1970 Aug; 17 (3):629-644. government site. [Google Scholar] Simpson GR, Bermingham S. Poisoning by carbamate pesticides. In rural Asia, carbamate and organophosphates are often used for intentional self-injurious behaviors and account for an estimated combined 200,000 fatalities per year. Carbamates are typically used as pesticides; however, some also have medical uses. severe vomiting and diarrhea. Organophosphates and carbamates, although different structurally, both inhibit cholinesterase activity. Environmental science and pollution research international. For primary and secondary amines, the acidic CO 2 can react with two moles of amine forming an amine carbamate . Latex gloves do not provide adequate protection for insecticides. Carbamates are N-methyl carbamates derived from a carbamic acid and cause carbamylation of acetylcholinesterase at neuronal synapses and neuromuscular junctions. [patient.info], Epidemiology Frequency United States In the United States, more than 18,000 products are licensed for use, and each year more than 2 billion pounds of pesticides are applied to crops, homes, schools, parks, and forests. PloS one. Arrhythmias such as ventricular extrasystoles, atrial fibrillation, and ventricular fibrillation are evidence of abnormal cardiac rhythm. In: StatPearls [Internet]. 12. It is important to identify the cause of poisoning and manage patients accordingly to avoid instances of death. Carbamates are N-methyl carbamates derived from a carbamic acid and cause carbamylation of acetylcholinesterase at neuronal synapses and neuromuscular junctions. Eddleston M, Szinicz L, Eyer P, Buckley, N (2002) Oximes in Acute Organophosphate Pesticide Poisoning: a Systematic Review of Clinical Trials. Increased acetylcholine levels in the autonomic nervous system increase sympathetic and parasympathetic activity. Human exposure to banned pesticides reported to the French Poison Control Centers: 2012-2016. Data is disputedregarding carbamate toxicity's adequate adsorption by activated charcoal. Rat data shows peak inhibition of cholinesterases by 30 minutes after oral administration. The present invention relates to a derivative compound in which a biphenyl group is introduced into an aminoalkanoic acid, a stereoisomer thereof, or a pharmaceutically acceptable The clinical manifestations of occupational carbofuran poisoning recorded were nausea and vomiting (82.3%). Patients should be closely monitored for respiratory failure due to weakness of respiratory muscles. The carbamate is formed when an uncharged lysine side chain near the ion reacts with a carbon dioxide molecule from the air ( not the substrate carbon dioxide molecule), which then renders it charged, and, therefore, able to bind the Mg 2+ ion. Environ Sci Pollut Res Int. While they possess a similar mechanism of action to the irreversible phosphorylation of acetylcholinesterase by organophosphates, carbamates bind to acetylcholinesterase reversibly. Carbamates typically have a more benign clinical course compared to OP poisonings due to transient cholinesterase inhibition and rapid reactivation of AChE enzymatic activity. Some muscarinic causes of cardio-respiratory failure (bronchorrhoea, bronchospasm, bradycardia. [11] Carbamate formation is a critical step in the formation of biomass from atmospheric carbon dioxide. Guideline: Organophosphate/Carbamate Exposure -Management This document reflects what is currently regarded as safe practice. Pesticide poisoning is the most common cause of OPC and carbamate poisoning as the vast majority of pesticides still contain OPCs and carbamates. Nuclear medicine, 1977 Feb [PubMed PMID: 23957083]. Suicidal mode of poisoning was most common in our patients and constituted 63.20%. Indian J Occup Environ Med. 3. For Organophosphate poisoning only - reactivates AChE by removing phosphate group oxime-OP complex then excreted by kidneys. [3], Acetylcholinesterase (AChE) normally hydrolyzes acetylcholine to acetic acid and choline, leading to the cessation of neurotransmitter signaling. A study analyzed 115 patients exposed to organophosphate poisoning and compared their clinical presentation and findings on ECG. This site complies with the HONcode standard for trustworthy health information: verify here. In this instance, nasogastric lavage can be instituted. JavaScript is disabled in your web browser. Studies are limited for initially assessing patient morbidity and mortality. All rights reserved. degrdn., toxicity, fugitive . DDT has been formulated in multiple forms, including solutions in xylene or petroleum distillates, emulsifiable