Self-harm Intent Research Articles

Effectiveness of Integrating Suicide Care in Primary Care : Secondary Analysis of a Stepped-Wedge, Cluster Randomized Implementation Trial.

Primary care encounters are common among patients at risk for suicide. To evaluate the effectiveness of implementing population-based suicide care (SC) in primary care for suicide attempt prevention. Secondary analysis of a stepped-wedge, cluster randomized implementation trial. (ClinicalTrials.gov: NCT02675777). 19 primary care practices within a large health care system in Washington State, randomly assigned launch dates. Adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018. Practice facilitators, electronic medical record (EMR) clinical decision support, and performance monitoring supported implementation of depression screening, suicide risk assessment, and safety planning. Clinical practice and patient measures relied on EMR and insurance claims data to compare usual care (UC) and SC periods. Primary outcomes included documented safety planning after population-based screening and suicide risk assessment and suicide attempts or deaths (with self-harm intent) within 90 days of a visit. Mixed-effects logistic models regressed binary outcome indicators on UC versus SC, adjusted for randomization stratification and calendar time, accounting for repeated outcomes from the same site. Monthly outcome rates (percentage per 10 000 patients) were estimated by applying marginal standardization. During UC, 255 789 patients made 953 402 primary care visits and 228 255 patients made 615 511 visits during the SC period. The rate of safety planning was higher in the SC group than in the UC group (38.3 vs. 32.8 per 10 000 patients; rate difference, 5.5 [95% CI, 2.3 to 8.7]). Suicide attempts within 90 days were lower in the SC group than in the UC group (4.5 vs. 6.0 per 10 000 patients; rate difference, -1.5 [CI, -2.6 to -0.4]). Suicide care was implemented in combination with care for depression and substance use. Implementation of population-based SC concurrent with a substance use program resulted in a 25% reduction in the suicide attempt rate in the 90 days after primary care visits. National Institute of Mental Health.

P4: Successful VA-Extracorporeal Membrane Oxygenation course in a patient with intentional Calcium Channel Blocker overdose without the need for mechanical ventilation

Background: Cardiovascular medication overdose constitutes about 3.5% of all drug overdoses, and carries a mortality of 16%. Calcium channel blockers (CCBs) and beta blockers account for more than 65% of these deaths. Overdose of cardiovascular medications cause impaired cardiac contractility, vasoplegia, and/or rhythm disturbances. We review the current literature and case reports of VA ECMO being utilized to support patients with cardiovascular medication overdose. Methods: We present a case of a 20-year-old female with no medical history presenting with bradycardia and hypotension after ingesting ninety ezetimibe 10mg, seventy-five nebivolol 10mg, and one hundred and eighty amlodipine 5mg, from her mother’s medication, with the intent of self harm. Patient received glucagon, calcium, lipid emulsion, and was being supported on vasopressin, norepinephrine, epienephrine, phenylephrine and dopamine. The patients HR 78 and SBP 68mmHg. Laboratory significant for leukocytosis and elevated lactic acid. On exam, patient was lethargic, without respiratory distress. Echocardiogram revealed EF 55-65% and a large right ventricular mass suspicious for atrial myxoma. Patient was initiated on peripheral Veno-Arterial ECMO using Femoral-Femoral configuration to provide circulatory support as a bridge to allow drug metabolism and clearance. Results: Following 72 hours of VA-ECMO, vasopressors were weaned, with ECMO successfully being discontinued. Throughout the ECMO course, the patient had no respiratory compromise and did not require intubation or mechanical ventilation. Following decannulation, the patient was discharged to follow for an elective resection of the atrial myxoma. Conclusion: ECMO has been reported as a rescue therapy in CCB and Beta blocker overdose when refractory to medical therapy. Conventional medical therapy includes limiting absorption, increasing elimination and hemodynamic support using vasopressor agents, intravenous (IV) calcium infusion, hyperinsulinemia therapy, glucagon infusion, and IV lipid emulsion. This unique case demonstrates the successful utilization of VA ECMO to support patients with cardiovascular medication overdose and illustrates the potential for hemodynamic support without the need for ventilator support. This is the only known report of VA ECMO being utilized for calcium channel overdose while the patient is awake and unventilated throughout their ECMO course.

