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Buckley NA, Jayawardane P, Weerasinghe V, Dawson AH, Dassanayake TL. Serial repetitive nerve stimulation studies in organophosphorus poisoning indicate two distinct pathophysiological processes occur at the neuromuscular junction in the intermediate syndrome. Clin Toxicol (Phila) 2024:1-10. [PMID: 38738692 DOI: 10.1080/15563650.2024.2343744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 04/11/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Intermediate syndrome is an important cause of respiratory failure following acute organophosphorus pesticide poisoning. The objective of this study was to examine the pathophysiology of this syndrome by analysis of sequential repetitive nerve stimulation studies in patients with acute organophosphorus pesticide poisoning. METHODS Thirty-four consenting symptomatic patients with acute organophosphorus pesticide poisoning with intermediate syndrome (n = 10) or a milder forme fruste intermediate syndrome (n = 24) were assessed prospectively with daily physical examination and repetitive nerve stimulation done on the right and left median and ulnar nerves. The compound muscle action potential at 1, 3, 10, 15, 20 and 30 Hertz was measured with a train of ten stimuli. The amplitudes of the resulting stimuli were normalized to the first stimulus (100 per cent) and plotted against time. The decrease in the area under the curve of all the second stimulus compound muscle action potentials in the first 0.3 seconds was measured as a means of quantifying the refractory block. The decrease in the area under the curve under the 10, 15, 20 and 30 Hertz compound muscle action potentials relative to this pooled second stimulus compound muscle action potentials-area under the curve indicated the extent of additional rate-dependent block (decreasing compound muscle action potential-area under the curve over the first 0.3 seconds after the first stimulus with increasing Hertz). RESULTS These new measurements strongly correlated with the severity of weakness. Refractory block was seen in most patients but was more severe in those with intermediate syndrome than those with forme fruste (partial) intermediate syndrome (median 55 per cent versus 16 per cent, P = 0.0001). Similar large differences were found for rate-dependent block (30 per cent versus 7 per cent, P = 0.001), which was uncommon in forme fruste intermediate syndrome but found in nine out of 10 patients with intermediate syndrome. Rate dependent block was generally only observed after 24 hours. The simplest strong predictor was total block at 30 Hertz repetitive nerve stimulation (89 per cent [interquartile range 73 to 94 per cent] versus 21 per cent [4 to 55 per cent]; P < 0.0001), which was very similar to total block calculated by summing other calculations. DISCUSSION These findings likely represent depolarization and desensitization block from prolonged excessive cholinergic stimulation but it is not clear if these are from pre- or post-synaptic pathology. An animal model of intermediate syndrome with repetitive nerve stimulation studies might enable a better pathophysiological understanding of the two types of block. LIMITATIONS The limited number of repetitive nerve stimulation studies performed were sufficient to demonstrate proof-of-concept, but further studies with more patients are needed to better define the correlates, clinical relevance and possible diagnostic/prognostic roles for the use of this technique. CONCLUSION There are two easily distinguishable pathophysiological abnormalities in the neuromuscular block in intermediate syndrome. While they often coincide, both may be observed in isolation. The total and rate-dependent block at 30 Hertz are strongly associated with more severe weakness.
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Affiliation(s)
- Nicholas A Buckley
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Translational Australian Clinical Toxicology (TACT) Research Group, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Pradeepa Jayawardane
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka
| | - Vajira Weerasinghe
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Translational Australian Clinical Toxicology (TACT) Research Group, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Andrew H Dawson
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Translational Australian Clinical Toxicology (TACT) Research Group, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Tharaka Lagath Dassanayake
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Physiology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Nash E, Dawson AH, Haber P, Gribble R, Volovets A. Substance use during hospitalisation requiring an urgent clinical response: an opportunity for intervention. Intern Med J 2024. [PMID: 38263859 DOI: 10.1111/imj.16336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/01/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND There are few reports on drug use in patients while hospitalised and none regarding management or clinical outcomes. AIMS To describe cases of drug use by inpatients requiring an urgent clinical response. METHODS We retrospectively reviewed cases at a teaching hospital in Sydney, Australia, from February 2019 to March 2021. RESULTS Thirty cases were identified, with no deaths. Two patient groups were identified: (i) substance use disorders, using illicit drugs and (ii) self-harm history, using prescribed or over-the-counter drugs. Management involved cardiac monitoring (40%), intensive care (30%), charcoal (20%), antidotes (20%) and intubation (13%). Discharge was planned in 22 of 30 patients, against medical advice in four and directed by medical staff in four. CONCLUSIONS Inpatient drug use requiring an urgent clinical response was infrequently recognised but presents a risk of harm to patients and staff and increases service utilisation and costs. Both harm reduction and systematic approaches guided by institutional policy are recommended. Using these events as reachable moments to address driving factors may modify patients' risk from future events.
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Affiliation(s)
- Emily Nash
- Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew H Dawson
- Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Haber
- Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Robert Gribble
- Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Psychiatry, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Anastasia Volovets
- Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Shahmy S, Kularatne SAM, Gawarammana IB, Rathnayake SS, Dawson AH. Compliance with national snakebite treatment guidelines in rural Sri Lankan hospitals: a cluster randomized controlled trial of a brief educational intervention. BMC Med Educ 2023; 23:390. [PMID: 37245040 DOI: 10.1186/s12909-023-04375-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 05/18/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND Snakebite is a global health problem that predominantly occurs in rural areas. In Sri Lanka, the majority of snakebite patients first present to smaller rural primary hospitals. Improving care delivered at rural hospitals has the potential to reduce morbidity and mortality from snakebites. OBJECTIVE In this study, we evaluated whether an educational intervention would increase compliance with national snakebite treatment guidelines in primary hospitals. METHODS The hospitals were randomized into educational intervention (n = 24) and control groups (n = 20). The intervention hospitals received a brief educational intervention based on Sri Lankan Medical Association (SLMA) guidelines on the management of snakebites. Control hospitals had free access to the guidelines but no additional promotion. Four outcomes were assessed: pre- and post-test knowledge at the completion of a one-day workshop of educational intervention (intervention group only); improvement in the quality of the patient's medical records; appropriateness of transfers to higher hospitals; and quality of overall management graded by a blinded expert. The data was collected over a period of 12 months. RESULTS All case notes of snakebite hospital admissions were reviewed. There were 1021 cases in the intervention group hospitals and 1165 cases in the control hospitals. Four hospitals in the intervention group and three hospitals in the control group did not have snakebite admissions and were excluded from the cluster analysis. The absolute quality of care was high in both groups. Post-test knowledge was improved (p < 0.0001) following the intervention group's educational workshop. There was no statistical difference between the two groups in terms of clinical data documentation in hospital notes (scores, p = 0.58) or transfer appropriateness (p = 0.68)-both of which were significantly different from the guidelines. CONCLUSION Education of primary hospital staff improved the immediate knowledge gained but did not improve record-keeping or the appropriateness of inter-hospital patient transfer. TRIAL REGISTRATION The study was registered with Sri Lanka Medical Associations' clinical trial registry. Reg. No SLCTR -2013-023. Registered: 30/07/2013.
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Affiliation(s)
- Seyed Shahmy
- National Science and Technology Commission of Sri Lanka, Colombo, Sri Lanka.
