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1.
PLoS One ; 15(11): e0242437, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-33211766

RESUMEN

INTRODUCTION: Adverse childhood experiences (ACE) have been recognized as an important risk factor for suicidal behaviour among adults, but evidence from low and middle-income countries is lacking. This study explored associations between ACE and hospital admission due to non-fatal self-poisoning in Sri Lanka. METHODS: This was a case-control study. Adults admitted to a tertiary care hospital for medical management of self-poisoning were included as cases, and age and sex matched controls were recruited from the outpatient department. ACE were measured using the World Health Organization's Childhood Adversity Scale. Logistic regression models adjusting for age, sex, ethnicity, and religion were used to quantify the association between ACE and self-poisoning. RESULTS: The study included 235 cases and 451 controls. Cases were 2.5 times (95% CI 1.8, 3.6) more likely to report an ACE than controls and had higher ACE scores. Childhood physical abuse (OR 4.7, 95% CI 1.2, 19.0) and emotional abuse or neglect (OR 3.7, 95% CI 1.3, 10.1, and 3.7, 95% CI 2.3, 6.0 respectively), increased the risk of self-poisoning in adulthood, as did witnessing household violence (OR 2.2, 95% CI 1.4, 3.4), growing up in a household with a mentally ill or suicidal household member (OR 2.1, 95% CI 1.2, 3.4), and experiencing parental death/separation/divorce (OR 3.1, 95% CI 2.0, 4.9) as a child. CONCLUSIONS: Reducing exposures to ACEs should be a priority for prevention of suicide and self-harm in Sri Lanka. Innovative methods to increase support for children facing adversity should be explored.

2.
Psychol Med ; : 1-9, 2020 Sep 11.
Artículo en Inglés | MEDLINE | ID: mdl-32912344

RESUMEN

BACKGROUND: There is increasing evidence that domestic violence (DV) is an important risk factor for suicidal behaviour. The level of risk and its contribution to the overall burden of suicidal behaviour among men and women has not been quantified in South Asia. We carried out a large case-control study to examine the association between DV and self-poisoning in Sri Lanka. METHODS: Cases (N = 291) were patients aged ⩾18 years, admitted to a tertiary hospital in Kandy Sri Lanka for self-poisoning. Sex and age frequency matched controls were recruited from the hospital's outpatient department (N = 490) and local population (N = 450). Exposure to DV was collected through the Humiliation, Afraid, Rape, Kick questionnaire. Multivariable logistic regression models were conducted to estimate the association between DV and self-poisoning, and population attributable fractions were calculated. RESULTS: Exposure to at least one type of DV within the previous 12 months was strongly associated with self-poisoning for women [adjusted OR (AOR) 4.08, 95% CI 1.60-4.78] and men (AOR 2.52, 95% CI 1.51-4.21), compared to those reporting no abuse. Among women, the association was strongest for physical violence (AOR 14.07, 95% CI 5.87-33.72), whereas among men, emotional abuse showed the highest risk (AOR 2.75, 95% CI 1.57-4.82). PAF% for exposure to at least one type of DV was 38% (95% CI 32-43) in women and 22% (95% CI 14-29) in men. CONCLUSIONS: Multi-sectoral interventions to address DV including enhanced identification in health care settings, community-based strategies, and integration of DV support and psychological services may substantially reduce suicidal behaviour in Sri Lanka.

3.
BMJ Open ; 9(8): e027766, 2019 08 18.
Artículo en Inglés | MEDLINE | ID: mdl-31427319

RESUMEN

INTRODUCTION: Childhood adversity (CA) has been suggested as a key risk factor for suicidal behaviour, but evidence from low/middle-income countries is lacking. In Sri Lanka, CA, in the form of child maltreatment or as a consequence of maternal separation, has been highlighted in primarily qualitative or case series work, as a potentially important determinant of suicidal behaviour. To date, there have been no quantitative studies to investigate CA as a key exposure associated with suicidal behaviour in Sri Lanka. The aim of the research is to understand the association between CA and suicidal behaviour in Sri Lanka and to identify potentially modifiable factors to reduce any observed increased risk of suicidal behaviour associated with CA. METHODS AND ANALYSIS: This is a hospital-based case-control study. Cases (n=200) will be drawn from individuals admitted to the medical toxicology ward of the Teaching Hospital Peradeniya, Sri Lanka, for medical management of intentional self-poisoning. Sex and age frequency-matched controls (n=200) will be recruited from either patients or accompanying visitors presenting at the outpatient department and clinic of the same hospital for conditions unrelated to the outcome of interest. Conditional logistic regression will be used to investigate the association between CA and deliberate self-poisoning and whether the association is altered by other key factors including socioeconomic status, psychiatric morbidity, current experiences of domestic violence and social support. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Ethical Review Committee of the Faculty of Medicine, University of Peradeniya, Sri Lanka. Researchers have been trained in administering the questionnaire and a participant safety and distress protocol has been designed to guide researchers in ensuring participant safety and how to deal with a distressed participant. Results will be disseminated in local policy fora and peer-reviewed articles, local media, and national and international conferences.


