Exploration of associations between deliberate self-poisoning and psychiatric disorders in rural Sri Lanka: A case-control study.

Psychiatric disorders are important predictors of deliberate self-harm. The present study was carried out to determine the associations between DSM-IV TR Axis- I & II disorders and deliberate self-poisoning (DSP) in a rural agricultural district in Sri Lanka. Patients residing in the district who presented with DSP were randomly selected for the study. Both the cases and age, sex, and, residential area, matched controls were assessed for DSM-IV TR Axis- I & II disorders based on the Structured Clinical Interview for DSM-IV-TR Axis I and II Disorders (SCID I & II) conducted by a specialist psychiatrist. Cases consisted of 208 (47.4%) males and 231 (52.6%) females. More than one third (37%) of males and more than half (53.7%) of females were aged below 20 years. DSM-IV TR axis-I and/or II psychiatric diagnoses were diagnosed in 89 (20.3%) of cases and 14 (3.2%) controls. Cases with a DSM-IV TR axis-I diagnosis were older than the cases without psychiatric diagnosis (32 and 19 years), p<0.0001. Having a depressive episode was associated with a 19 times higher risk for DSP. Being a male aged > = 30 years and having an alcohol use disorder carried a 21 times excess risk for DSP. A fivefold excess risk for DSP was found among 10-19 year old females with borderline personality traits. Depressive disorder and alcohol-related disorders were significantly associated with the older participants who presented with DSP. The overall prevalence of psychiatric disorders associated with DSP in rural Sri Lanka was significantly lower compared to the rates reported in the West and other countries in the region. Therefore, health and research priorities to reduce self-harm in Sri Lanka should focus both on psychiatric and non-psychiatric factors associated with DSP.

A prospective study of repetition of self-harm following deliberate self-poisoning in rural Sri Lanka.

INTRODUCTION: Repetition of deliberate self-harm is an important predictor of subsequent suicide. Repetition rates in Asian countries appear to be significantly lower than in western high-income countries. Methodological differences in studies, and the impact of access to means of self-harm with comparatively higher lethality have been suggested as reasons for these reported differences. This prospective study determines the rates and demographic patterns of deliberate self-poisoning (DSP), suicide and repeated deliberate self-harm resulting non-fatal and fatal outcomes in rural Sri Lanka. METHODS: Details of DSP admission in all hospitals (n = 46) and suicides reported to all police stations (n = 28) in a rural district were collected for the years 2011, 2012 and 2013. Demographic details of the cohort of patients admitted to all hospitals in 2011 due to deliberate self-poisoning (N = 4022), were screened to link with patient records and police reports of the successive two years with high sensitivity using a computer program. Then high specificity manual matching of all screened links was performed to identify repetition within 2 years of initial presentation. Life time repetition was assessed in a randomly selected subset of DSP patients (n = 433). RESULTS: There were 15,639 DSP admissions, aged more than 9 years, and 1078 suicides during the study period. The incidence of deliberate self-poisoning and suicide in the population within the study area were 248.3/100,000 and 20.7/100,000 respectively, in 2012. Repetition rates at four weeks, one-year and two-years were 1.9% (95% CI 1.5-2.3%), 5.7% (95% CI 5.0-6.4) and 7.9% (95% CI 7.1-8.8) respectively. The median interval between two attempts were 92 (IQR 10-238) and 191 (IQR 29-419.5) days for the one and two-year repetition groups. The majority of patients used the same poison in the repeat attempt. The age and duration of hospital stay of individuals with repetitive events were not significantly different from those who had no repetitive events. The rate of suicide at two years following DSP was 0.7% (95% CI 0.4-0.9%). The reported life time history of deliberate self-harm attempts was 9.5% (95% CI 6.7-12.2%). CONCLUSIONS: The comparatively low rates of repetition in rural Sri Lanka was not explained by higher rates of suicide, access to more lethal means or differences in study methodology.