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
| | | | - Indika B Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Shantha S Rathnayake
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew H Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Central Clinical School, University of Sydney, Sydney, Australia
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Chan BSH, Sheppeard V, Dawson AH. E‐cigarette or vaping product use‐associated lung injury in an adolescent. Med J Aust 2022; 216:374. [DOI: 10.5694/mja2.51473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 01/20/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Betty SH Chan
- Prince of Wales Hospital and Community Health Services Sydney NSW
| | | | - Andrew H Dawson
- Royal Prince Alfred Hospital Sydney NSW
- New South Wales Poisons Information Centre Children’s Hospital at Westmead Sydney NSW
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Perananthan V, Wijerathna T, Mohamed F, Gawarammana IB, Dawson AH, Buckley NA. Circulating intestinal fatty acid binding protein and intestinal toxicity in Russell's viper envenomation. Clin Toxicol (Phila) 2022; 60:311-318. [PMID: 34378471 DOI: 10.1080/15563650.2021.1965160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/24/2021] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Abdominal pain is known to be an early clinical predictor of severe systemic Russell's viper (RV) envenomation and is often associated with the later development of coagulopathy and neurotoxicity. The mechanism of abdominal pain is unknown, but we postulated it might be due to intestinal microvascular endothelial gut damage. Gut-toxicity can be detected using the novel biomarker Intestinal Fatty Acid Binding Protein (IFABP). We also wanted to explore the mechanisms and consequences of this toxicity by measuring procalcitonin as a specific marker of sepsis triggered by bacterial endotoxin, and serum cystatin-C (CysC) as a measure of acute kidney injury. We hypothesised that severe gut-injury might lead to gut-barrier failure, translocation of gastrointestinal microorganisms, associated sepsis and systemic inflammatory response syndrome (SIRS), with a possible exacerbation of snake-bite severity, including acute kidney injury that was previously attributed to direct venom effects. METHODS Serial plasma samples previously collected from 16 RV envenomations with abdominal pain, 15 RV envenomations without abdominal pain and 25 healthy controls were assayed for IFABP. A subgroup of these RV envenomations were assayed for procalcitonin (n = 24) and serum CysC (n = 11). RESULTS The median peak IFABP for RV envenomations was much higher than healthy controls [3703.0 pg/mL (IQR 2250.1-13702.0 pg/mL) vs. 270.1 pg/mL (IQR 153.5-558.0 pg/mL) (p < 0.001)]. There was no difference in those with and without abdominal pain [3801.4 pg/mL (IQR 2080.5-22446.3 pg/mL) vs. 3696.6 pg/mL (IQR 2280.3-4664.7 pg/mL) (p = 1.0)]. Peak procalcitonin levels were elevated in envenomed patients 30.1 ng/ml (IQR: 13.1-59.7 ng/ml) with a level >2ng/mL indicative of severe sepsis] and also correlated with peak IFABP (r = 0.55, p = 0.006, n = 24). Peak serum CysC was also elevated and also correlated with IFABP (r = 0.71, p = 0.037, n = 9). CONCLUSION IFABP is significantly elevated indicating enterocyte damage occurs in RV envenomation. IFABP correlated with markers of sepsis (procalcitonin) and acute kidney injury (serum CysC) suggesting that enterocyte damage resulting in translocation of microbial associated molecular patterns (MAMPs) contributes to RV envenomation associated SIRS and sepsis.
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Affiliation(s)
- Varan Perananthan
- Edith Collins Research Institute, Royal Prince Alfred Hospital, Sydney, Australia
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Disciplines of Pharmacology/Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Thilini Wijerathna
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Disciplines of Pharmacology/Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
- Department of Pharmacy, Faculty of Allied Health Sciences, University of Peradeniya
- Australian Kidney Biomarker Reference Laboratory, Department of Nephrology, Prince of Wales Hospital and Clinical School, University of New South Wales, Sydney, Australia
| | - Indika B Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew H Dawson
- Edith Collins Research Institute, Royal Prince Alfred Hospital, Sydney, Australia
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Disciplines of Pharmacology/Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Nicholas A Buckley
- Edith Collins Research Institute, Royal Prince Alfred Hospital, Sydney, Australia
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Disciplines of Pharmacology/Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
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Evans NT, Williams N, Perananthan V, Lugg W, Dawson AH, Osborn DA. Neonatal serotonin toxicity. J Paediatr Child Health 2022; 58:189-190. [PMID: 33724598 DOI: 10.1111/jpc.15443] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/08/2021] [Accepted: 02/25/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Nadia T Evans
- RPA Newborn Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Nicholas Williams
- RPA Newborn Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Varan Perananthan
- Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - William Lugg
- Perinatal Psychiatry Service, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Andrew H Dawson
- Drug Health Services, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David A Osborn
- RPA Newborn Care, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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7
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Chan BS, Kiss A, McIntosh N, Sheppeard V, Dawson AH. E-cigarette or vaping product use-associated lung injury in an adolescent. Med J Aust 2021; 215:313-314.e1. [PMID: 34490629 DOI: 10.5694/mja2.51244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 05/24/2021] [Accepted: 05/27/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Betty S Chan
- Prince of Wales Hospital and Community Health Services, Sydney, NSW
| | - Alexander Kiss
- Public Health Unit, South Eastern Sydney Local Health District, Sydney, NSW
| | - Nathan McIntosh
- Centre for Population Health, Western Sydney Local Health District, Sydney, NSW
| | - Vicky Sheppeard
- Public Health Unit, South Eastern Sydney Local Health District, Sydney, NSW
| | - Andrew H Dawson
- Drug Health Services, Royal Prince Alfred Hospital, Sydney, NSW.,New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Sydney, NSW
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8
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Buckley NA, Fahim M, Raubenheimer J, Gawarammana IB, Eddleston M, Roberts MS, Dawson AH. Case fatality of agricultural pesticides after self-poisoning in Sri Lanka: a prospective cohort study. Lancet Glob Health 2021; 9:e854-e862. [PMID: 33901424 PMCID: PMC8131203 DOI: 10.1016/s2214-109x(21)00086-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 02/01/2021] [Accepted: 02/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pesticide poisoning is among the most common means of suicide globally, but can be prevented with regulation of the most hazardous agents. We aimed to compare the lethality of pesticides ingested by our cohort, seek evidence on variation between human and regulatory animal toxicity, and establish change over time in the case fatality of individual pesticides in Sri Lanka. METHODS We examined the case fatality of agricultural pesticides in a prospective cohort in nine hospitals serving rural populations in Sri Lanka. We included all patients (>11 years) who had presented to a South Asian Clinical Toxicology Research Collaboration study hospital during the study period. Patients were enrolled by clinical research assistants and were regularly reviewed. Identification of the ingested pesticide was generally on the basis of history or positive identification of the container, supported by nested blood analysis. FINDINGS From March 31, 2002, to Dec 31, 2019, 34 902 patients (median age 29 years [IQR 21-40]; 23 060 [66·1%] male) presented with a possible or known pesticide self-poisoning. We identified 23 139 specific pesticides that were ingested. Poisoning was fatal in 2299 (6·6%) patients. Case fatality varied greatly from 0·0% (several substances) to 41·8% (paraquat). The three most toxic agents (ie, paraquat, dimethoate, and fenthion) were banned between 2008 and 2011. Since 2013, the five agents causing the most deaths (ie, profenofos, propanil, fenobucarb, carbosulfan, and quinalphos) had a case fatality of 7·2-8·6%. A steady decline was seen in overall case fatality of pesticide poisoning (10·5% for 2002-06 to 3·7% for 2013-19), largely attributable to pesticide bans. A modest fall in case fatality for non-banned pesticides was also seen. INTERPRETATION Declines seen in case fatalities of poisonings with non-banned pesticides suggest that medical management improved over time. The human data for acute toxicity of pesticides should drive hazard classifications and regulation. We believe that a global benchmark for registration of pesticides should include a less than 5% case fatality after self-poisoning, which could prevent many deaths and have a substantial effect on global suicide rates. FUNDING The Wellcome Trust and the National Health and Medical Research Council of Australia. TRANSLATIONS For the Sinhala and Tamil translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Nicholas A Buckley
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka; Pharmacology, Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Mohamed Fahim
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka; Faculty of Allied Health Sciences, Department of Pharmacy, University of Peradeniya, Kandy, Sri Lanka; Pharmacology, Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Jacques Raubenheimer
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka; Pharmacology, Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Indika B Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka
| | - Michael Eddleston
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka; Centre for Pesticide Suicide Prevention, and Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Michael S Roberts
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka; Basil Hetzel Institute for Translational Health Research, UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia; Diamantina Institute, University of Queensland, Brisbane, QLD, Australia
| | - Andrew H Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Kandy, Sri Lanka; Pharmacology, Biomedical Informatics and Digital Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Perananthan V, Tremonti C, Nash E, Jiranantakan T, Dawson AH. Rapid detection, toxicosurveillance and public health response to stimulant adulteration with acetyl fentanyl. Med J Aust 2021; 214:533-533.e1. [PMID: 34050540 DOI: 10.5694/mja2.51112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Varan Perananthan
- Royal Prince Alfred Hospital, Sydney, NSW.,University of Sydney, Sydney, NSW
| | - Chris Tremonti
- Royal Prince Alfred Hospital, Sydney, NSW.,Centre for Alcohol and Other Drugs, New South Wales Ministry of Health, Sydney, NSW
| | - Emily Nash
- Royal Prince Alfred Hospital, Sydney, NSW.,University of Sydney, Sydney, NSW
| | - Thanjira Jiranantakan
- Centre for Alcohol and Other Drugs, New South Wales Ministry of Health, Sydney, NSW.,NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
| | - Andrew H Dawson
- Royal Prince Alfred Hospital, Sydney, NSW.,NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
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Noghrehchi F, Dawson AH, Raubenheimer JE, Buckley NA. Role of age-sex as underlying risk factors for death in acute pesticide self-poisoning: a prospective cohort study. Clin Toxicol (Phila) 2021; 60:184-190. [PMID: 34032543 DOI: 10.1080/15563650.2021.1921186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND There is growing evidence in the literature that patients' age is associated with increased risk of death in acute pesticide poisoning. However, few studies have investigated whether the age effect differs between males and females. We aimed to examine the association between age-sex and risk of death in acute pesticide self-poisoning. METHODS A prospective cohort of deliberate pesticide-poisoned patients admitted to ten rural Sri Lankan hospitals between March 2002 and December 2019. The pesticide ingested was identified based on identification of container or history. A mixed effects logistic regression was fitted to investigate the effect of age-sex on death in acute pesticide self-poisoning adjusting for clinical symptoms on admission, measured by Glasgow Coma Scale and Poison Severity Score, and controlling for clustering among hospital sites. RESULTS In total, 201 different pesticides were ingested by patients. 6,643 patients ingested an unknown pesticide. A single pesticide was co-ingested with alcohol by 4,603 patients. Of the 28,303 patients enrolled, 2,028 patients died, resulting in case fatality of 7.2% (95% CI 6.9-7.5). The effect of age on case fatality was stronger for males after 21 years of age. The odds of dying for each 5 years increase in age was 1.26 (95% CI 1.23-1.28) times higher for males versus 1.14 (95% CI 1.10-1.19) times higher for females. Missing data were handled by multiple imputation. CONCLUSION Patient's age-sex are important risk factors for death in acute pesticide self-poisoning even after controlling for clinical effects. The age effect on the odds of dying was significantly different for males and females, with this effect being stronger for males. Given that patient's age and sex are very easy to collect on admission, our study highlights the need for incorporating these risk factors in policy and clinical decisions.
