matched test group
subjects and the healthy controls in table 3.2. There was no significant difference in the
age between the three groups (test group vs. hospitalised controls: p = 0.957. hospitalised
controls vs. healthy controls: p = 0.772). Supplementary data on the background
information of the three groups are tabulated in appendix 3.

As expected by one-to-one matching, there was no significant difference either in

sex or age distribution among the three groups. Matching for age and sex helped to
eliminate two major confounding factors affecting the outcome variables.

Table 3.2: Age distribution of organophosphorus poisoned patients, matched hospitalised

control group and healthy controls.
Group

Age. mean (SE) (years)

Sample drawn from test group (n = 11)

19.8 (1.2)

Sample drawn from healthy controls (n = 11)

19.3 (1.0)

Hospitalised controls (n = 11)

19.7 (1.2)
Comparison of groups
Significance
(p value)

Mean difference (95%

confidence interval) (years)

Test group vs. Hospitalised controls

0.957

0.1 (-3.4 3.6)

Hospitalised controls vs. Healthy controls

0.772

0.4 (-3.7 2.8)

Compared groups

64

3.2.

Episode of poisoning, management measures and complications

3.2.1. Test group

All the test subjects had ingested an OP insecticide; 43 intentionally and one
accidentally. The types of OP insecticides that the patients have taken are given in table
3.3. The most common OP compound was chlorpyrifos, accounting for about one-third
(34.1%) of the intoxications in the sample. It was followed by dimethoate, fenthion,
phenthoate, coumaphos, diazinon, methamidophos, oxydemeton-methyl and profenofos.
According to WHO classification, coumaphos is considered extremely hazardous (class
Ia); fenthion, methamidophos and oxydemeton-methyl are considered highly hazardous
(class Ib); and chlorpyrifos, dimethoate, phenthoate, diazinon and profenofos are labelled
moderately hazardous (class II) (Anonymous, 2000). In seven cases, the exact type of
OP compound was not confirmed, although circumstantial evidence and clinical features
indicated an OP as the causative agent. Appendix 4 gives the details of the type and the
amount of the insecticide that each patient has taken. The amount is a rough estimate
based on the information given by the victim and other informers.

The 43 patients with intentional ingestion were seen by a psychiatrist. In 34 of

them, poisonings were categorized as impulsive acts of self-harm, and they were not on
any drugs on the day of testing. Nine patients were diagnosed as having depression, and

65

at the time of initial testing, eight were on the antidepressant fluoxetine, and one patient
was on amitriptyline.

Table 3.3: The type of organophosphorus (OP) insecticide ingested by patients.

Type of OP insecticide

Number of patients
(% of total number of patients)

Chlorpyrifos

15 (34.1)

Dimethoate

7 (15.9)

Fenthion

6 (13.6)

Phenthoate

4 (9.1)

Coumaphos

1 (2.3)

Diazinon

1 (2.3)

Methamidophos

1 (2.3)

Oxydemeton-methyl

1 (2.3)

Profenofos

1 (2.3)

Not known

7 (15.9)

Twenty-nine patients were directly admitted to the Teaching Hospital, Peradeniya.

In these patients the median duration between ingestion and first documented clinical
examination ranged from 30 minutes to 6 hours with a median of 1.0 hour (also see
Appendix 4). Others were initially admitted to the local hospital and then transferred to
the Teaching Hospital Peradeniya. In these patients the duration between ingestion and
first clinical assessment was not available.

66

Cholinergic features observed in each patient are given in appendix 4, and the
pattern of observed clinical features among the sample is shown in figure 3.2. Among the
features of cholinergic crisis, respiratory signs were the most prevalent in the sample.
Twenty-five out of 44 patients had dyspnoea and/or lung signs. Other common signs
were miosis and excessive sweating/salivation. Bradycardia was observed only in two
patients. Many features of cholinergic overactivity were not detected in the study
participants, may be because it was not possible to assess all the patients within a short
time of exposure and monitor them regularly.

Appendix 5 summarises the treatment measures, complications and hospital stay of

each participant of the test group. Every patient has received at least one dose of atropine.
All the patients except one, were administered at least one dose of pralidoxime. Sixteen
patients developed respiratory failure needing ventilatory support, at some stage of
hospitalised care. Hospital stay of the test group ranged from three to 31 days, with a
median hospital stay of seven days.

67

30

number of patients

25

20

15

10

impaired
consciousness

dyspnoea / lung
signs

excessive
sweating /
salivation

miosis

bradycardia

fasciculation

clinical feature

Figure 3.2: Number of patients that showed each cholinergic feature.

3.2.2. Hospitalised control group

All these patients had taken paracetamol, attempting deliberate self-harm.

According to the psychiatric assessment one patient was depressed, and was on
fluoxetine at the time of cognitive assessment. Others have taken the drug impulsively.
The dose of paracetamol, and the duration of hospital stay in each subject is given in
appendix 6. The dose ranged from 7.5 to 31.5 grams with a mean of 13.3 grams. All the
patients have received N-acetylcystine. Median hospital stay was five days. It ranged

68

from three to six days. None of the patients developed hepatic encephalopathy which can
affect cognitive functions.

3.3. Inter-group comparison of the measures of cognitive processing, visual and

motor components

Neurological examination on the day of cognitive testing did not reveal any new
information which led to exclusion of test or control subjects. The measures of cognitive
processing, visual and motor conduction of the participants of test and control groups are
given in appendix 7. Some parameters could not be measured in some subjects due to
various practical difficulties. Particularly, P300 ERP could not be recorded in the first
few test and control subjects of the series, because ERP recording techniques were
available only after some time of commencement of data collection. In each test, numbers
of test and control subjects whose measurements were taken are shown in table 3.4.
However, each matched control performed all the tests done by the matched test subject.

69

Table 3.4: Numbers of subjects whose measurements were taken in tests of information
processing.
Number of subjects
Parameter

test group
(total = 44)

healthy

hospitalised

controls

controls

(total = 43)

(total =11)

Simple visual reaction time

43

43

11

Recognition visual reaction time

42

42

11

P100 latency

43

43

10

Total motor conduction time

42

42

10

Peripheral motor conduction time

42

42

10

Central motor conduction time

42

42

10

42

42

10

41

41

10

P300 latency

32

32

P300 amplitude

29

29

Cognitive processing time of simple

reactions
Cognitive processing time of recognition
reactions

3.3.1. Visual reaction time

RVRT was longer than SVRT in each subject. Comparisons of VRT data in the
test group and the control groups are illustrated in figures 3.3 and 3.4.

70

SVRT was 274.0 " 8.5ms in the test group and 252.8 " 4.9ms in the healthy control
group. This difference was significant (p = 0.035). RT findings of the subgroup drawn
from the test group and matched hospitalised control group are shown in figure 3.4.
SVRTs were 312.6 " 18.2ms, 254.4 " 9.9ms and 250.0 " 5.5ms in matched test subjects,
healthy individuals and hospitalised controls respectively. SVRT of the test subjects was
significantly longer than that of the hospitalised controls (p = 0.007). SVRT was similar
in the two control groups (p = 0.700).

RVRT was also significantly delayed in the test group (p = 0.023). It was 511.3 "
15.5ms in the test group and 470.2 " 8.6ms in healthy controls. Patients with OP
poisoning had a significantly delayed RVRT compared to those with paracetamol
overdose (p = 0.004). There was no significant difference in RVRT between two control
groups (p = 0.147).

71

600
511.3
470.2

Reaction time (ms)

500
400
274.0

300

Test group
Healthy controls

252.8

200
100
0
SVRT

RVRT

Figure 3.3: VRT in the test group and healthy controls.

700
555.0

Reaction time (ms)

600

477.9

500
400
300

441.2
Test subjects
Healthy controls
Hospitalised controls

312.6
254.4

250.0

200
100
0
SVRT

RVRT

Figure 3.4: VRT in the test subjects, matched hospitalised controls and healthy controls.

72

3.3.2. Components of visual reaction time

VRT is the sum of the visual conduction time (i.e. P100 latency), motor conduction
time (i.e. TMCT) and CPT. This section gives the results of these components.

3.3.2.1. Visual conduction

P100 VEP latency, which denotes the afferent component of the visual reactions,
was not significantly different among the groups. Figure 3.5 shows a VEP tracing
recorded in a patient with OP poisoning.

5V
20ms

Figure 3.5: VEPs of a patient with OP poisoning (no. 47). The recordings of the right eye
and the left eye are superimposed (P100 latency- right side: 98.5ms, left side: 96.8ms).

The distribution of P100 latencies are presented in figure 3.6. P100 latency was
100.6 " 0.9ms in the test group and 101.5 " 0.8ms in the healthy control group. The
difference was not significant (p = 0.395). In both groups P100 had a narrow distribution.

73

Hospitalised control group had a P100 latency of 100.6 " 0.7ms. In the matched test
subjects P100 latency was 99.1 " 1.4ms. The difference was not significant (p = 0.368).
According to these results, the duration of the afferent component of visual reactions is
similar in patients with OP poisoning and the controls.

120

115

115

110

P100 latency (ms)

P100 latency (ms)

110

105

100

100.6

101.5

95

90

105

100

100.5

100.6

99.1

95

90

85
Test
group

85

Healthy
controls

Test
subjects

Healthy
controls

Hospitalised
controls

Figure 3.6: Distribution of P100 latency. A: test group and healthy controls. B: test
subjects, matched hospitalised controls and matched healthy controls.

3.3.2.2. Motor component

Motor component of the reaction was analysed in 3 sub-components viz. TMCT:
duration of transmission of motor impulses from the primary motor cortex to the muscle,
PMCT: the duration of signal transmission from spinal motor roots to the muscle and

74

CMCT: the difference between TMCT and PMCT. CMCT is mainly contributed by
conduction time along the corticospinal tracts. Figure 3.7 shows MEPs recorded after
magnetic stimulation in a patient with OP poisoning.
Stim

2mV
5ms

Figure 3.7: MEPs in a patient with OP poisoning (no. 54). The onset of the MEP
waveform is marked in each tracing. Upper two tracings were recorded after TMS
(TMCT = 15.8ms). Lower two tracings were recorded after spinal magnetic stimulation
(PMCT = 11.5ms).

Figure 3.8 compares these parameters in the test group and healthy control group.
TMCT was 15.46 " 0.24ms and PMCT was 9.44 " 0.17ms in the patients. In healthy
controls TMCT was 15.26 " 0.19ms and PMCT was 9.24 " 0.13ms. All three
components of motor conduction were similar in the patients and healthy controls. The p
values were 0.510, 0.370 and >0.999 for TMCT, PMCT and CMCT respectively.