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

BACKGROUND: Lower socioeconomic position (SEP) is associated with an increased risk of suicidal behaviour in high-income countries, but this association is unclear in low-income and middle-income countries. METHODS: We investigated the association of SEP with attempted suicide in a cross-sectional survey of 165 233 Sri Lankans. SEP data were collected at the household (assets, social standing (highest occupation of a household member), foreign employment and young (≤40 years) female-headed households) and individual level (education and occupation). Respondent-reported data on suicide attempts in the past year were recorded. Random-effects logistic regression models, accounting for clustering, were used to investigate the association of SEP with attempted suicide. RESULTS: Households reported 398 attempted suicides in the preceding year (239 per 100 000). Fewer assets (OR 3.2, 95% CI 2.4 to 4.4) and having a daily wage labourer (ie, insecure/low-income job; OR 2.3, 95% CI 1.6 to 3.2) as the highest occupation increased the risk of an attempted suicide within households. At an individual level, daily wage labourers were at an increased risk of attempted suicide compared with farmers. The strongest associations were with low levels of education (OR 4.6, 95% CI 2.5 to 8.4), with a stronger association in men than women. CONCLUSIONS: We found that indicators of lower SEP are associated with increased risk of attempted suicide in rural Sri Lanka. Longitudinal studies with objective measures of suicide attempts are needed to confirm this association. TRIAL REGISTRATION NUMBER: NCT01146496; Pre-results.

A randomized controlled trial of fresh frozen plasma for coagulopathy in Russell's viper (Daboia russelii) envenoming.

Essentials Russell's viper envenoming is a major health issue in South Asia and causes coagulopathy. We studied the effect of fresh frozen plasma and two antivenom doses on correcting coagulopathy. Fresh frozen plasma did not hasten recovery of coagulopathy. Low-dose antivenom did not worsen coagulopathy. SUMMARY: Background Russell's viper (Daboia russelii) envenoming is a major health issue in South Asia and causes venom-induced consumption coagulopathy (VICC). Objectives To investigate the effects of fresh frozen plasma (FFP) and two antivenom doses in correcting VICC. Methods We undertook an open-label randomized controlled trial in patients with VICC at two Sri Lankan hospitals. Patients with suspected Russell's viper bites and coagulopathy were randomly allocated (1 : 1) to high-dose antivenom (20 vials) or low-dose antivenom (10 vials) plus 4 U of FFP. The primary outcome was the proportion of patients with an International Normalized Ratio (INR) of < 2 at 6 h after antivenom administration. Secondary outcomes included anaphylaxis, major hemorrhage, death, and clotting factor recovery. Results From 214 eligible patients, 141 were randomized: 71 to high-dose antivenom, and 70 to low-dose antivenom/FFP; five had no post-antivenom blood tests. The groups were similar except for a delay of 1 h in antivenom administration for FFP patients. Six hours after antivenom administration, 23 of 69 (33%) patients allocated to high-dose antivenom had an INR of < 2, as compared with 28 of 67 (42%) allocated to low-dose antivenom/FFP (absolute difference 8%; 95% confidence interval - 8% to 25%). Fifteen patients allocated to FFP did not receive it. Severe anaphylaxis occurred equally frequently in each group. One patient given FFP developed transfusion-related acute lung injury. Three deaths occurred in low-dose antivenom/FFP patients, including one intracranial hemorrhage. There was no difference in recovery rates of INR or fibrinogen, but there was more rapid initial recovery of factor V and FX in FFP patients. Conclusion FFP after antivenom administration in patients with Russell's viper bites did not hasten recovery of coagulopathy. Low-dose antivenom/FFP did not worsen VICC, suggesting that low-dose antivenom is sufficient.

Phase II study of magnesium sulfate in acute organophosphate pesticide poisoning.