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Affiliation(s)
- Firouzeh Noghrehchi
- Translational Australian Clinical Toxicology (TACT) Research Group, Discipline of Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Andrew H Dawson
- Translational Australian Clinical Toxicology (TACT) Research Group, Discipline of Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia.,Central Clinical School, University of Sydney, Sydney, Australia
| | - Jacques E Raubenheimer
- Translational Australian Clinical Toxicology (TACT) Research Group, Discipline of Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Nicholas A Buckley
- Translational Australian Clinical Toxicology (TACT) Research Group, Discipline of Biomedical Informatics & Digital Health, Sydney Medical School, University of Sydney, Sydney, Australia
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Bethmont A, Harper CE, Chan BSH, Dawson AH, McAnulty J. Increasing illicit use of nitrous oxide in presentations to
NSW
emergency departments. Med J Aust 2019; 211:429-429.e1. [DOI: 10.5694/mja2.50377] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Betty SH Chan
- Prince of Wales Hospital and Community Health Services Sydney NSW
| | - Andrew H Dawson
- Royal Prince Alfred Hospital Sydney NSW
- NSW Poisons Information Service Sydney NSW
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Cairns R, Brown JA, Wylie CE, Dawson AH, Isbister GK, Buckley NA. Paracetamol poisoning‐related hospital admissions and deaths in Australia, 2004–2017. Med J Aust 2019; 211:218-223. [DOI: 10.5694/mja2.50296] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 05/29/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Rose Cairns
- NSW Poisons Information CentreChildren's Hospital at Westmead Sydney NSW
- University of Sydney Sydney NSW
| | - Jared A Brown
- NSW Poisons Information CentreChildren's Hospital at Westmead Sydney NSW
- Centre for Big Data Research in HealthUniversity of New South Wales Sydney NSW
| | | | - Andrew H Dawson
- NSW Poisons Information CentreChildren's Hospital at Westmead Sydney NSW
- Royal Prince Alfred Hospital Sydney NSW
| | | | - Nicholas A Buckley
- NSW Poisons Information CentreChildren's Hospital at Westmead Sydney NSW
- University of Sydney Sydney NSW
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13
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Cairns R, Karanges EA, Wong A, Brown JA, Robinson J, Pearson SA, Dawson AH, Buckley NA. Trends in self-poisoning and psychotropic drug use in people aged 5-19 years: a population-based retrospective cohort study in Australia. BMJ Open 2019; 9:e026001. [PMID: 30787095 PMCID: PMC6398641 DOI: 10.1136/bmjopen-2018-026001] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To characterise trends in self-poisoning and psychotropic medicine use in young Australians. DESIGN Population-based retrospective cohort study. SETTING Calls taken by the New South Wales and Victorian Poisons Information Centres (2006-2016, accounting for 70% of Australian poisoning calls); medicine dispensings in the 10% sample of Australian Pharmaceutical Benefits Scheme data (July 2012 to June 2016). PARTICIPANTS People aged 5-19 years. MAIN OUTCOME MEASURES Yearly trends in intentional poisoning exposure calls, substances taken in intentional poisonings, a prevalence of psychotropic use (dispensing of antidepressants, antipsychotics, benzodiazepines and medicines for attention deficit hyperactivity disorder (ADHD)). RESULTS There were 33 501 intentional poisonings in people aged 5-19 years, with an increase of 8.39% per year (95% CI 6.08% to 10.74%, p<0.0001), with a 98% increase overall, 2006-2016. This effect was driven by increased poisonings in those born after 1997, suggesting a birth cohort effect. Females outnumbered males 3:1. Substances most commonly taken in self-poisonings were paracetamol, ibuprofen, fluoxetine, ethanol, quetiapine, paracetamol/opioid combinations, sertraline and escitalopram. Psychotropic dispensing also increased, with selective serotonin reuptake inhibitors (SSRIs) increasing 40% and 35% July 2012 to June 2016 in those aged 5-14 and 15-19, respectively. Fluoxetine was the most dispensed SSRI. Antipsychotics increased by 13% and 10%, while ADHD medication dispensing increased by 16% and 10%, in those aged 5-14 and 15-19, respectively. Conversely, dispensing of benzodiazepines to these age groups decreased by 4% and 5%, respectively. CONCLUSIONS Our results signal a generation that is increasingly engaging in self-harm and is increasingly prescribed psychotropic medications. These findings indicate growing mental distress in this cohort. Since people who self-harm are at increased risk of suicide later in life, these results may foretell future increases in suicide rates in Australia.
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Affiliation(s)
- Rose Cairns
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Sydney Pharmacy School, The University of Sydney, Sydney, New South Wales, Australia
| | - Emily A Karanges
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Health, Heidelberg, Victoria, Australia
| | - Jared A Brown
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
| | - Jeff Robinson
- Victorian Poisons Information Centre, Austin Health, Heidelberg, Victoria, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew H Dawson
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
- Pharmacology, University of Sydney, Sydney, New South Wales, Australia
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Cairns R, Brown JA, Lachireddy K, Wylie C, Robinson J, Dawson AH, Buckley NA. Button battery exposures in Australian children: a prospective observational study highlighting the role of poisons information centres. Clin Toxicol (Phila) 2019; 57:404-410. [DOI: 10.1080/15563650.2018.1537492] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Rose Cairns
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
- Sydney Pharmacy School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jared A. Brown
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
| | | | - Carol Wylie
- Queensland Poisons Information Centre, Lady Cilento Children’s Hospital, Brisbane, Australia
| | - Jeff Robinson
- Victorian Poisons Information Centre, Austin Health, Melbourne, Australia
| | - Andrew H. Dawson
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
- Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Nicholas A. Buckley
- NSW Poisons Information Centre, The Children’s Hospital at Westmead, Sydney, Australia
- Pharmacology, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Tangiisuran B, Jiva M, Ariff AM, Abdul Rani NA, Misnan A, Rashid SM, Majid MIA, Dawson AH. Evaluation of types of poisoning exposure calls managed by the Malaysia National Poison Centre (2006-2015): A retrospective review. BMJ Open 2018; 8:e024162. [PMID: 30598487 PMCID: PMC6318535 DOI: 10.1136/bmjopen-2018-024162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Accidental or intentional poisoning is a public health concern requiring intervention. The current study designs to evaluate the types of poisoning exposure calls received by the Malaysia National Poison Centre (NPC) over a 10-year period. SETTINGS AND DATA SOURCES The poisoning enquiries database (2006-2015) from the Malaysia NPC was used for the analysis. PARTICIPANTS The NPC records all telephone calls that it manages using a validated and standardised form. Demographics and types of the poisoning exposure calls were extracted and descriptive analysis was applied. PRIMARY AND SECONDARY OUTCOMES The primary outcome of this study is to evaluate NPC data for trends in the poisoning exposure calls based on the types and modes of poisoning over a 10-year period. The secondary outcome is to evaluate the characteristics of human exposure cases based on the calls received by the NPC. RESULTS There was a notable increase in the number of poisoning exposure calls noticed during the 10-year period but dropped significantly in 2012. The highest number of poisoning exposure calls came from Selangor (21.0%), Perak (18.0%) and Negeri Sembilan (9.8%). More than half of the exposure was intentional (53.8%) involving more women (50.3%) as compared with men (41.9%), and in the 20-29 years age group category (33.5%). Exposure mostly occurred at home (96%) through the ingestion route (94.1%). Pharmaceutical products (40.5%), pesticides (31.7%) and household products (20.1%) were the common agents implicated for intentional exposure. CONCLUSIONS There is an increasing trend in enquiries on poisoning exposure calls made to the NPC. Most of the intentional poisoning exposures occurred among younger women and involved pharmaceuticals, pesticides or household products. Poisoning safety education and other interventions are needed to curb poisoning incidents.
