Impact of online toxicology training on health professionals: the Global Educational Toxicology Uniting Project (GETUP)

OBJECTIVE

The Global Educational Toxicology Uniting Project (GETUP), supported by the American College of Medical Toxicology, links countries with and without toxicology services via distance education with the aim to improve education. Due to the lack of toxicology services in some countries there is a knowledge gap in the management of poisonings. We describe our experience with the worldwide delivery of an online introductory toxicology curriculum to emergency doctors and other health professionals treating poisoned patients.

METHODS

We delivered a 15-module introductory Internet-based toxicology curriculum to emergency doctors and health professionals, conducted from August to December 2016. This Internet-based curriculum was adapted from one used to teach emergency residents toxicology in the United States. Modules covered themes such as pharmaceutical (n = 8), toxidromes (n = 2) and agrochemicals (n = 5) poisoning. Participants completed pre-test and post-test multiple choice questions (MCQs) before and after completing the online module, respectively, throughout the course. We collected information on participant demographics, education and training, and perception of relevance of the curriculum. Participants gave feedback on the course and how it affected their practice.

RESULTS

One hundred and thirty-six health professionals from 33 countries participated in the course: 98 emergency doctors/medical officers, 25 physicians, eight pharmacists/poisons information specialists, two toxicologists, two medical students and one nurse. Median age of participants was 34 years. Median number of years postgraduate was seven. Ninety (65%) had access to either a poisons information centre over the phone or toxicologist and 48 (35%) did not. All participants expected the course to help improve their knowledge. Overall median pre-module MCQ scores were 56% (95%CI: 38, 75%) compared to post-module MCQ scores median 89% (95% CI: 67, 100%) (p < .0001).

CONCLUSIONS

Our participants demonstrated an increase in medical knowledge based on performance on MCQs. An online toxicology curriculum is an effective way to deliver education to health professionals treating poisoned patients and can help to bridge the knowledge gap and change practice in developed and developing countries.

Is socioeconomic position associated with risk of attempted suicide in rural Sri Lanka? A cross-sectional study of 165 000 individuals

BACKGROUND

Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high-income countries, but this association is unclear in low-income and middle-income countries.

METHODS

We investigated the association of SEP with attempted suicide in a cross-sectional survey of 165 233 Sri Lankans. SEP data were collected at the household (assets, social standing (highest occupation of a household member), foreign employment and young (≤40 years) female-headed households) and individual level (education and occupation). Respondent-reported data on suicide attempts in the past year were recorded. Random-effects logistic regression models, accounting for clustering, were used to investigate the association of SEP with attempted suicide.

RESULTS

Households reported 398 attempted suicides in the preceding year (239 per 100 000). Fewer assets (OR 3.2, 95% CI 2.4 to 4.4) and having a daily wage labourer (ie, insecure/low-income job; OR 2.3, 95% CI 1.6 to 3.2) as the highest occupation increased the risk of an attempted suicide within households. At an individual level, daily wage labourers were at an increased risk of attempted suicide compared with farmers. The strongest associations were with low levels of education (OR 4.6, 95% CI 2.5 to 8.4), with a stronger association in men than women.

CONCLUSIONS

We found that indicators of lower SEP are associated with increased risk of attempted suicide in rural Sri Lanka. Longitudinal studies with objective measures of suicide attempts are needed to confirm this association.

TRIAL REGISTRATION NUMBER

NCT01146496; Pre-results.

Relationship between prescribed psychotropic medications and co-ingested alcohol in intentional self-poisonings

BackgroundAcute alcohol consumption is a major risk factor for suicide, therefore investigating factors associated with alcohol-related self-harm warrant attention.AimsTo investigate the influence of prescribed psychotropic medications on the odds of co-ingesting alcohol preceding or during intentional efforts to self-poison.MethodA cross-sectional analysis of consecutive hospital presentations following intentional self-poisoning was conducted. A total of 7270 patients (4363 women) aged 18-96 were included.ResultsThe odds of alcohol co-ingestion were increased in those not prescribed any medication (odds ratio (OR) = 1.27, 99% CI 1.10-1.46, P<0.001) and in impulsive self-poisonings (OR = 1.39, 99% CI 1.11-1.74, P<0.001). Odds were decreased in those prescribed anticonvulsants (OR = 0.69, 99% CI 0.51-0.93), antipsychotics (OR = 0.55, 99% CI 0.45-0.66) and antidepressants (OR = 0.87, 99% CI 0.77-0.99).ConclusionsFindings indicate that being medicated for a psychiatric illness may reduce the likelihood of alcohol consumption during times of acute distress, hence perhaps may reduce the risk of intentional self-poisoning.