In the hospitalised control group, TMCT, PMCT and CMCT were 14.73 " 0.47ms,
8.86 " 0.34ms and 5.87 " 0.35ms respectively (figure 3.9). These values in the matched
test subjects were 15.10 " 0.57ms, 9.40 " 0.46ms and 5.70 " 0.24ms respectively. The
measures of motor conduction were similar in the two groups (p values for TMCT: 0.624,

75

PMCT: 0.357, CMCT: 0.696). These results show that the duration of the motor
component (which include the central and peripheral motor conduction) of psychomotor
reactions is similar in patients and the controls.
18
16

15.46

15.26

time (ms)

14
12
9.44 9.24

10
8

Test group
Healthy controls

6.02 6.02

6
4
2
0
TMCT

PMCT

CMCT

Figure 3.8: Motor conduction times in patients and healthy controls.

18
16

15.10
14.71 14.73

14

time (ms)

12
9.40

10

9.17

Test subjects
8.86

Healthy controls

8
5.70 5.54 5.87

Hospitalised
controls

4
2
0
TMCT

PMCT

CMCT

Figure 3.9: Motor conduction times in test subjects, matched hospitalised controls and
matched healthy controls.

76

3.3.2.3. CPT of visual reactions

CPTSVR was shorter than CPTRVR in all subjects. Figures 3.10 and 3.11 summarise
the findings of cognitive processing.

3.3.2.3.1. CPT(SVR)
CPTSVR in the test group was 158.7 " 9.0ms. It ranged from 78.4ms to 310.6ms. In
healthy control group CPTSVR was 137.1 " 4.8ms. Test group had a significantly delayed
CPTSVR compared to that of the healthy individuals (p = 0.037).

The subjects drawn from the test group are compared with the matched patients
with paracetamol overdose in figure 3.11. CPTSVR was 190.0 " 18.6ms in the test
subjects, 135.0 " 6.2ms in hospitalised control group and 135.2 " 9.5ms in matched
healthy control subjects. The data distribution was wider in the test subjects in
comparison to both control groups. Test subjects had a significantly prolonged CPTSVR
compared to the matched controls with paracetamol overdose (p = 0.017). Results of the
two control groups were similar (p = 0.991).

3.3.2.3.2. CPTRVR
Inter-group differences in CPTRVR show a similar pattern to the differences in
CPTSVR. CPTRVR was 397.5 " 16.0ms of the test group and 355.7 " 8.4ms in healthy
control group. The patients had a significantly prolonged CPTRVR in comparison to their
healthy counterparts (p = 0.024). CPTRVR in the patients with OP poisoning ranged form

77

229.9ms to 712.3ms. The data were more closely distributed in the healthy control group,
ranging from 269.6ms to 467ms. CPT(RVR) were 322 " 12.8ms, 414.4 " 21.3ms and
350.7 " 19.4ms in hospitalised controls, matched test subjects and matched healthy
individuals respectively. The difference between the patients with OP poisoning and
matched patients with paracetamol overdose was highly significant (p = 0.002), the test
subjects having a marked delay in cognitive processing. There was no significant
difference between the CPTRVR of hospitalised controls and matched healthy individuals
(p = 0.239).

CPT results indicate that cognitive processing components of simple visual

reactions and recognition visual reactions were prolonged in the test group in comparison
to healthy control group and hospitalised control group.

450

397.5

400

355.7

350
time (ms)

300
250
200
150

158.7

Test group
Healthy controls
137.1

100
50
0
CPT(SVR)

CPT(RVR)

Figure 3.10: CPT(SVR) and CPT(RVR) in the test group and healthy control group.

78

500.0
414.4

450.0

Reaction time (ms)

400.0

350.7

350.0
300.0
250.0

Test subjects
Healthy controls
Hospitalised controls

190.0

200.0
150.0

322.4

135.2

135.0

100.0
50.0
0.0
CPT(SVR)

CPT(RVR)

Figure 3.11: CPT(SVR) and CPT(RVR): test subjects, matched hospitalised controls and
healthy controls.

3.3.3. P300 ERP

Grand average P300 waveforms of the study groups are shown in figure 3.12.
Distribution of P300 latencies is illustrated in figure 3.13. Auditory P300 ERP latency
was 376.8 " 8.85ms in the test group, ranging from 291ms to 561ms. In healthy control
group it was 344.1 " 6.0ms with a range of 259ms to 408ms. The P300 latency was
32.7ms longer in patients, and this delay was highly significant (p = 0.003). The control
group with paracetamol overdose had a P300 latency of 341.6 " 7.4ms. The latency in
the subgroup of matched OP poisoned patients was 383.2 " 11.9ms, showing a
comparatively highly significant prolongation (p = 0.009). In matched healthy control
subjects P300 latency was 345.0 " 7.8ms, and this was similar to the P300 latency of the

79

hospitalised control group (p = 0.753). These findings indicate that auditory information
processing is prolonged in patients with OP poisoning compared to both control groups.

200

400

600

800

__

test group
healthy
control
group

5V

OP poisoned
patients
0

200

400

600

800

healthy
controls
__

5V

paracetamol
controls

Figure 3.12: Grand average ERP waveforms for target tones. (A) test group and healthy
control group. (B) subgroup of OP poisoned patients, matched healthy controls and
matched paracetamol controls.

80

480

600
550

440

450
400
376.8
350

344.1

P300 latency (ms)

P300 latency (ms)

500

300

400
383.2
360
345.0

341.6

320

250

280

200

Test
group

Test
subjects

healthy
controls

Healthy
controls

Hospitalised
controls

Figure 3.13: Distribution of P300 latencies. A: test group and healthy control group. B:
matched hospitalised controls, test subjects and healthy individuals.

Figure 3.14 shows distribution of P300 amplitudes in the study groups. P300
amplitude was 10.8 (7.2 -14.9) V in the test group and 9.4 (7.9 16.0) V in healthy
control group. These were not significantly different (p = 0.963). The amplitudes in
hospitalised control group, matched test subjects and healthy controls were 13.9 (8.3
15.3) V, 12.6 (8.4 14.9) V and 8.7 (8.0 9.9) V respectively. These group
differences were also not significant (test group vs. hospitalised controls: p = 0.965.
hospitalised controls vs. healthy controls: p = 0.508).

35

28

30

24

25

20

P300 amplitude (mV)

P300 amplitude (mV)

81

20
15
10

10.8

16
12
8

13.9

12.6
8.7

9.4
4

Test
group

Healthy
controls

Test
Healthy
subjects controls

Hospitalised
controls

Figure 3.14: Distribution of P300 amplitudes. A: Test group vs. healthy control group.
B: matched test subjects and healthy individuals vs. hospitalised controls.

3.3.4. Summary of Inter-group comparison of measures of information processing

Inter-group comparison of the parameters of information processing are

summarised in tables 3.5 and 3.6. Findings related to visuomotor information processing
indicate that visual reaction speed is significantly impaired in OP poisoned patients, even
after recovery from the cholinergic phase. However, durations of afferent conduction (i.e.
P100 latency) and efferent conduction (TMCT, CMCT and PMCT) were similar in
patients and the two control groups. Test group showed significant delay in cognitive
processing both in simple visual reactions and recognition visual reactions. This indicates

82

that in patients with OP poisoning, impairment occurs in cognitive component of visual

reactions rather than in sensory or motor components. Cognitive processing of auditory
information was also delayed in the test group as reflected by delayed P300 latencies.
However, P300 amplitude was similar in the patients and the controls.

Table 3.5: Comparison of the measures of information processing: test group (initial
assessment) vs. healthy controls.
Mean (SE) (ms)
Parameter
Test group

Healthy

Significance

controls

Mean difference
(95% CI) (ms)

SVRT

274.0 (8.5)

252.8 (4.8)

0.035

21.1 (1.6 40.7)

RVRT

511.3 (15.5)

470.2 (8.6)

0.023

41.2 (5.8 76.5)

P100 latency

100.6 (0.9)

101.5 (0.8)

0.395

-1.0 (-3.2 1.3)

TMCT

15.46 (0.24)

15.26 (0.19)

0.510

0.20 (-0.40 0.80)

PMCT

9.44 (0.17)

9.24 (0.13)

0.370

0.20 (-0.24 0.64)

CMCT

6.02 (0.18)

6.02 (0.15)

>0.999

<0.01 (-0.47 0.47)

CPT(SVR)

158.7 (9.0)

137.1 (4.8)

0.037

21.6 (1.3 41.9)

CPT(RVR)

397.5 (16.0)

355.7 (8.4)

0.024

41.8 (5.6 77.9)

P300 latency

376.8 (8.8)

344.1 (6.0)

0.003

32.7 (11.3 54.2)

83

Table 3.6: Comparison of the measures of information processing: hospitalised controls

vs. matched test group subjects and healthy controls.

(9.9)

(5.5)

555.0

477.9

441.2

(33.0)

(21.3)

(11.8)

P100

99.1

100.5

100.6

latency

(1.4)

(1.6)

(0.7)

15.10

14.71

14.73

(0.57)

(0.43)

(0.47)

9.40

9.17

8.86

(0.46)

(o.40)

(0.34)

5.70

5.54

5.87

(0.24)

(0.30)

(0.35)

190.0

135.2

135.0

(18.6)

(9.5)

(6.2)

414.4

350.7

322.4

(21.3)

(19.4)

(12.8)

P300

383.2

345.0

341.6

latency

(11.9)

(7.8)

(7.4)

RVRT

TMCT

PMCT

CMCT

CPT(SVR)
CPT(RVR)

0.700

0.004

0.147

0.368

0.982

0.624

0.975

0.357

0.563

0.696

0.484

0.017

0.991

0.002

0.239

0.009

0.753

Healthy controls vs.