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Affiliation(s)
- Balamurugan Tangiisuran
- National Poison Centre, Universiti Sains Malaysia, 11800 USM, Penang, Malaysia
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 USM, Penang, Malaysia
| | - Maryam Jiva
- Institute of Pharmaceutical Sciences, Kings College London, London, UK
| | | | | | - Asdariah Misnan
- National Poison Centre, Universiti Sains Malaysia, 11800 USM, Penang, Malaysia
| | - Sazaroni Md Rashid
- National Poison Centre, Universiti Sains Malaysia, 11800 USM, Penang, Malaysia
| | | | - Andrew H Dawson
- Royal Prince Alfred Hospital and Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Cairns R, Brown JA, Dawson AH, Davis W, Buckley NA. Carols by glow sticks: a retrospective analysis of Poisons Information Centre data. Med J Aust 2018; 209:505-508. [DOI: 10.5694/mja18.01032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/09/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Rose Cairns
- NSW Poisons Information Centre, The Childrenˈs Hospital at Westmead, Sydney, NSW
- University of Sydney, Sydney, NSW
| | - Jared A Brown
- NSW Poisons Information Centre, The Childrenˈs Hospital at Westmead, Sydney, NSW
| | - Andrew H Dawson
- NSW Poisons Information Centre, The Childrenˈs Hospital at Westmead, Sydney, NSW
- National Poisons Register, Royal Prince Alfred Hospital, Sydney, NSW
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De Silva ANLM, Dawson AH, Gawarammana IB, Tennakoon S, Rajapakse T. Study protocol: a pilot randomized controlled trial to evaluate the acceptability and feasibility of a counseling intervention, delivered by nurses, for those who have attempted self-poisoning in Sri Lanka. Pilot Feasibility Stud 2018; 4:150. [PMID: 30258649 PMCID: PMC6151905 DOI: 10.1186/s40814-018-0341-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 09/12/2018] [Indexed: 12/12/2022] Open
Abstract
Background Deliberate self-harm in the form of non-fatal self-poisoning is a major public health problem in Sri Lanka. Previous work suggests that many nurses in Sri Lanka—particularly those who work in primary care in the medical treatment of persons who attempt self-poisoning—already approach their role in a holistic fashion and consider “advising” or “counseling” patients after self-poisoning to be a part of their nursing role. But there is no formal training given to such nurses at present nor has the efficacy or feasibility of such an intervention been assessed in Sri Lanka. The aims of this pilot study are to explore the potential efficacy, acceptability, and feasibility of carrying out a counseling intervention that could be delivered by nurses for persons who present to hospital for medical management of non-fatal self-poisoning. Methods/design The study will be carried out at the Toxicology Unit of Teaching Hospital Peradeniya, Sri Lanka. A pilot randomized controlled trial will be carried out among participants admitted to Teaching Hospital Peradeniya for medical management of non-fatal self-poisoning. The primary objective of this study is to explore the acceptability and feasibility of a counseling intervention being delivered by nurses. The secondary objectives are to explore the efficacy of the intervention for the improvement of skills to cope with situations of acute emotional distress, and to reduce rates of anxiety, depression, and future repetition and suicidal ideation. A nurse’s experiences and attitudes regarding the acceptability and feasibility of implementing this intervention and participant experiences of the intervention and its effects will be explored via qualitative interviews and focus group discussions. Discussion It is anticipated that the findings of this pilot study will help determine and assess the acceptability and feasibility of this counseling intervention, as well as indicate the more useful aspects of this intervention in order to develop it for further exploration in a larger trial. Trial registration SLCTR/2017/008 Registered on 21st March 2017
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Affiliation(s)
- A N L M De Silva
- 1South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew H Dawson
- 2Central Clinical School, University of Sydney, Sydney, Australia
| | - Indika B Gawarammana
- 3Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Sampath Tennakoon
- 4Department of Community Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Thilini Rajapakse
- 5Department of Psychiatry, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
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Huynh A, Cairns R, Brown JA, Lynch AM, Robinson J, Wylie C, Buckley NA, Dawson AH. Patterns of poisoning exposure at different ages: the 2015 annual report of the Australian Poisons Information Centres. Med J Aust 2018; 209:74-79. [PMID: 29976129 DOI: 10.5694/mja17.01063] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/29/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To characterise the types of calls received by Australian Poisons Information Centres (PICs) in Australia, and to analyse poisoning exposures by age group, circumstances of exposure, and the types of substances involved. Design, setting: Retrospective analysis of call records from all four Australian PICs (national coverage). MAIN OUTCOME MEASURES Basic demographic information; exposure circumstances, substance types involved in each age group; recommendations for management (eg, stay at home, go to hospital). RESULTS There were 204 906 calls to Australian PICs in 2015, 69.0% from the general public, 27.9% from health professionals; 16.2% of calls originated from hospitals. 170 469 calls (including re-calls about an exposure) related to 164 363 poison exposure events; 64.4% were unintentional, 18.1% were the consequences of medication error, and 10.7% involved deliberate self-poisoning. Most exposures were of 20-74-year-old adults (40.1%) or 1-4-year-old toddlers (36.0%). The PICs advised callers to stay at home for 67.4% of exposures, and to present to hospital for 10.9%. The most common substances involved in exposures overall were household cleaners (10.2%) and paracetamol-containing analgesics (7.3%). Exposures of infants and toddlers were most frequently to household cleaning substances (17.8%, 15.3% respectively) and personal care items (6.6%, 7.3%); callers were usually advised to stay at home (88.5%, 86.4%). Deliberate self-poisoning (49.1%) and hospital referral (23.9%) were most frequent for adolescents. Exposures of adults (20-74 years) frequently involved psychotropic pharmaceuticals (17.8%) or painkillers (15.1%). Exposures in adults over 74 were typically medication errors involving cardiovascular (23.6%), anticoagulant (4.6%), or antidiabetic (4.1%) medications. CONCLUSIONS Poisoning is a significant public health problem throughout life, but the nature of the hazards differs markedly between age groups. PIC data could inform strategic public health interventions that target age-specific poisoning hazards.
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Affiliation(s)
- Alanna Huynh
- NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
| | - Rose Cairns
- NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
| | - Jared A Brown
- NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
| | - Ann-Maree Lynch
- Western Australian Poisons Information Centre, Sir Charles Gairdner Hospital, Perth, WA
| | - Jeff Robinson
- Victorian Poisons Information Centre, Austin Health, Melbourne, VIC
| | - Carol Wylie
- Queensland Poisons Information Centre, Lady Cilento Children's Hospital, Brisbane, QLD
| | - Nicholas A Buckley
- NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
| | - Andrew H Dawson
- NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW
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Brvar M, Chan MY, Dawson AH, Ribchester RR, Eddleston M. Magnesium sulfate and calcium channel blocking drugs as antidotes for acute organophosphorus insecticide poisoning – a systematic review and meta-analysis. Clin Toxicol (Phila) 2018; 56:725-736. [DOI: 10.1080/15563650.2018.1446532] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Miran Brvar
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Centre for Clinical Toxicology and Pharmacology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Ming Yin Chan
- Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, Hong Kong, ROC
| | - Andrew H. Dawson
- Sydney Medical School, University of Sydney, Sydney, Australia
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Kandy, Sri Lanka
| | | | - Michael Eddleston
- Pharmacology, Toxicology, and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Kandy, Sri Lanka
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20
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Kularatne SAM, Shahmy S, Rathnayake SS, Dawson AH. Clinico-epidemiology of arthropod stings and bites in primary hospitals of North Western province of Sri Lanka. Clin Toxicol (Phila) 2018; 56:880-885. [PMID: 29508631 DOI: 10.1080/15563650.2018.1447120] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Arthropod stinging and bites are common environmental hazards in Sri Lanka. However, their medical importance has not been fully evaluated yet. This study aims to study the burden, epidemiology, and outcome of stings and bites in primary hospitals in the Kurunegala district in North Western Province (NWP) of Sri Lanka. METHODOLOGY The study was conducted one year from 25th May 2013 to 25th May 2014. Details of all stings and bites admissions and their outcomes were retrospectively extracted from hospital records in all 44 primary hospitals in the district. RESULTS There were 623 stings and bites with population incidence of 38/100,000 (95% CI 27-52). There were no deaths. Median age was 38 years (IQR: 19-53 years), and 351 (56%) were males. Most of stings and bites (75%) occurred in the daytime. Median time to hospital arrival was 55 minutes (IQR: 30 min to 2 h). The offending arthropods had been identified in 557 (89%) cases, of them, 357 (57%) were Hymenoptera (hornet and bees), 99 centipedes, 61 spiders and 40 scorpions. Local pain occurred in 346 (56%) cases - centipede 69 (70%), Scorpion 24 (60%), spider 36 (59%), Hymenoptera 187 (52%) and unidentified 30 (45%). Hymenoptera stings and spider bites occurred between 06 am to 12 noon, and scorpion stings and centipede bites mostly occurred between 06 pm to 12 midnight. Mild, moderate to severe anaphylaxis reactions occurred in 173 (28%) patients including 110 Hymenoptera stings - mild 39, moderate 62 and severe 9. From primary hospitals, 53(9%) cases had been transferred to tertiary care units for further management. Of them, 41 cases were Hymenoptera stings and 24 (58%) of them had mild, moderate to severe anaphylaxis. In the entire group, 27% severe cases received adrenaline. CONCLUSIONS The primary hospitals in NW province of Sri Lanka manage large numbers of arthropod stings and bites. These include Hymenoptera (hornet and bee), centipedes, spiders, and scorpions. Pain, swellings and anaphylactic reactions were the most common adverse effects.