Intravascular hemolysis in phenol poisoning: An unforeseen and rare complication

The black phenyl is a powerful germ killer used for homes, hospitals, which is easily accessible and can be consumed with the intention of self harm. Cases of intravascular hemolysis through inhalation or spillage has been reported, but intravascular hemolysis following ingestion is rarely reported. A 25 year old previously healthy male presented after alleged ingestion of black phenyl and was asymptomatic at presentation. By day 4, he developed fever, icterus, tachycardia, fatigue and dark brown urine. Labs were Hgb 3.6g/dl, platelet count 2.75 lakhs/ul, creatinine 1.1mg/ dI, AST 244U/L, ALT 69U/L, Total Bilirubin 4.65g/dl (Indirect 3.35) PT 14.6, INR 1.23. By Day 6, urine color darkened, suggestive of ongoing hemolysis with LDH level of 3614 U/L. Over the full hospital stay, urine output was maintained, and he didn't develop acute kidney injury. By Day 9, patient's symptoms improved & he was discharged on day 12. These compounds interfere with oxidative phosphorylation in cells, making red blood cells losing osmotic equilibrium. This metabolic handicap may lead to premature red blood cell lysis. Though asymptomatic at presentation, patient developed serious intravascular hemolysis and hemoglobinuria by day 4. This suggests the need for admission of asymptomatic patients, constant monitoring and to anticipate toxic potentials of the compound. The dearth of enough literature on this rare complication made us report this first case from North East India.

Accuracy of ICD-10-CM encounter diagnoses from health records for identifying self-harm events.

Assess the accuracy of ICD-10-CM coding of self-harm injuries and poisonings to identify self-harm events. In 7 integrated health systems, records data identified patients reporting frequent suicidal ideation. Records then identified subsequent ICD-10-CM injury and poisoning codes indicating self-harm as well as selected codes in 3 categories where uncoded self-harm events might be found: injuries and poisonings coded as undetermined intent, those coded accidental, and injuries with no coding of intent. For injury and poisoning encounters with diagnoses in those 4 groups, relevant clinical text was extracted from records and assessed by a blinded panel regarding documentation of self-harm intent. Diagnostic codes selected for review include all codes for self-harm, 43 codes for undetermined intent, 26 codes for accidental intent, and 46 codes for injuries without coding of intent. Clinical text was available for review for 285 events originally coded as self-harm, 85 coded as undetermined intent, 302 coded as accidents, and 438 injury events with no coding of intent. Blinded review of full-text clinical records found documentation of self-harm intent in 254 (89.1%) of those originally coded as self-harm, 24 (28.2%) of those coded as undetermined, 24 (7.9%) of those coded as accidental, and 48 (11.0%) of those without coding of intent. Among patients at high risk, nearly 90% of injuries and poisonings with ICD-10-CM coding of self-harm have documentation of self-harm intent. Reliance on ICD-10-CM coding of intent to identify self-harm would fail to include a small proportion of true self-harm events.

Psychiatric care following deliberate self-harm and prospective mortality: evidence from a national cohort of patients in routine care

