Hemodialysis clearance of glyphosate following a life-threatening ingestion of glyphosate-surfactant herbicide.

CONTEXT: Ingestion of glyphosate-surfactant herbicides (GlySH) can result in acute kidney injury, electrolyte abnormalities, acidosis, cardiovascular collapse, and death. In severe toxicity, the use of hemodialysis is reported, but largely unsupported by kinetic analysis. We report the dialysis clearance of glyphosate following a suicidal ingestion of a glyphosate-containing herbicide. CASE DETAILS: A 62-year-old man was brought to the emergency department (ED) 8.5 h after drinking a bottle of commercial herbicide containing a 41% solution of glyphosate isopropylamine, in polyoxyethyleneamine (POEA) surfactant and water. He was bradycardic and obtunded with respiratory depression necessitating intubation and mechanical ventilation. Initial laboratory results were significant for the following: pH, 7.11; PCO2, 64 mmHg; PO2, 48 mmHg; potassium, 7.8 mEq/L; Cr 3.3, mg/dL; bicarbonate, 22 mEq/L; anion gap, 18 mEq/L; and lactate, 7.5 mmol/L. Acidosis and hyperkalemia persisted despite ventilation and fluid resuscitation. The patient underwent hemodialysis 16 h post ingestion, after which he demonstrated resolution of acidosis and hyperkalemia, and improvement in clinical status. Serum glyphosate concentrations were drawn prior to, during, and after hemodialysis. The extraction ratio and hemodialysis clearance were calculated to be 91.8% and 97.5 mL/min, respectively. DISCUSSION: We demonstrate the successful clearance of glyphosate using hemodialysis, with corresponding clinical improvement in a patient with several poor prognostic factors (advanced age, large volume ingested, and impaired consciousness). The effects of hemodialysis on the surfactant compound are unknown. Hemodialysis can be considered when severe acidosis and acute kidney injury complicate ingestion of glyphosate-containing products.

Efficacy, safety and palatability of a new broad-spectrum anthelmintic formulation in dogs.

The efficacy, safety and palatability of a new flavoured chewable anthelmintic tablet were investigated in dogs. The efficacy, based on worm counts, of a single recommended therapeutic dose (RTD) of 5 mg pyrantel + 20 mg oxantel + 5 mg praziquantel/kg bodyweight was assessed in experimental infections (EI) and natural infections (NI) with Trichuris vulpis, Echinococcus granulosus and Toxocara canis. For T vulpis, the efficacy of the treatment was 99.3 per cent in EI (comparing groups of six treated and six control dogs) and 100 per cent in NI (nine treated and nine control dogs). For E granulosus, the efficacy was more than 99.9 per cent in EI (11 treated and 11 control dogs). For T canis, the efficacy was 94.3 per cent in EI (10 treated and 10 control dogs) and 100 per cent in NI (12 treated and 13 control dogs). In a field study, Ancylostoma caninum (11 dogs) and T canis (11 dogs) faecal egg counts were reduced by more than 99 per cent, and in eight dogs with Dipylidium caninum proglotides in the faeces the efficacy was 100 per cent. The tablets were readily consumed by 56 of 64 (87.5 per cent) privately owned dogs. Safety was assessed in groups of six dogs treated either once with twice the RTD, once with six times the RTD, with twice the RTD on three consecutive days, or untreated. There were no significant differences in blood parameters between the groups, and no abnormal clinical findings. Two dogs treated with six times the RTD vomited, but no vomiting was observed when administration was repeated two days later.

Delivery of smoking prevention and cessation services to adolescents.