BACKGROUND: Acute organophosphorus (OP) poisoning is relatively common and a major cause of death from poisoning in developing countries. Magnesium has been shown to be of benefit in animal models. METHODS: We conducted a phase II study of bolus doses of (MgSO4) in 50 patients with acute organophosphate poisoning. Patients eligible for inclusion had ingested OP and had cholinergic symptoms consistent with moderate or severe poisoning. All patients received standard care of atropinization titrated to control muscarinic symptoms and pralidoxime. The trial was run in 4 sequential groups of patients. Participants in each group received a different total dose of MgSO4 (20%) administered as intermittent bolus doses infused over 10-15 min or placebo. There was one control patient for every 4 patients who received MgSO4. Group A (16 patients) received a total of 4 gm MgSO4 as a single bolus, group B (8 patients) received 8 gm (in two 4 gm doses q4H), group C (8 patients) received 12 gm (in three 4 gm doses q4H) group D (8 patients) received 16 gm (in four 4 gm doses q4H) and control (10 patients) received placebo). Patients were closely monitored for any adverse reaction like significant clinical neuromuscular disturbance and respiratory depression. RESULTS: No adverse reactions to magnesium were observed. The 24 hour urinary magnesium concentration were statistically different between 16 gm (234.74 ± 74.18 mg/dl) and control (118.06 ± 30.76 mg/dl) (p = 0.019), while it was much lower than the 80% of the intravenous magnesium load. Six patients died in control group compared to 3 in 4 gm, 2 in 8 gm and 1 in 12 gm group. There was no mortality in 16 gm group. CONCLUSION: Magnesium was well tolerated in this study. Larger studies are required to examine for efficacy.

Acceptability and effect of a community-based alcohol education program in rural Sri Lanka.

AIMS: To assess the effectiveness and acceptability of a brief community-based educational program on changing the drinking pattern of alcohol in a rural community. METHODS: A longitudinal cohort study was carried out in two rural villages in Sri Lanka. One randomly selected village received a community education program that utilized street dramas, poster campaigns, leaflets and individual and group discussions. The control village had no intervention during this period. The Alcohol Use Disorder Identification Test (AUDIT) was used to measure the drinking pattern before and at 6 and 24 months after the intervention in males over 18 years of age in both villages. The recall and the impact of various components of the intervention were assessed at 24 months post-intervention. RESULTS: The intervention was associated with the development of an active community action group in the village and a significant reduction in illicit alcohol outlets. The drama component of the intervention had the highest level of recall and preference. Comparing the control and intervention villages, there were no significant difference between baseline drinking patterns and the AUDIT. There was a significant reduction in the AUDIT scores in the intervention village compared with the control at 6 and 24 months (P < 0.0001). CONCLUSIONS: A community-based education program had high acceptance and produces a reduction in alcohol use that was sustained for 2 years.

Validity of referral hospitals for the toxicovigilance of acute poisoning in Sri Lanka.

OBJECTIVE: To identify the hospital admission data set that best captures the incidence of acute poisoning in rural Sri Lanka. METHODS: Data were collected on all acute poisoning cases admitted to 34 primary and 1 referral hospital in Anuradhapura district from September 2008 to January 2010. Three admission data sets were compared with the "true" incidence of acute poisoning to determine the systematic bias inherent to each data set. "True" incidence was calculated by adding all direct admissions (not transfers) to primary hospitals and to the referral hospital. The three data sets were: (i) all admissions to primary hospitals only; (ii) all admissions to the referral hospital only (direct and referrals), and (iii) all admissions to both primary hospitals and the referral hospital ("all admissions"). The third is the government's routine statistical method but counts transfers twice, so for the study transferred patients were counted only once through data linkage. FINDINGS: Of 3813 patients admitted for poisoning, 3111 first presented to a primary hospital and 2287 (73.5%) were later transferred to the referral hospital, where most deaths (161/177) occurred. All data sets were representative demographically and in poisoning type, but referral hospital data yielded a more accurate case-fatality rate than primary hospital data or "all admissions" data. Admissions to primary hospitals only or to the referral hospital only underestimated the incidence of acute poisoning by about 20%, and data on "all admissions" overestimated it by 60%. CONCLUSION: Admission data from referral hospitals are easily obtainable and accurately reflect the true poisoning incidence.

Peripheral burning sensation: a novel clinical marker of poor prognosis and higher plasma-paraquat concentrations in paraquat poisoning.

