A neonate with metabolic acidosis: Intentional ethylene glycol poisoning.

We present a rare case of the intentional poisoning of a neonate. An 8-day old child presented to an academic pediatric emergency department (ED) with respiratory distress and decreased intake. In the ED the patient was stabilized, and workup uncovered an anion gap metabolic acidosis. Blood, urine, and CSF cultures were negative at 48 h and a metabolic screen revealed elevated glycine. Calcium oxalate crystals were later found in the urinalysis, raising concern for ethylene glycol poisoning. The patient's father admitted to mixing antifreeze with the child's formula. The workup of an ill or distressed neonate should be methodical, ruling out sepsis, inborn errors of metabolism, cardiac disease, trauma, and less common etiologies such as intestinal catastrophes, renal or hepatic disease, neurologic disease, drug withdrawal, non-accidental trauma, formula mixing errors, and poisoning.

Operational use of household bleach to "crash and release" Aedes aegypti prior to Wolbachia-infected mosquito release.

Dengue (family Flaviviridae, genus Flavivirus, DENV) remains the leading arboviral cause of mortality in the tropics. Wolbachia pipientis has been shown to interrupt DENV transmission and is presently being trialled as a biological control. However, deployment issues have arisen on methods to temporarily suppress wild mosquito populations before Wolbachia-infected mosquito releases. By suppressing wild populations, fewer Ae. aegypti releases are required to achieve a sustainable Wolbachia density threshold. Furthermore, public distress is reduced. This study tests the application of domestic bleach (4% NaCIO) to temporarily "crash" immature Aedes populations in water-filled containers. Spray application NaClO (215 ppm) resulted in a mean 48-h mortality of 100, 100, 97, and 88% of eggs, second-instar larvae, fourth-instar larvae, and pupae, respectively. In the field, NaClO delayed ovipositing by 9 d in cooler months, and 11 d in hotter months, after which oviposition resumed in treated receptacles. We found bleach treatment of pot-plant bases did not cause wilting, yellowing, or dropping of leaves in two ornamental plants species. Domestically available NaClO could be adopted for a "crash and release" strategy to temporarily suppress wild populations of Ae. aegypti in containers before release of Wolbachia-infected mosquitoes. The "crash and release" strategy is also applicable to other mosquito species, e.g., Aedes albopictus (Skuse), in strategies using released mosquitoes.

Dosing patterns for duloxetine and predictors of high-dose prescriptions in patients with major depressive disorder: analysis from a United States third-party payer perspective.

BACKGROUND: Major depressive disorder (MDD) is a common illness that affects ∼7% of adults in the United States each year. Duloxetine is a dual reuptake inhibitor of serotonin and norepinephrine that has demonstrated efficacy and tolerability in the treatment of MDD. OBJECTIVE: The purpose of our study was to examine dosing patterns and pretreatment predictors of high-dose duloxetine therapy for patients with MDD in the usual clinical setting. METHODS: Data were from 6132 commercially insured patients with MDD initiated on duloxetine during 2005 and 2006. Patients had no duloxetine use in the previous 6 months and had continuous enrollment in a health plan for the 12 months immediately preceding and following initiation. Dosing patterns and predictors of high-dose therapy with duloxetine were examined. RESULTS: Initial doses of duloxetine were <60 mg/d, 60 mg/d, 90 mg/d, and ≥120 mg/d for 32.4%, 60.9%, 3.1%, and 3.5% of patients, respectively. Maximum daily doses were <60 mg, 60 mg, 90 mg, and ≥120 mg for 16.3%, 59.3%, 11.0%, and 13.3% of patients, respectively. Patients treated with >60 mg/d for at least 2 months were older, were more likely to have been treated by a psychiatrist, had greater comorbidity, and had used more health care resources and psychotropic and pain medications in the previous year. The following factors were independently associated with doses of >60 mg/d: older age (odds ratio [OR] = 1.33-1.46); comorbid neuropathic pain (OR = 1.88); fibromyalgia (OR = 1.36); dysthymic disorder (OR = 1.24); prior injury/poisoning (OR = 1.19); physician specialty (psychiatrist, OR = 1.55); and prior use of psychostimulants (OR = 1.26), benzodiazepines (OR = 1.19), venlafaxine (OR = 1.35), or atypical antipsychotics (OR = 1.35). CONCLUSIONS: Most of the commercially insured patients in this dataset were initiated and maintained on a duloxetine dose of 60 mg/d. Although the data are limited in their generalizability, the characteristics associated with higher dose therapy describe a complex group of patients who may require more intensive drug treatment and monitoring.