OBJECTIVES: To describe the delivery of smoking prevention and cessation screening and counseling practices to adolescents and to examine the effect of physician specialty, sex, practice characteristics, and familiarity with preventive care guidelines on the delivery of smoking cessation counseling services. METHODS: Cross-sectional self-reported survey of pediatricians and family physicians in 3 New York metropolitan statistical areas who had seen 1 or more adolescents for well care within the past 6 months. RESULTS: Of 564 eligible physicians, 371 (66%) responded. Physicians reported asking most adolescents about smoking (91%) but were less likely to ask about peer smoking use (41%) or smokeless tobacco use (32%). Similarly, they reported assessing motivation to quit for 81% of smokers, but less often helped set quit dates (34%) or scheduled follow-up visits (28%). Family physicians were more likely to provide more effective smoking cessation interactions than pediatricians (mean smoking counseling performance score, 61 vs. 53; P<.001). Family physicians were also more likely to be familiar with National Cancer Institute guidelines than pediatricians (48% vs. 27%; P<.001). Female physicians reported having spent more time with their last adolescent patient (mean, 26 vs 21 minutes; P<.001) and more often spent time alone with adolescent patients (85% vs. 76% of visits; P<.001) than did male physicians. In multivariate modeling, specialty, familiarity with National Cancer Institute guidelines, time spent, and confidentiality factors were associated with better smoking counseling performance. CONCLUSION: Familiarity with smoking cessation guidelines and physician's specialty and practice style with adolescents are associated with better delivery of tobacco cessation counseling to adolescents.

Where are we on teen sex?: Delivery of reproductive health services to adolescents by family physicians.

BACKGROUND AND OBJECTIVES: This study describes variation in reproductive health preventive services delivery to adolescents by family physicians in Upstate New York. METHODS: We surveyed a stratified random sample of 354 family physicians from three New York State metropolitan statistical areas about the proportion of their adolescent patients (ages 15-18) to whom they deliver preventive reproductive health interventions. Responses were averaged to create a preventive care practice score. RESULTS: Of 295 eligible respondents, 179 returned completed surveys (61%). Eighty-one percent were male. Respondents did not vary by geographical area. However, female family physicians were less likely to respond than males, and olderfamily physicians were less likely to respond than more-recent graduates. On average, family physicians reported asking 79% of their adolescent patients about contraceptive use, 73% about condom use, 72% about sexual relationships, and 61% about sexual behaviors. Only 36% reported asking teens when they thought sex was appropriate, and 30% had discussed sexual orientation. Seventy-six percent of physicians discussed adolescents' risks of HIV with adolescent patients, 78% advised adolescent patients to use condoms, 21% gave handouts about HIV, and 9% gave condoms to adolescent patients. Factors associated with provision of more preventive reproductive services included regularly discussing confidentiality, more-recent medical school graduation, placing a high value on the American Academy of Family Physicians recommendations, having read Centers for Disease Control immunization guidelines, having read American Academy of Pediatrics guidelines, and female gender Overall, these factors explained 26% of the variance in provision of preventive reproductive services. CONCLUSIONS: Family physicians report providing most reproductive preventive services to more than half of their patients. Female physicians, older physicians, physicians who regularly discuss confidentiality, and physicians who have a more-positive attitude toward andfamiliarity with preventive care guidelines are more likely to provide reproductive health screening and counseling during adolescent visits.

Improving adolescent preventive care in community health centers.

OBJECTIVE: To evaluate implementation of the Guidelines for Adolescent Preventive Services (GAPS) in Community and Migrant Health Centers (CMHCs). DESIGN: Before and after comparison of health center policy, clinician and adolescent self-report, and chart reviews in 5 CMHCs. PARTICIPANTS: Eighty-one preintervention and 80 one-year postintervention providers and 318 preintervention and 331 postintervention 14- to 19- year-old adolescent patients being seen for well visits at 5 CMHCs. INTERVENTION: Health center staff were trained to implement GAPS and were provided resource materials, patient questionnaires, and clinician manuals. MAIN OUTCOME MEASURES: Delivery of and receipt of preventive services and perceived access to care. RESULTS: CMHC systems changes were related to stronger leadership commitment to adolescent care. Providers reported high levels of preventive services delivery before and after guideline implementation. After guideline implementation, adolescents reported increases in having discussed prevention content with providers in 19 of 31 content areas, including increased discussion of physical or sexual abuse (10% before to 22% after), sexual orientation (13% to 27%), fighting (6% to 21%), peer relations (37% to 52%), suicide (7% to 22%), eating disorders (11% to 28%), weapons (5% to 22%), depression (16% to 34%), smokeless tobacco (10% to 29%), and immunizations (19% to 48%). Adolescents were also more likely to report knowing where to get reproductive or mental health services and were more likely to have received health education materials. Implementation also increased documentation of recommended screening and counseling in 51 of 79 specific content areas assessed in chart reviews. CONCLUSION: Implementing GAPS increased the receipt of preventive services at these health centers. Adolescents received more comprehensive screening and counseling, more health education materials, and had greater access to care after implementation. GAPS implementation may help improve the quality of care for adolescents.