Hospitalised controls

(18.2)

0.007

Mean difference (95% CI) (ms)

Test subjects vs.

hospitalised controls

250.0

(p)
Healthy controls vs.
Hospitalised controls

Hospitalised controls
(n = 11)

254.4

SVRT

Significance

Test subjects vs.

hospitalised controls

Healthy controls
(n = 11)

312.6

Parameter

Test group subjects

(n = 11)

Mean (SE) (ms)

62.6

4.44

(21.1 104.2)

(-19.2 28.1)

113.9

36.7

(40.7 187.1)

(-14.0 87.5)

-1.4

-0.1

(-4.8 1.8)

(-3.8 3.7)

0.37

-0.02

(-1.19 1.93)

(-1.36 1.32)

0.54

0.31

(-0.65 1.74)

(-0.80 1.42)

-0.17

-0.33

(-1.07 0.73)

(-1.30 0.64)

54.9

0.13

(11.7 98.1)

(-23.8 24.0)

92.1

28.3

(39.0 145.1)

(-20.5 77.1)

41.7

-1.2

(12.1 71.3)

(-7.6 5.1)

84

3.3.5. Correlations between measures of cognitive processing

The correlations between measures of cognitive processing within an individual

were assessed pooling all study participants (n = 94) (table 3.7). Figure 3.15 is a scatter
plot where the CPT(SVR) of each individual is plotted against his/her CPT(RVR) value.
There was a highly significant, moderate, positive correlation (r = 0.579, p < 0.001)
between CPT(SVR) and CPT(RVR). Similarly, there was a significant but weaker positive
correlation between CPT(RVR) and P300 latency (r = 0.321, p = 0.008) (figure 3.16).
However, CPT(SVR) and P300 latency did not show a significant correlation (r = 0.225, p
= 0.630).

Table 3.7: Correlation between parameters of cognitive processing in all study

participants (n = 94).
Compared parameters

Pearsons correlation

Significance (p)

coefficient (r)
CPT(SVR) vs. CPT(RVR)

0.579

<0.001

CPT(SVR) vs. P300 latency

0.225

0.63

CPT(RVR) vs. P300 latency

0.321

0.008

CPT (RVR) (milliseconds)

85

800

700

600

500
400

300
200
0

100

200

300

400

CPT(SVR) (milliseconds)

Figure 3.15: Correlation between CPT(SVR) and CPT(RVR). r = 0.579. p <0.001.

P300 latency (milliseconds)

500

400

300

200
200

300

400

500

600

700

800

CPT(RVR) (milliseconds)

Figure 3.16: Correlation between CPT(RVR) and P300 latency. r = 0.321. p = 0.008.

86

3.4. Follow up assessment of the patients with OP insecticide poisoning

Follow up assessment of the test group was done after a median duration of 6
months of exposure. This ranged from 4 to 13 months, as some patients were unable to
attend on the initially scheduled date due to practical reasons. Of the 44 patients assessed
in the first time, 30 (i.e. 68%) returned for the follow up assessment. This consisted of 20
males and 10 females. All tests of information processing were carried out in all 30
subjects except in two, in whom VEPs and MEPs could not be recorded due to
unavailability of the testing equipment. Detailed results of the follow up are tabulated in
appendix 7.4.

3.4.1. Visual reaction time

Changes in VRT form the initial post-cholinergic phase to the follow up assessment
are shown in figure 3.17. After six months SVRT was reduced in 12 patients and
increased in 18patients. Their mean SVRT at six months was 280.9 " 9.2ms compared to
271.8 " 10.3ms in the first assessment. However, the follow up results were not
significantly different from the initial findings (p = 0.407).

After six months, RVRT values had reduced in 18 patients, unchanged in one and
increased in 10. The RVRT in the follow up was 462.6 " 11.5ms, compared to 505.2
" 18.6ms in the initial testing. This improvement was highly significant (p = 0.007).

87

450

900

400

800

350
RVRT (ms)

SVRT (ms)

700

300
250

600
500

200

400

150
100

300

first assessment

follow up
assessment

first assessment

follow up
assessment

Figure 3.17: Changes in VRT from initial post-cholinergic phase assessment to the
follow up assessment. A: SVRT. B: RVRT.

3.4.2. Components of visual reaction time

3.4.2.1.

Visual conduction

Figure 3.18 shows the differences in P100 VEP latency in the two assessments (n =
28). P100 latency in these patients was 100.0ms " 0.9ms in the first occasion and 99.6
" 0.9ms after six months. This change of 0.4ms was not significant (p = 0.651).

88

120.0

P100 latency (ms)

115.0
110.0
105.0
100.0
95.0
90.0
85.0
first assessment

follow up assessment

Figure 3.18: Changes in P100 VEP latency from initial post-cholinergic phase
assessment to the follow up assessment.

3.4.2.2. Motor component

Figure 3.19 illustrates the changes in motor conduction latencies six months after
poisoning. TMCT was 15.35 " 0.28ms in the first assessment and was 15.94 " 0.25ms
after six months, showing no significant change (p = 0.55). However PMCT was
significantly shortened in the second occasion (p = 0.034). It was 9.54ms " 0.23 in the
post-cholinergic phase and 9.12 " 0.20ms in the follow up testing. CMCT had prolonged
significantly after six months (p <0.001). It was 5.81 " 0.22ms immediately after the
acute phase and 6.82 " 0.24ms at six months, showing a prolongation of 14.8%.

89

20.0
19.0
18.0
TMCT (ms)

17.0
16.0
15.0
14.0
13.0
12.0
11.0
10.0
first assessment

follow up assessment

13.0
12.0

10.0

CMCT (ms)

PMCT (ms)

11.0

9.0
8.0
7.0
6.0
5.0
4.0

first
assessment

follow up
assessment

11.0
10.0
9.0
8.0
7.0
6.0
5.0
4.0
3.0
2.0
1.0
0.0
first
assessment

follow up
assessment

Figure 3.19: Measures of motor conduction in the first assessment and the follow up in
the patients with OP poisoning. A: TMCT. B: PMCT. C: CMCT.

3.4.2.3. CPT of visual reactions

Changes in CPT(SVR) and CPT(RVR) in the patients are shown in figure 3.20. Initial
and follow up CPT(SVR) was assessed in 28 patients. CPT(SVR) was 159.3 " 11.2ms in the

90

post-cholinergic phase and 166.3 " 9.8ms six months after poisoning. This change was
not significant (p = 0.527). Twenty-seven patients had their CPT(RVR) assessed in both
stages. It was 389.5 " 20.2ms in the first assessment and 346.9 " 12.5ms in the follow

350

800

300

700

250

600

CPT (RVR) (ms)

CPT (SVR) (ms)

up, showing an 11% improvement which was significant (p = 0.012).

200
150
100
50

400
300
200

500

100

first
assessment

follow up
assessment

first
assessment

follow up
assessment

Figure 3.20: CPT of visual reactions in the patients in the first assessment and the follow
up assessment. A: CPT(SVR). B: CPT(RVR).

3.4.3. P300 ERP

Grand average ERP waveforms of the first assessment and the follow up are
depicted in figure 3.21. Changes in patients P300 latencies and amplitudes are illustrated
figure 3.22. ERPs were recorded in 25 patients in both stages. In the immediate postcholinergic phase, P300 latency was 364.2 " 7.7ms. After six months it was 362.8

91

" 12.5ms, showing no significant improvement (p = 0.863). As seen in figure 3.21A,

only few patients showed marked changes in P300 latency after six months. Over the
period of six months the mean intra-individual variation of P300 latency was 31.3ms,
which was 8.5% of their initial value. In the follow up assessment, median P300
amplitude was 14.5 (7.4 18.0) V. This was not significantly different (p = 0.628) from
their initial P300 amplitude which was 11.3 (7.2 16.8) V.

1st visit
0

200

400

600

800
__

follow
up

5V

Figure 3.21: Grand average ERP waveforms of the first assessment and the follow up
assessment of the patients with OP poisoning (P300 peaks are marked).

500

35

450

30

P300 amplitude (mV)

P300 latency (ms)

92

400
350
300
250

20
15
10
5

200

25

first
assessment

follow up
assessment

first assessment

follow up
assessment

Figure 3.21: P300 ERP changes in patients with OP poisoning: first assessment vs.
follow up assessment. A: P300 latency. B: P300 amplitude.

3.4.4. Summary of the comparison of initial and follow up assessments of the

parameters of cognitive processing, afferent and efferent conduction

The follow up results of the test subjects are compared with their initial postcholinergic phase findings in table 3.8. In the immediate post-cholinergic phase patients
with OP poisoning had delayed CPT(SVR), CPT(RVR) and P300 latency, in comparison to
the controls. According to the results of the follow up assessment, CPT(RVR) was found to
be improved after six months, whilst delay in CPT(SVR) and P300 latency was persistent.
The sensory component (i.e. P100 latency) and the motor component (i.e. TMCT), which
were similar to those of the controls, had not changed after six months.

93

Table 3.8: Comparison of parameters of information processing of the test group patients
in the initial post-cholinergic phase and the follow up (n = 30).
Parameter

Mean (SE) (ms)

(number of

First

Follow-up

subjects)

assessment

assessment

SVRT (30)

271.8 (10.3)

RVRT (29)

Mean

Significance

280.9 (9.2)

improvement
-9.0
(-31.0
12.9)
(95%
CI)(ms)

(p)
0.407

505.2 (18.6)

462.6 (11.5)

42.6 (12.3 72.8)

0.007

P100 latency (28)

100.0 (0.9)

99.6 (0.9)

0.42 (-1.5 2.3)

0.651

TMCT (28)

15.35 (0.28)

15.94 (0.25)

-0.59 (-1.19 0.01)

0.055

PMCT (28)

9.54 (0.23)

9.12 (0.20)

0.42 (0.04 0.81)

0.034

CMCT (28)

5.81 (0.22)

6.82 (0.24)

-1.01 (-1.51 -0.52)

<0.001

CPT(SVR) (28)

159.3 (11.2)

166.3 (9.8)

-7.0 (-29.2 15.3)

0.527

CPT(RVR) (27)

389.5 (20.2)

346.9 (12.5)

42.6 (10.3 74.9)

0.012

P300 latency (25)

364.2 (7.7)

362.8 (6.7)

1.4 (-14.7 17.4)

0.863

94

Section 4
DISCUSSION

The aim of the present research study was to assess the cognitive sequelae of acute
OP insecticide poisoning. In contrast to previous studies (Savage et al., 1988; Rosenstock
et al., 1991; Steenland et al., 1994, Wesseling et al., 2002) which used
neuropsychological tests, present research work evaluated cognitive functions using more
objective and quantitative psychophysiological parameters of information processing.