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Affiliation(s)
| | - Seyed Shahmy
- b South Asian Clinical Toxicology Research Collaboration , University of Peradeniya , Peradeniya , Sri Lanka
| | - Shantha S Rathnayake
- b South Asian Clinical Toxicology Research Collaboration , University of Peradeniya , Peradeniya , Sri Lanka
| | - Andrew H Dawson
- b South Asian Clinical Toxicology Research Collaboration , University of Peradeniya , Peradeniya , Sri Lanka.,c Central Clinical School , University of Sydney , Sydney , Australia
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Gawarammana I, Buckley NA, Mohamed F, Naser K, Jeganathan K, Ariyananada PL, Wunnapuk K, Dobbins TA, Tomenson JA, Wilks MF, Eddleston M, Dawson AH. High-dose immunosuppression to prevent death after paraquat self-poisoning – a randomised controlled trial. Clin Toxicol (Phila) 2017; 56:633-639. [DOI: 10.1080/15563650.2017.1394465] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Indika Gawarammana
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Nicholas A. Buckley
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, University of Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, University of Sydney, Sydney, Australia
| | | | - K. Jeganathan
- Anuradhapura Hospitals, Anuradhapura, Sri Lanka
- Rathnapura Hospitals, Rathnapura, Sri Lanka
| | | | - Klintean Wunnapuk
- Therapeutics Research Centre, School of Medicine, University of Queensland, Brisbane, Australia
- Department of Forensic Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Timothy A. Dobbins
- Department of Pharmacology, University of Sydney, Sydney, Australia
- National Drug and Alcohol Research Centre, Sydney, Australia
| | | | - Martin F. Wilks
- Swiss Centre for Applied Human Toxicology, University of Basel, Basel, Switzerland
| | - Michael Eddleston
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh and National Poisons Information Service – Edinburgh Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Andrew H. Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Pharmacology, University of Sydney, Sydney, Australia
- Royal Prince Alfred Hospital, Sydney, Australia
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Chan BS, Dawson AH, Buckley NA. Response to the letter regarding “Is it really safe to withhold folinic acid when less than 1000 mg/m 2 methotrexate is ingested?”. Clin Toxicol (Phila) 2017; 55:1020. [DOI: 10.1080/15563650.2017.1315822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Betty S. Chan
- Clinical Toxicology Unit & Emergency Department, Prince of Wales Hospital, Sydney, New South Wales, Australia
- New South Wales Poisons Information Centre, Sydney, Australia
| | - Andrew H. Dawson
- New South Wales Poisons Information Centre, Sydney, Australia
- Drug Health, Royal Prince Alfred Hospital, Sydney, Australia
| | - Nicholas A. Buckley
- New South Wales Poisons Information Centre, Sydney, Australia
- Clinical Pharmacology, University of Sydney, Sydney, Australia
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Pearson M, Metcalfe C, Jayamanne S, Gunnell D, Weerasinghe M, Pieris R, Priyadarshana C, Knipe DW, Hawton K, Dawson AH, Bandara P, deSilva D, Gawarammana I, Eddleston M, Konradsen F. Effectiveness of household lockable pesticide storage to reduce pesticide self-poisoning in rural Asia: a community-based, cluster-randomised controlled trial. Lancet 2017; 390:1863-1872. [PMID: 28807536 PMCID: PMC5655546 DOI: 10.1016/s0140-6736(17)31961-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 06/27/2017] [Accepted: 07/05/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Agricultural pesticide self-poisoning is a major public health problem in rural Asia. The use of safer household pesticide storage has been promoted to prevent deaths, but there is no evidence of effectiveness. We aimed to test the effectiveness of lockable household containers for prevention of pesticide self-poisoning. METHODS We did a community-based, cluster-randomised controlled trial in a rural area of North Central Province, Sri Lanka. Clusters of households were randomly assigned (1:1), with a sequence computer-generated by a minimisation process, to intervention or usual practice (control) groups. Intervention households that had farmed or had used or stored pesticide in the preceding agricultural season were given a lockable storage container. Further promotion of use of the containers was restricted to community posters and 6-monthly reminders during routine community meetings. The primary outcome was incidence of pesticide self-poisoning in people aged 14 years or older during 3 years of follow-up. Identification of outcome events was done by staff who were unaware of group allocation. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT1146496. FINDINGS Between Dec 31, 2010, and Feb 2, 2013, we randomly assigned 90 rural villages to the intervention group and 90 to the control group. 27 091 households (114 168 individuals) in the intervention group and 26 291 households (109 693 individuals) in the control group consented to participate. 20 457 household pesticide storage containers were distributed. In individuals aged 14 years or older, 611 cases of pesticide self-poisoning had occurred by 3 years in the intervention group compared with 641 cases in the control group; incidence of pesticide self-poisoning did not differ between groups (293·3 per 100 000 person-years of follow-up in the intervention group vs 318·0 per 100 000 in the control group; rate ratio [RR] 0·93, 95% CI 0·80-1·08; p=0·33). We found no evidence of switching from pesticide self-poisoning to other forms of self-harm, with no significant difference in the number of fatal (82 in the intervention group vs 67 in the control group; RR 1·22, 0·88-1·68]) or non-fatal (1135 vs 1153; RR 0·97, 0·86-1·08) self-harm events involving all methods. INTERPRETATION We found no evidence that means reduction through improved household pesticide storage reduces pesticide self-poisoning. Other approaches, particularly removal of highly hazardous pesticides from agricultural practice, are likely to be more effective for suicide prevention in rural Asia. FUNDING Wellcome Trust, with additional support from the American Foundation for Suicide Prevention, Lister Institute of Preventive Medicine, Chief Scientist Office of Scotland, University of Copenhagen, and NHMRC Australia.
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Affiliation(s)
- Melissa Pearson
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, and Centre for Pesticide Suicide Prevention, University of Edinburgh, Edinburgh, UK; South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Chris Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Shaluka Jayamanne
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka; Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - David Gunnell
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka; School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Manjula Weerasinghe
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka; Department of Community Medicine, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - Ravi Pieris
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Chamil Priyadarshana
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Duleeka W Knipe
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka; School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Andrew H Dawson
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Palitha Bandara
- Provincial Department of Health Services, Anuradhapura, North Central Province, Sri Lanka
| | - Dhammika deSilva
- Provincial Department of Health Services, Anuradhapura, North Central Province, Sri Lanka
| | - Indika Gawarammana
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka; Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Michael Eddleston
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, and Centre for Pesticide Suicide Prevention, University of Edinburgh, Edinburgh, UK; South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.
| | - Flemming Konradsen
- South Asian Clinical Toxicology Research Collaboration (SACTRC), Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka; Department of Public Health, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Zawahir S, Gawarammana I, Dargan PI, Abdulghni M, Dawson AH. Activated charcoal significantly reduces the amount of colchicine released from Gloriosa superba in simulated gastric and intestinal media. Clin Toxicol (Phila) 2017; 55:914-918. [PMID: 28535126 PMCID: PMC5942148 DOI: 10.1080/15563650.2017.1325897] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND Poisoning with Gloriosa superba, a plant containing colchicine, is common in Sri Lanka. OBJECTIVES This study was to estimate release of colchicine from 5 g of different parts of Gloriosa superba in simulated gastric and intestinal media, and examine the binding efficacy of activated charcoal (AC) to colchicine within this model. METHODS A USP dissolution apparatus-II was used to prepare samples for analysis of colchicine using HPLC. RESULTS Cumulative colchicine release from tuber in gastric media at 120 minutes was significantly higher (2883 μg/g) than in intestinal media (1015 μg/g) (p < .001). Mean ± SD cumulative colchicine concentration over 2 hours from tuber, leaves and trunk in gastric medium was 2883.15 ± 1295.63, 578.25 ± 366.26 and 345.60 ± 200.08 μg/g respectively and the release in intestinal media was 1014.75 ± 268.16, 347.40 ± 262.61 and 251.55 ± 285.72 μg/g respectively. Introduction of 50 g of AC into both media made colchicine undetectable (<0.1 μg/ml). CONCLUSIONS The tuber released the highest quantity of colchicine. The colchicine release and elapse time to achieve saturated, equilibrium dissolution mainly depends on physicochemical properties of plant part. Significant in vitro binding of colchicine to AC suggests that AC has a role in decontamination of patients presenting to hospital after ingestion of Gloriosa superba.