Developing quality measures for adolescent care: validity of adolescents' self-reported receipt of preventive services.

OBJECTIVE: To demonstrate the feasibility of directly surveying adolescents about the content of preventive health services they have received and to assess the validity of adolescent self-reported recall. DATA SOURCES/SETTING: Audiotaped encounters, telephone interviews, and chart reviews with 14-21 year olds being seen for preventive care visits at 15 pediatric and family medicine private practices, teaching hospital clinics, and health centers. DESIGN: 537 adolescents presenting for well visits were approached, 400 (75 percent) consented, 374 (94 percent) were audiotaped, and 354 (89 percent) completed telephone interviews either two to four weeks or five to seven months after their visits. Audiotapes were coded for screening and counseling across 34 preventive service content areas. Intraobserver reliability (Cohen's kappa) ranged from 0.45 for talking about peers to 0.94 for discussing tobacco. The sensitivity and specificity of the adolescent self-reports were assessed using the audiotape coding as the gold standard. RESULTS: Almost all adolescents surveyed (94 percent) remembered having had a preventive care visit, 93 percent identified the site of care, and most (84 percent) identified the clinician they had seen. There was wide variation in the prevalence of screening, based on the tape coding. Adolescent self-report was moderately or highly sensitive and specific at two weeks and six months for 24 of 34 screening and counseling items, including having discussed: weight, diet, body image, exercise, seatbelts, bike helmet use, cigarettes/smoking, smokeless tobacco, alcohol, drugs, steroids, sex, sexual orientation, birth control, condoms, HIV, STDs, school, family, future plans, emotions, suicidality, and abuse. Self-report was least accurate for blood pressure/cholesterol screening, immunizations, or for having discussed fighting, violence, weapon carrying, sleep, dental care, friends, or over-the-counter drug use. CONCLUSION: Adolescents' self-report of the care they have received is a valid method of determining the content of preventive health service delivery. Although recall of screening and counseling is more accurate within two to four weeks after preventive care visits, adolescents can report accurately on the care they had received five to seven months after the preventive health care visits occurred.

Quality control in generic anthelmintics: is it adequate?

We became increasingly concerned about indications of possible substandard efficacy of some generic anthelmintics, particularly after P.C. van Schalkwyk (personal communication, 1990) had found some batches of imported generic products obtained from international brokers to be poorly active, despite apparently normal physical characteristics. Therefore, considering the serious consequences this would have for sheep farming, it was decided to test the efficacy of some of the generic rafoxanide products available on the South African market. One of the three commercial formulations (of highly reputable companies) tested against a known susceptible strain of Haemonchus contortus in sheep was markedly substandard, with an arithmetic mean efficacy of 66.2% (Class B, Reinecke, 1973), compared to Class A efficacy of the other two, which also differed significantly from one another (Mann-Whitney; P = 0.01). Larger differences were found between the three products against a natural infection with a partially resistant strain of H. contortus than against the susceptible strain, with corresponding arithmetic mean efficacies of 28.7% (Class X, or ineffective), 71.3% (Class B) and 87.7% (also Class B). It is concluded that the most likely reason for the observed differences is that international brokers do not disclose the sources of supply of different batches of active ingredient (with the result that the companies buying anthelmintics from them have no way of telling when a source of supply is changed); that the efficacy of such batches differs; and that efficacy testing of individual batches in some cases is inadequate. It is suggested that registering authorities should consider simplified efficacy testing of each new batch of active ingredient before it may be marketed.