INTRODUCTION: Self-poisoning with paraquat has a case fatality ratio (CFR) over 65% in Sri Lanka. Plasma-paraquat concentration is the best prognostic indicator for patient outcome but is not readily available. Alternative surrogate clinical markers could be useful in management and determining prognosis. Anecdotal reports by medical and research staff suggested that patients who complained of burning sensation of the body had a poor prognosis and a prospective study was initiated. METHODS: This was a prospective observational study in three hospitals in Sri Lanka. We collected demographic data, presence or absence of burning sensation, and major outcome, and determined the plasma-paraquat concentration within 24 h post-ingestion. RESULTS: There were 179 patients with deliberate self-ingestion of paraquat over 30 months. Burning sensation was reported in 84 patients (48%), which was initiated at a median of 1 day (range 1-3 days) post-ingestion. Of the patients who had burning, 61 died [CFR = 72.62%; 95% confidence interval (CI) = 62-81]. Of the 91 patients who had no peripheral burning, 23 died (CFR = 25.27%, 95% CI = 18.15-35.9). Presence of peripheral burning sensation was associated with a significantly higher risk of death (odds ratio = 7.8, 95% CI = 3.9-15, p < 0.0001). Patients who complained of peripheral burning died at a median of 36 h (interquartile range = 30.5-88) following ingestion whereas those who had no peripheral burning died at a median of 50.5 h (interquartile range = 16.75-80). The difference was not significant (p > 0.05). Median admission plasma-paraquat concentration in patients with peripheral burning (2.67 microg/mL, 95% CI = 0.84-14.2) was significantly higher than in the patients with no peripheral burning (0.022 microg/mL, 95% CI = 0.005-0.78; p < 0.001). Peripheral burning has a sensitivity of 0.72 (95% CI = 0.6-8) and specificity of 0.74 (95% CI = 0.64-0.08) and a positive predictive value of 0.73 (95% CI = 0.6-0.8). DISCUSSION: It is possible that this symptom may help discriminate between patients who have poor chance of survival and those who may potentially benefit from interventions. The mechanism is not clear but could either include a direct concentration-related effect or be a marker of oxidative stress. CONCLUSION: Presence of burning sensation is associated with high plasma-paraquat concentrations and is strongly predictive of death.

Poisoning with the S-Alkyl organophosphorus insecticides profenofos and prothiofos.

BACKGROUND: Many organophosphorus (OP) insecticides have either two O-methyl or two O-ethyl groups attached to the phosphorus atom. This chemical structure affects their responsiveness to oxime-induced acetylcholinesterase (AChE) reactivation after poisoning. However, several OP insecticides are atypical and do not have these structures. AIM: We aimed to describe the clinical course and responsiveness to therapy of people poisoned with two S-alkyl OP insecticides-profenofos and prothiofos. DESIGN: We set up a prospective cohort of patients with acute profenofos or prothiofos self-poisoning admitted to acute medical wards in two Sri Lankan district hospitals. Clinical observation was carried out throughout their inpatient stay; blood samples were taken in a subgroup for assay of cholinesterases and insecticide. RESULTS: Ninety-five patients poisoned with profenofos and 12 with prothiofos were recruited over 5 years. Median time to admission was 4 (IQR 3-7) h. Eleven patients poisoned with profenofos died (11/95; 11.6%, 95% CI 5.9-20); one prothiofos patient died (1/12; 8.3%, 95% CI 0.2-38). Thirteen patients poisoned with profenofos required intubation for respiratory failure (13/95; 13.7%, 95% CI 7.5-22); two prothiofos-poisoned patients required intubation. Both intubations and death occurred late compared with other OP insecticides. Prolonged ventilation was needed in those who survived-a median of 310 (IQR 154-349) h. Unexpectedly, red cell AChE activity on admission did not correlate with clinical severity-all patients had severe AChE inhibition (about 1% of normal) but most had only mild cholinergic features, were conscious, and did not require ventilatory support. CONCLUSION: Compared with other commonly used OP insecticides, profenofos and prothiofos are of moderately severe toxicity, causing relatively delayed respiratory failure and death. There was no apparent response to oxime therapy. The lack of correlation between red cell AChE activity and clinical features suggests that this parameter may not always be a useful marker of synaptic AChE activity and severity after OP pesticide poisoning.

Emerging epidemic of fatal human self-poisoning with a washing powder in Southern Sri Lanka: a prospective observational study.