IntroductionPsychiatric care following self-harm treatment is pivotal in patients´ life both in short- and long-terms.ObjectivesTo examine follow-up psychiatric care received by patients treated for deliberate self-harm (DSH), and to assess the influence of psychiatric referral and treatment attendance on risk for subsequent mortality.MethodsNationwide registries were interlinked to follow all DSH patients for data on personal socioeconomic status, clinical features of DSH, psychiatric treatment and cause of death. Data were analyzed with Logistic regression and cause-specific survival analysis.Results The study identified 43153 patients involving 69569 DSH episodes. Of these patients 15.7% were referred or transferred to psychiatric services and 51.0% attended psychiatric treatment within subsequent 3 months. Evidently, prior psychiatric history and psychiatric comorbidities had strong influence on both referral and attendance to psychiatric healthcare, personal socioeconomic status also deviated the likelihoods. During the follow-up, 7041 patients died from suicide (n=911) or other causes (n=6130). While suicide risk was highly associated with male gender, middle age, and particularly, prior and coexisting psychopathologies, other cause mortality was strongly associated with old age and socioeconomic disadvantages. Meanwhile, a referral to psychiatric services was associated with suicide risk, and the risk was particularly high for patients who received the referral but did not attend psychiatric treatment. The observed effect was more pronounced during the early years, and in patients of young or middle age and those with a clear intent of self-harm.ConclusionsThe insightful findings highlight the importance of patients´ attendance and engagement in follow-up psychiatric care on risk for subsequent mortality.DisclosureNo significant relationships.

Association of Psychiatric Services Referral and Attendance Following Treatment for Deliberate Self-harm With Prospective Mortality in Norwegian Patients

Psychiatric care following somatic treatment for deliberate self-harm (DSH) is pivotal in patients' lives both in the short and long term, but evidence to guide such care is limited. To examine follow-up psychiatric care for patients treated for DSH (ie, intentional self-injury or self-poisoning, irrespective of motivation) at hospital emergency departments and to assess the association of psychiatric referral and treatment attendance with risk of subsequent mortality in these patients. Retrospective data from several Norwegian registries were interlinked to follow up a national cohort of all patients with hospital-treated DSH for up to 11 years from 2008 through 2018. Data were analyzed from March to October 2021. Socioeconomic characteristics, psychiatric history, and clinical features of DSH. Referral to psychiatric services, attendance in psychiatric treatment, and prospective mortality were the 3-stage outcomes during follow-up. Logistic regression with odds ratios and cause-specific survival analysis with hazard ratios were used to examine associations between exposures and outcomes. The study identified 43 153 patients (24 286 [56.3%] female; median [IQR] age at index DSH, 39.0 [23.0-56.0] years) involving 69 569 DSH episodes. Of these patients, 6762 (15.7%) were referred to psychiatric services after somatic treatment for DSH, and 22 008 patients (51.0%) attended psychiatric treatment within 3 months of discharge following somatic treatment for DSH. Prior psychiatric history and psychiatric disorders comorbid with DSH were associated with both referral to and attendance in psychiatric care. During follow-up, 7041 patients died by suicide (n = 911) or other causes (n = 6130). While suicide risk was associated with male sex, age 35 to 64 years, and particularly prior and coexisting psychopathologies, other-cause mortality was associated with age 65 years and older and socioeconomic disadvantage. Patients with psychiatric referrals generally had an increased risk of suicide, but the risk was particularly high among patients who received a referral but did not subsequently attend psychiatric treatment (adjusted hazard ratio, 3.07; 95% CI, 2.28-4.12). The observed association was more pronounced during the first years of follow-up and in patients aged 10 to 34 years or 35 to 64 years and those with a clear intent of self-harm. This national cohort study found an association between psychiatric care attendance following treatment for DSH and prospective mortality, highlighting the importance of patient engagement in psychiatric treatment.