Acute cholinergic crisis is well known to cause central and peripheral nervous
system dysfunction. Previous studies on long-term sequelae on acute OP pesticide
poisoning assessed the patients many months to years after poisoning (Savage et al. 1988:
9 years. Rosenstock et al., 1991: 2 years. Steenland et al., 1994: 7 years. Wesseling et al.,
2002: 27 months). Present study tested the patients within a time window between these
two extremes. To minimise the central nervous system effects of acute cholinergic crisis,
the patients were tested after clinical recovery from the cholinergic phase of poisoning. A
follow up assessment was performed six months after poisoning, to evaluate the longlasting changes of cognitive functions.

95

The results showed delayed SVRT and RVRT in patients, in comparison to those of
the control groups. The measures of visual conduction (viz. P100 latency) and motor
conduction (viz. TMCT, PMCT and CMCT) did not show any impairment. CPT
measurements reflected that cognitive processing in simple visual reactions and
recognition visual reactions were prolonged in patients. The results of the ERP studies
revealed delayed P300 latency in the patients in comparison to the controls. There was no
difference in the P300 amplitude. The follow up assessment after six months showed an
improvement in CPT(RVR). However, the delay in CPT(SVR) and P300 latency was
persistent. The sensory component (i.e. P100 latency) and the motor component (i.e.
TMCT) of visual reactions and P300 amplitude remained normal.

4.1. Effects of OP on visual reaction time

Reaction time is usually incorporated into neurotoxicity test batteries. It has been
found to be delayed by alcohol and sedative drugs (Kosinski, 2006). Results of the
present study indicate acute OP insecticide poisoning leads to slowing of SVRT and
RVRT. Impairment in simple visual reactions appears to last for at least up to six months.
This is in contrast to previous reports on delayed effects of acute OP insecticide
poisoning, where the SVRT was similar in patients and matched controls (Rosenstock et
al., 1991; Steenland et al., 1994; Wesseling et al., 2002). However, the mean duration
between exposure and cognitive assessment was much longer in previous studies
(Rosenstock et al., 1991: 24 months. Steenland et al., 1994: 7 years. Wesseling et al.,

96

2002: 27 months). It is possible that these patients had developed psychomotor deficits
after poisoning, recovered over the following few months and were completely normal at
the time of testing (i.e. after 2 to 7 years of exposure). However, this explanation cannot
be substantiated with evidence as those studies have not assessed the patients during the
recovery period from acute poisoning. In line with our findings, some studies on chronic /
repeated exposure to OP compounds have reported delayed SRT in the exposed groups
(Bazylewicz et al., 1999; Fielder et al., 1997; Kilburn et al., 1995). However, none of the
previous studies on long-term sequelae of OP compounds had used RRT tests which
assess more complex cognitive processes compared to SRT tests.

4.2. Importance of analysis of individual components of visual reactions

A visuomotor reaction involves execution of a movement in response to a visual

stimulus. Therefore, visual reaction time is a combination of afferent (visual) conduction,
cognitive processing and efferent conduction. The sensory and motor components
constitute a significant proportion in visual reactions, particularly in SVRT. In our
patients, mean SVRT was 274.0ms and CPTSVR was only 158.7ms (58%) and sensory
and motor conduction constituted 115.3ms (42%) of the duration of the total reaction. As
sensory and motor conduction constitute a significant proportion of the total reaction,
normal variations or pathological deviations in sensory or motor conduction can affect
RT and therefore may give wide variations in the results of RT studies. OP induced
delayed neuropathy is a major confounding factor in this respect. Delayed

97

polyneuropathy manifests after 1-4 weeks of acute OP poisoning, causing slowed sensory
and motor conduction (Lotti & Moretto, 2005; Glynn, 2006). There is mounting evidence
on the effects of OP on visual conduction as well. Prolonged P100 VEP latencies have
been reported in experimental animals exposed to OP compounds (Boyes et al., 1994),
victims of OP nerve agent sarin (Murata et al., 1997) and farmers exposed to OP
pesticides (Kaloianova, 1989). However visual and motor conduction latencies in our
patient group were similar to that of the controls so that apparently peripheral conduction
was not a confounding factor in the present study.

4.3. Cognitive processes and the flow of information in visuomotor reactions

Cognitive processing time, the parameter that we have introduced in this study is
not affected by previously mentioned variations in peripheral conduction, and thus a
better measure of cognitive processing speed in visual reactions. CPT results in this study
indicate that the prolongation of visual reactions is due to impaired cognitive processing
rather than delayed peripheral conduction.

According to our findings, OP insecticides appear to affect one or more aspects of

cognitive processes involved in visual reactions. In simple visual reactions, these stages
include detection of presence of the visual stimulus, transmission of visual
representations to the frontal motor association areas and initiation of the predetermined
motor response in the motor cortex. The main cognitive process involved in recognition

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visual reactions is considered to be stimulus discrimination. However, moderately strong,

significant positive correlation between intra-individual CPTSVR and CPTRVR (figure
3.12) suggest presence of common central processing stages in simple and recognition
visual reactions.

Cognitive processing of visuomotor reactions appears to involve numerous cortical

and subcortical neuronal pathways connecting the occipital cortex and precentral gyrus.
RT tasks performed while obtaining recordings from intracerebral electrodes provide
evidence about the anatomical correlates of cognitive processing in sensorimotor
reactions. These experiments were done on patients who underwent stereotaxic surgeries.
One of the early studies showed prominent thalamic potentials appearing between a
stimulus and a motor response, indicating thalamic involvement in cognitive processing
(Haider et al., 1969).

Bare et al (2003) reported a study where intracerebral ERP recordings were

obtained in a motor task triggered by auditory and visual stimuli. Their findings suggest
that extensive cortico-subcortical networks including primary sensory and motor areas,
supplementary motor area, multiple sites of the frontal lobe, some parts of the temporal
lobe, cingulate gyrus, basal ganglia, insula, and the posterior thalamus are engaged in
parallel cognitive processing of sensory information in a movement related task.

99

Recent studies have also helped to figure-out the sequence of information flow from
primary visual cortex to the primary motor cortex. The initial part - flow of information
from primary visual cortex via dorsal (occipito-parietal) and ventral (occipitotemporal)
visual pathways to the prefrontal cortex - was studied by Foxe and Simpson (2002), by
recording ERPs using high density electrode arrays with 128 recording channels. They
showed that visual information flows along both dorsal and ventral streams to prefrontal
cortex, the dorsal stream being faster. This initial flow from primary occipital cortex to
the dorsolateral prefrontal cortex took only 30ms. Thus, given that activity in visual
sensory areas typically continues for 100400 ms (depending on the type of the visual
reaction) prior to the motor output, it appears that there is time for multiple iterations
where information flows back and forth between occipital, parietal and frontal areas
along feedback and feedforward loops. This evidence is in line with Bare et al (2003)
who suggested involvement of multiple parallel processing pathways in visual and
auditory information processing in movement related tasks.

Combined choice VRT and TMS studies of Schluter et al. (1998) provided valuable
evidence on the flow of information in premotor area and the motor cortex in visuomotor
reactions. In choice reaction tasks there are more than one type of stimuli, each type of
stimulus demanding a different type of response. According to pioneering studies of
Donders (1968), the cognitive processing in choice reaction task is more complex than
simple and recognition reaction tasks and requires stimulus discrimination as well as
response selection. The choice RTs of Schluter et al. (1998) study were longer (300

100

600ms) than the RRT and SRT in our study. They were able to delay the choice VRT by
applying TMS on the premotor cortex 100 140ms after presentation of the stimulus and
on the primary motor cortex 300 340ms after presentation of the visual stimulus, while
the subject performed the RT task with the contralateral hand. This means that in a choice
reaction task, the neuronal signals triggered by the visual stimulus takes 100 140 ms to
reach the premotor cortex and 300 340ms to reach the primary motor cortex.

In summary, the duration defined as CPT in our study appears to involve multiple
cognitive processes viz. stimulus detection, stimulus discrimination and linking the visual
representations with planned motor responses. Recent studies that used combined
behavioural and electrophysiological paradigms (Schluter et al., 1998; Foxe & Simpson,
2002; Bares et al., 2003) indicate that the information flows from primary visual cortex
via visual association areas, dorsal and ventral visual pathways, numerous subcortical
nuclei (thalamus, basal ganglia), prefrontal cortex, premotor cortex to the primary motor
cortex where the cognitive processing component ends. However, neural impulse
transmission is not linear and unidirectional. The information processing appears to
involve multiple iterations along numerous feedback and feedforward loops between
these areas, before initiation of motor output in the primary motor cortex.

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4.4. Long-term effects of OP pesticide poisoning on visuomotor information

processing

Although evidence on the long-term effects of OP on VRT is controversial,

neuropsychological studies on delayed effects of OP poisoning report impairment in
number of other neurobehavioral tests of visuomotor information processing (table 4.1).

Savage et al. (1988) report a study carried out in United Sates, which compared 100
patients admitted to hospital with matched controls, after an average of nine years of
poisoning. They found the victims of OP poisoning had significantly deficient
performance on visuomotor coordination, visuomotor coding speed, and motor speed.
However, there were no differences on electroencephalographic data or neurological
examination.

Rosenstock et al. (1991) studied a population of Nicaraguan agricultural workers

poisoned by OP insecticides, to determine whether a single episode of acute intoxication
could lead to long-term neuropsychological dysfunction. Thirty-six males hospitalized
with acute OP poisoning (mostly methamidophos) were subjected to neuropsychological
assessment approximately 24 months after poisoning, with matched controls. However,
in addition to acute intoxication some patients also had had chronic exposure which also
might affect the central nervous system (Daniell et al., 1992; Stephens et al., 1995;
Fiedler et al., 1997; London et al., 1997; Steenland et al., 2000). The researchers found

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several cognitive deficits in the poisoned subjects, including auditory and visual
attention, visual memory, visuomotor coding speed, visuomotor coordination, visual
problem solving and motor steadiness. The patients also reported symptoms consistent
with central nervous system involvement. There was no difference in, SRT and motor
speed between the patients and the controls.

Steenland et al. (1994) compared 128 men poisoned with OP pesticides, on average,
seven years before testing, with 90 controls. Cognitive functions were tested using
neuropsychological testing tools. Only one cognitive test (sustained visual attention) was
significantly worse in the poisoned group. Many cognitive functions that were impaired
in the patients of Rosenstocks study (Rosenstock, et al., 1991) (viz. visual memory,
visuomotor speed, visuomotor coordination) were similar between poisoned and the
control groups in this study. Neuropsychological test results of motor speed, memory and
learning were also similar between patients and controls.