concentrates, water-wettable powders, granules, aerosols, smoke candles and charges for vaporizers and lotions.. From 1950 to 1980, DDT was extensively used in agriculture - more than 40,000 tonnes each year worldwide - and it has been estimated that a total . This type of blood analysis is inexpensive but inconvenient in terms of time taken to obtain the results. Common agents resulting in toxic exposure are aldicarb, carbofuran, carbaryl, ethinenocarb, fenobucarb, oxamyl, methomyl, pirimicarb, propoxur, and trimethacarb. Kb billet Kb ssonkort Bliv partner Book arrangement Kontakt os Se din profil. Chlorpyrifos, the organophosphate agent of dursban, is found in some popular household roach and ant sprays, including Raid and Black Flag ( figure 2 ). Summarize interprofessional team strategies for improving care and outcomes in patients with carbamate toxicity. EC Microbi-ology 11.3 (2017): 106-113. . We do not control or have responsibility for the content of any third-party site. Some experts recommend administering 1 g/kg of single-dose activated charcoal if the patient presents within 1 hour of a massive life-threatening GI ingestion. -. Morais S, Dias E, de Lourdes Pereira M. Carbamates: Human Exposure and Health Effects. Of these manifestations, muscle fasciculations and weakness are typical. organophosphate poisoning carbamate poisoning insecticides Received March 2, 1987. While laboratory testing is available, results often take many hours to return, and lifesaving treatments should be instituted before laboratory diagnosis. Learn more about the MSD Manuals and our commitment to Global Medical Knowledge. Medical providers should avoid self-contamination by wearing personal protective equipment (PPE). Supportive therapy is key. The administration of oximes, acetylcholinesterase reactivators, in carbamate poisoning is controversial because of the potential toxicity of oximes in conjunction with carbamate . Centers for Disease Control (CDC). [authorstream.com], Seizures controlled with benzodiazepines. Medical Supervision of Pesticide Workers: Guidelines for Physicians. They inhibit plasma and red blood cell (RBC) cholinesterase, preventing breakdown of acetylcholine, which then accumulates in synapses. Accepted May 5, 1987. involuntary urination and defecation. During 2003, pesticide poisoning accounted for 4.5% of deaths and ranked the sixth leading cause of death in Sri Lanka. Organophosphates and carbamates are common insecticides that inhibit cholinesterase activity, causing acute muscarinic manifestations (salivation, lacrimation, urination, diarrhea, emesis, The clinical manifestations of occupational carbofuran poisoning recorded were nausea and. Carbamate toxicity Contents 1 Background 2 Clinical Features 2.1 Autonomic Nervous System Receptors and Their Effects 3 Differential Diagnosis 3.1 SLUDGE Syndrome 3.2 Weakness 3.3 Chemical weapons 3.4 Symptomatic bradycardia 4 Evaluation 5 Management 5.1 Decontamination 5.2 Supportive Care 5.3 Antidotes 6 Antidotes 6.1 Atropine 6.2 Pralidoxime One prospective trial of acutely poisoned patients with either OPs or carbamates found that a Glasgow comascore of less than 13 on presentation was indicative of a poor prognosis. 34. Special Considerations: Special Considerations O rganophosphates are usually dissolved in hydrocarbon bases; thus, the clinician should consider hydrocarbon pneumonitis and not to do, Once the patient is stable and atropinised, consider careful brief, There is no reason to use a large-bore oro-, All three family members developed symptoms that were compatible with cholinesterase inhibition: headache, lightheadedness, wheezing, shortness of breath, nausea, and, Cardiac arrhythmias, including heart block and QTc prolongation may be due to, Less than 30 min after tracheal extubation, the patients respiratory status worsened because of major. Presentation Nicotinic alkaloids such as nicotine and coniine cause similar symptoms to carbamate toxicity with CNS excitation, autonomic activation, and skeletal muscle stimulation via ganglionic autonomic stimulation of the parasympathetic and sympathetic nervous systems as well as the nicotinic receptors on skeletal muscle. Given the shorter duration of carbamate toxicity, data assessing mortality, ventilator days, and healthcare cost are likely representative of OP poisonings. Hansen S R 1995 Management of organophoshate and carbamate toxicoses. [ 4 ] This is a significant problem which may also affect children and further research in this field is necessary. Remove the person from the source of exposure to prevent further poisoning. Patients