Self-inflicted stab injury with abdominal evisceration: A case report

Introduction and importanceSelf-inflicted abdominal stab injury with an intention of self-harm is uncommon. Moreover, self-inflicted injury leading to avulsion of the colon has rarely been reported in the literature. We report a case of a 42-years-female with schizoaffective disorder who presented with self-inflicted stab injury on the abdomen resulting in abdominal evisceration.Presentation of caseA 42-years-female with schizoaffective disorder (F25) for 10 years presented to the emergency department with multiple, self-inflicted injuries on the abdomen. A large free portion of the omentum and segment of the bowel were brought in a plastic carry bag. Examination revealed multiple transverse hesitation cuts in the epigastrium and a single deep penetrating transverse cut resulting in the evisceration of the omentum and colon. Intra-operatively, avulsion of a large portion of the greater omentum and missing segment of the mid transverse colon was observed. The patient underwent an immediate abdominal exploration and side-to-side colo-colic anastomosis along with diversion ileostomy. At three months following primary surgery, ileostomy closure was done.ConclusionPatients with schizophrenia spectrum psychosis are at risk of self-harm and in our case a schizoaffective patient presented with self-inflicted injuries that required an emergency abdominal exploration and repair. This case highlights a multi-disciplinary approach for the management of these cases and mandates clinicians and caregivers to be more vigilant to restrict injuries in the future.

Self-poisoning as a cause of admission in a medical intensive care unit and a question of misuse of prescription medications

BackgroundSelf-poisoning accounts for between 3 and 17% of intensive care unit (ICU) admissions. ObjectivesTo display the misused substances, intention, and outcome of patients admitted to the ICU due to self-poisoning. MethodsA retrospective review of ICU admissions using an electronic patient database was performed. ResultsA total of 149 patients were admitted, accounting for 4.6% of ICU admissions.Self-poisoning with self-harm was more frequent than without self-harm intent (62.4% vs. 37.6%). 64.4% of ingested substances were misused prescribed drugs. Females used antipsychotics (X2 = 15, p< 0.05) and benzodiazepines (X2 =11.52, p< 0.05), and males ingested antipsychotics (X2 = 12, p< 0.05) with a self-harm intent. Antipsychotics were always used with a self-harm intent. Illicit drugs (X2 =9.14, p< 0.05) and ethanol (X2 =7.34, p< 0.05) were mostly used without self-harm intent. 102 patients (68.5%) continued treatment in a psychiatric clinic, more often women (X2 (1,N = 145)=7.94, p< 0.005). The readmission rate was low. Mortality was 2.6%. ConclusionSelf-poisoning is an infrequent cause of ICU admission. Prescribed psychotropic medications, including benzodiazepines, antipsychotics, and antidepressants were the most frequently misused substances. Psychiatric consultation before the ICU discharge and subsequent psychiatric treatment might lower the repetition and readmission rate.

Are Facial Gunshot Wounds More Fatal When They Are Self-Inflicted or Other-Inflicted?

This was a retrospective cohort study of the 2014 Nationwide Emergency Department Sample (NEDS). Intraoral and submental projectile entry points may be less fatal than other facial entry points due to the indirect access to the intracranial structures and the protection offered by the intervening maxillofacial complex. Because intraoral and submental trajectories are almost always present in the setting of attempted suicide, this study sought to determine if intent (self-harm versus other-harm) influenced mortality in facial gunshot wound (GSW) patients. All patients with a diagnosis of a facial fracture secondary to firearm injury were included in the study sample. The primary predictor was self-harm. Secondary predictors were derived from patient, injury, and hospitalization characteristics. The study outcome was death. Univariate time to event analyses were conducted for all study predictors. A multivariate regression model for mortality was created using all relevant predictors. The final sample included 668 facial GSW injuries, of which 19.3% were attributed to self-harm. Self-inflicted GSWs were more likely to involve the mandible (58.9 vs 46.0%, P < 0.01), ZMC/maxilla (47.3 vs 32.5%, P < 0.01), and intracranial cavity (48.1 vs 22.6%, P < 0.01). The overall mortality rate was 7.3%, and the mean time to death was 2.2 days. After controlling for pertinent covariates, the risk of mortality was independently decreased with mandibular injury (HR = 0.36, P = 0.03). However, mortality was increased by self-harm intent (HR = 3.94, P < 0.01) and intracranial involvement (HR = 11.24, P < 0.01). Consistent with a pattern of intraoral and submental entry points, self-inflicted facial GSWs demonstrated higher rates of mandibular injury. Despite this finding, self-harm injuries still carried a higher incidence of intracranial injury and a greater independent risk of mortality. Our results refute any notion that the mechanism and trajectory of self-inflicted GSWs is less fatal.