Asunto(s)
Adultos Sobrevivientes del Maltrato a los Niños/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Envenenamiento/epidemiología , Conducta Autodestructiva/epidemiología , Intento de Suicidio/estadística & datos numéricos , Adulto , Adultos Sobrevivientes del Maltrato a los Niños/psicología , Estudios de Casos y Controles , Hospitales de Enseñanza , Humanos , Proyectos de Investigación , Factores de Riesgo , Sri Lanka/epidemiología , Intento de Suicidio/psicología
4.
BMC Public Health ; 18(1): 1349, 2018 Dec 06.
Artículo en Inglés | MEDLINE | ID: mdl-30522467

RESUMEN

BACKGROUND: Acute paediatric poisoning is a common public health concern for both developed and developing countries. The type of agent and underlying cause differ depending on the social, cultural, economic and educational background. The objectives of this study were to identify the incidence and pattern of paediatric poisoning in a rural district in Sri Lanka and establish whether tertiary referral hospital data are a useful surrogate for estimating district level epidemiology of paediatric poisoning. METHODS: A subset of epidemiological data were obtained from March 2011 to February 2013 from a randomized controlled trial (SLCTR/2010/008) conducted in 45 hospitals in Kurunegala district. RESULTS: The age adjusted annual incidence of all cause of acute poisoning in children aged 1 to 12 years in the study area was 60.4 per 100,000. The incidence of poisoning of younger age group (1 to 6 years; 76 per 100,000) was significantly higher than older age group (7 to 12 years; 41 per 100,000) (p = 0.0001) in Kurunegala district. The annual incidence rate of paediatric admissions due to deliberate self-poisoning is 18 per 100,000 population. This study also established that admission data from primary hospitals provided the most accurate epidemiological information on paediatric poisoning. CONCLUSIONS: In rural districts of Sri Lanka, acute paediatric poisoning cases were less frequent and less severe compared to adult poisoning cases (426-446 per 100,000 population). The incidence of poisoning was significantly higher among young children with compared to old children. In this study, deliberate self-poisoning among older children was more frequently seen than in other comparable countries. Because most of the admissions are directed to and managed by primary hospitals, data from referral hospitals alone cannot be used to represent the true incidence of acute poisoning within a district. The data set from all the primary hospitals (n = 44) yielded more accurate poisoning incidence amongst a paediatric population.


Asunto(s)
Envenenamiento/epidemiología , Población Rural/estadística & datos numéricos , Niño , Preescolar , Estudios Epidemiológicos , Femenino , Humanos , Incidencia , Lactante , Masculino , Registros Médicos , Envenenamiento/terapia , Sri Lanka/epidemiología , Centros de Atención Terciaria
5.
Qual Health Res ; 23(11): 1481-94, 2013 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-24135311

RESUMEN

Different hospitals produce different cultures-products of relationships between people of different staff categories and people from external community groups. These relationships demonstrate unique social dynamics in rural peripheral hospitals that form a major part of the health care system in Sri Lanka and other developing countries. Understanding the existing social dynamics might be useful when trying to implement new treatment guidelines that can involve behavior change. We aimed to explore the existing social dynamics in peripheral hospitals in rural Sri Lanka by examining the treatment related to cases of acute self-poisoning that is a common, highly interactive medical emergency. These hospitals demonstrate higher levels of community influence in treatment decisions and closer interactions between hospital staff. We argue that health care teamwork is effective in peripheral hospitals, resulting in benefits to all staff, who see these hospitals as better places to work and train, in contrast to a commonly held belief that such rural hospitals are disadvantaged and difficult places.


Asunto(s)
Actitud del Personal de Salud , Hospitales Rurales/organización & administración , Cultura Organizacional , Envenenamiento/psicología , Envenenamiento/terapia , Intento de Suicidio/psicología , Adulto , Relaciones Comunidad-Institución , Toma de Decisiones , Femenino , Grupos Focales , Humanos , Comunicación Interdisciplinaria , Entrevistas como Asunto , Masculino , Grupo de Atención al Paciente/organización & administración , Relaciones Profesional-Paciente , Investigación Cualitativa , Sri Lanka
6.
PLoS One ; 8(8): e71787, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-23990989

RESUMEN

BACKGROUND: In developing countries, including Sri Lanka, a high proportion of acute poisoning and other medical emergencies are initially treated in rural peripheral hospitals. Patients are then usually transferred to referral hospitals for further treatment. Guidelines are often used to promote better patient care in these emergencies. We conducted a cluster randomized controlled trial (ISRCTN73983810) which aimed to assess the effect of a brief educational outreach ('academic detailing') intervention to promote the utilization of treatment guidelines for acute poisoning. METHODS AND FINDINGS: This cluster RCT was conducted in the North Central Province of Sri Lanka. All peripheral hospitals in the province were randomized to either intervention or control. All hospitals received a copy of the guidelines. The intervention hospitals received a brief out-reach academic detailing workshop which explained poisoning treatment guidelines and guideline promotional items designed to be used in daily care. Data were collected on all patients admitted due to poisoning for 12 months post-intervention in all study hospitals. Information collected included type of poison exposure, initial investigations, treatments and hospital outcome. Patients transferred from peripheral hospitals to referral hospitals had their clinical outcomes recorded. There were 23 intervention and 23 control hospitals. There were no significant differences in the patient characteristics, such as age, gender and the poisons ingested. The intervention hospitals showed a significant improvement in administration of activated charcoal [OR 2.95 (95% CI 1.28-6.80)]. There was no difference between hospitals in use of other decontamination methods. CONCLUSION: This study shows that an educational intervention consisting of brief out-reach academic detailing was effective in changing treatment behavior in rural Sri Lankan hospitals. The intervention was only effective for treatments with direct clinician involvement, such as administering activated charcoal. It was not successful for treatments usually administered by non-professional staff such as forced emesis for poisoning. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN73983810 ISRCTN73983810.