Trajectories of response to treatment with atypical antipsychotic medication in patients with schizophrenia pooled from 6 double-blind, randomized clinical trials.

Research has identified distinct trajectories of antipsychotic response in patients with chronic schizophrenia in short-duration trials (~12 weeks). This post-hoc analysis identified trajectories in patients with chronic schizophrenia treated for ≤24 weeks. We pooled data from 1990 patients with chronic schizophrenia from 6 randomized, double-blind, olanzapine-comparator trials of atypical antipsychotics. Trajectory analysis identified homogeneous subpopulations within the larger heterogeneous population. Baseline demographics were compared between the identified latent classes. Five distinct response trajectories based on Positive and Negative Syndrome Scale (PANSS) Total score were identified: Dramatic Responders (n=47/1990, 2.4%), severely-ill patients (PANSS=124) with rapid and sustained improvement (51%) by Week 3; Partial Responders (n=1802/1990, 90.6%), moderately-ill (PANSS=90) with minimal improvement (21%) by Week 4, and little further improvement; Partial Responders-Unsustained (Late) (n=32/1990, 1.6%), markedly-ill (PANSS=95) with minimal initial improvement followed by worsening after Week 12; Partial Responders-Unsustained (Early) (n=28/1990, 1.4%), markedly-ill (PANSS=102) with minimal initial improvement followed by worsening after Week 8; and Delayed Responders (n=81/1990, 4.1%), markedly-to-severely-ill (PANSS=113) with minimal (11%) improvement at Week 8, but noticeable improvement thereafter (49%). Significant differences were noted for several baseline characteristics (p<.05) and discontinuation rates (46%-72%). Dramatic Responders were younger and more likely to be female and Hispanic with higher baseline illness severity. Analysis of antipsychotic response over 24 weeks in a large, pooled, heterogeneous population treated for schizophrenia revealed 5 distinct trajectories. Most patients had modest and sustained improvements during atypical antipsychotic treatment, regardless of their baseline illness severity, representing a partial response to currently available treatments.

Sampling biases of the BG-sentinel trap with respect to physiology, age, and body size of adult Aedes aegypti (Diptera: Culicidae).

Currently, Aedes aegypti (L.) control strategies are being developed that involve manipulation of the vector at the adult stage (e.g., the use of the bacterial endosymbiont Wolbachia to shorten the life span of the vector population). These novel strategies demand adult sampling methods to measure changes in population size, structure (age, sex ratio), and, ultimately, the success of the program. Each sampling method presents certain biases. Once these biases are defined, methods used to estimate population size and structure can be calibrated accordingly, resulting in more accurate and complex estimates of the vector population. A series of mark-release-recapture experiments with adult Ae. aegypti were conducted in a large outdoor flight cage and an indoor setting in far north Queensland, Australia. The biases of the BG-Sentinel trap (BGS) were investigated across several categories, as follows: 1) mosquito age; 2) sex; 3) physiological status; and 4) body size. Biases were not detected across age groups or body sizes. A significant bias was detected across physiological groups: nulliparous females were recaptured at a significantly lower rate than all other groups except blood-fed parous females, which were also recaptured at a low rate by the BGS. Males were recaptured at a higher rate than all groups, but only a significant difference in recapture rates was observed between males and nulliparous females. Previous studies show that the BGS is a highly effective tool for Ae. aegypti surveillance. The BGS proves to be a reliable tool in Ae. aegypti surveillance with consistent sampling outcomes. The sampling bias of the BGS is measurable and can be used to generate more accurate estimates of the adult population and its attributes.

Evaluation of BG-sentinel trap trapping efficacy for Aedes aegypti (Diptera: Culicidae) in a visually competitive environment.