with CNS toxicity can present with altered mental status and may be unable to provide a detailed history on presentation. Pralidoxime (2-PAM) is given after atropine to relieve neuromuscular symptoms. Subsequently, carbamates have a similar toxicological presentation to OP poisonings with a duration of toxicity that is typically less than 24 hours. A presence of prolonged QT interval should be investigated as it is pathognomic for carbamate poisoning [3]. In the United States, consider contacting the regional poison center at 1-800-222-1222 for assistance with patient management as well as providing data for epidemiologic purposes. [emedicine.medscape.com], The rapid and effective stabilisation and treatment of pesticide-poisoned patients on their admission should reduce the number of early deaths, improve the prognosis for surviving patients over the next few days, and reduce the number and severity of Due to the continued cutaneous absorption of carbamate pesticides, decontamination should take place as soon as possible. Copyright 2022 Merck & Co., Inc., Rahway, NJ, USA and its affiliates. According to the Annual Health Statistics 2007 In: StatPearls [Internet]. Symptoma is a Digital Health Assistant & Symptom Checker. These insecticides inhibit the enzyme acetylcholinesterase (AChE), producing an 'acute cholinergic crisis' with reduced consciousness, bradycardia, Consider volume resuscitation with normal saline or ringer to treat Bradycardia and. . All clothing should be removed from the patients, and the skin should be triple-washed with water, then soap and water, and then rinsed again with water. [4] Occupational exposure is known Chronic neuropathy may develop. Objectives: Identify the etiology of carbamate toxicity. Berkeley, California, 1988. We previously found that ziram, a carbamate pesticide, significantly reduced perforin, granzyme A (GrA), granzyme B (GrB), granzyme 3/K (Gr3/K), and granulysin (GRN) levels in NK-92MI cells, a huma. The trusted provider of medical information since 1899, Organophosphate Poisoning and Carbamate Poisoning, Last full review/revision Jun 2022| Content last modified Sep 2022, Organophosphates and carbamates are common insecticide ingredients that inhibit cholinesterase activity, causing acute muscarinic manifestations (eg, salivation, lacrimation, urination, diarrhea, emesis, bronchorrhea, bronchospasm, bradycardia, miosis) and some nicotinic symptoms, including muscle fasciculations and weakness. The most effective agents were vitamin C, curcumin, vitamin E, quercetin, selenium, chrysin, and garlic extract. Patients need to have continued monitoring for potential respiratory failure, requiring mechanical ventilation after atropine administration. Results: Out of a total of 1258 Organophosphorous poisoning cases, males were (34.5%) and females were (65.5%). [patient.info], There is little evidence of risk to healthcare workers from managing OP poisoned patients as long as universal precautions are followed see refs 5, 6 below Prognosis Varies markedly. Use if neuromuscular dysfunction is present. 5. Most patients have bradycardia and, if poisoning is severe, hypotension. Dermal exposure can also be very toxic. In Bonagura J D, Kirk R W (ed) Kirk's Current Veterinary Therapy 12th Edition W B Saunders Co, Philadelphia 245 - 248 17. Some organophosphates were developed as nerve agents Nerve Chemical-Warfare Agents Nerve agents are chemical-warfare agents that act directly at nerve synapses, typically increasing the activity of acetylcholine. Identify the etiology of carbamate toxicity. Pharmacology 101 e OrganoPhosphate Poisoning Treatment Carbamate ECG may reveal tachycardia or rarely bradycardia. Body mass index as a prognostic factor in organophosphate-poisoned patients. Symptoms vary, but certain common syndromes may suggest particular classes of poisons. Carbamates cause reversible inhibition of the acetylcholinesterase enzyme,which is present at parasympathetic and sympathetic ganglia, parasympathetic muscarinic terminal junctions, sympathetic fibers located in sweat glands, and nicotinic receptors at the skeletal neuromuscular junction. As you may know, people have look numerous times for their favorite novels like this . Combined,these two classes of insecticides are calculated to require between 1 million and 2 million ventilator days every year and account for a large burden of morbidity, mortality, and medical expenses worldwide. Multiple-dose activated charcoal in acute self-, Laudari S, Patowary BS, Sharma SK, Dhungel S, Subedi K, Bhattacharya R, et al. Masterclass. Brndbyernes Idrtsforening