Asunto(s)
Hospitales Rurales , Personal de Hospital/educación , Envenenamiento/terapia , Guías de Práctica Clínica como Asunto , Enfermedad Aguda , Antídotos/uso terapéutico , Carbón Orgánico/uso terapéutico , Análisis por Conglomerados , Educación Continua , Hospitalización/estadística & datos numéricos , Humanos , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Compuestos de Pralidoxima/uso terapéutico , Sri Lanka
7.
BMC Public Health ; 12: 593, 2012 Aug 02.
Artículo en Inglés | MEDLINE | ID: mdl-22852867

RESUMEN

BACKGROUND: Acute poisoning is a major public health issue in many parts of the world. The epidemiology and the mortality rate is higher in low and middle income countries, including Sri Lanka. The aim of this study was to provide details about the epidemiology of acute poisoning in a rural Sri Lankan district and to identify the changing patterns and epidemiology of poisoning. METHODS: A prospective study was conducted from September 2008 to January 2010 in all hospitals with inpatient facilities in Anuradhapura district of North Central Province of Sri Lanka. Acute poisoning data was extracted from patient charts. Selected data were compared to the data collected from a 2005 study in 28 hospitals. RESULTS: There were 3813 poisoned patients admitted to the hospitals in the Anuradhapura district over 17 months. The annual population incidence was 447 poisoning cases per 100,000 population. The total number of male and female patients was approximately similar, but the age distribution differed by gender. There was a very high incidence of poisoning in females aged 15-19, with an estimated cumulative incidence of 6% over these five years. Although, pesticides are still the most common type of poison, medicinal drug poisonings are now 21% of the total and have increased 1.6 fold since 2005. CONCLUSIONS: Acute poisoning remains a major public health problem in rural Sri Lanka and pesticide poisoning remains the most important poison. However, cases of medicinal drug poisoning have recently dramatically increased. Youth in these rural communities remain very vulnerable to acute poisoning and the problem is so common that school-based primary prevention programs may be worthwhile.Lalith Senarathna, Shaluka F Jayamanna, Patrick J Kelly, Nick A Buckley,michael J Dibley, Andrew H Dawson. These authors contributed equally to this work.


Asunto(s)
Envenenamiento/epidemiología , Población Rural/estadística & datos numéricos , Conducta Autodestructiva/epidemiología , Adolescente , Adulto , Distribución por Edad , Anciano , Carbamatos/envenenamiento , Niño , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Intoxicación por Organofosfatos , Plaguicidas/envenenamiento , Plantas Tóxicas/envenenamiento , Envenenamiento/mortalidad , Vigilancia de la Población , Medicamentos bajo Prescripción/envenenamiento , Conducta Autodestructiva/mortalidad , Distribución por Sexo , Sri Lanka/epidemiología , Thevetia/envenenamiento
8.
Toxicol Lett ; 201(3): 270-6, 2011 Mar 25.
Artículo en Inglés | MEDLINE | ID: mdl-21256202

RESUMEN

Human data on protein binding and dose-dependent changes in toxicokinetics for MCPA are very limited. 128 blood samples were obtained in 49 patients with acute MCPA poisoning and total and unbound concentrations of MCPA were determined. The Scatchard plot was biphasic suggesting protein binding to two sites. The free MCPA concentration increased when the total concentration exceeded 239mg/L (95% confidence interval 198-274mg/L). Nonlinear regression using a two-site binding hyperbola model estimated saturation of the high affinity binding site at 115mg/L (95%CI 0-304). Further analyses using global fitting of serial data and adjusting for the concentration of albumin predicted similar concentrations for saturable binding (184mg/L and 167mg/L, respectively) without narrowing the 95%CI. In 25 patients, the plasma concentration-time curves for both bound and unbound MCPA were approximately log-linear which may suggest first order elimination, although sampling was infrequent so zero order elimination cannot be excluded. Using a cut-off concentration of 200mg/L, the half-life of MCPA at higher concentrations was 25.5h (95%CI 15.0-83.0h; n=16 patients) compared to 16.8h (95%CI 13.6-22.2h; n=10 patients) at lower concentrations. MCPA is subject to saturable protein binding but the influence on half-life appears marginal.


Asunto(s)
Ácido 2-Metil-4-clorofenoxiacético/farmacocinética , Ácido 2-Metil-4-clorofenoxiacético/envenenamiento , Herbicidas/farmacocinética , Herbicidas/envenenamiento , Ácido 2-Metil-4-clorofenoxiacético/toxicidad , Enfermedad Aguda , Adulto , Albúminas/metabolismo , Algoritmos , Relación Dosis-Respuesta a Droga , Femenino , Semivida , Herbicidas/toxicidad , Humanos , Masculino , Dinámicas no Lineales , Unión Proteica , Análisis de Regresión , Diálisis Renal , Intento de Suicidio , Sobrevida , Ultracentrifugación , Ultrafiltración , Adulto Joven
9.
PLoS Med ; 7(10): e1000357, 2010 Oct 26.
Artículo en Inglés | MEDLINE | ID: mdl-21048990