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Affiliation(s)
- Shukry Zawahir
- Faculty of Medicine, University of Ruhuna, Galle, Sri Lanka
- Faculty of Pharmacy, University of Sydney, Sydney, Australia
| | - Indika Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Paul I. Dargan
- Department of Clinical Toxicology, Guy’s and St. Thomas’s NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Mahfoudh Abdulghni
- Unaizah College of Pharmacy, Qassim University, Unaizah, Kingdom of Saudi Arabia
| | - Andrew H. Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Central Clinical School, The University of Sydney, Sydney, Australia
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Shahmy S, Kularatne SAM, Rathnayake SS, Dawson AH. A prospective cohort study of the effectiveness of the primary hospital management of all snakebites in Kurunegala district of Sri Lanka. PLoS Negl Trop Dis 2017; 11:e0005847. [PMID: 28827807 PMCID: PMC5578683 DOI: 10.1371/journal.pntd.0005847] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 08/31/2017] [Accepted: 08/02/2017] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Sri Lanka records substantial numbers of snakebite annually. Primary rural hospitals are important contributors to health care. Health care planning requires a more detailed understanding of snakebite within this part of the health system. This study reports the management and epidemiology of all hospitalised snakebite in the Kurunegala district in Sri Lanka. METHODOLOGY The district has 44 peripheral/primary hospitals and a tertiary care hospital-Teaching Hospital, Kurunegala (THK). This prospective study was conducted over one year. All hospitals received copies of the current national guidelines on snakebite management. Clinical and demographic details of all snakebite admissions to primary hospitals were recorded by field researchers and validated by comparing with scanned copies of the medical record. Management including hospital transfers was independently assessed against the national guidelines recommendation. Population rates were calculated and compared with estimates derived from recent community based surveys. RESULTS There were 2186 admissions of snakebites and no deaths in primary hospitals. An additional 401 patients from the district were admitted directly to the teaching hospital, 2 deaths were recorded in this group. The population incidence of hospitalized snakebite was 158/100,000 which was significantly lower than community survey estimates of 499/100,000. However there was no significant difference between the incidence of envenomation of 126/100,000 in hospitalised patients and 184/100,000 in the community survey. The utilisation of antivenom was appropriate and consistent with guidelines. Seventy patients received antivenom. Anaphylactic reactions to antivenom occurred in 22 patients, treatment reactions was considered to be outside the guidelines in 5 patients. Transfers from the primary hospital occurred in 399(18%) patients but the majority (341) did not meet the guideline criteria. A snake was identified in 978 cases; venomous snakebites included 823 hump-nosed viper (Hypnalespp), 61 Russell's viper, 14 cobra, 13 common krait, 03 saw scaled viper. CONCLUSIONS Primary hospitals received a significant number of snakebites that would be missed in surveys conducted in tertiary hospitals. Adherence to guidelines was good for the use of antivenom but not for hospital transfer or treatment of anaphylaxis. The large difference in snakebite incidence between community and hospital studies could possibly be due to non-envenomed patients not presenting. As the majority of snakebite management occurs in primary hospitals education and clinical support should be focused on that part of the health system.
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Affiliation(s)
- Seyed Shahmy
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | | | - Shantha S. Rathnayake
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew H. Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Central Clinical School, University of Sydney, Sydney, Australia
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Chitty KM, Isbister GK, Dawson AH, Buckley NA. Authors' reply. Br J Psychiatry 2017; 211:53-54. [PMID: 28673950 DOI: 10.1192/bjp.211.1.53a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Kate M Chitty
- Kate M. Chitty, Research Fellow, Translational Australian Clinical Toxicology Research Group, Discipline of Pharmacology, University of Sydney, Australia. ; Geoffrey K. Isbister, Andrew H. Dawson, Nicholas A. Buckley, University of Sydney, Australia
| | - Geoffrey K Isbister
- Kate M. Chitty, Research Fellow, Translational Australian Clinical Toxicology Research Group, Discipline of Pharmacology, University of Sydney, Australia. ; Geoffrey K. Isbister, Andrew H. Dawson, Nicholas A. Buckley, University of Sydney, Australia
| | - Andrew H Dawson
- Kate M. Chitty, Research Fellow, Translational Australian Clinical Toxicology Research Group, Discipline of Pharmacology, University of Sydney, Australia. ; Geoffrey K. Isbister, Andrew H. Dawson, Nicholas A. Buckley, University of Sydney, Australia
| | - Nicholas A Buckley
- Kate M. Chitty, Research Fellow, Translational Australian Clinical Toxicology Research Group, Discipline of Pharmacology, University of Sydney, Australia. ; Geoffrey K. Isbister, Andrew H. Dawson, Nicholas A. Buckley, University of Sydney, Australia
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Wong A, Vohra R, Dawson AH, Stolbach A. Impact of online toxicology training on health professionals: the Global Educational Toxicology Uniting Project (GETUP). Clin Toxicol (Phila) 2017; 55:981-985. [PMID: 28617194 DOI: 10.1080/15563650.2017.1330480] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
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.
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Affiliation(s)
- Anselm Wong
- a Victorian Poisons Information Centre and Austin Toxicology Service , Austin Hospital and University of Melbourne , Victoria , Australia.,b School of Clinical Sciences , Monash University , Victoria , Australia
| | - Rais Vohra
- c Fresno Medical Center , University of California San Francisco , Fresno , CA , USA
| | - Andrew H Dawson
- d Royal Prince Alfred Hospital and Sydney Medical School , University of Sydney , NSW , Australia
| | - Andrew Stolbach
- e Department of Toxicology and Emergency , John Hopkins Hospital , Baltimore , MD , USA
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Knipe DW, Gunnell D, Pieris R, Priyadarshana C, Weerasinghe M, Pearson M, Jayamanne S, Dawson AH, Mohamed F, Gawarammana I, Hawton K, Konradsen F, Eddleston M, Metcalfe C. Is socioeconomic position associated with risk of attempted suicide in rural Sri Lanka? A cross-sectional study of 165 000 individuals. BMJ Open 2017; 7:e014006. [PMID: 28336743 PMCID: PMC5372106 DOI: 10.1136/bmjopen-2016-014006] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- D W Knipe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
| | - D Gunnell
- School of Social and Community Medicine, University of Bristol, Bristol, UK
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
| | - R Pieris
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
| | - C Priyadarshana
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
| | - M Weerasinghe
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
- Faculty of Medicine & Allied Sciences, Department of Community Medicine, Rajarata University of Sri Lanka, Anuradhapura, Sri Lanka
| | - M Pearson
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology Unit, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
| | - S Jayamanne
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
- Faculty of Medicine, University of Kelanyia, Kelanyia, Sri Lanka
| | - A H Dawson
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
- Central Clinical School, University of Sydney, Sydney, Australia
| | - F Mohamed
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
- Translational Australian Clinical Toxicology (TACT) Group, School of Medical Science, University of Sydney, Sydney, Australia
| | - I Gawarammana
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
- Faculty of Medicine, Department of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - K Hawton
- Department of Psychiatry, Centre for Suicide Research, University of Oxford, Oxford, UK
| | - F Konradsen
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
- Faculty of Health and Medical Sciences, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - M Eddleston
- Faculty of Medicine, South Asian Clinical Toxicology Research Collaboration (SACTRC), University of Peradeniya, Peradeniya, Sri Lanka
- Clinical Pharmacology Unit, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK
| | - C Metcalfe
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Chitty KM, Dobbins T, Dawson AH, Isbister GK, Buckley NA. Relationship between prescribed psychotropic medications and co-ingested alcohol in intentional self-poisonings. Br J Psychiatry 2017; 210:203-208. [PMID: 28104739 DOI: 10.1192/bjp.bp.115.172213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 08/17/2016] [Accepted: 10/07/2016] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Kate M Chitty
- Kate M. Chitty, BSc Hons, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Timothy Dobbins, PhD, National Drug and Alcohol Research Centre, University of New South Wales, New South Wales; Andrew H. Dawson, MB, BS, FRCP, FRACP, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Geoffrey K. Isbister, BSc, MBBS, FACEM, MD, Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales; Nicholas A. Buckley, BMed, FRACP, MD, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Timothy Dobbins
- Kate M. Chitty, BSc Hons, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Timothy Dobbins, PhD, National Drug and Alcohol Research Centre, University of New South Wales, New South Wales; Andrew H. Dawson, MB, BS, FRCP, FRACP, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Geoffrey K. Isbister, BSc, MBBS, FACEM, MD, Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales; Nicholas A. Buckley, BMed, FRACP, MD, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew H Dawson
- Kate M. Chitty, BSc Hons, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Timothy Dobbins, PhD, National Drug and Alcohol Research Centre, University of New South Wales, New South Wales; Andrew H. Dawson, MB, BS, FRCP, FRACP, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Geoffrey K. Isbister, BSc, MBBS, FACEM, MD, Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales; Nicholas A. Buckley, BMed, FRACP, MD, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Geoffrey K Isbister
- Kate M. Chitty, BSc Hons, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Timothy Dobbins, PhD, National Drug and Alcohol Research Centre, University of New South Wales, New South Wales; Andrew H. Dawson, MB, BS, FRCP, FRACP, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Geoffrey K. Isbister, BSc, MBBS, FACEM, MD, Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales; Nicholas A. Buckley, BMed, FRACP, MD, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas A Buckley
- Kate M. Chitty, BSc Hons, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Timothy Dobbins, PhD, National Drug and Alcohol Research Centre, University of New South Wales, New South Wales; Andrew H. Dawson, MB, BS, FRCP, FRACP, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales; Geoffrey K. Isbister, BSc, MBBS, FACEM, MD, Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales; Nicholas A. Buckley, BMed, FRACP, MD, Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Osborne NJ, Cairns R, Dawson AH, Chitty KM, Buckley NA. Epidemiology of coronial deaths from pesticide ingestion in Australia. Int J Hyg Environ Health 2017; 220:478-484. [PMID: 28238609 DOI: 10.1016/j.ijheh.2017.01.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Nicholas J Osborne
- Clinical Pharmacology and Toxicology, Sydney Medical School, University of Sydney, Sydney 2006 Australia; European Centre for Environment and Human Health, University of Exeter Medical School, Truro TR1 3HD, UK.