Epidemiology of coronial deaths from pesticide ingestion in Australia

Pesticides in Australia are tightly regulated but it is unknown how this may affect the distribution of misuse and self-harm across Australia, both spatially and within subgroups in the population. We performed an observational study to examine spatial differences in suicide/deliberate poisonings with pesticides in Australia. We examined Coronial inquest cases of self-harm by pesticide ingestion for the years 2001-2013 (n=209). Coronial cases were older, more likely to be male, have lower SES status and live in outer regional areas as opposed to cities when compared to the general population. Case densities (cases/100,000 population) were lower in large capital cities and higher in agricultural areas: despite this half the cases occurred in major cities.

Arsenic trioxide poisoning: a description of two acute overdoses

Arsenic is a traditional poison that has a history extending back into ancient times, as a medicinal agent, a homicidal poison and more recently in deliberate and unintentional self-poisoning. We report two cases of acute poisoning with an unwettable formulation of arsenic trioxide. Both patients had early gastrointestinal toxicity and were treated with early whole bowel irrigation (WBI). Chelation therapy with dimercaptosuccinic acid (dimercaptosuccinate, DMSA) was commenced within 24 hours and serial blood and urine arsenic concentrations were measured. Neither patient suffered any adverse outcome in spite of very high blood and urine concentrations of arsenic. Arsenic quantification in blood, urine and faeces suggested that enhanced gastrointestinal decontamination was minimally effective for decontamination and that DMSA for at least two weeks was required.

A bedside test for methemoglobinemia, Sri Lanka

Problem

Propanil is an aniline herbicide that is widely used for rice cultivation, but is also used for self-poisoning. Toxicity from propanil is largely due to methemoglobinemia. In resource-poor settings, the capacity to determine methemoglobin concentration is insufficient and prevents effective case management, which results in increased deaths from propanil poisoning.

Approach

Blood with a methemoglobin concentration greater than 15% of total haemoglobin levels appears brownish in colour. We introduced a colour reference chart that can be used to semiquantitatively determine methemoglobinemia. Each ward in three rural hospitals received a chart. Ward staff, medical officers and trainee doctors were given a presentation describing the test method and how it should be used with the relevant national treatment guidelines.

Local setting

In three rural hospitals in Sri Lanka, 401 patients were admitted with a diagnosis of propanil poisoning before the introduction of this test (2003–2007) and 262 patients after it was introduced (2008–2014), 46 of 663 patients died.

Relevant changes

The chart can be freely produced with any good-quality colour printer. In three rural hospitals, deaths from propanil poisoning fell from 10% of those admitted with this diagnosis in 2003–2007 (38/401) to 3% (8/262) in 2008–2014 and the use of methylene blue increased from 10% (13/136) to 55% (59/107) over this period.

Lessons learnt

This simple bedside test was associated with increased use of the first line treatment for propanil poisoning and improved survival. In 2011, the test was included in the national guidelines for the management of propanil poisoning.

Harmonizing post-market surveillance of prescription drug misuse: a systematic review of observational studies using routinely collected data (2000-2013)

BACKGROUND

Prescription drug misuse is a growing public health concern globally. Routinely collected data provide a valuable tool for quantifying prescription drug misuse.

OBJECTIVE

To synthesize the global literature investigating prescription drug misuse utilizing routinely collected, person-level prescription/dispensing data to examine reported measures, documented extent of misuse and associated factors.

METHODS

The MEDLINE, EMBASE, CINAHL, MEDLINE In Process, Scopus citations and Google Scholar databases were searched for relevant articles published between 1 January 2000 and 31 July 2013. A total of 10,803 abstracts were screened and 281 full-text manuscripts were retrieved. Fifty-two peer-reviewed, English-language manuscripts met our inclusion criteria-an aim/method investigating prescription drug misuse in adults and a measure of misuse derived exclusively from prescription/dispensing data.