RESUMEN

BACKGROUND: agricultural pesticide poisoning is a major public health problem in the developing world, killing at least 250,000-370,000 people each year. Targeted pesticide restrictions in Sri Lanka over the last 20 years have reduced pesticide deaths by 50% without decreasing agricultural output. However, regulatory decisions have thus far not been based on the human toxicity of formulated agricultural pesticides but on the surrogate of rat toxicity using pure unformulated pesticides. We aimed to determine the relative human toxicity of formulated agricultural pesticides to improve the effectiveness of regulatory policy. METHODS AND FINDINGS: we examined the case fatality of different agricultural pesticides in a prospective cohort of patients presenting with pesticide self-poisoning to two clinical trial centers from April 2002 to November 2008. Identification of the pesticide ingested was based on history or positive identification of the container. A single pesticide was ingested by 9,302 patients. A specific pesticide was identified in 7,461 patients; 1,841 ingested an unknown pesticide. In a subset of 808 patients, the history of ingestion was confirmed by laboratory analysis in 95% of patients. There was a large variation in case fatality between pesticides-from 0% to 42%. This marked variation in lethality was observed for compounds within the same chemical and/or WHO toxicity classification of pesticides and for those used for similar agricultural indications. CONCLUSION: the human data provided toxicity rankings for some pesticides that contrasted strongly with the WHO toxicity classification based on rat toxicity. Basing regulation on human toxicity will make pesticide poisoning less hazardous, preventing hundreds of thousands of deaths globally without compromising agricultural needs. Ongoing monitoring of patterns of use and clinical toxicity for new pesticides is needed to identify highly toxic pesticides in a timely manner.


Asunto(s)
Agroquímicos/toxicidad , Plaguicidas/toxicidad , Envenenamiento/mortalidad , Enfermedad Aguda , Adulto , Animales , Estudios de Cohortes , Femenino , Humanos , Masculino , Plaguicidas/envenenamiento , Envenenamiento/clasificación , Estudios Prospectivos , Ratas , Sri Lanka/epidemiología , Análisis de Supervivencia , Organización Mundial de la Salud , Adulto Joven
10.
PLoS Med ; 6(6): e1000104, 2009 Jun 30.
Artículo en Inglés | MEDLINE | ID: mdl-19564902

RESUMEN

BACKGROUND: Poisoning with organophosphorus (OP) insecticides is a major global public health problem, causing an estimated 200,000 deaths each year. Although the World Health Organization recommends use of pralidoxime, this antidote's effectiveness remains unclear. We aimed to determine whether the addition of pralidoxime chloride to atropine and supportive care offers benefit. METHODS AND FINDINGS: We performed a double-blind randomised placebo-controlled trial of pralidoxime chloride (2 g loading dose over 20 min, followed by a constant infusion of 0.5 g/h for up to 7 d) versus saline in patients with organophosphorus insecticide self-poisoning. Mortality was the primary outcome; secondary outcomes included intubation, duration of intubation, and time to death. We measured baseline markers of exposure and pharmacodynamic markers of response to aid interpretation of clinical outcomes. Two hundred thirty-five patients were randomised to receive pralidoxime (121) or saline placebo (114). Pralidoxime produced substantial and moderate red cell acetylcholinesterase reactivation in patients poisoned by diethyl and dimethyl compounds, respectively. Mortality was nonsignificantly higher in patients receiving pralidoxime: 30/121 (24.8%) receiving pralidoxime died, compared with 18/114 (15.8%) receiving placebo (adjusted hazard ratio [HR] 1.69, 95% confidence interval [CI] 0.88-3.26, p = 0.12). Incorporating the baseline amount of acetylcholinesterase already aged and plasma OP concentration into the analysis increased the HR for patients receiving pralidoxime compared to placebo, further decreasing the likelihood that pralidoxime is beneficial. The need for intubation was similar in both groups (pralidoxime 26/121 [21.5%], placebo 24/114 [21.1%], adjusted HR 1.27 [95% CI 0.71-2.29]). To reduce confounding due to ingestion of different insecticides, we further analysed patients with confirmed chlorpyrifos or dimethoate poisoning alone, finding no evidence of benefit. CONCLUSIONS: Despite clear reactivation of red cell acetylcholinesterase in diethyl organophosphorus pesticide poisoned patients, we found no evidence that this regimen improves survival or reduces need for intubation in patients with organophosphorus insecticide poisoning. The reason for this failure to benefit patients was not apparent. Further studies of different dose regimens or different oximes are required.


Asunto(s)
Antídotos/uso terapéutico , Insecticidas/envenenamiento , Compuestos Organoplatinos/envenenamiento , Compuestos de Pralidoxima/uso terapéutico , Acetilcolinesterasa/metabolismo , Adulto , Antídotos/efectos adversos , Antídotos/farmacocinética , Atropina/farmacología , Quimioterapia Combinada , Femenino , Humanos , Intubación Intratraqueal , Masculino , Envenenamiento/mortalidad , Compuestos de Pralidoxima/efectos adversos , Compuestos de Pralidoxima/farmacocinética
11.
Bull World Health Organ ; 87(3): 180-5, 2009 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-19377713