Clinical and pathological profile of paraquat poisoning cases - A cross-sectional study in Odisha, India

Agriculture being the primary mode of occupation in Odisha leads to the rampant and widespread use of chemical pesticides and herbicides. Paraquat is a widely used herbicide. Ingestion of PQ irrespective of the quantity could be fatal with life-threatening effects on the gastrointestinal (GI) tract, kidney, liver, lungs, and other organs. Death is usually associated with respiratory insufficiency due to an oxidative insult to the Type-II alveolar epithelium with subsequent fibrosis.All cases of paraquat ingestion coming to AIIMS, Bhubaneswar casualty from July 2020 to November 2020 were studied for their clinical findings. The fatal cases were subjected to autopsy and findings noted.Men were most commonly involved. All of the patients had self-harm intent while consuming. The most common presenting symptoms were difficulty in swallowing, Respiratory system was most commonly affected. The cause of death was attributed to respiratory and multi-organ failure.Paraquat is widely marketed for its efficacy and low environmental toxicity. Lack of a specific antidote increases the fatality. The most common cause of death is respiratory failure. Paraquat causes renal failure by causing hypovolemia, circulatory failure, septicemia, and direct toxicity. The mainstay of treatment is supportive though the use of immune-suppressants has shown some positive results.

A Mysterious Case of a 33-Year-Old Female Schizophrenic Patient Who Ingested a Kilogram of Metals: A Case Report

Introduction: Globally, 20 million people are affected by schizophrenia. In Uganda, the prevalence is reported to be 710 per 100,000 population. Unlike normal adults who are less likely to have foreign body ingestion, patients with mental illnesses such as schizophrenia are at an increased risk of both intentional and accidental foreign body ingestion. Therefore, health workers must be vigilant while assessing such patients not to miss out on the diagnosis as unwitnessed foreign body ingestion presents a diagnostic challenge. Observation: We received a 33-year-old female diagnosed with schizophrenia four years before this admission as a referral. She presented at MNRH A&E with complaints of abdominal pain, non-bilious vomiting, and progressive weight loss. She had multiple admissions in private hospitals before her referral to MNRH where several investigations were done with inconclusive results. Upper GI endoscopy revealed multiple foreign bodies in the stomach. An erect abdominal x-ray was then done to rule out distal gastrointestinal involvement and/or perforation. An emergency laparotomy was performed and over 170 different metallic objects of varying sizes were completely evacuated. She reported that she ingested them in response to the compelling auditory hallucinations but had no intention of self-harm. Conclusion: Foreign body ingestion presents a diagnostic challenge in adults. The various impairments among mentally ill patients put them at an increased risk hence the need for suspicious diagnostic evaluation of those presenting with abdominal symptoms. Both health workers and families have a role to play in the prevention of such life-threatening emergencies.

Risk Factors for Overdose in Young People Who Received Substance Use Disorder Treatment.

To identify substance and psychiatric predictors of overdose (OD) in young people with substance use disorders (SUDs) who received treatment. We conducted a retrospective review of consecutive medical records of young people who were evaluated in a SUD program between 2012 and 2013 and received treatment. An independent group of patients from the same program who received treatment and had a fatal OD were also included in the sample. OD was defined as substance use associated with a significant impairment in level of consciousness without intention of self-harm, or an ingestion of a substance that was reported as a suicide attempt. t Tests, Pearson's χ2 , and Fisher's exact tests were performed to identify predictors of OD after receiving treatment. After initial evaluation, 127 out of 200 patients followed up for treatment and were included in the sample. Ten (8%) of these patients had a nonfatal OD. Nine patients who received treatment and had a fatal OD were also identified. The sample's mean age was 20.2 ± 2.8 years. Compared with those without OD, those with OD were more likely to have a history of intravenous drug use (odds ratio [OR]: 36.5, P < .001) and mood disorder not otherwise specified (OR: 4.51, P = .01). Intravenous drug use and mood dysregulation increased risk for OD in young people who received SUD treatment. It is important to identify clinically relevant risk factors for OD specific to young people in SUD treatment due to the risk for death associated with OD. (Am J Addict 2019;28:382-389).