RESULTS

Four proxies of prescription drug misuse were commonly used across studies: number of prescribers, number of dispensing pharmacies, early refills and volume of drugs dispensed. Overall, 89 unique measures of misuse were identified across the 52 studies, reflecting the heterogeneity in how measures are constructed: single or composite; different thresholds, cohort definitions and time period of assessment. Consequently, it was not possible to make definitive comparisons about the extent (range reported 0.01-93.5 %), variations and factors associated with prescription drug misuse.

CONCLUSIONS

Routine data collections are relatively consistent across jurisdictions. Despite the heterogeneity of the current literature, our review identifies the capacity to develop universally accepted metrics of misuse applied to a core set of variables in prescription/dispensing claims. Our timely recommendations have the potential to unify the global research field and increase the capacity for routine surveillance of prescription drug misuse.

Who gets antidotes? choosing the chosen few

An understanding of mechanisms, potential benefits and risks of antidotes is essential for clinicians who manage poisoned patients. Of the dozens of antidotes currently available, only a few are regularly used. These include activated charcoal, acetylcysteine, naloxone, sodium bicarbonate, atropine, flumazenil, therapeutic antibodies and various vitamins. Even then, most are used in a minority of poisonings. There is little randomized trial evidence to support the use of most antidotes. Consequently, decisions about when to use them are often based on a mechanistic understanding of the poisoning and the expected influence of the antidote on the patient's clinical course. For some antidotes, such as atropine and insulin, the doses employed can be orders of magnitude higher than standard dosing. Importantly, most poisoned patients who reach hospital can recover with supportive care alone. In low risk patients, the routine use of even low risk antidotes such as activated charcoal is unwarranted. In more serious poisonings, decisions regarding antidote use are generally guided by a risk/benefit assessment based on low quality evidence.

Pharmacological management of anticholinergic delirium - theory, evidence and practice

The spectrum of anticholinergic delirium is a common complication following drug overdose. Patients with severe toxicity can have significant distress and behavioural problems that often require pharmacological management. Cholinesterase inhibitors, such as physostigmine, are effective but widespread use has been limited by concerns about safety, optimal dosing and variable supply. Case series support efficacy in reversal of anticholinergic delirium. However doses vary widely and higher doses commonly lead to cholinergic toxicity. Seizures are reported in up to 2.5% of patients and occasional cardiotoxic effects are also recorded. This article reviews the serendipitous path whereby physostigmine evolved into the preferred anticholinesterase antidote largely without any research to indicate the optimal dosing strategy. Adverse events observed in case series should be considered in the context of pharmacokinetic/pharmacodynamic studies of physostigmine which suggest a much longer latency before the maximal increase in brain acetylcholine than had been previously assumed. This would favour protocols that use lower doses and longer re-dosing intervals. We propose based on the evidence reviewed that the use of cholinesterase inhibitors should be considered in anticholinergic delirium that has not responded to non-pharmacological delirium management. The optimal risk/benefit would be with a titrated dose of 0.5 to 1 mg physostigmine (0.01-0.02 mg kg(-1) in children) with a minimum delay of 10-15 min before re-dosing. Slower onset and longer acting agents such as rivastigmine would also be logical but more research is needed to guide the appropriate dose in this setting.

A Randomized Controlled Trial of a Brief Intervention for Delayed Psychological Effects in Snakebite Victims

Background

Snakebite results in delayed psychological morbidity and negative psycho-social impact. However, psychological support is rarely provided to victims.

Aim

To assess the effectiveness of a brief intervention which can be provided by non-specialist doctors aimed at reducing psychological morbidity following snakebite envenoming.

Method

In a single blind, randomized controlled trial, snakebite victims with systemic envenoming [n = 225, 168 males, mean age 42.1 (SD 12.4) years] were randomized into three arms. One arm received no intervention (n = 68, Group A), the second received psychological first aid and psychoeducation (dispelling prevalent cultural beliefs related to snakebite which promote development of a sick role) at discharge from hospital (n = 65, Group B), while the third received psychological first aid and psychoeducation at discharge and a second intervention one month later based on cognitive behavioural principles (n = 69, Group C). All patients were assessed six months after hospital discharge for the presence of psychological symptoms and level of functioning using standardized tools.