RESUMEN

OBJECTIVE: To estimate the direct financial costs to the Sri Lanka Ministry of Health of treating patients after self-poisoning, particularly from pesticides, in a single district. METHODS: Data on staff, drug, laboratory and other inputs for each patient admitted for self-poisoning were prospectively collected over a one-month period from one general hospital (2005) and five peripheral hospitals (2006) in the Anuradhapura district. Data on transfers to secondary- and tertiary-level facilities were obtained for a 6-month period from 30 peripheral hospitals. The cost of the inputs in United States dollars (US$), using 2005 figures, was derived from hospital accounts. FINDINGS: The average total cost of treating a self-poisoned patient at the general hospital was US$ 31.83, with ward staff input and drugs being the highest expenditure category and only US$ 0.19 of this sum related to capital and maintenance costs. The average total cost of treatment was highest for self-poisoning with pesticides (US$ 49.12). The patients placed in the intensive care unit, who comprised 5% of the total, took up 75% of the overall treatment cost for all self-poisoned patients at the general hospital. The average total cost of treating self-poisoned patients at peripheral hospitals was US$ 3.33. The average patient cost per transfer was US$ 14.03. In 2006, the total cost of treating self-poisoned patients in the Anuradhapura district amounted to US$ 76,599, of which US$ 53,834 were comprised of pesticide self-poisonings. Based on the total treatment cost per self-poisoned patient estimated in this study, the cost of treating self-poisoned patients in all of Sri Lanka in 2004 was estimated at US$ 866,304. CONCLUSION: The cost of treating pesticide self-poisonings may be reduced by promoting the use of less toxic pesticides and possibly by improving case management in primary care hospitals. Additional research is needed to assess if increasing infrastructure and staff at peripheral hospitals could reduce the overall cost to the government, optimize case management and reduce pressure on secondary services.


Asunto(s)
Costos de Hospital/tendencias , Envenenamiento/economía , Conducta Autodestructiva , Enfermedad Aguda , Financiación Gubernamental , Humanos , Plaguicidas/efectos adversos , Envenenamiento/epidemiología , Estudios Prospectivos , Sri Lanka/epidemiología
12.
BMC Public Health ; 8: 373, 2008 Oct 28.
Artículo en Inglés | MEDLINE | ID: mdl-18954469

RESUMEN

BACKGROUND: Deliberate self-poisoning is a major public heath issue in developing countries. In rural Sri Lanka deliberate self-poisoning is one of the leading causes of hospital death. The majority of patients with poisoning present to rural hospitals for initial treatment that are staffed by non-specialist and often relatively junior doctors. The treatment of self-poisoning patients poses numerous clinical challenges and further difficulties are experienced if patients are uncooperative and aggressive, intoxicated with alcohol or suffering mental illness. Previous research in developed countries has examined self-poisoning patients and their treatment but little is know about self-poisoning patient care in the context of rural health provision in developing countries. This study provides the first focused exploration of the experiences and perceptions of primary care rural hospital doctors in Sri Lanka toward the treatment of self-poisoning patients. METHODS: Semi-structured in-depth interviews were conducted with fifteen doctors from rural hospitals in the North Central Province, Sri Lanka. All interviews were recorded and transcribed and subject to thematic analysis. RESULTS: Participating doctors did perceive that treating self-poisoning patients in a primary care rural hospital as potentially confidence-building. However, resource issues such as the lack of medication, equipment and staffing were seen as important challenges to treating self-poisoning patients. Other challenges identified included disparity with community and other staff members regarding expectations of care, a sense of professional isolation and a lack of continuing education programs. CONCLUSION: Addressing professional isolation through educational and trainee programs for doctors and reducing the variance in expectations between professional groups and the community has the potential to improve delivery of care for self-poisoning patients.


Asunto(s)
Médicos/psicología , Envenenamiento/terapia , Población Rural , Conducta Autodestructiva , Adulto , Actitud del Personal de Salud , Hospitalización , Humanos , Entrevistas como Asunto , Envenenamiento/etnología , Sri Lanka
13.
Lancet ; 371(9612): 579-87, 2008 Feb 16.
Artículo en Inglés | MEDLINE | ID: mdl-18280328

RESUMEN

BACKGROUND: The case-fatality for intentional self-poisoning in the rural developing world is 10-50-fold higher than that in industrialised countries, mostly because of the use of highly toxic pesticides and plants. We therefore aimed to assess whether routine treatment with multiple-dose activated charcoal, to interrupt enterovascular or enterohepatic circulations, offers benefit compared with no charcoal in such an environment. METHODS: We did an open-label, parallel group, randomised, controlled trial of six 50 g doses of activated charcoal at 4-h intervals versus no charcoal versus one 50 g dose of activated charcoal in three Sri Lankan hospitals. 4632 patients were randomised to receive no charcoal (n=1554), one dose of charcoal (n=1545), or six doses of charcoal (n=1533); outcomes were available for 4629 patients. 2338 (51%) individuals had ingested pesticides, whereas 1647 (36%) had ingested yellow oleander (Thevetia peruviana) seeds. Mortality was the primary outcome measure. Analysis was by intention to treat. The trial is registered with controlled-trials.com as ISRCTN02920054. FINDINGS: Mortality did not differ between the groups. 97 (6.3%) of 1531 participants in the multiple-dose group died, compared with 105 (6.8%) of 1554 in the no charcoal group (adjusted odds ratio 0.96, 95% CI 0.70-1.33). No differences were noted for patients who took particular poisons, were severely ill on admission, or who presented early. INTERPRETATION: We cannot recommend the routine use of multiple-dose activated charcoal in rural Asia Pacific; although further studies of early charcoal administration might be useful, effective affordable treatments are urgently needed.