INTRODUCTION: Self-poisoning is a public health problem in Sri Lanka. A new laundry detergent consisting of a sachet each of 1.2 g of potassium permanganate and 12.5 g of oxalic acid has become a popular agent among the youth for self-poisoning. METHOD: Prospective clinical data and major outcomes were recorded in all patients admitted to a referring and a referral hospital. Serial biochemistry was performed in 20 patients. Postmortem examinations were performed in some patients. RESULTS: There were 115 patients. The majority developed symptoms of the gastrointestinal tract within the first 24 h. There were 18 deaths. Ingestion of oxalic acid was associated with a case fatality ratio of 25.4% (95% CI = 14-39), while ingestion of both potassium permanganate and oxalic acid was associated with a case fatality ratio of 9.8% (95% CI = 3.2-21). Ingestion of more than one sachet was associated with a significantly higher risk of death (risk ratio = 13.26, 95% CI = 3.2-54, p < 0.05). Majority of the deaths occurred within an hour since ingestion. Postmortem examinations revealed mucosal ulceration in the majority of deaths. DISCUSSION: This case series brings to light an emerging epidemic of fatal self-poisoning in Sri Lanka from a compound that is not regulated. As deaths occur soon after ingestion, medical management of these patients is bound to be difficult. CONCLUSION: This case series highlights a fatal mode of self-poisoning that could be controlled through regulation of the manufacture and sale of the product.

Management of acute paracetamol poisoning in a tertiary care hospital.

OBJECTIVES: To compare the management of acute paracetamol poisoning with the best evidence available, and to determine the effect of plasma paracetamol level estimation on the management. DESIGN: Descriptive study with an intervention. SETTING: Medical wards of the National Hospital of Sri Lanka, Colombo. PATIENTS: Patients admitted with a history of acute paracetamol poisoning. INTERVENTION: Measurement of plasma paracetamol. METHODS: Data were obtained from the patients, medical staff and medical records. Plasma paracetamol was estimated between 4-24 hours of paracetamol ingestion. The current management practices were compared with the best evidence on acute paracetamol poisoning management. RESULTS: 157 patients were included. The mean ingested dose of paracetamol was 333 mg/kg body weight. Majority of the patients (84%) were transfers. Induced emesis and activated charcoal were given to 91% of patients. N-acetylcysteine was given to 66, methionine to 55, and both to 2. Aclinically important delay in the administration of antidotes was noted; 68% of patients received antidotes after 8 hours of the acute ingestion. Only 31 (26%) had paracetamol levels above the Rumack-Matthew normogram. 74 patients received an antidote despite having a plasma paracetamol level below the toxic level according to the normogram. INTERPRETATION: Management of acute paracetamol poisoning could be improved by following best available evidence and adapting cheaper methods for plasma paracetamol estimation.

Comparison of two commonly practiced atropinization regimens in acute organophosphorus and carbamate poisoning, doubling doses vs. ad hoc: a prospective observational study.

There is a wide variation and lack of evidence in current recommendations for atropine dosing schedules leading to subsequent variation in clinical practice. Therefore, we sought to examine the safety and effectiveness of a titrated vs. ad hoc atropine treatment regimen in a cohort of patients with acute cholinesterase inhibitor pesticide poisoning. A prospective cohort study was conducted in three district secondary referral hospitals in Sri Lanka using a structured data collection form that collected details of clinical symptoms and outcomes of cholinesterase inhibitor pesticide poisoning, atropine doses, and signs of atropinization. We compared two hospitals that used a titrated dosing protocol based on a structured monitoring sheet for atropine infusion with another hospital using an ad hoc regime. During the study, 272 symptomatic patients with anticholinesterase poisoning requiring atropine were admitted to the three hospitals. Outcomes of death and ventilation were analyzed for all patients, 226 patients were prospectively assessed for atropine toxicity. At baseline, patients in the titrated dose cohort had clinical signs consistent with greater toxicity. This in part may be due to ingestion of more toxic organophosphates. They received less pralidoxime and atropine, and were less likely to develop features of atropine toxicity, such as delirium (1% vs. 17%), hallucinations (1% vs. 35%), or either (1% vs. 35%) and need for patient restraint (3% vs. 48%) compared with the ad hoc dose regime. After adjusting for the pesticides ingested, there was no difference in mortality and ventilatory rates between protocols. Ad hoc high dose atropine regimens are associated with more frequent atropine toxicity without any obvious improvement in patient outcome compared with doses titrated to clinical effect. Atropine doses should be titrated against response and toxicity. Further education and the use of a structured monitoring sheet may assist in more appropriate atropine use in anticholinesterase pesticide poisoning.