Results

At six months, there was a decreasing trend in the proportion of patients who were positive for psychiatric symptoms of depression and anxiety from Group A through Group B to Group C (Chi square test for trend = 7.901, p = 0.005). This was mainly due to a decreasing trend for symptoms of anxiety (chi-square for trend = 11.256, p = 0.001). There was also decreasing trend in the overall prevalence of disability from Group A through Group B to Group C (chi square for trend = 7.551, p = 0.006), predominantly in relation to disability in family life (p = 0.006) and social life (p = 0.005). However, there was no difference in the proportion of patients diagnosed with depression between the three groups (chi square for trend = 0.391, p = 0.532), and the intervention also had no effect on post-traumatic stress disorder.

Conclusions

A brief psychological intervention, which included psychological first aid and psychoeducation plus cognitive behavioural therapy that can be provided by non-specialist doctors appeared to reduce psychiatric symptoms and disability after snakebite envenoming, but not depression or post-traumatic stress disorder.

Trial Registration

Sri Lanka Clinical Trials Registry: SLCTR/2011/003

Snakebite is an important health problem in many rural communities in tropical countries. However, little is known about the lasting physical and mental health effects following a bite. We recently reported that mental problems, with harmful social outcomes, can occur in many people after they are bitten by a snake. As the affected are often poor farmers or manual workers, this may affect their livelihoods. We, therefore, performed a trial which looked at the effectiveness of short psychological interventions, lasting about 15 and 20 minutes, which can be provided by even non-specialist doctors, in reducing these mental and social problems in people bitten by snakes. Our results show that such interventions may indeed be helpful to reduce some of these problems, but more research is needed to improve these interventions, especially so that they that can reduce post-traumatic stress disorder and depression after snakebite.

A prospective cohort study of trends in self-poisoning, Newcastle, Australia, 1987-2012: plus ça change, plus c'est la même chose

OBJECTIVE

To examine inhospital mortality and morbidity associated with self-poisoning with different drug classes over an extended period.

DESIGN, SETTING AND PARTICIPANTS

A prospective cohort study over 26 years (1987-2012) with limited follow-up of patients presenting consecutively to a primary and tertiary referral toxicology centre covering Newcastle, Lake Macquarie and Port Stephens, Australia.

MAIN OUTCOME MEASURES

Hospital length of stay, types of drugs ingested, intensive care unit (ICU) admission, requirement for ventilation, inhospital deaths and rates of antidepressant drug use in Australia.

RESULTS

Over the study period, there were 17 266 admissions of patients poisoned by 34 342 substances (16 723 drugs available only on prescription). The median length of stay was 16 hours, 12.2% of patients (2101/17 266) were admitted to an ICU, 7.4% (1281/17 266) were ventilated and 78 (0.45%) died in hospital. Patient demographics, social and psychiatric factors remained stable over the 26-year period, but case fatality decreased (from 0.77% [15/1955] to 0.17% [7/4060]) as did ICU admissions (19.2% [376/1955] to 6.9% [280/4060]), ventilation (13.7% [268/1955] to 4.8% [193/4060]) and LOS. The most frequently ingested substances were alcohol, benzodiazepines, paracetamol, antidepressants and antipsychotics. There was a substantial fall in some highly toxic drugs (tricyclic antidepressants, barbiturates, conventional antipsychotics and theophylline), but increases in less toxic selective serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors and paracetamol. A greater than sixfold increase in community antidepressant use was accompanied by only minor changes in overall and antidepressant self-poisoning rates.

CONCLUSION

Over two decades, there were decreases in poisonings by many highly toxic drugs which were associated with substantial reductions in morbidity and inhospital deaths. Despite massive increases in the number of antidepressant prescriptions, neither rates of self-harm nor the proportion of antidepressant poisonings increased markedly.

Policymaking 'under the radar': a case study of pesticide regulation to prevent intentional poisoning in Sri Lanka

BACKGROUND

Suicide in Sri Lanka is a major public health problem and in 1995 the country had one of the highest rates of suicide worldwide. Since then reductions in overall suicide rates have been largely attributed to efforts to regulate a range of pesticides. The evolution, context, events and implementation of the key policy decisions around regulation are examined.

METHODS

This study was undertaken as part of a broader analysis of policy in two parts-an explanatory case study and stakeholder analysis. This article describes the explanatory case study that included an historical narrative and in-depth interviews.