Asunto(s)
Antídotos/administración & dosificación , Carbón Orgánico/administración & dosificación , Envenenamiento/tratamiento farmacológico , Adulto , Femenino , Escala de Coma de Glasgow , Humanos , Modelos Logísticos , Masculino , Intoxicación por Organofosfatos , Plaguicidas/envenenamiento , Envenenamiento/clasificación , Envenenamiento/mortalidad , Población Rural , Sri Lanka , Intento de Suicidio , Thevetia/envenenamiento , Insuficiencia del Tratamiento
14.
BMC Emerg Med ; 7: 2, 2007 May 11.
Artículo en Inglés | MEDLINE | ID: mdl-17498281

RESUMEN

BACKGROUND: The case fatality for intentional self-poisoning in rural Asia is 10-30 times higher than in the West, mostly due to the use of highly toxic poisons. Activated charcoal is a widely available intervention that may - if given early - bind to poisons in the stomach and prevent their absorption. Current guidelines recommend giving a single dose of charcoal (SDAC) if patients arrive within an hour of ingestion. Multiple doses (MDAC) may increase poison elimination at a later time by interrupting any enterohepatic or enterovascular circulations. The effectiveness of SDAC or MDAC is unknown. Since most patients present to hospital after one hour, we considered MDAC to have a higher likelihood of clinical benefit and set up a study to compare MDAC with no charcoal. A third arm of SDAC was added to help determine whether any benefit noted from MDAC resulted from the first dose or all doses. METHODS/DESIGN: We set up a randomised controlled trial assessing the effectiveness of superactivated charcoal in unselected adult self-poisoning patients admitted to the adult medical wards of three Sri Lankan secondary hospitals. Patients were randomised to standard treatment or standard treatment plus either a single 50 g dose of superactivated charcoal dissolved in 300 ml of water or six doses every four hours. All patients with a history of poison ingestion were approached concerning the study and written informed consent taken from each patient, or their relative (for unconscious patients or those <16 yrs), recruited to the study. The exclusion criteria were: age under 14 yrs; prior treatment with activated charcoal during this poisoning episode; pregnancy; ingestion of a corrosive or hydrocarbon; requirement for oral medication; inability of the medical staff to intubate the patient with a Glasgow Coma Score <13; presentation >72 hrs post-ingestion, and previous recruitment. The primary outcome was in-hospital mortality; secondary outcomes included the occurrence of serious complications (need for intubation, time requiring assisted ventilation, fits, cardiac dysrhythmias). Analysis will be on an intention-to-treat basis; the effects of reported time to treatment after poisoning and status on admission will also be assessed. DISCUSSION: This trial will provide important information on the effectiveness of both single and multiple dose activated charcoal in the forms of poisoning commonly seen in rural Asia. If charcoal is found to be effective, it should be possible to make it widely available across rural Asia in an affordable formulation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN02920054.

15.
Clin Toxicol (Phila) ; 45(2): 132-5, 2007.
Artículo en Inglés | MEDLINE | ID: mdl-17364629

RESUMEN

BACKGROUND: Although activated charcoal is widely used for the treatment of self-poisoning, its effectiveness is unknown. An important consideration is patient compliance since poor compliance will limit effectiveness. We aimed to describe compliance in a randomized controlled trial (RCT) performed in Sri Lanka, presuming that this would set the upper limits for compliance in routine clinical use. METHOD: 1,103 patients randomized to single or multiple (six doses q4h) 50 g doses of superactivated charcoal were prospectively observed. Charcoal was given by study doctors who recorded the amount ingested and the amount of persuasion required for the patients to drink the charcoal. RESULTS: 559 patients were randomized to receive one dose and 544 to receive six doses. Data was available for 1,071 (97%) patients. Eighty-eight were unable to complete their course; 98 required a NG tube, leaving 885 patients that received the first dose by mouth. The mean estimated amount of the prescribed dose of charcoal taken orally as a single or first dose was 83% (95% C.I. 82-84%). For patients receiving multiple doses, this amount fell over the next five doses to 66% (63-69%). While only 3.2% of patients refused the first dose, 12.3% refused the sixth. Relatively less persuasion was required for patients ingesting the first or single dose; 38% of patients required intense persuasion by the sixth dose. CONCLUSION: Compliance for a single dose of superactivated charcoal among trial patients was good. However, even in the ideal circumstances of a RCT, compliance decreased thereafter for patients taking more than one dose.


Asunto(s)
Carbón Orgánico/administración & dosificación , Cooperación del Paciente , Envenenamiento/tratamiento farmacológico , Carbón Orgánico/uso terapéutico , Relación Dosis-Respuesta a Droga , Esquema de Medicación , Humanos , Intubación Gastrointestinal , Estudios Prospectivos , Sri Lanka
16.
Bull World Health Organ ; 84(4): 276-82, 2006 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-16628300