The efficacy of Diflubenzuron against the body louse (Damalinia limbata) of Angora goats.

The efficacy of an insect growth regulator, Diflubenzuron, to control biting lice (Damalinia limbata) on Angora goats was investigated. Lice on goats which were dipped in a concentration of 625 g Diflubenzuron to 1,000 1 water and then kept in quarantine was eradicated after a single treatment. Nymphs remained present on these goats up to 4 weeks and adult lice up to 8 weeks post-treatment. A single treatment provided greater than 90% reduction in nymphal stages from Week 6 to Week 16 post-treatment in treated goats continuously exposed to reinfestation. The treatment reduced adult louse infestations on these goats by 78-94% through Weeks 6-16 post-treatment. At the end of the trial (24 weeks post-treatment), these goats had 88% fewer nymphs and 84% fewer adult lice compared with untreated control goats.

Alcohol and estrogen levels in postmenopausal women: the spectrum of effect.

Compared with alcohol-abstaining normal postmenopausal women, estradiol levels are known to be statistically increased in normal postmenopausal women who consume alcoholic beverages moderately, and to be even further increased in alcoholic postmenopausal women with cirrhosis. This study was undertaken to evaluate whether or not there is a spectrum of changes in levels of sex steroids and pituitary hormones associated with alcohol abstinence, alcohol use, and alcohol-induced cirrhosis in the absence of current alcohol abuse. For levels of estradiol and testosterone, as well as for the estradiol to testosterone ratio, all three groups differed significantly from each other; for the pituitary hormones, levels in the abstainers and alcohol users were similar and statistically different from levels in the alcoholic cirrhotic women. Compared with the alcohol-abstaining women, the relationships of age and estradiol with levels of the other hormones were disturbed for 4 of 11 correlations examined among the alcohol users, and for 9 of 11 correlations evaluated among the alcoholic cirrhotic women. These findings suggest that not only are hormonal relationships markedly disrupted among alcoholic cirrhotics, but also that alcoholic beverage consumption in the range of 0.1-28 total weekly drinks results in detectable perturbations of the normal hormonal relationships expected in postmenopausal women.

"Binge" versus steady drinking: effects on the liver in the ovariectomized rat.

Substantial interest exists as to whether or not differential effects in liver injury based on the pattern of alcohol intake exist; and further, if they do, are they simply a function of the total dose over time. A rat model in which ethanol (ETOH) at doses of 12%, 24%, or 36% of total calories was isocalorically administered for 4 months either daily or intermittently (4 days of ETOH, 3 days of control diet, repeatedly) was used to assess this question. There were significant differences in the two feeding pattern groups between 36% ETOH rats for the liver weight corrected for body weight, the fat infiltration score, the total amount of ETOH consumed/mg body weight, the proportion of animals with a fat infiltration score > 2, and albumin levels. There was a significant difference between 12% ETOH rats for the liver weight corrected for body weight. Of particular relevance is the comparison to be made between Daily 12% ETOH and Binge 24% ETOH animals, because these two groups consumed an identical total amount of ETOH/mg body weight (Daily: 445 +/- 5 vs. Binge: 468 +/- 15) and thus these animals are comparable in terms of ETOH dose over time but different in terms of the pattern of ETOH exposure. There were no differences in the liver/body ratio (Daily: 235 +/- 6 vs. Binge: 232 +/- 4), fat infiltration score (Daily: 2.5 +/- 4 vs. Binge: 2.4 +/- 0.3), the proportion of animals with a fat infiltration score > 2 (Daily: 5/10 vs. Binge: 4/8), or albumin levels (Daily: 3.0 +/- 0.1 vs. Binge: 3.1 +/- 0.1.(ABSTRACT TRUNCATED AT 250 WORDS)

Suicidality in affectively disordered adolescent inpatients.