RESULTS

A timeline and chronology of policy actions and influence were derived from interview and document data. Fourteen key informants were interviewed and four distinct policy phases were identified. The early stages of pesticide regulation were dominated by political and economic considerations and strongly influenced by external factors. The second phase was marked by a period of local institution building, the engagement of local stakeholders, and expanded links between health and agriculture. During the third phase the problem of self-poisoning dominated the policy agenda and closer links between stakeholders, evidence and policymaking developed. The fourth and most recent phase was characterized by strong local capacity for policymaking, informed by evidence, developed in collaboration with a powerful network of stakeholders, including international researchers.

CONCLUSIONS

The policy response to extremely high rates of suicide from intentional poisoning with pesticides shows a unique and successful example of policymaking to prevent suicide. It also highlights policy action taking place 'under the radar', thus avoiding policy inertia often associated with reforms in lower and middle income countries.

Clenbuterol toxicity: a NSW poisons information centre experience

OBJECTIVE

To describe the epidemiology and toxicity of clenbuterol in exposures reported to the NSW Poisons Information Centre (NSWPIC).

DESIGN AND SETTING

Retrospective observational study analysing data from all calls about clenbuterol exposure recorded in the NSWPIC database from 1 January 2004 to 31 December 2012. The NSWPIC coversthe Australian jurisdictions New South Wales, Tasmania and the Australian Capital Territory 24 hours a day and provides after-hours cover for the rest of Australia for 7 nights each fortnight.

MAIN OUTCOME MEASURES

Total number of exposures, source of call (hospital, health care worker, member of the public), time from exposure to call, reasons for drug use, clinical features and advice given.

RESULTS

Callers reported 63 exposures to clenbuterol, with a dramatic increase from three in 2008 to 27 in 2012. Of the 63 calls, 35 were from hospital, two from paramedics, one from general practice and 21 direct from the public. At least 53 patients (84%) required hospitalisation. The commonest reasons for use were bodybuilding and slimming. The most common features were tachycardia (24 patients), gastrointestinal disturbance (16) and tremor (11). Exposure was also associated with cardiotoxicity including one cardiac arrest in a 21-year-old man.

CONCLUSION

Although a well recognised doping issue among elite athletes, clenbuterol use has spread out into the general public, especially during 2012, and should be considered in patients using bodybuilding or slimming products who present with protracted sympathomimetic features. The potential for misuse of this substance requires reconsideration of its current poison schedule registration and its availability.

The effectiveness of a 'train the trainer' model of resuscitation education for rural peripheral hospital doctors in Sri Lanka

BACKGROUND

Sri Lankan rural doctors based in isolated peripheral hospitals routinely resuscitate critically ill patients but have difficulty accessing training. We tested a train-the-trainer model that could be utilised in isolated rural hospitals.

METHODS

Eight selected rural hospital non-specialist doctors attended a 2-day instructor course. These "trained trainers" educated their colleagues in advanced cardiac life support at peripheral hospital workshops and we tested their students in resuscitation knowledge and skills pre and post training, and at 6- and 12-weeks. Knowledge was assessed through 30 multiple choice questions (MCQ), and resuscitation skills were assessed by performance in a video recorded simulated scenario of a cardiac arrest using a Resuci Anne Skill Trainer mannequin.

RESULTS/DISCUSSION/CONCLUSION

Fifty seven doctors were trained. Pre and post training assessment was possible in 51 participants, and 6-week and 12-week follow up was possible for 43, and 38 participants respectively. Mean MCQ scores significantly improved over time (p<0.001), and a significant improvement was noted in "average ventilation volume", "compression count", and "compressions with no error", "adequate depth", "average depth", and "compression rate" (p<0.01). The proportion of participants with compression depth ≥40mm increased post intervention (p<0.05) and at 12-week follow up (p<0.05), and proportion of ventilation volumes between 400-1000mls increased post intervention (p<0.001). A significant increase in the proportion of participants who "checked for responsiveness", "opened the airway", "performed a breathing check", who used the "correct compression ratio", and who used an "appropriate facemask technique" was also noted (p<0.001). A train-the-trainer model of resuscitation education was effective in improving resuscitation knowledge and skills in Sri Lankan rural peripheral hospital doctors. Improvement was sustained to 12 weeks for most components of resuscitation knowledge and skills. Further research is needed to identify which components of training are most effective in leading to sustained improvement in resuscitation.

Social dynamics in rural Sri Lankan hospitals: revelations from self-poisoning cases

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.

Effect of a brief outreach educational intervention on the translation of acute poisoning treatment guidelines to practice in rural Sri Lankan hospitals: a cluster randomized controlled trial

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