RESUMEN

OBJECTIVES: Most data on self-poisoning in rural Asia have come from secondary hospitals. We aimed to: assess how transfers from primary to secondary hospitals affected estimates of case-fatality ratio (CFR); determine whether there was referral bias according to gender or poison; and estimate the annual incidence of all self-poisoning, and of fatal self-poisoning, in a rural developing-world setting. METHODS: Self-poisoning patients admitted to Anuradhapura General Hospital, Sri Lanka, were reviewed on admission from 1 July to 31 December 2002. We audited medical notes of self-poisoning patients admitted to 17 of the 34 surrounding peripheral hospitals for the same period. FINDINGS: A total of 742 patients were admitted with self-poisoning to the secondary hospital; 81 died (CFR 10.9%). 483 patients were admitted to 17 surrounding peripheral hospitals. Six patients (1.2%) died in peripheral hospitals, 249 were discharged home, and 228 were transferred to the secondary hospital. There was no effect of gender or age on likelihood of transfer; however, patients who had ingested oleander or paraquat were more likely to be transferred than were patients who had taken organophosphorus pesticides or other poisons. Estimated annual incidences of self-poisoning and fatal self-poisoning were 363 and 27 per 100,000 population, respectively, with an overall CFR of 7.4% (95% confidence interval 6.0-9.0). CONCLUSION: Fifty per cent of patients admitted to peripheral hospitals were discharged home, showing that CFRs based on secondary hospital data are inflated. However, while incidence of self-poisoning is similar to that in England, fatal self-poisoning is three times more common in Sri Lanka than fatal self-harm by all methods in England. Population based data are essential for making international comparisons of case fatality and incidence, and for assessing public health interventions.


Asunto(s)
Hospitalización/estadística & datos numéricos , Transferencia de Pacientes , Envenenamiento/epidemiología , Intento de Suicidio/estadística & datos numéricos , Adulto , Femenino , Humanos , Incidencia , Masculino , Envenenamiento/mortalidad , Derivación y Consulta , Población Rural , Sri Lanka/epidemiología
17.
Lancet ; 366(9495): 1452-9, 2005.
Artículo en Inglés | MEDLINE | ID: mdl-16243090

RESUMEN

BACKGROUND: Although more than 100 organophosphorus insecticides exist, organophosphorus poisoning is usually regarded as a single entity, distinguished only by the compound's lethal dose in animals. We aimed to determine whether the three most common organophosphorus insecticides used for self-poisoning in Sri Lanka differ in the clinical features and severity of poisoning they cause. METHODS: We prospectively studied 802 patients with chlorpyrifos, dimethoate, or fenthion self-poisoning admitted to three hospitals. Blood cholinesterase activity and insecticide concentration were measured to determine the compound and the patients' response to insecticide and therapy. We recorded clinical outcomes for each patient. FINDINGS: Compared with chlorpyrifos (35 of 439, 8.0%), the proportion dying was significantly higher with dimethoate (61 of 264, 23.1%, odds ratio [OR] 3.5, 95% CI 2.2-5.4) or fenthion (16 of 99, 16.2%, OR 2.2, 1.2-4.2), as was the proportion requiring endotracheal intubation (66 of 439 for chlorpyrifos, 15.0%; 93 of 264 for dimethoate, 35.2%, OR 3.1, 2.1-4.4; 31 of 99 for fenthion, 31.3%, 2.6, 1.6-4.2). Dimethoate-poisoned patients died sooner than those ingesting other pesticides and often from hypotensive shock. Fenthion poisoning initially caused few symptoms but many patients subsequently required intubation. Acetylcholinesterase inhibited by fenthion or dimethoate responded poorly to pralidoxime treatment compared with chlorpyrifos-inhibited acetylcholinesterase. INTERPRETATION: Organophosphorus insecticide poisoning is not a single entity, with substantial variability in clinical course, response to oximes, and outcome. Animal toxicity does not predict human toxicity since, although chlorpyrifos is generally the most toxic in rats, it is least toxic in people. Each organophosphorus insecticide should be considered as an individual poison and, consequently, patients might benefit from management protocols developed for particular organophosphorus insecticides.


Asunto(s)
Reactivadores de la Colinesterasa/uso terapéutico , Insecticidas/envenenamiento , Intoxicación por Organofosfatos , Compuestos de Pralidoxima/uso terapéutico , Acetilcolinesterasa/sangre , Adulto , Carbón Orgánico/uso terapéutico , Cloropirifos/sangre , Cloropirifos/envenenamiento , Dimetoato/sangre , Dimetoato/envenenamiento , Femenino , Fentión/sangre , Fentión/envenenamiento , Escala de Coma de Glasgow , Humanos , Insecticidas/sangre , Masculino , Mortalidad , Compuestos Organofosforados/sangre , Estudios Prospectivos , Sri Lanka
18.
Ann Emerg Med ; 46(3): 275-84, 2005 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-16126140

RESUMEN

STUDY OBJECTIVE: Data on poisoning with MCPA (4-chloro-2-methyl-phenoxyacetic acid) are limited to 6 case reports. Our objective is to describe outcomes from intentional self-poisoning with MCPA in a prospective case series of 181 patients presenting to hospitals in Sri Lanka. METHODS: Patient information was collected by on-site study physicians as part of an ongoing prospective cohort study of poisoned patients. Medical history, clinical details, and blood samples were obtained prospectively. RESULTS: Overall clinical toxicity was minimal in 85% of patients, including mild gastrointestinal symptoms in 44% of patients. More severe clinical signs of chlorophenoxy poisoning reported previously, such as rhabdomyolysis, renal dysfunction, and coma, also occurred but were uncommon. Eight patients died (4.4%). Most deaths occurred suddenly from cardiorespiratory arrest within 48 hours of poisoning; the pathophysiological mechanism of death was not apparent. The correlation between admission plasma MCPA concentration and clinical markers of severity of toxicity (physical signs, symptoms, and increased creatine kinase level) was poor. CONCLUSION: Intentional self-poisoning with MCPA generally causes mild toxicity, but cardiorespiratory arrest and death may occur. All patients should receive routine resuscitation and supportive care. It seems reasonable to correct acidosis and maintain an adequate urine output, but there is insufficient evidence to support other specific interventions. Our data do not support a clinical role for measurement of plasma MCPA in the acute management of poisoning, and insufficient data were available to fully examine the utility of measured electrolytes and creatine kinase levels.