| | - Rose Cairns
- Clinical Pharmacology and Toxicology, Sydney Medical School, University of Sydney, Sydney 2006 Australia; New South Wales Poison Information Centre, The Children's Hospital at Westmead, Westmead 2145, NSW, Australia
| | - Andrew H Dawson
- Clinical Pharmacology and Toxicology, Sydney Medical School, University of Sydney, Sydney 2006 Australia; New South Wales Poison Information Centre, The Children's Hospital at Westmead, Westmead 2145, NSW, Australia
| | - Kate M Chitty
- Clinical Pharmacology and Toxicology, Sydney Medical School, University of Sydney, Sydney 2006 Australia
| | - Nicholas A Buckley
- Clinical Pharmacology and Toxicology, Sydney Medical School, University of Sydney, Sydney 2006 Australia; New South Wales Poison Information Centre, The Children's Hospital at Westmead, Westmead 2145, NSW, Australia
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Chan BS, Dawson AH, Buckley NA. What can clinicians learn from therapeutic studies about the treatment of acute oral methotrexate poisoning? Clin Toxicol (Phila) 2017; 55:88-96. [DOI: 10.1080/15563650.2016.1271126] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Betty S. Chan
- Clinical Toxicology Unit & Emergency Department, Prince of Wales Hospital, Sydney, Australia
- New South Wales Poisons Information Centre, Sydney, Australia
| | - Andrew H. Dawson
- New South Wales Poisons Information Centre, Sydney, Australia
- Drug Health, Royal Prince Alfred Hospital, Sydney, Australia
| | - Nicholas A. Buckley
- New South Wales Poisons Information Centre, Sydney, Australia
- Clinical Pharmacology Department, University of Sydney, Sydney, Australia
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Wong A, Stolbach A, Dawson AH, Vohra R. The impact of online toxicology training on Fijian emergency doctors' knowledge: the Global Educational Toxicology Uniting Project (GETUP). Clin Toxicol (Phila) 2016; 55:161-162. [PMID: 27824267 DOI: 10.1080/15563650.2016.1253848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- A Wong
- a Victorian Poisons Information Centre and Austin Toxicology Service , Austin Hospital, University of Melbourne , Heidelberg , Victoria , Australia.,b School of Clinical Sciences , Monash University , Victoria , Australia
| | - A Stolbach
- c Department of Toxicology and Emergency , John Hopkins Hospital , Baltimore , MD , USA
| | - A H Dawson
- d Royal Prince Alfred Hospital and Sydney Medical School, University of Sydney , Sydney , NSW , Australia
| | - R Vohra
- e Fresno Medical Center, University of California San Francisco , Fresno , CA , USA
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Abstract
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.
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Affiliation(s)
- Geoffrey K Isbister
- Discipline of Clinical Pharmacology, University of Newcastle, Newcastle, NSW, Australia.
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Buckley NA, Dawson AH, Isbister GK. Authors' reply to Thomas and colleagues. BMJ 2016; 353:i3461. [PMID: 27353871 DOI: 10.1136/bmj.i3461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Nicholas A Buckley
- NSW Poisons Information Centre, Sydney, NSW, Australia Sydney Medical School, University of Sydney, Sydney NSW 2006, Australia Department of Clinical Toxicology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew H Dawson
- NSW Poisons Information Centre, Sydney, NSW, Australia Sydney Medical School, University of Sydney, Sydney NSW 2006, Australia Department of Clinical Toxicology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Geoffrey K Isbister
- NSW Poisons Information Centre, Sydney, NSW, Australia Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
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Shihana F, Dawson AH, Buckley NA. A bedside test for methemoglobinemia, Sri Lanka. Bull World Health Organ 2016; 94:622-5. [PMID: 27516640 PMCID: PMC4969983 DOI: 10.2471/blt.15.158147] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 03/03/2016] [Accepted: 03/03/2016] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Fathima Shihana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew H Dawson
- NSW Poisons Information Centre, Sydney Children's Hospital Network, Australia
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Shihana F, Dawson AH, Dobbins T, Dissanayake D, Buckley NA. A bedside test for methaemoglobinemia improved antidote use in propanil poisoning. Clin Toxicol (Phila) 2016; 54:576-80. [DOI: 10.1080/15563650.2016.1177651] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Fathima Shihana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew H. Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- NSW Poisons Information Centre, The Children’s Hospital, Westmead, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Timothy Dobbins
- Sydney Medical School, University of Sydney, New South Wales, Australia
| | - Dhammika Dissanayake
- Department of Pathology, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Nicholas A. Buckley
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- NSW Poisons Information Centre, The Children’s Hospital, Westmead, NSW, Australia
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, New South Wales, Australia
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Affiliation(s)
- Nicholas A Buckley
- NSW Poisons Information Centre, Sydney, NSW, Australia Sydney Medical School, University of Sydney, Sydney NSW 2006, Australia Department of Clinical Toxicology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Andrew H Dawson
- NSW Poisons Information Centre, Sydney, NSW, Australia Sydney Medical School, University of Sydney, Sydney NSW 2006, Australia Department of Clinical Toxicology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Geoffrey K Isbister
- NSW Poisons Information Centre, Sydney, NSW, Australia Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
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Blanch B, Buckley NA, Mellish L, Dawson AH, Haber PS, Pearson SA. Harmonizing post-market surveillance of prescription drug misuse: a systematic review of observational studies using routinely collected data (2000-2013). Drug Saf 2016; 38:553-64. [PMID: 25968812 DOI: 10.1007/s40264-015-0294-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Bianca Blanch
- Pharmacoepidemiology and Pharmaceutical Policy Research Group, Faculty of Pharmacy, University of Sydney, A15-Pharmacy and Bank Building, Sydney, NSW, 2006, Australia,
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Buckley NA, Dawson AH, Juurlink DN, Isbister GK. Who gets antidotes? choosing the chosen few. Br J Clin Pharmacol 2016; 81:402-7. [PMID: 26816206 DOI: 10.1111/bcp.12894] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/25/2016] [Accepted: 01/26/2016] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- Nicholas A Buckley
- NSW Poisons Information Centre, The Childrens Hospital Westmead, Sydney, New South Wales.,Sydney Medical School, University of Sydney, Sydney, New South Wales.,Department of Clinical Toxicology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Andrew H Dawson
- NSW Poisons Information Centre, The Childrens Hospital Westmead, Sydney, New South Wales.,Sydney Medical School, University of Sydney, Sydney, New South Wales.,Department of Clinical Toxicology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - David N Juurlink
- Departments of Medicine, Paediatrics and Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Geoffrey K Isbister
- NSW Poisons Information Centre, The Childrens Hospital Westmead, Sydney, New South Wales.,Clinical Toxicology Research Group, University of Newcastle, Newcastle, New South Wales, Australia
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Dawson AH, Buckley NA. Pharmacological management of anticholinergic delirium - theory, evidence and practice. Br J Clin Pharmacol 2015; 81:516-24. [PMID: 26589572 DOI: 10.1111/bcp.12839] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/08/2015] [Accepted: 11/16/2015] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Andrew H Dawson
- NSW Poisons Information Center, Westmead Childrens Hospital, Sydney.,Central Clinical School, Royal Prince Alfred Hospital, University of Sydney, Sydney
| | - Nicholas A Buckley
- NSW Poisons Information Center, Westmead Childrens Hospital, Sydney.,School of Pharmacology, Sydney Medical School, University of Sydney, D06 - Blackburn Building, Sydney, NSW, 2006, Australia
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Wijesinghe CA, Williams SS, Kasturiratne A, Dolawaththa N, Wimalaratne P, Wijewickrema B, Jayamanne SF, Isbister GK, Dawson AH, Lalloo DG, de Silva HJ. A Randomized Controlled Trial of a Brief Intervention for Delayed Psychological Effects in Snakebite Victims. PLoS Negl Trop Dis 2015; 9:e0003989. [PMID: 26261987 PMCID: PMC4532481 DOI: 10.1371/journal.pntd.0003989] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 07/15/2015] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | | | - Geoffrey K. Isbister
- South Asian Clinical Toxicology Research Collaboration, Peradeniya, Sri Lanka
- Clinical Toxicology Research Group, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew H. Dawson
- South Asian Clinical Toxicology Research Collaboration, Peradeniya, Sri Lanka
- Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - David G. Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Buckley NA, Whyte IM, Dawson AH, Isbister GK. A prospective cohort study of trends in self-poisoning, Newcastle, Australia, 1987-2012: plus ça change, plus c'est la même chose. Med J Aust 2015; 202:438-42. [PMID: 25929508 DOI: 10.5694/mja14.01116] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Accepted: 01/09/2015] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
| | - Ian M Whyte
- Calvary Mater Newcastle, Newcastle, NSW, Australia