Wesseling et al. (2002) reported a study conducted on banana plantation workers in

Costa Rica. They compared 81 male workers hospitalized due to poisoning with OP
and/or carbamate pesticides, on average 27 moths prior to testing, with 130 workers who
had not been poisoned. Similar to the patients of the Rosenstock et al. (1991) study, these
patients also had additional chronic occupational exposure to OP pesticides. The
researchers applied the same neuropsychological test battery that Rosenstock et al. (1991)
applied. Although the author reported that the poisoned subjects performed less well

103

than controls on tests measuring psychomotor and visuomotor skills, language function
and affect the differences were significant only in visuomotor coding speed (i.e. digitsymbol substitution test) and two tests of neuropsychiatric symptoms. The findings of
these studies on visual information processing and psychomotor performance are
summarized in table 4.1.

Table 4.1: Neuropsychological findings of the epidemiological studies on chronic effects

of acute OP pesticide poisoning. (Note: 0 = no difference between patients and controls;
= poor performance in poisoned group; NA = not assessed)
Savage

Rosenstock Steenland Wesseling

Cognitive / psychomotor

et al.

et al.

et al.

et al.

function (test)

(1988)

(1991)

(1994)

(2002)

n = 100

n = 36

n = 128

n = 91

NA

NA

NA

Sustained visual attention

(continuous performance test)
Visuomotor coding speed
(digit-symbol substitution test)
Simple reaction time
Hand-eye coordination
(Santa-Ana dexterity test)
Motor steadiness
(Pursuit aiming test)
Motor speed
(finger tapping speed test)

104

None of the tests were positive in all four studies. However, sustained visual
attention was impaired in patients in two out of three studies, and visuomotor coding
speed was significantly impaired in the patients in three out of four studies.

In sustained visual attention tests, the subject needs to press a key as quickly as
possible when a target stimulus appears amid the temporal sequence of various other
visual stimuli. For instance the stimuli may be letters. Thus the test paradigm is quite
similar to RVRT test applied in our study but the target stimulus appears only
occasionally amid the distracters so that the subject needs to maintain the attention for a
longer period before responding to a target stimulus.

In the digit symbol substitution test (i.e. the test of visuomotor coding speed) a
panel shows the digits from one to nine and a set of symbols matching each digit. The
subject is presented a paper with a random series of digits and asked to draw the
matching symbols against the digits as quickly as possible. The number of appropriate
symbols that the subject draws within fixed time period is taken as a measure visuomotor
coding speed. This test demands much more perceptual and psychomotor resources and
hence is considered one of the most sensitive neuropsychological tests to detect minimal
brain damage (Lezak, 1995). This may be the reason for it to be positive in three out of
the four previous studies (see also table 4.1). However, the subjects who are not used to
handling pencils / pens are at a considerable disadvantage under time pressure, and
perform poorly even if their cognitive functions are normal. VRT tests demand less

105

elaborate fine motor skills and hence valid for assessment of populations in wider
variations in literacy and social background.

However sustained visual attention test, digit symbol substitution test and the SVRT
and the RVRT tests that we have applied in this study share some common cognitive
operations involved in visuomotor information processing viz. processing the perceptual
properties of visual stimuli and connecting the visual representations with motor
responses. In all these tests, attention plays a major role as an activity variable in
determining the speed of visuomotor information processing. Furthermore, in all these
experimental tasks cognitive processing begins in the primary visual cortex and end in
the primary motor cortex, and therefore the test performance is determined by the
structural integrity of the neural pathways discussed earlier. In the present study we
categorically analysed the information transfer from the primary visual cortex to the
primary motor cortex, and found it is slowed in patients with OP poisoning. Cognitive
processing in simple visual reactions was persistently delayed even after six months.
Thus, our findings, with the support of the evidence from the previous literature, strongly
suggest that OP insecticide poisoning is associated with slowing of cognitive processes
operating in visuomotor tasks.

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4.5. Effects of OP poisoning on P300 event-related potential

To date there are only three published studies on OP related ERP changes: one
related to poisoning by OP warfare agent sarin (Murata et al., 1997) and two related to
chronic exposure to OP pesticides (Teo et al., 1987; Misra et al., 1994). Present study is
the first research that assessed delayed ERP changes following acute OP insecticide
poisoning. Our results indicate that acute OP insecticide poisoning leads to prolongation
of P300 latency which persist up to at least six months after poisoning.

Murata et al. (1997) reported a very much similar study that assessed the victims (n
= 18; nine men and nine women) exposed to OP warfare agent sarin during the Tokyo
subway sarin attack in 1995. Auditory P300 was tested in victims six months after
exposure and the results were compared with those of an age- and sex- matched control
group. Similar to our testing paradigm, their subjects mentally counted the target stimuli
in an oddball paradigm that used 80% target stimuli and 20% standard stimuli. However,
the interval between two successive stimuli was always constant (2 seconds) unlike in our
study where successive stimuli were randomly timed. Corroborating the findings of the
present study, the sarin exposed group showed a significant delay in P300 latency in
comparison to the controls (p < 0.001). In their study, both the patients and the controls
had shorter P300 latencies than the corresponding groups in our study. Mean P300
latency in our patients after six months of poisoning was 362.8ms and it was 320ms in

107

their test group. Our healthy controls had a mean P300 latency of 344.1ms and in their
control group mean P300 latency was 290ms.

Teo et al. (1987) tested ERPs in pest control operators during low, medium and
high spraying activity. The subjects had P300 prolongation during high spraying activity.
This was accompanied by a significant depression in red blood cell ChE levels. Similarly
Misra et al. (1994) reported a study in which ERPs of 31 workers engaged in spraying
fenthion and matched control subjects were tested. Pesticide applicatoers had a mean
duration of exposure of 10.5 years (range 1-14 years). The researchers have concluded
that P300 latency though was prolonged in one subject only but the group difference
was significant. Similar to our findings there was no significant difference in P300
amplitude between pesticide applicators and the controls.

Combined ERP and RRT paradigms have revealed that P300 latency is a measure
of stimulus evaluation time (Kutas et al., 1977; McCarthy and Donchin, 1981). Later,
researchers have redefined this stimulus evaluation process in the context of selective
attention and updating of working memory (Donchin & Coles, 1988; Polich and Criado,
2006; Polich, 2007). After initial introduction of the target and the standard stimuli, the
working memory system of the brain retains their perceptual properties (In the auditory
oddball paradigm applied in this study the perceptual property was the pitch of the
sound). On subsequent exposure during the test session, auditory processing pathways of
the brain present the perceptual representations of the stimulus to update the mental

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representations in the working memory systems, and the neural systems involved in
attention selectively attend target stimulus. This updating of working memory and
activation of attention systems generate potentials in multiple cortical and subcortical
centres. The combined electrical activity can be recorded over the scalp as P300 ERP.

Our results show a weak positive correlation between auditory P300 latency and
RVRT (figure 3.13). Though one can expect individuals with shorter RRTs to have
shorter P300 latencies, the pioneering studies have shown that the correlation between
these two are not always strong (Kutas et al, 1977). This is because recognition RT
involves response selection in addition to stimulus evaluation. This difference in the
cognitive operations involved in choice reaction tasks and P300 generation have also
been shown by subsequent workers (McCarthy and Donchin, 1981).

P300 amplitude was similar in the patients and the controls. ERP amplitude reflects
the intensity of activation of neural structures in the brain by the task variables (Kok,
1990). Thus it seems that the patients can allocate the same amount of neural resources to
the stimulus evaluation task, although this recruitment is slower.

Neural substrates of ERPs have been explored more extensively, relative to those
of visuomotor reactions. It appears that P300 waveform is an electrical activity resulting
from interactions between multiple brain structures. Many areas of the brain have been
hypothesized to be sources of P300 component. They include the diencephalon (Yingling

109

& Hosobuchi, 1984; Katayama et al., 1985; Velasco et al., 1986), medial temporal lobe
structures (Halgren et al., 1980, 1995a, 1995b; Wood et al., 1980, 1984; Okada et al.,
1983), and various neocortical areas (Vaughan and Ritter, 1970; Simson et al., 1977;
Courchesne, 1978; Desmedt & Debecker, 1979; Wood & McCarthy, 1985). Lesions to
the inferior parietal lobule are known to disrupt the behavioral correlates of P300,
suggesting that the lateral neocortex of the inferior parietal lobule is a critical locus of
generating P300 (Smith et al., 1990). OP associated abnormalities in P300 may reflect
damage to one or more of the above subsystems.

In summary, the findings of the present study and previously reported evidence
related to acute and chronic exposure strongly suggest that OP compounds are associated
with slowing of attention processes and updating of working memory, leading to delayed
auditory stimulus evaluation. As the P300 deficits are persistent well beyond the acute
stage of poisoning it appears that the effects of OP has gone beyond temporary
biochemical disturbances and perhaps involve structural damage to neural substrates
underlying attentional processes and working memory system.

4.6. OP induced brain damage: corroborating evidence from human studies and
animal experiments

As discussed above, CPT and ERP abnormalities in OP poisoning may be

associated with structural brain damage. Neuropathological findings of animal

110

experiments corroborate this association. Experimental animals exposed to OP

compounds have demonstrated long-lasting neurochemical and neuropathological
changes in the CNS. Rats received intramuscular injections of large doses of OP nerve
gas soman have shown extensive neuropathological lesions after 15 to 28 days. The
lesions, characterized by axonal degeneration, were seen in the cerebral cortex, basal
ganglia, thalamus, subthalamic region, hypothalamus, hippocampus, fornix, preoptic
area, superior colliculus, pretectal area, basilar pontine nuclei, medullary tegmentum, and
corticospinal tracts (Petras, 1981). The animals did not develop seizures during the period
and the experimenter noted that the changes were different from hypoxic damage,
suggesting that soman induced brain damage was at least partially independent of
hypoxia. Furthermore, rats received subcutaneous injections of maximum tolerated dose
(279mg/kg) of chlorpyrifos have demonstrated significant AChE inhibition in cerebral
cortex and striatum up to six weeks of exposure (Pope et al., 1992). Supportive evidence
for OP induced brain damage comes from apoptosis of cultured rat cortical neurons
(Caughlan et al., 2004), and non-cholinesterase mediated alterations of proteins of
cultured neurons (Schuh et al., 2002) exposed to chlorpyrifos.