Asunto(s)
Ácido 2-Metil-4-clorofenoxiacético/envenenamiento , Herbicidas/envenenamiento , Intento de Suicidio , Ácido 2-Metil-4-clorofenoxiacético/sangre , Adolescente , Adulto , Biomarcadores/sangre , Estudios de Cohortes , Creatina Quinasa/sangre , Medicina de Emergencia/métodos , Femenino , Herbicidas/sangre , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Envenenamiento/sangre , Envenenamiento/terapia , Estudios Prospectivos , Sri Lanka , Análisis de Supervivencia
19.
J Toxicol Clin Toxicol ; 42(6): 865-75, 2004.
Artículo en Inglés | MEDLINE | ID: mdl-15533026

RESUMEN

OBJECTIVE: Early deaths from organophosphorus (OP) pesticide self-poisoning result from respiratory failure and cardiovascular collapse. Therapy requires the urgent use of atropine to reverse cholinergic excess, thereby improving respiratory function, heart rate, and blood pressure. We aimed to assess variation in textbook recommendations for early atropinisation and to see whether this variation affected time to stabilisation using model data from 22 severely poisoned patients seen in a Sri Lankan clinical trial. METHODS: We extracted prospectively recorded data on atropine requirements for 22 OP poisoned patients who required intubation but survived to discharge. We did a systematic search for textbook recommendations for initial atropinisation regimens. These regimens were then applied to data from the Sri Lankan patients. RESULTS: The patients required a mean of 23.4 mg (standard deviation 22.0, range 1-75 mg) atropine to clear the lungs, raise the pulse above 80 bpm, and restore systolic blood pressure to more than 80 mmHg. Textbook recommendations varied markedly--atropinisation of an average patient, requiring the mean dose of 23.4 mg, would have taken 8 to 1380 mins; atropinisation of a very ill patient, requiring 75 mg, would have taken 25 to 4440 mins. Atropinisation was attained most rapidly with a regimen of increasing bolus doses after failure to respond to the previous bolus. CONCLUSIONS: There is great variation in recommendations for atropinisation, with some regimens taking hours and even days to stabilise a patient. The guidelines are very flexible--possibly appropriate for experienced emergency physicians or clinical toxicologists, but completely inappropriate for the inexperienced junior doctors who see most cases worldwide. We recommend that a consensus guideline be developed by appropriate organisations to bring order to this important part of OP therapy, while acknowledging the paucity of data to drive the guidelines.


Asunto(s)
Atropina/administración & dosificación , Atropina/uso terapéutico , Antagonistas Muscarínicos/administración & dosificación , Antagonistas Muscarínicos/uso terapéutico , Intoxicación por Organofosfatos , Plaguicidas/envenenamiento , Protocolos Clínicos , Humanos , Suicidio/estadística & datos numéricos , Intento de Suicidio/estadística & datos numéricos
20.
J Toxicol Clin Toxicol ; 42(7): 955-63, 2004.
Artículo en Inglés | MEDLINE | ID: mdl-15641641

RESUMEN

OBJECTIVE: Fipronil, a broad spectrum N-phenylpyrazole insecticide that inhibits GABAA-gated chloride channels, has been in use since the mid-1990s. A high affinity for insect compared to mammalian GABA receptors results in lower animal toxicity than other insecticides blocking this channel. To date, only two accidental cases of fipronil poisoning in humans have been published. CASE SERIES: We report seven patients with fipronil self-poisoning seen prospectively in Sri Lanka together with pharmacokinetics for four patients. Non-sustained generalized tonic-clonic seizures were seen in two patients (peak measured plasma fipronil concentrations 1600 and 3744 microg/L); both were managed with diazepam without complications. A patient with a peak measured plasma concentration of 1040 microg/L was asymptomatic throughout his stay. Plasma concentration was still high at discharge 3-4 days post-ingestion when the patients were well. Retrospective review of >1000 pesticide poisoning deaths since 1995 found only one death from fipronil-based products. In contrast to the good outcome of the above cases, this patient required intubation and ventilation and had continuous fits despite therapy with barbiturates and benzodiazepines. CONCLUSIONS: Our experience with prospectively observed patients suggests that fipronil poisoning is characterized by vomiting, agitation, and seizures, and normally has a favorable outcome. Management should concentrate on supportive care and early treatment of seizures. However, further experience is needed to determine whether increased susceptibility to fipronil or larger doses can produce status epilepticus.


Asunto(s)
Canales de Cloruro/antagonistas & inhibidores , Insecticidas/envenenamiento , Pirazoles/envenenamiento , Receptores de GABA-A/efectos de los fármacos , Enfermedad Aguda , Adolescente , Adulto , Resultado Fatal , Femenino , Humanos , Insecticidas/sangre , Insecticidas/farmacocinética , Activación del Canal Iónico/efectos de los fármacos , Masculino , Exposición Profesional , Estudios Prospectivos , Pirazoles/sangre , Pirazoles/farmacocinética , Estudios Retrospectivos , Suicidio , Intento de Suicidio
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