Forty-two suicidal and 14 nonsuicidal affectively ill adolescent psychiatric inpatients were compared with respect to clinical phenomenology and measures of cognitive distortion, social skills, and familial-environmental stress. The suicidal group had an earlier onset and longer duration of affective illness and greater self-rated depression. The suicidal group also evinced greater cognitive distortion, less assertiveness, a greater likelihood of both a history and exposure to familial suicidality, and more life stressors within the 12 months prior to hospitalization. Among those suicidal patients who presented with a suicide attempt, suicidal intent was related to "double depression," comorbidity with substance abuse or conduct disorder, lack of assertiveness, family conflict, and family history of suicidal behavior. Early identification and treatment of affectively ill youth that target the above-noted domains may prevent much of the associated morbidity and mortality due to suicidality.

Phenobarbital treatment and major depressive disorder in children with epilepsy: a naturalistic follow-up.

Of an original cohort of 39 epileptic patients, 28 were observed for a median of 26.5 months after an initial psychiatric interview. As had been noted in the original cohort, treatment with phenobarbital, as compared with treatment with carbamazepine or no anticonvulsant, was associated with higher rates of depression (38% vs 0%, P = .04). Depression associated with phenobarbital treatment at intake did not remit spontaneously on follow-up as long as phenobarbital use continued. Those patients treated with phenobarbital who were previously depressed and whose medication was changed to either carbamazepine or no medication showed nonsignificant trends toward declines in both the frequency and severity of depressive symptoms. These results provide further evidence that treatment with phenobarbital increases the risk for depression in epileptic patients and should be avoided when clinically feasible, particularly in patients with a personal or family history of affective disorder. Epileptic patients who receive phenobarbital because of clinical considerations should be monitored closely for symptoms of an affective disorder, and if depression is detected, a change to an alternative anticonvulsant may result in amelioration of depressive symptomatology.

An outbreak of suicide and suicidal behavior in a high school.

In a high school of 1,496 students, two students committed suicide within 4 days. During an 18-day period that included the two suicides, seven students attempted suicide and an additional 23 manifested suicidal ideation. Compared to expected rates, the rates of both completed and attempted suicide were markedly elevated. Seventy-five percent of the members of the cluster had at least one major psychiatric disorder antedating their exposure. One hundred ten students thought to be at high risk were psychiatrically screened on site. Within this group, students who became suicidal after exposure were more likely than their nonsuicidal counterparts to be currently depressed and to have had past episodes of depression and suicidality. Close friends of the victims manifested suicidality at a lower psychopathological threshold than those who were less close to the victims. Students who are friends of a victim or who have a history of affective disorder and/or previous suicidality should be screened for suicidality after exposure.

Risk factors for adolescent suicide. A comparison of adolescent suicide victims with suicidal inpatients.

The characteristics of adolescent suicide victims (n = 27) were compared with those of a group at high risk for suicide, suicidal psychiatric inpatients (n = 56) who had either seriously considered (n = 18) or actually attempted (n = 38) suicide. The suicide victims and suicidal inpatients showed similarly high rates of affective disorder and family histories of affective disorder, antisocial disorder, and suicide, suggesting that among adolescents there is a continuum of suicidality from ideation to completion. However, four putative risk factors were more prevalent among the suicide victims: (1) diagnosis of bipolar disorder; (2) affective disorder with comorbidity; (3) lack of previous mental health treatment; and (4) availability of firearms in the homes, which taken together accurately classified 81.9% of cases. In addition, suicide completers showed higher suicidal intent than did suicide attempters. These findings suggest a profile of psychiatric patients at high risk for suicide, and the proper identification and treatment of such patients may prevent suicide in high-risk clinical populations.