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Pearson M, Zwi AB, Buckley NA, Manuweera G, Fernando R, Dawson AH, McDuie-Ra D. Policymaking 'under the radar': a case study of pesticide regulation to prevent intentional poisoning in Sri Lanka. Health Policy Plan 2015; 30:56-67. [PMID: 24362640 PMCID: PMC4287191 DOI: 10.1093/heapol/czt096] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2013] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Melissa Pearson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka and School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Randwick NSW, 2502 Australia, Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia, South Asian Clinical Toxicology Research Collaboration, Prince of Wales Hospital Clinical School, University of New South Wales, NSW, Australia, Scientific Support Branch, Secretariat of the Basel, Rotterdam and Stockholm Conventions, United Nations Environment Programme, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and Department of Forensic Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and NSW Poisons Information Service, Westmead Childrens Hospital, Sydney, Australia and School of Social Sciences and International Studies, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia
| | - Anthony B Zwi
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka and School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Randwick NSW, 2502 Australia, Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia, South Asian Clinical Toxicology Research Collaboration, Prince of Wales Hospital Clinical School, University of New South Wales, NSW, Australia, Scientific Support Branch, Secretariat of the Basel, Rotterdam and Stockholm Conventions, United Nations Environment Programme, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and Department of Forensic Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and NSW Poisons Information Service, Westmead Childrens Hospital, Sydney, Australia and School of Social Sciences and International Studies, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia
| | - Nicholas A Buckley
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka and School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Randwick NSW, 2502 Australia, Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia, South Asian Clinical Toxicology Research Collaboration, Prince of Wales Hospital Clinical School, University of New South Wales, NSW, Australia, Scientific Support Branch, Secretariat of the Basel, Rotterdam and Stockholm Conventions, United Nations Environment Programme, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and Department of Forensic Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and NSW Poisons Information Service, Westmead Childrens Hospital, Sydney, Australia and School of Social Sciences and International Studies, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia
| | - Gamini Manuweera
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka and School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Randwick NSW, 2502 Australia, Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia, South Asian Clinical Toxicology Research Collaboration, Prince of Wales Hospital Clinical School, University of New South Wales, NSW, Australia, Scientific Support Branch, Secretariat of the Basel, Rotterdam and Stockholm Conventions, United Nations Environment Programme, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and Department of Forensic Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and NSW Poisons Information Service, Westmead Childrens Hospital, Sydney, Australia and School of Social Sciences and International Studies, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia
| | - Ravindra Fernando
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka and School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Randwick NSW, 2502 Australia, Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia, South Asian Clinical Toxicology Research Collaboration, Prince of Wales Hospital Clinical School, University of New South Wales, NSW, Australia, Scientific Support Branch, Secretariat of the Basel, Rotterdam and Stockholm Conventions, United Nations Environment Programme, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and Department of Forensic Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and NSW Poisons Information Service, Westmead Childrens Hospital, Sydney, Australia and School of Social Sciences and International Studies, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia
| | - Andrew H Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka and School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Randwick NSW, 2502 Australia, Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia, South Asian Clinical Toxicology Research Collaboration, Prince of Wales Hospital Clinical School, University of New South Wales, NSW, Australia, Scientific Support Branch, Secretariat of the Basel, Rotterdam and Stockholm Conventions, United Nations Environment Programme, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and Department of Forensic Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and NSW Poisons Information Service, Westmead Childrens Hospital, Sydney, Australia and School of Social Sciences and International Studies, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia
| | - Duncan McDuie-Ra
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Sri Lanka and School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Randwick NSW, 2502 Australia, Health, Rights and Development (HEARD@UNSW), School of Social Sciences, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia, South Asian Clinical Toxicology Research Collaboration, Prince of Wales Hospital Clinical School, University of New South Wales, NSW, Australia, Scientific Support Branch, Secretariat of the Basel, Rotterdam and Stockholm Conventions, United Nations Environment Programme, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and Department of Forensic Medicine, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka, South Asian Clinical Toxicology Research Collaboration, University of Peradeniya Sri Lanka and NSW Poisons Information Service, Westmead Childrens Hospital, Sydney, Australia and School of Social Sciences and International Studies, Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia
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Brett J, Dawson AH, Brown JA. Clenbuterol toxicity: a NSW poisons information centre experience. Med J Aust 2014; 200:219-21. [PMID: 24580525 DOI: 10.5694/mja13.10982] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 10/01/2013] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Jonathan Brett
- Drug Health, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - Andrew H Dawson
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jared A Brown
- NSW Poisons Information Centre, The Children's Hospital at Westmead, Sydney, NSW, Australia
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Rajapakse BN, Neeman T, Dawson AH. The effectiveness of a 'train the trainer' model of resuscitation education for rural peripheral hospital doctors in Sri Lanka. PLoS One 2013; 8:e79491. [PMID: 24255702 PMCID: PMC3821851 DOI: 10.1371/journal.pone.0079491] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 09/22/2013] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Bishan N. Rajapakse
- Australian National University, Canberra, Australia
- South Asian Clinical Toxicology Research Collaboration, University of Peradeniya, Peradeniya, Sri Lanka
| | - Teresa Neeman
- Statistical Consulting Unit, Australian National University, Canberra, Australia
| | - Andrew H. Dawson
- Australian National University, Canberra, Australia
- Central Clinical School, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
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Abstract
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.
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Senarathna L, Buckley NA, Dibley MJ, Kelly PJ, Jayamanna SF, Gawarammana IB, Dawson AH. 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. PLoS One 2013; 8:e71787. [PMID: 23990989 PMCID: PMC3747188 DOI: 10.1371/journal.pone.0071787] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 07/02/2013] [Indexed: 11/19/2022] Open
Abstract
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
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Affiliation(s)
- Lalith Senarathna
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
- * E-mail:
| | - Nick A. Buckley
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Professorial Medicine Unit, POW Clinical School, University of New South Wales, Sydney, Australia
| | - Michael J. Dibley
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Patrick J. Kelly
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Shaluka F. Jayamanna
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Indika B. Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Andrew H. Dawson
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
- Professorial Medicine Unit, POW Clinical School, University of New South Wales, Sydney, Australia
- Royal Prince Alfred Clinical School, University of Sydney, Sydney, NSW, Australia
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Dawson AH, Wilks MF. With the benefit of hindsight: trials using retrospective controls versus randomized controlled trials in clinical toxicology. Clin Toxicol (Phila) 2013; 51:525-6. [PMID: 23862757 DOI: 10.3109/15563650.2013.821130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- A H Dawson
- NSW Poisons Information Centre, Childrens Hospital at Westmead, Sydney, Australia Central Clinical School, Royal Prince Alfred Hospital Sydney.
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