As discussed so far, many of the brain areas subjected to neurochemical and

histopathological changes in animal experiments (viz. thalamus and subthalamic nuclei,
hypothalamus and hippocampus) appear to mediate cognitive processing in visuomotor
reactions and generation of P300 ERP in humans (Haider et al., 1969; Halgren et al.,
1980, 1995a, 1995b; Okada et al., 1983; Wood et al., 1980, 1984; Yingling & Hosobuchi,

111

1984; Katayama et al., 1985; Velasco et al., 1986). This association further strengthens
the notion that the OP induced cognitive dysfunction in humans may be secondary to
structural brain damage rather than purely due to biochemical alterations.

Abou-Donia (2003), hypothesised that OP induced long-term cognitive dysfunction

occurs due to brain cell necrosis following neurotransmitter disturbances due to seizures
that occur in the acute cholinergic crisis. However, the animal studies of Petras (1981)
and previously discussed human studies show that long-term cognitive impairment is not
always preceded by seizures in the acute stage of poisoning. Even in our study sample,
none of the patients developed seizures, at least during the hospital stay. Thus it appears
development of seizures in the acute stage is not the sole causative factor for long-term
cognitive dysfunction. The exact mechanism of OP induced structural brain damage and
long-term cognitive dysfunction is yet to be figured-out.

4.7. Limitations of the study

In the present study, patients recovery from the cholinergic phase of poisoning was
solely made on clinical grounds as the facilities were not available for cholinesterase
measurements. However, evaluation of red blood cell cholinesterase levels would give a
better reflection of the severity of the acute cholinesterase inhibition and the extent of
recovery from the cholinergic phase of intoxication.

112

Sixteen patients in our test group developed respiratory impairment and needed
mechanical ventilatory support. It was impossible to know whether they developed
cerebral hypoxia and if so, to what extent. If there was significant cerebral hypoxia, it
becomes a confounding factor; because the possibility is there for the hypoxic brain
damage may have caused the cognitive impairment, independent of the chemical insult of
the OP compounds. The measures of cognitive processing in those who needed
ventilation and those who did not were not compared, because the two groups were
different in age and sex distribution (which were the two main confounding variables).
However, as described in previous studies, histopathological lesions observed in animals
exposed to OP are different form those of hypoxic brain damage, suggesting that OP can
cause brain damage independent of cerebral hypoxia (Petras, 1981).

The third limitation was related to the calculation of CPT. RT experiments required
the subjects to activate a response switch by pressing a button with a finger. This brings a
fourth factor the movement time (MT) - into the equation. Thus the RT equals the sum
of sensory conduction time, CPT, motor conduction time and MT. However, once the
MEPs are generated and the muscle starts contracting, the movement time largely
depends on the distance between the resting finger position and the response button
(Fitts, 1954). We made the subjects to rest the finger lightly on the response button itself
on expecting the stimulus, so that the distance of finger movement was only few
millimetres. By this, we minimised the actual contribution of the MT to the total RT. The
positioning of the finger made the movement distance constant for all subjects,

113

minimising the inter-subject variation of MT. If the facilities are available, the movement
time of the RT can be removed by recording the electromyography on the surface of the
muscle when the subject performs a RT task. This technique has been used by some
previous workers (Stull & Kearney, 1978). Then the latency between the stimulus and the
onset of electromyographic activity can be taken as the RT. This latency would be devoid
of the MT and would be equal to the sum of the durations of sensory conduction,
cognitive processing and motor conduction.

114

Section 5
CONCLUSIONS AND FUTURE DIRECTIONS

The results of the present study indicate that organophosphorus insecticide

poisoning leads to slowing of cognitive functions involved in visuomotor information
processing and auditory stimulus evaluation. These effects last beyond the clinical
recovery from the cholinergic phase of poisoning, and particularly the deficits in auditory
stimulus evaluation and cognitive processing in simple visual reactions appears to be
persistent even six months after poisoning. These findings warrant long-term prospective
studies which periodically assess cognitive functions of patients using objective,
quantitative tools such as CPT and ERPs. Such assessment would help to understand the
natural course of the cognitive impairment resulting from acute OP poisoning. CPT and
ERPs could also be used to evaluate cognitive sequelae following different protocols of
management of acute OP poisoning.

Cognitive dysfunction associated chronic low level exposure to OP compounds also

has drawn a great deal of attention during past few decades, but the research has
produced contradicting evidence. Recent workers in this area have highlighted the
limitations in the existing neuropsychological assessment methods (Steenland, 2000;

115

Kamel & Hoppin, 2004). Because the testing tools used in this study elicited impairment
in cognitive processing speed in patients with acute OP poisoning, next step would be to
apply the same test battery in chronic occupational and environmental exposure
conditions.

Cognitive processing time, a novel measure of cognitive processing introduced in

this study appears to have wider practical applications. It can substitute VRT in the
assessment of cognitive processing of visual information. CPT could be used to assess
the severity and progress of cognitive dysfunction that follows other intoxications such as
carbon monoxide poisoning and in disease states where psychomotor deficits may occur.

116

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138

APPENDICES

139

Appendix 1: Patient information sheet and consent form

PROCEDURE OF OBTAINING INFORMED WRITTEN CONSENT OF THE
SUBJECTS IN THE STUDY
Dear Sir / Madam,

I am a Lecturer in the Department of Physiology, Faculty of Medicine, University

of Peradeniya.
I am studying the effects of drug overdose on brain functions and thinking
process.
I request your assistance in this research project by giving your consent for the
necessary information and measurements to be collected, by answering the
questions asked as accurately as possible and by participating the
neurophysiological tests.
Collected information include,
o A description on the episode of poisoning
o Any other illnesses
o Social and family background
The testing procedure would take about one hour. They consist of,
o Reaction time tests
o Nerve conduction studies
o Vision and hearing tests
I assure that these tests do not carry any risks for your health.
Any expenses for travelling etc. and other expenses incurred by you will be
refunded.
The data obtained would be considered confidential and will not be use for any
other purpose, other than for the analysis of this study.

Thank you for your co-operation.

Dr. W. D. M. T. L. Dassanayake.
Lecturer, Department of Physiology,
Faculty of Medicine,
University of Peradeniya.

.
-----------------------------------------------------------------------------------------------------------

140

I hereby certify that I have read and understood the above information and conditions and
I give my consent to participate as a subject / control in this research project.
Name:
Date:

.
Signature

141

Appendix 2: Structured data sheets

2.1. Test group (patients)
2.2. Healthy controls
2.3. Hospitalised controls

142

Appendix 2.1: Test group (patients with OP poisoning)

143

144

145

146

Appendix 2.2: Healthy controls

147

148

Appendix 2.3: Hospitalised controls

149

150

151

Appendix 3: Supplementary data: personal details of the subjects

Appendix 3.1: Personal details of the test group.

(Note: M = male, F = female)
Serial
No.

1
6
8
9
10
12
13
14
16
17
18
20
22
23
25
26
27
28
29
31
32
34

matched controls
sex

M
F
M
M
M
M
M
M
M
F
F
M
M
M
F
F
F
M
M
M
M
F

age
(yrs)

healthy

23
34
27
18
19
48
17
24
28
24
18
21
17
22
23
19
28
22
28
20
56
32

45
39
34
80
46
12
63
24
30
25
64
48
49
52
53
64
26
54
29
78
57
50

years of
formal
education

hospitalised

11

6
4

11
10
11
3
11
11
0
11
11
11
11
11
13
6
9
10
0
11
4
10

Continued.

152

Appendix 3.1 (continued): Personal details of the test group.

(Note: M = male, F = female)
matched controls
Serial
No.
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56

sex

age
(yrs)

healthy

m
m
m
f
f
f
f
f
m
f
m
m
m
f
f
f
m
m
m
m
m
m

27
19
21
30
17
24
23
14
50
26
21
29
24
17
19
16
28
22
26
19
16
34

55
56
62
68
58
65
66
60
67
69
73
71
70
72
74
75
79
76
81
77
82
51

hospitalised

9
5

7
3
1

11

formal
Education
(years)
10
10
9
11
10
0
10
9
5
11
13
4
10
11
11
11
11
0
8
11
11
8

153

Appendix 3.2: Personal details of healthy control group.

(Note: M = male, F = female)
serial
No.

sex

age
(yrs)

matched patient

12
24
25
26
29
30
34
39
45
46
48
49
50
51
52
53
54
55
56
57
58
60
61
63
64
65
66
67
68
69

M
M
F
F
M
M
M
F
M
M
M
M
F
M
M
F
M
M
M
M
F
F
M
M
F
F
F
M
F
F

48
25
23
29
27
28
23
33
19
20
19
17
33
34
20
20
19
25
20
52
17
15
23
18
19
21
21
51
29
26

12
14
17
27
29
16
8
6
1
10
20
22
34
56
23
25
28
35
36
32
39
42
37
13
18, 26
40
41
43
38
44

formal
education
(years)
13
17
13
18
11
11
13
11
13
11
11
11
9
11
11
13
11
11
11
11
11
10
13
11
11
9
11
11
11
13

Continued.

154

Appendix 3.2 (continued): Personal details of healthy control group.

(Note: M = male, F = female)
serial
No.

sex

age
(yrs)

matched patient

70
71
72
73
74
75
76
77
78
79
80
81
82

M
M
F
M
F
F
M
M
M
M
M
M
M

24
31
18
18
18
16
22
19
22
28
25
26
16

47
46
48
45
49
50
52
54
31
51
9
53
55

formal
education
(years)
10
11
11
11
11
11
11
11
11
11
13
11
10

155

Appendix 3.3: Personal details of hospitalised control group.