Brndby Support Fanafdelingen Brndby Tifo. Persistently elevated acetylcholine levels due to AChE inhibition lead to increased neurotransmitter signaling. II. Carbamates can also produce the intermediate syndrome seen in OP poisonings but do not lead to chronic toxicity or delayed syndromes, as carbamate bonds are hydrolyzed from acetylcholine spontaneously and rarely cause symptoms after 24 to 48 hours. Those who developed ventricular tachycardia died regardless of appropriate medical management. It is important to remember that the adrenergic symptoms of tachycardia, hypertension, and mydriasisalsomay be present due to acetylcholine-dependent activation of nicotinic receptors in sympathetic ganglia. Carbamate is a pesticide derived from carbamic acid and primarily affects nerve impulse transmission. Summarize interprofessional team strategies for improving care and outcomes in patients with carbamate toxicity. Patterns of hospital transfer for self-poisoned patients in rural SriLanka: implications for estimating the incidence of self-poisoning in the developing world. Handb Clin Neurol. decontamination respiratory evaluation, and if necessary, intubation atropine administration, often at large doses, to reduce cardiopulmonary symptoms; This must be done before "aging" occurs - conformational change that makes OP bond to AChE irreversible, Pralidoxime can actually bind and inhibit AChE once all AChE enzymes have aged, and can make the toxicity worse, Window to aging depends on the agent, and is a matter of debate, but pralidoxime within 1-2 hours of exposure is the goal, Adult: 1-2gm IV over 15-30min; repeat in 1 hour if needed, Child: 20-40mg/kg IV over 20min; repeat in 1 hour if needed, Admit all patients with respiratory or CNS compromise and all who require atropine. Providers should wear appropriate PPE during decontamination. Telephone: (415)-540-3063. Howland M A, Aaron C K 1994 . Intravenous infusion of sodium bicarbonate has shown to have beneficial effects in OP poisoning by helping in moderate alkalinization (blood pH between 7.45 and 7.55) in a dose of 5 mEq/ kg in 60 min followed by 5-6 mEq/kg/day [ 1, 7 ]. These therapies are also discussed in greater detail in the fifth edition of Recognition and Management of Pesticide Poisonings. Rezaie A, Abdi M, Abdollahi M. Benefits of magnesium sulfate in the management of acute human poisoning by organophosphorus insecticides. 2015;131:149-68. doi: 10.1016/B978-0-444-62627-1.00010-X. Vomitus and diarrhea may cause cutaneous absorption in providers in cases of GI ingestions. MeSH 1988;81:121-126. An official website of the United States government. The American journal of emergency medicine. Some are used medically to reverse neuromuscular blockade (eg, neostigmine, pyridostigmine, edrophonium) or to treat glaucoma (echothiopate), myasthenia gravis (pyridostigmine), and Alzheimer disease (tacrine and donepezil). Limited data exist evaluating the efficacy of benzodiazepines for seizures secondary to insecticide poisonings, as seizures are uncommon in large case series of carbamate andOP toxicity. [ 4 ] This is a significant problem which may also affect children and further research in this field is necessary. Gastric lavage. Clinical toxicology (Philadelphia, Pa.). 2014 Jul [PubMed PMID: 24856742], Yang PY,Tsao TC,Lin JL,Lyu RK,Chiang PC, Carbofuran-induced delayed neuropathy. Acetylcholinesterase is reversibly inhibited, leading to increased acetylcholine neurotransmission and resulting in parasympathetic symptoms (DUMBBELS: defecation, urination, miosis, bronchospasm, or bronchorrhea, emesis, lacrimation, salivation) as well as potential sympathetic symptoms of tachycardia and hypertension. Pathophysiology Organophosphates and carbamates are absorbed through the gastrointestinal tract, lungs, and skin. Cases of carbamate poisoning may have predominate parasympathetic symptoms. J Assoc Off Anal Chem. While they possess a similar mechanism of action to the irreversible phosphorylation of acetylcholinesterase by organophosphates, carbamates bind to acetylcholinesterase reversibly. However, when faced with undifferentiated insecticide toxicity, pralidoxime can be given, as administration in carbamate toxicity is unlikely to be detrimental, and the benefit for OP intoxication is well described. Organophosphate and carbamate insecticides are responsible for 100,000+ deaths worldwide, particularly in developing countries due to its availability. In cases of undifferentiated insecticide toxicity, treat empirically, as if it is outpatient ingestion, as pralidoxime is unlikely to be harmful in