The BG-Sentinel (BGS) trap uses visual and olfactory cues as well as convection currents to attract Aedes aegypti (L.). The impact of the visual environment on trapping efficacy of the BGS trap for Ae. aegypti was investigated. Four- to 5-d nulliparous female and male Ae. aegypti were released into a semicontrolled room to evaluate the effect of the presence, reflectance, and distribution of surrounding harborage sites on BGS trapping efficacy. Low-reflective (dark) harborage sites near the BGS had a negative effect on both male and nulliparous female recapture rates; however, a more pronounced effect was observed in males. The distribution (clustered versus scattered) of dark harborage sites did not significantly affect recapture rates in either sex. In a subsequent experiment, the impact of oviposition sites on the recapture rate of gravid females was investigated. Although gravid females went to the oviposition sites and deposited eggs, the efficacy of the BGS in recapturing gravid females was not compromised. Ae. aegypti sampling in the field will mostly occur in the urban environment, whereby the BGS will be among oviposition sites and dark harborage areas in the form of household items and outdoor clutter. In addition to understanding sampling biases of the BGS, estimations of the adult population size and structure can be further adjusted based on an understanding of the impact of dark harborage sites on trap captures. Outcomes from this suite of experiments provide us with important considerations for trap deployment and interpretation of Ae. aegypti samples from the BGS trap.

Maintenance of response with atypical antipsychotics in the treatment of schizophrenia: a post-hoc analysis of 5 double-blind, randomized clinical trials.

BACKGROUND: How long an antipsychotic is effective in maintaining response is important in choosing the correct treatment for people with schizophrenia. This post-hoc analysis describes maintenance of response over 24 or 28 weeks in people treated for schizophrenia with olanzapine, risperidone, quetiapine, ziprasidone, or aripiprazole. METHODS: This was a post-hoc analysis using data from 5 double-blind, randomized, comparative trials of 24 or 28 weeks duration in which olanzapine was compared to risperidone (1 study; N = 339), quetiapine (1 study; N = 346), ziprasidone (2 studies; N = 548 and 394) or aripiprazole (1 study; N = 566) for treatment of schizophrenia. For each study, time to loss of response in patients who met criteria for response at Week 8 and the proportion of patients who lost response following Week 8 were compared by treatment group. The number needed to treat (NNT) with olanzapine rather than comparator to avoid loss of one additional responder over 24 or 28 weeks of treatment was calculated for each study. RESULTS: Time maintained in response was significantly longer (p < .05) for olanzapine compared to risperidone, quetiapine, and ziprasidone. Olanzapine did not significantly differ from aripiprazole. The proportion of patients who lost response was significantly lower for olanzapine versus risperidone, quetiapine, and ziprasidone (p < .05). NNTs to avoid one additional patient with loss of response with olanzapine versus risperidone, quetiapine and ziprasidone were favourable, ranging from 5 to 9. CONCLUSION: During 24 and 28 weeks of treatment, the antipsychotics studied differed in the time that treated patients with schizophrenia remained in response and the proportion of patients who lost response. Olanzapine treatment resulted in a consistent and statistically significant advantage in maintenance of response compared to treatment with risperidone, quetiapine and ziprasidone; but not compared to treatment with aripiprazole.

Evaluation of three traps for sampling Aedes polynesiensis and other mosquito species in American Samoa.

The efficacy of the recently developed BG-Sentinel mosquito trap baited with BG-Lure (a combination of lactic acid, ammonia, and caproic acid) was evaluated in American Samoa against the omnidirectional Fay-Prince trap and the Centers for Disease Control and Prevention (CDC) light trap, both baited with carbon dioxide. The BG-Sentinel trap captured the greatest number of the important filariasis and dengue vector Aedes (Stegomyia) polynesiensis at all 3 collection locations; however, its catch rate was not significantly different from that of the Fay-Prince trap at 2 of the 3 trapping locations. The CDC light trap caught very few Ae. polynesiensis. The Fay-Prince trap was more efficient than the other 2 traps for collecting Aedes (Aedimorphus) nocturnus, Aedes (Finlaya) spp., Culex quinquefasciatus, and Culex annulirostris. The efficacy and convenience of the BG-Sentinel suggest further research is warranted to evaluate its potential as a possible efficient and safe alternative to landing catches for sampling Ae. polynesiensis in research and control efforts against filariasis and dengue in the South Pacific.