(Note: M = male, F = female)
serial
No.

sex

age
(yrs)

matched patient

1
2
3
4
5
6
7
8
9
10
11

F
F
F
F
F
M
M
F
F
F
M

16
18
18
22
27
22
23
19
16
22
14

50
18
49
25
44
23
33
39
42
22
14

formal
education
(years)
12
11
11
11
11
11
13
13
11
13
9

156

Appendix 4: Supplementary Data: Details of type of organophosphorus compound

20

2.5

90
75
30
50

54
30
12

4.0
1.0
1.0
1.3

500

100

50

500
400

30
100

15
40

12

Fenthion

13
14
16
17
18

Phenthoate
Chlorpyrifos
not known
Diazinon
not known

20

Fenthion

21
22

Dimethoate
Chlorpyrifos
Oxydemetonmethyl
Chlorpyrifos
Chlorpyrifos
Dimethoate
not known
Dimethoate
Dimethoate
Phenthoate
Chlorpyrifos
Chlorpyrifos

23
25
26
27
28
29
31
32
34
35

Lebaycid
50%EC
Elsan 50
Lorsban 40%EC

500
Lebaycid
50%EC
Lorsban 40%EC
Metasystox R
EC25%
Lorsban 40%EC
Lorsban 40%EC
Demro
Judo
Demro
Elsan 50
Pattas
Lorsban 40%EC

30

15

500

120

60

400
400

100
60

40
24

250

200

50

400
400
400
400
400
400
500
400
400

excessive
sweating /
salivation
dyspnoea / lung
signs
impaired
consciousness

10

600
400
400

miosis

500

Tamaron
Lorsban 40%EC
Demro

bradycardia

Baytex 50%

Meth1midophos
Chlorpyrifos
Dimethoate
not known

Cholinergic features
fasciculation

duration from
exposure to 1st
examination (h)

Fenthion

6
8
9
10

dose (g)

brand name

strength (g/l)

generic name

Serial No.

Organophosphorus compound

estimated volume
(ml)

and clinical features

1
1
1

1
1

6.0

1
1

1
2.0
3.0

24
20
8
24
85
20
20

1
1
1
1
1

1
1
1

0.5
1

2.5
60
50
40
20
60
170
50
50

1
1
1
1

0.5
2.0
0.5
1.0
0.5

1
1
1
1
1

Note: 1 = given clinical feature was present in the patient.

Continued

Chlorpyrifos

50

Chlorpyrifos

51
52
53
54
55
56

Fenthion
not known
Chlorpyrifos
Dimethoate
not known
Dimethoate

Judo

30

12

1.0

15

7.5

0.5
0.5

50
100
100
40

20
40
50
16

0.5

50

20

1.0

400

1
1

1.0
1

30

12

500

50

25

400
400

100
100
50
100

40
40

1.0
1.0

40

1.5

1
1
1
1
1

1
1

1.0

1
1

Note: 1 = given clinical feature was present in the patient.

1
1
1
1
1

1.0

400

400

1
1

excessive
sweating /
salivation
dyspnoea / lung
signs
impaired
consciousness

49

400

miosis

Chlorpyrifos

400
400
500
500
400
500
500
400

3.0
3.0
3.5

bradycardia

48

Demro
Pattas
Baytex 50%
Selectron
Judo
Elsan 50
Beytex 50%
Judo
Lorsban
40%EC
Judo
Lorsban
40%EC

30
50
50

Cholinergic features
fasciculation

Asuntol

duration from
exposure to 1st
examination (h)

brand name

Coumaphos
Chlorpyrifos
Phethoate
not known
Dimethoate
Chlorpyrifos
Malathion
profenofos
Chlorpyrifos
Phenthoate
Malathion
Chlorpyrifos

dose (g)

generic name

36
37
38
39
40
41
42
43
44
45
46
47

strength (g/l)

Serial No.

Organophosphorus compound

estimated volume
(ml)

157

1
1
1

1
1

1
1

158

Appendix 5: Test Group: outline of treatment measures and hospital stay

Serial
No.

Atropine

Pralidoxime

respiratory failure and

ventilatory support

hospital
stay (days)

18

15

10

12

21

13

14

10

16

17

18

20

21

21

22

10

23

31

25

26

27

28

29

31

32

34

15

35

Note: 1 = treatment given

0 = treatment not given

Continued.

159

Appendix 5 (continued): Test Group: Outline of treatment measures and hospital

stay
Serial
No.

Atropine

Pralidoxime

respiratory failure and

ventilatory support

hospital
stay (days)

36

37

38

13

39

13

40

14

41

14

42

43

44

45

10

46

20

47

48

49

50

51

22

52

53

54

55

21

56

10

Note: 1 = treatment given

0 = treatment not given

160

Appendix 6: Clinical details of the hospitalised control group

Serial
No.

dose (g)

Specific
treatment

Depression

Antidepressants

hospital
stay (days)

10

N-acetylcystine

10

N-acetylcystine

12.5

N-acetylcystine

10

N-acetylcystine

15

N-acetylcystine

present

fluoxetine

31.5

N-acetylcystine

20

N-acetylcystine

7.5

N-acetylcystine

N-acetylcystine

10

12

N-acetylcystine

11

10

N-acetylcystine

161

Appendix 7: Measures of information processing

cognitive processing time

of recognition visual
reactions (ms)

451.7
517.7
347.3
482.3
492.3
479.7
506.7
406.0
493.3
468.7
451.3
595.3
419.0
501.3
471.3
.

118.0
105.0
104.0
107.0
106.0
101.0
93.1
100.0
110.0
98.6
96.8
100.0
101.0
99.8
106.0
.

17.1
13.8
16.0
16.4
17.2
16.1
16.9
19.0
15.2
15.7
16.7
13.6
16.0
14.9
.

9.4
9.3
10.0
9.4
12.3
8.4
8.8
11.2
8.9
10.3
9.8
9.2
10.5
8.3
.

7.7
4.5
6.0
7.0
4.9
7.7
8.1
7.8
6.3
5.4
6.9
4.4
5.5
6.6
.

167.1
94.9
135.9
199.0
110.6
195.5
115.2
157.8
149.5
145.5
176.8
135.2
167.2
171.1
.

395.8
229.9
359.5
370.3
361.3
397.5
288.9
364.1
354.9
338.8
478.4
304.2
385.5
350.7
.

233.3
230.3
282.3
225.3
256.0
419.3
240.7

517.3
466.7
487.6
449.7
609.0
698.7
558.0

101.0
107.0
89.7
105.0
95.7
94.9
104.0

13.8
15.1
14.2
15.5
16.1
13.8
16.8

8.9
10.6
9.8
9.4
9.7
8.7
9.7

4.9
4.5
4.4
6.1
6.4
5.1
7.1

118.1
108.4
178.4
104.9
144.2
310.6
119.5

402.1
344.8
383.7
329.3
497.2
590.0
436.8

P300 amplitude (V)

cognitive processing time

of simple visual reactions
(ms)

257.7
289.0
212.3
258.7
321.0
229.0
304.7
232.3
287.0
263.3
258.0
293.7
250.0
283.0
291.7
.

P300 latency (ms)

central motor conduction

time (ms)

M
F
M
M
M
M
M
M
M
F
F
M
M
M
F
F
F
M
M
M
M
F
M

peripheral motor
conduction time (ms)

Sex

23
34
27
18
19
48
17
24
28
24
18
21
17
22
23
19
28
22
28
20
28
32
27

total motor conduction

time (ms)

age (years)

.
.
.
.
.
.
.
.
.
.
2
.
.
6
4
.
.
.
.
.
.
.
.

P100 latency (ms)

matched hospitalised
control no.

45
39
61
80
46
12
63
24
30
25
64
48
49
52
53
64
26
54
29
34
57
50
55

recognition visual reaction

time

matched healthy control

No.

1
6
8
9
10
12
13
14
16
17
18
20
22
23
25
26
27
28
29
31
32
34
35

simple visual reaction time

Patient's serial no.

Appendix 7.1: Measures of information processing: test group

.
.
.
.
.
.

363
.
.
.
.
.
430
.
.
.
.
.

23.6
.
.
.
.
.

333
388
377
561
.

22.5
8.9
16.7
10.9
.

370
.

3.3
.

329
368
340
336

8.2
11.9
2.8

Note: M = male, F = female

Continued.

162

Patient's serial no.

matched healthy control

No.

matched hospitalised
control no.

age (years)

Sex

simple visual reaction time

recognition visual reaction

time

P100 latency (ms)

total motor conduction

time (ms)

peripheral motor
conduction time (ms)

central motor conduction

time (ms)

cognitive processing time

of simple visual reactions
(ms)

cognitive processing time

of recognition visual
reactions (ms)

P300 latency (ms)

P300 amplitude (V)

Appendix 7.1 (continued): Measures of information processing: test group

36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56

56
61
68
58
65
66
60
67
69
73
71
70
72
74
75
79
76
81
77
82
51

.
.
.
8
.
10
9
.
5
.
.
7
.
3
1
.
.
.
.
11
.

19
21
30
17
24
23
14
50
26
21
29
24
17
19
16
28
22
26
19
16
34

M
M
F
F
F
F
F
M
F
M
M
M
F
F
F
M
M
M
M
M
M

187.7
236.0
303.7
404.7
310.3
397.7
311.7
237.0
292.0
230.0
234.7
238.7
368.3
347.3
375.7
259.3
241.3
201.7
221.0
239.0
224.3

393.3
579.3
447.3
562.0
545.7
829.0
455.0
776.0
504.7
351.0
492.0
534.0
588.7
646.0
609.3
450.7
451.7
.
359.3
541.7
489.0

93.8
102.0
104.0
98.2
104.0
104.0
97.8
97.9
106.0
104.0
95.8
97.7
95.2
90.9
96.9
99.4
88.6
104.0
104.0
101.0
96.4

15.5
15.0
12.9
12.9
14.4
13.1
15.1
16.9
15.1
15.2
15.4
18.3
14.6
11.9
16.7
17.0
18.4
15.3
15.8
14.4
15.7

8.8
8.3
8.0
7.8
7.8
8.8
8.5
10.2
10.0
9.2
10.4
12.0
8.1
7.2
10.0
9.9
9.7
8.2
11.6
9.4
10.2

6.7
6.7
4.9
5.1
6.6
4.3
6.6
6.7
5.1
6.0
5.0
6.3
6.5
4.7
6.7
7.1
8.7
7.1
4.2
5.0
5.5

78.4
118.8
186.7
293.6
192.2
281.0
198.8
122.2
170.9
111.0
123.5
122.7
258.5
244.5
262.1
142.9
134.4
82.6
101.7
123.2
112.2

284.0
462.1
330.3
450.9
427.6
712.3
342.1
661.2
393.6
232.0
380.8
418.1
478.9
543.2
495.7
334.3
344.7
.
240.0
425.9
376.9

341
369
291
345
379
355
384
406
373
331
373
352
458
417
340
412
393
388
343
458
355

16.9
8.3
20.9
14.6
6.2
14.9
12.6
.
8.4
31.9
11.2
5.2
7.3
7.2
7.0
5.2
4.0
7.2
14.3
23.2
10.8

163

Sex

simple visual reaction time

recognition visual reaction

time

P100 latency (ms)

total motor conduction

time (ms)

peripheral motor
conduction time (ms)

central motor conduction

time (ms)