Supporting Providers After Drug Overdose Death.

Supporting Providers After Drug Overdose Death.

Carer insights into self-harm in the very old: A qualitative study.

To examine the insights of carers to better understand self-harm in their older relatives. An in-depth interview was conducted with the nominated relative/friend (carer) of a person over 80 who had self-harmed within the last month. Carer interpretation and experience of the self-harm and clinical care were explored qualitatively. Audio recordings were transcribed and the content thematically analyzed using N-VIVO. Thirty-two carers of 30 older people who self-harmed were interviewed. Physical, social, and psychological issues were identified as contributory to self-harm. Themes relating to the perceived barriers to seeking help included "they can't communicate," "suicide and secrets," and "invalidation." Themes for the intent of self-harm were "attention seeking" and "wanting to die." Themes which emerged for consequences of self-harm for carers were "anger," "guilt and self-blame," and "it made us ill." Themes for solutions to address the underlying factors leading to self-harm were "more practical support and structure," "improving communication," "removing means of self-harm," "advance care directives as a solution for suffering," and "ignoring self-harm." Clinical care themes were "shared shame and stigma," "safety and supervision vs being locked up," "clinicians dismissing the carer," and "relief and support." Validation of carer perspectives and understanding family dynamics may improve communication at various system levels and inform interventions for older persons, concurrently support families, and potentially reduce risk of repeat self-harm. Good care must be holistic, be person-centred, and relieve carer burden. A shared understanding and psychotherapeutic approaches to management of self-harm in late life should be considered.

Epidemiological trend of suicide in center of Iran from 2012 to 2016

ObjectivesSuicide is a conscious act in which the individual deliberately commit and unusual act with the intention of self-harm. The present study aims to examine some epidemiological factors affecting attempted and completed suicide rate during 2012–2016 in NajafAbad, a city in Isfahan province. MethodsThis is a cross-sectional study. The subjects are 2138 cases involved in suicide attempt during 2012–2016 that gone to Montazeri and Al-Zahra hospital. Chi-square, logistic regression and Cochran–Armitage test was used for data analysis. ResultTotally, 1385 (64.8%) patients were female and 47.8% were younger than 24 years of age. The most common method of suicide was medication overdose (91.1%). In multivariable analysis, male gender (OR: 2.67; CI 95% 1.53 to 4.64) was a risk factor for fatal suicide and application of chemical methods (OR: 0.018; CI 95% 0.010 to 0.032) was a protective factor. Results regarding completed suicide trend analysis shows that this trend has had a significant statistical difference in men (p = 0.019) but in women this trend doesn't statistically significant difference. (p = 0.209). ConclusionsAccording to the findings of the present study, attempted and completed suicide rate in Najafabad is relatively high compared to other regions in Islamic Republic of Iran. The completed suicide rate was significant in men which achieved its greatest value in 2015. Suicide attempt rate didn't show a significant statistical difference in both men and women.

Risk Factors for Overdose in Treatment-Seeking Youth With Substance Use Disorders.