carbamate toxicity. Worldwide, acute pesticide poisoning is causing major health problems with high mortality in developing countries.Objective: The objective of our study was to establish that early management of acute poisoning with organophosphorus and carbamate in ICU along with ventilatory support in severe respiratory distress reduces the mortality rate . drooling or excessive phlegm. . Based on the pharmacokinetics of various carbamates encountered, rapid symptom onset secondary to dermal exposure is possible. The specific toxin should be identified if possible. . Central nervous system symptoms from increased acetylcholine include confusion, delirium, hallucinations, tremor, and seizures. Adverse effects of pralidoxime: dizziness. More serious findings included prolonged QT interval, polymorphic ventricular tachycardia (VT) which manifested in five patients and ventricular fibrillation (VF) that was found in 3 patients. Most patients will experience complete recovery within 24 hours. Pralidoxime (2-PAM) is commonly given to patients with OP toxicity early in the presentation to prevent the aging process as OPs irreversibly bind to AChE. However, the potential benefit from oxime therapy in aldicarb poisoning has been described. Adverse effects of pralidoxime: dizziness, headache, Symptoms of paradichlorobenzene poisoning: STOMACH AND INTESTINES Diarrhea. Neoprene or nitrile gloves provide adequate protection from cutaneous exposures, and the provider should wear full PPE with a minimum of a gown, mask, and face shield. Poison Management of Carbamate The carbamate insecticides act similarly to the Intubation often needed due to significant respiratory secretions / bronchospasm. Studies have shown potentially increased AChE inactivation if pralidoxime is administered in cases of carbaryl poisoning. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. -, Patel S, Sangeeta S. Pesticides as the drivers of neuropsychotic diseases, cancers, and teratogenicity among agro-workers as well as general public. Exposures can occur from cholinomimetic medications such as carbachol, methacholine, and pilocarpine or nonpharmacologic agents such as muscarine-containing mushrooms. [utexas.influuent.utsystem.edu], Pneumonitis and/or atelectasis developed in ten patients, including six who had ingested a petroleum distillate-containing insecticide. Pediatric cases caused by playing on a sporting field after insecticide spraying have been reported. One, sarin, has been used by terrorists. Prophylactic diazepam may help prevent neurocognitive sequelae after moderate to severe organophosphate poisoning. This site needs JavaScript to work properly. Management of acute childhood poisonings caused by selected insecticides and herbicides. Organophosphorus and carbamate insecticide poisoning. The patient reported taking the following medications: morphine SA 30 mg bid, meloxicam 15 mg daily, amitriptyline 100 mg qhs, amlodipine 5 mg daily, hydrocodone/acetaminophen 5/325 mg q12h prn, atorvastatin 20 mg qhs, omeprazole 20 mg qam, senna 187 mg daily prn, psyllium 1 packet dissolved in water daily prn, and cholecalciferol 1,000 IU daily. Symptoms of Carbamates Poisoning in Dogs Instead, paralysis should be induced using nondepolarizing neuromuscular blockers such as rocuronium. Carbamates are cleared spontaneously within about 48 hours after exposure. Although OPC and carbamates are structurally distinct, they have similar clinical manifestations and generally require the same management. Organophosphates and carbamates are absorbed through the gastrointestinal tract, lungs, and skin. Levels of butyrylcholinesterase (BuChE) and red cell acetylcholinesterase (RBC AChE) can be obtained in the evaluation of potential OP and carbamate toxicity. Succinylcholine is absolutely contraindicated, Dosing with atropine and pralidoxime are time dependent and provides ability to reverse symptoms while awaiting agent metabolism. Initial dosage is 2 to 5 mg IV (0.05 mg/kg in children); the dose can be doubled every 3 to 5 minutes as needed. Muscarinic toxidrome with prominent respiratory findings, pinpoint pupils, muscle cramping, and weakness. The time to symptom onset is dependent on the exposure dose and the toxicity of the given carbamate. 2014 Jul;32(7):693-6. Liquid chromatographic determination of N-methylcarbamate insecticides and metabolites in crops. Toxicity from cholinesterase inhibitors for the treatment of Alzheimer dementia (i.e., donepezil) is rare. [ 5 ]. 1974;99(42):2106-2108. doi:10.1055/s-0028-1108097. 