Identification of strategies to prevent death after pesticide self-poisoning using a Haddon matrix.

Despite pesticide self-poisoning causing around 300 000 deaths each year in the rural Asia Pacific region, no comprehensive public health response has yet been formulated. The authors have developed a Haddon matrix to identify factors that increase the risk of fatal rather than non-fatal pesticide self-poisoning in Sri Lanka. Many important host factors such as age, gender, and genetics are not alterable; factors that could be changed-alcohol use and mental health-have previously proved difficult to change. Interventions affecting agent or environmental factors may be easier to implement and more effective, in particular those limiting the human toxicity and accessibility of the pesticides, and the quality, affordability, and accessibility of health care in the community. Controlled studies are required to identify effective strategies for prevention and harm minimization and to garner political support for making the changes necessary to reduce this waste of life. Lessons learnt from Sri Lanka are likely to be highly relevant for much of rural Asia.

The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity.

BACKGROUND: There are difficulties with the diagnosis of serotonin toxicity, particularly with the use of Sternbach's criteria. AIM: To improve the criteria for diagnosing clinically significant serotonin toxicity. DESIGN: Retrospective analysis of prospectively collected data METHODS: We studied all patients admitted to the Hunter Area Toxicology Service (HATS) following an overdose of a serotonergic drug from January 1987 to November 2002 (n = 2222). Main outcomes were: diagnosis of serotonin toxicity by a clinical toxicologist, fulfillment of Sternbach's criteria and treatment with a serotonin receptor (5-HT(2A)) antagonist. A learning dataset of 473 selective serotonin reuptake inhibitor (SSRI)-alone overdoses was used to determine individual clinical features predictive of serotonin toxicity by univariate analysis. Decision rules using CART analysis were developed, and tested on the dataset of all serotonergic overdose admissions. RESULTS: Numerous clinical features were associated with serotonin toxicity, but only clonus (inducible, spontaneous or ocular), agitation, diaphoresis, tremor and hyperreflexia were needed for accurate prediction of serotonin toxicity as diagnosed by a clinical toxicologist. Although the learning dataset did not include patients with life-threatening serotonin toxicity, hypertonicity and maximum temperature > 38 degrees C were universal in such patients; these features were therefore added. Using these seven clinical features, decision rules (the Hunter Serotonin Toxicity Criteria) were developed. These new criteria were simpler, more sensitive (84% vs. 75%) and more specific (97% vs. 96%) than Sternbach's criteria. DISCUSSION: These redefined criteria for serotonin toxicity should be more sensitive to serotonin toxicity and less likely to yield false positives.

Feasibility of prehospital treatment with activated charcoal: Who could we treat, who should we treat?

OBJECTIVES: To investigate the feasibility and potential risk benefit of prehospital administration of activated charcoal. METHODS: Review of deliberate self poisoning presentations to the emergency department (ED) of a toxicology unit by ambulance over six years. Data were extracted from a standardised prospective database of poisonings. Outcomes included: number of patients attended by ambulance and number arriving in emergency within one hour. Cases were stratified by ingestion type, based on toxicity and sedative activity. RESULTS: 2041 poisoning admissions were included. The median time to ambulance attendance was 1 h 23 min (IQR 37 min-3 h) and to hospital attendance was 2 h 15 min (IQR 1 h 25 min-4 h). In 774 cases (38%) ambulance attendance occurred within one hour, but in only 161 (8%) did ED attendance occur within one hour. Non-sedating, highly toxic substances were ingested in 55 cases, 24 (23 with GCS>14) with ambulance attendance, and five with ED attendance, within one hour. Conversely 439 patients ingested a less toxic, sedative agent, 160 with ambulance attendance, and 32 with ED attendance, within one hour. Limiting decontamination to patients ingesting highly toxic, non-sedating compounds (GCS<14) reduces the proportion requiring treatment to 23 of the 774 (3.0%), an additional 18 patients. CONCLUSION: More patients could potentially be decontaminated if all patients attended by ambulance within one hour received charcoal. However, this would expose 128 patients with sedative, low risk poisonings to the risk of aspiration, and only treat 18 extra high risk poisonings. This small potential benefit of prehospital charcoal is unlikely to justify the expense in training and protocols required to implement it