Overdoses (ODs) are among the leading causes of death in youth with substance use disorders (SUDs). Our aim was to identify the prevalence of OD and characteristics associated with a history of OD in youth presenting for SUD outpatient care. A systematic retrospective medical record review was conducted of consecutive psychiatric and SUD evaluations for patients aged 16 to 26 years with DSM-IV-TR criteria SUD at entry into an outpatient SUD treatment program for youth between January 2012 and June 2013. Unintentional OD was defined as substance use without intention of self-harm that was associated with a significant impairment in level of consciousness. Intentional OD was defined as ingestion of a substance that was reported as a suicide attempt. T tests, Pearson χ² tests, and Fisher exact tests were performed to evaluate characteristics associated with a history of OD. We examined the medical records of 200 patients (157 males and 43 females) with a mean ± SD age of 20.2 ± 2.8 years. At intake, 58 patients (29%) had a history of OD, and 62% of those patients had a history of unintentional OD only (n = 36). Youth with ≥ 2 SUDs were 3 times more likely to have a history of OD compared to youth with 1 SUD (all P < .05). Compared to those without a history of OD, those with an OD were more likely to be female and have lifetime histories of alcohol, cocaine, amphetamine, anxiety, depressive, and/or eating disorders (all P < .05). High rates of OD exist in treatment-seeking youth with SUD. OD was associated with more SUDs and psychiatric comorbidity.

Vendor-based restrictions on pesticide sales to prevent pesticide self-poisoning - a pilot study

BackgroundIn South Asia, up to 20% of people ingesting pesticides for self-poisoning purchase the pesticide from a shop with the sole intention of self-harm. Individuals who are intoxicated with alcohol and/or non-farmers represent 72% of such high-risk individuals. We aimed to test the feasibility and acceptability of vendor-based restrictions on pesticide sales for such high-risk individuals.MethodsWe conducted a pilot study in 14 (rural = 7, urban = 7) pesticide shops in Anuradhapura District of Sri Lanka. A two-hour training program was delivered to 28 pesticide vendors; the aim of the training was to help vendors recognize and respond to customers at high risk of pesticide self-poisoning. Knowledge and attitudes of vendors towards preventing access to pesticides for self-poisoning at baseline and in a three month follow-up was evaluated by questionnaire. Vendors were interviewed to explore the practice skills taught in the training and their assessment of the program.ResultsThe scores of knowledge and attitudes of the vendors significantly increased by 23% (95% CI 15%–32%, p < 0.001) and by 16% (95% CI 9%–23%, p < 0.001) respectively in the follow-up. Fifteen (60%) vendors reported refusing sell pesticides to a high-risk person (non-farmer or intoxicated person) in the follow-up compared to three (12%) at baseline. Vendors reported that they were aware from community feedback that they had prevented at least seven suicide attempts. On four identified occasions, vendors in urban shops had been unable to recognize the self-harming intention of customers who then ingested the pesticide. Only 2 (8%) vendors were dissatisfied with the training and 23 (92%) said they would recommend it to other vendors.ConclusionsOur study suggests that vendor-based sales restriction in regions with high rates of self-poisoning has the potential to reduce access to pesticides for self-poisoning. A large-scale study of the effectiveness and sustainability of this approach is needed.

Overdose and adverse drug event experiences among adult patients in the emergency department

IntroductionOverdose is a leading cause of injury and death in the United States. Emergency Department (ED) patients have an elevated prevalence of substance use. This study describes overdose/adverse drug event experiences among adult ED patients to inform strategies to address overdose risk. MethodsPatients seeking care at a large ED in the city of Flint, Michigan participated in a computerized self-assessment during 2011–2013 (n=4571). Overdose was assessed with a broad definition and included occurrences that could be considered adverse drug events. Among those with this type of experience, additional items assessed symptoms, outcomes, and intent. Results12% reported an overdose history. Of participants' most serious overdoses, 74% were without clear intent for self-harm, although this was true of only 61% of overdoses involving opiates or sedatives, and 52% had symptoms present that indicated that it was life-threatening. Binge drinking on a monthly basis (ORs=1.4) was associated with a medically serious overdose compared to never having an overdose. Compared to no drug use in the last year, use of one drug was associated with an OR of 1.8, two drugs was associated with an OR of 5.8, three drugs was associated with an OR of 8.4, and four or more drugs was associated with an OR of 25.1 of having had a medically serious overdose (all p<0.05). ConclusionsMost overdose experiences among ED patients were without clear intent of self-harm. The ED may be an appropriate setting for efforts to reduce overdose risk, especially among polysubstance users.