48
25
23
29
27
28
23
33
19
20
19
17
33
34
20
20
19
25
20
52
17
15
23

M
F
M
M
M
M
F
M
M
M
M
M
M
M
F
M
F
F
F
M
F
F
M

222.2
230.0
298.7
235.3
277.7
264.3
265.7
250.0
210.7
245.0
258.7
206.7
257.0
313.0
268.3
238.7
234.7
224.3
298.7
296.7
323.0
229.0
271.7

391.3
387.3
447.3
458.3
440.3
456.0
401.3
566.3
371.6
454.7
421.7
469.3
441.3
487.7
466.0
504.7
524.6
442.3
450.0
555.0
603.7
386.0
443.7

96.6
102.0
101.0
99.8
101.0
104.0
105.0
99.2
106.0
98.4
100.0
105.0
99.9
100.0
98.1
102.0
99.0
92.5
107.0
117.0
103.0
100.0
98.5

17.0
15.4
18.2
16.2
15.4
14.9
15.2
15.9
.
13.9
16.5
15.8
15.4
16.8
15.8
14.6
15.9
14.6
15.8
15.2
13.8
12.2
15.7

11.0
9.4
9.3
9.3
9.3
9.4
9.3
9.5
.
9.2
9.0
9.3
10.5
10.0
9.4
8.3
10.5
9.2
8.9
9.8
8.0
8.2
9.1

6.0
6.0
8.9
6.9
6.1
5.5
5.9
6.4
.
4.7
7.5
6.5
4.9
6.8
6.4
6.3
5.4
5.4
6.9
5.4
5.8
4.0
6.6

108.6
112.3
179.6
119.3
161.8
145.0
145.7
134.9
.
132.7
141.8
86.1
141.7
195.8
154.4
122.3
119.8
117.2
176.0
164.2
206.3
116.6
157.5

277.7
269.6
328.2
342.3
324.4
336.7
281.3
451.2
.
342.4
304.8
348.7
326.0
370.5
352.1
388.3
409.7
335.2
327.3
422.5
487.0
273.6
329.5

.
.
.
.
.
.
.
.
321
.
.
314
302
355
373
348
358
349
338
406
345
312
345

P300 amplitude (V)

age (years)

12
14
17
27
29
16
8
6
1
10
20
22
34
56
23
25
28
35
36
32
39
42
37

P300 latency (ms)

matched patient No.

12
24
25
26
29
30
34
39
45
46
48
49
50
51
52
53
54
55
56
57
58
60
61

cognitive processing time

of simple visual reactions
(ms)
cognitive processing time
of recognition visual
reactions (ms)

Serial No.

Appendix 7.2: Measures of information processing: healthy control group

.
.
.
.
.
.
.
.
.
.
.
4.7
.
11.7
9.9
19.5
16.0
7.9
11.5
10.5
6.5
8.2
11.0

Note: M = male, F = female

Continued

164

Appendix 7.2 (continued): Measures of information processing: healthy control

Sex

simple visual reaction time

recognition visual reaction

time

P100 latency (ms)

total motor conduction

time (ms)

peripheral motor
conduction time (ms)

central motor conduction

time (ms)

cognitive processing time

of simple visual reactions
(ms)

cognitive processing time

of recognition visual
reactions (ms)

P300 latency (ms)

P300 amplitude (V)

13

18

277.0

503.0

101.0

16.2

10.0

6.2

159.6

385.6

348

19.4

64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82

18,26
40
41
43
38
44
47
46
48
45
49
50
52
54
31
51
9
53
55

19
21
21
51
29
26
24
31
18
18
18
16
22
19
22
28
25
26
16

M
F
F
M
M
F
F
M
M
M
F
F
M
M
M
M
F
M
M

218.3
237.7
295.0
225.7
290.7
241.0
217.7
259.7
211.7
201.3
274.7
245.7
242.3
264.3
248.7
232.7
204.0
315.3
247.7

397.3
513.7
598.0
487.7
471.3
451.0
461.0
528.7
480.0
487.0
434.3
457.3
573.3
456.3
456.7
503.0
419.0
.
497.7

102.0
108.0
98.0
95.3
98.4
96.2
98.3
101.0
102.0
103.0
113.0
96.9
98.7
104.0
112.0
102.0
107.0
97.2
95.9

13.3
13.2
14.4
15.9
15.4
14.8
16.7
15.2
12.3
14.2
14.8
14.9
15.9
16.5
15.3
15.7
15.8
14.2
16.2

9.0
8.8
9.0
8.9
9.2
9.4
12.2
8.9
6.8
8.2
8.2
8.8
8.2
9.8
9.8
8.5
8.9
9.6
10.2

4.3
4.4
5.4
7.0
6.2
5.4
4.5
6.3
5.5
6.0
6.6
6.1
7.7
6.7
5.5
7.2
6.9
4.6
6.0

103.4
116.3
182.6
114.5
176.9
130.1
102.7
143.9
97.5
84.0
146.5
133.9
127.8
143.9
121.0
114.8
81.1
204.0
135.6

282.4
392.3
485.6
376.5
357.5
340.1
346.1
412.9
365.8
369.7
306.1
345.5
458.8
335.9
329.0
385.2
296.1
.
385.6

348
259
384
401
338
318
354
408
353
326
338
290
352
393
326
295
.
381
333

21.2
7.9
22.3
.
14.0
5.6
9.4
17.3
17.0
7.1
8.0
5.1
6.3
9.3
21.1
8.1
.
6.7
8.7

matched patient No.

63

Serial No.

age (years)

group

165

15.2
14.2
15.7
15.3
12.9
17.3
15.9
15.0
12.8

8.9
8.4
8.7
10.7
8.7
10.7
8.9
7.9
8.3

6.3
5.8
7.0
4.6
4.2
6.6
7.0
7.1
4.5

133.6
156.3
118.2
105.6
147.5
139.7
102.3
144.2
149.5

318.9
323.3
364.5
287.9
300.1
326.7
252.3
387.5
301.1

100.4

13.0

7.4

5.6

153.6

361.6

P300 amplitude (V)

103.3
98.5
97.2
99.8
99.7
102.0
101.2
99.2
104.4

P300 latency (ms)

437.3
436.0
477.3
403.0
412.7
446.0
369.3
501.7
418.3
476.3
475.0

cognitive processing time

of recognition visual
reactions (ms)

recognition visual reaction

time

252.0
269.0
231.0
220.7
260.0
259.0
219.3
258.3
266.7
247.3
267.0

cognitive processing time

of simple visual reactions
(ms)

simple visual reaction time

F
F
F
F
F
M
M
F
F
F
M

central motor conduction

time (ms)

Sex

16
18
18
22
27
22
23
19
16
22
14

peripheral motor
conduction time (ms)

age (years)

50
18
49
25
44
23
47
39
42
41
55

total motor conduction

time (ms)

matched patient No.

1
2
3
4
5
6
7
8
9
10
11

P100 latency (ms)

Serial No.

Appendix 7.3: Measures of information processing: hospitalised control group

341
329
319
333
372
344
348
311
377

13.9
17.2
3.8
24.1
15.3
2.4
8.3
14.1
10.0

166

recognition visual
reaction time

P100 latency (ms)

total motor
conduction time (ms)

peripheral motor
conduction time (ms)

central motor
conduction time (ms)

cognitive processing
time of simple visual
reactions (ms)

cognitive processing
time of recognition
visual reactions (ms)

305.3
240.7
203.0
300.0
287.7
249.7
263.0
298.3
269.3
327.7
235.0
296.0
243.7
248.0
258.3
233.7
274.3
322.3
280.3
334.0
248.0
259.7
256.0
426.0
337.7
405.3
235.7
215.3
264.0
307.7

507.3
412.7
386.3
448.3
377.7
400.0
460.7
538.0
501.7
498.3
414.3
418.0
491.7
463.3
421.3
407.7
452.7
528.0
501.7
517.7
382.7
440.0
498.5
646.0
544.0
449.3
406.3
369.3
489.3
449.0

108.2
114.2
98.1
90.4
96.5
99.0
101.6
102.0
96.4
97.1
108.0
92.8
95.1
97.7
101.2
95.1
99.2
97.6
99.9
95.3
105.8
100.9
99.2
101.8
98.7
100.3
97.1
99.5

18.2
15.9
15.7
14.9
16.7
14.9
15.0
15.8
14.7
15.8
18.1
15.5
16.5
14.2
17.8
15.0
15.3
14.9
15.9
16.4
19.1
14.4
16.1
13.8
15.5
16.2
18.2
15.8

10.2
10.2
10.5
7.5
8.8
8.9
8.1
9.4
8.2
8.8
11.2
10.4
8.5
8.2
9.8
8.8
8.2
8.5
8.2
8.3
9.2
9.7
8.1
7.7
9.2
10.0
9.2
11.5

8.0
5.7
5.2
7.4
7.9
6.0
6.9
6.4
6.5
7.0
6.9
5.1
8.0
6.0
8.0
6.2
7.1
6.4
7.7
8.1
9.9
4.7
8.0
6.1
6.3
6.2
9.0
4.3

178.9
147.1
89.2
194.7
174.5
135.8
146.4
180.5
158.2
214.8
108.9
187.7
132.1
136.2
139.4
123.6
159.9
209.9
164.5
222.3
123.1
144.4
140.8
310.5
223.5
288.8
120.4
100.0

380.9
282.6
272.5
343.0
264.5
286.1
344.1
420.1
390.6
385.5
288.2
309.7
388.6
351.5
302.4
297.6
338.2
415.6
385.9
406.0
257.8
324.7
383.3
530.5
429.9
332.8
291.1
254.0

.
.

.
.

.
.

.
.

.
.

.
.

P300 amplitude (V)

simple visual reaction

time

9
10
12
13
14
18
22
23
25
27
28
29
32
34
35
36
38
41
42
44
45
46
47
49
50
51
53
54
55
56

P300 latency (ms)

Patient's serial no.

Appendix 7.4: Measures of information processing: follow up visit of the test group

326
623
340
441
368
351
347
348
320
352
422
333
379
397
366
349
343
348
361
413
338
330
408
345
333
374
374
306
388
356

8.2
9.1
13.6
19.1
19.2
21.1
13.5
7.1
16.3
15.2
3.7
23.2
11.1
18.0
6.8
18.1
12.7
1.3
15.4
29.7
25.3
14.5
15.8
7.7
3.6
6.0
8.8
9.4
22.8
17.8