1. Organophosphate and carbamate poisonings: affects cholinesterase level (acetylcholinesterase), which inactivates acetylcholine and results in pesticide-poisoning symptoms such as fatigue, lightheadedness, nausea, vomiting, headaches, and seizures. Other chemical agents were used in combat before World War II read more . 2015; [PubMed PMID: 26563788], Boucaud-Maitre D,Rambourg MO,Sinno-Tellier S,Puskarczyk E,Pineau X,Kammerer M,Bloch J,Langrand J, Human exposure to banned pesticides reported to the French Poison Control Centers: 2012-2016. Do not wait for labora-tory conrmation. For topical exposure, clothes are removed, and the body surface is flushed thoroughly. Organophosphates and carbamates are common causes of poisoning and poison-related deaths worldwide. Water Environ Res. toxicology-of-organophosphate-carbamate-pesticides 2/25 Downloaded from stats.ijm.org on October 31, 2022 by guest among others. poisoning . This review identifies 24 ameliorating agents that were successfully used to manage 60 cases. Carbamates are a class of insecticides structurally and mechanistically similar to organophosphate (OP) insecticides. Organophosphorus Poisoning Current Management Guidelines Thank you for downloading Organophosphorus Poisoning Current Management Guidelines. Carbamates are a class of insecticides structurally and mechanistically similar to organophosphate (OP) insecticides. Journal of toxicology. Pneumonitis and/or atelectasis developed in ten patients, including six who had ingested a petroleum distillate-containing insecticide. These resources may provide guidance with long-term management decisions, such as discontinuation of atropine, and are important resources for data collection and analysis. MANAGEMENT (Pralidoxime) : MANAGEMENT ( Pralidoxime ) 25-50 mg/kg IV in 100 ml NS over 30 min. Carbamate poisoning cases are most often related to intentional oral ingestion or dermal occupational exposure. Emergency signs of . CARBAMATE POISONING BY, FAREED 1. This information may be more readily available than BuChE or RBC AChE levels. [aafp.org], YOU MIGHT ALSO LIKE 41 terms Clinical Toxicology Exam 2: Quiz Questions 46 terms Approach to the Dog & Cat with Epileptic Seizures OTHER SETS BY THIS CREATOR 8 terms Chi Institute Master Points 28 terms Chi Institute Back shu/Front mu points 41 terms [quizlet.com], The daughters symptoms had also decreased but she still experienced nausea, headache, sore throat, and some wheezing when in the apartment. Hayes WJ., Jr Epidemiology and general management of poisoning by pesticides. Moderate poisonings will necessitate 24 hours of observation, and patients requiring atropine should be admitted to a monitored setting for continued assessment of their respiratory status. [link.springer.com], You should call if you have any questions about poisoning or poison prevention. Thus, it is important to document the electrical potentials of the heart on electrocardiogram (ECG). Treasure Island (FL): StatPearls Publishing; 2022 Jan. Would you like email updates of new search results? In the developing world, cases of large outbreaks from contaminated food and crops have been reported. [medlineplus.gov], ABC's, Oxygen if needed Decontaminate skin, eyes to prevent ongoing absorption: remove clothes thoroughly cleanse skin - at least 2 separate water & detergent washes will remove up to 94% of residual organoP, even if done up to 6hrs after exposure; consider While they possess a similar mechanism of action to the irreversible phosphorylation of acetylcholinesterase by organophosphates, carbamates bind to acetylcholinesterase reversibly. 9. Symptoma empowers users to uncover even ultra-rare diseases. 10 subjects had euglycemia associated with, The toxic agent was determined to be a carbamate insecticide, for which, The activity of BChE correlates with the severity of poisoning and is a good tool to elucidate a, RBC cholinesterase level correlates better with severity and, There is little evidence of risk to healthcare workers from managing OP poisoned patients as long as universal precautions are followed see refs 5, 6 below, Although most patients with OPC and carbamate poisoning have a good, The rapid and effective stabilisation and treatment of pesticide-poisoned patients on their admission should reduce the number of early deaths, improve the, [] pesticides can lead both to depressive and anxiety disorders and also to cognitive defects (unrelated to psychiatric disorders). High lethality and minimal variation after acute self-poisoning with carbamate insecticides in Sri Lanka - implications for global suicide prevention.
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