Cyanide poisoning in Thailand before and after establishment of the National Antidote Project

Context: Antidote shortage is a global problem. In Thailand, the National Antidote Project (NAP) has operated since November 2010 to manage the national antidote stockpile, educate the healthcare providers on appropriate antidote use, and evaluate antidote usage.Objective: To evaluate the effect of NAP implementation on mortality rate and antidote use in cyanide poisoning cases arising from ingestion of cyanide or cyanogenic glycoside.Methods: This is a retrospective cohort of poisoning cases involving cyanide or cyanogenic glycoside ingestion reported to Ramathibodi Poison Center from 1 January 2007 to 31 December 2015. Mortality rate, antidote use, and appropriateness of antidote use (defined as correct indication, proper dosing regimen, and administration within 90 min) before and after NAP implementation were compared. Association between parameters and fatal outcomes was analyzed.Results: A total of 343 cases involving cyanide or cyanogenic glycoside ingestion were reported to Ramathibodi Poison Center. There were 213 cases (62.1%) during NAP (Project group) and 130 cases (37.9%) pre-NAP implementation (Before group). Implementation of NAP led to increased antidote use (39.9% in Project group versus 24.6% in Before group) and a higher rate of appropriate antidote use (74.1% in Project group versus 50.0% in Before group). All 30 deaths were presented with initial severe symptoms. Cyanide chemical source and self-harm intent were associated with death (OR: 12.919, 95% CI: 4.863–39.761 and OR: 10.747, 95% CI: 3.884–28.514, respectively). No difference in overall mortality rate (13 [10.0%] deaths before versus 17 [8.0%] deaths after NAP) was found. In subgroup analysis of 80 cases with initial severe symptoms, NAP and appropriate antidote use reduced mortality (OR: 0.327, 95% CI: 0.106–0.997 and OR: 0.024, 95% CI: 0.004–0.122, respectively). In the multivariate analysis of the cases with initial severe symptoms, presence of the NAP and appropriate antidote use independently reduced the risk of death (OR: 0.122, 95% CI: 0.023–0.633 and OR: 0.034, 95% CI: 0.007–0.167, respectively), adjusted for intent of exposure, cyanide source, age, and sex.Conclusions: After NAP implementation, both antidote use and appropriate antidote use increased. In cases presenting with severe symptoms, presence of the NAP and appropriate antidote use independently reduced the risk of mortality.

Depressive Symptoms in Women with Gestational Diabetes Mellitus: The LINDA-Brazil Study.

This study aimed to assess the frequency and severity of depressive symptoms and their relationship with sociodemographic characteristics in women with gestational diabetes mellitus (GDM) who participated in the LINDA-Brazil study. We conducted cross-sectional analyses of 820 women with GDM who were receiving prenatal care in the public health system. We conducted structured interviews to obtain clinical and sociodemographic information and applied the Edinburgh Postnatal Depression Scale (EPDS) to assess depressive symptoms. We classified the presence and severity of depressive symptoms using scores of ≥12 and ≥18, respectively. We used Poisson regression to estimate prevalence ratios (PR). Most of the women lived with a partner (88%), 50% were between 30 and 39 years old, 39% had finished high school, 39% had a family income of 1-2 minimum wages, and 47% were obese before their pregnancies. The presence of depressive symptoms was observed in 31% of the women, and severe depressive symptoms were observed in 10%; 8.3% reported self-harm intent. Lower parity and higher educational levels were associated with lower EPDS score. Depressive symptoms were common and frequently severe among women with GDM, indicating the need to consider this situation when treating such women, especially those who are more socially vulnerable. This trial is registered with NCT02327286, registered on 23 December 2014.