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Active surveillance of acute pesticide poisonings in a potato-growing region of highland Ecuador during 1991-1992 uncovered a rate of 171/100,000, due predominantly to occupational exposures to organophosphate and carbamate pesticides. Occupational exposure among agricultural workers was the most common reason for poisoning (32 male workers and 1 female worker, out of a total of 50 cases). Of these 33 cases, 28 of them reported pesticide application as the work task just prior to poisoning, with over 80% citing the use of World Health Organization Hazard Category I pesticides. The suicide rate of 17.1/100,000 and the overall mortality rate of 20.5/100,000 that we found are among the highest reported anywhere in the world. At the exchange rates prevailing at that time, median costs associated with these poisonings were estimated as follows: public and social security health care direct costs of US$ 9.85/case; private health costs of US$ 8.33/case; and lost-time indirect costs of US$ 8.33/agricultural worker. Each one of those costs was over five times the daily agricultural wage, which was then about US$ 1.50. Further costing of pesticide poisonings should be carried out in other settings to provide appropriate information for decisions about pesticide use. In addition, integrated pest management should be further evaluated as an appropriate technology to reduce the economic burden of illness from pesticide poisonings in developing countries.

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To explore the peripheral nervous system effects of regular agricultural pesticide use, a cross-sectional survey was conducted in highland Ecuador. Participants were 144 occupationally exposed farm members, 30 female farm members with little direct exposure, and 72 unexposed local town residents, frequency matched to the exposed people on age, sex, and education. Organophosphorus and carbamate insecticides and dithiocarbamate fungicides accounted for the majority of pesticide applications, with leaking backpack sprayers, minimal use of personal protective equipment, and frequent dermal contact being the norm. In polytomous logistic regression analyses, applicators had significantly greater odds for more current peripheral nerve symptoms (odds ratio OR = 3.1), signs of poor coordination (OR = 4.3), abnormal deep tendon reflexes (OR = 2.9), and reduced power (OR = 2.1) compared to controls. Mean toe vibration threshold scores, on a logarithmic scale, were significantly higher among applicators (beta = 0.035) and those reporting previous pesticide poisonings (beta = 0.074). Such indicators of peripheral nervous system effects may be due to a variety of factors, including high pesticide exposure conditions.

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International researchers have urged greater use of simple neurobehavioral batteries in developing country settings where higher levels of exposure and a variety of cultural and demographic factors may both occur. We conducted a cross-sectional survey of 144 farm members and 72 age and education frequency-matched controls from rural Ecuador, using an amplified Neurobehavioral Core Test Battery. Farm members ranged from those with only indirect pesticide contact to applicators regularly applying organophosphate and carbamate insecticides by backpack sprayer. The distributors of scores showed those with less than 4 years of formal education and at the extremes of age (< 16 or > 65 years old) contributed sufficiently to nonnormality that they had to be excluded from subsequent analyses (resultant n = 170). After adjustment for age and education, language-based IQ test scores and farm membership were the most consistent determinants of neurobehavioral outcomes. Visual-spatial tasks were the most sensitive to the effects of farm membership. Gender (women better than men), alcohol problems, and solvent use were also important for some neurobehavioral tests.

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Using a cross-sectional survey of potato farm workers in northern Ecuador, we examined the relationship between pesticide exposure and skin disorders. From a farm population census, all pesticide applicators and 1/2 of exposed field workers were selected. Controls were age-matched from urban occupations. Individual exposure measures included overall years and current hours working with pesticides. Farm-level measures included numbers of applications over the last 6 months and an application practices score (range 0-4). Each participant underwent a clinical skin examination, with patch tests to maneb on a sample of dermatitis cases. Exposure-related increases in conjunctivitis (7% of applicators, 0% in other groups), dermatitis (68% of exposed and 55% of applicators versus 31% of controls, p < 0.001) and pigmentation disorders (25% of exposed and applicators vs 10% controls, p = 0.06) were found. Among dermatitis cases (n = 117), 5% were positive to maneb on patch testing. In logistic regression analysis, significant predictors (p < 0.1) of dermatitis included years using fungicides (OR = 1.12 per year) and poor application practices (OR = 1.42 per score unit). Agricultural fungicide application in high-exposure situations can contribute to dermatitis prevalence among farm populations.

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To test the hypothesis that high-dose vitamin D2 supplementation would result in a lower incidence of radiographically detectable bone disease, we randomly assigned 40 very low birth weight infants to a control group who received vitamin D2 in a dosage of 400 IU/day and 41 to an experimental group who received a dosage of 2000 IU/day. After 6 weeks, radiographs from all infants were scored blindly for degree of radiographic bone disease, and serum osteocalcin and 25-hydroxyvitamin D levels were measured. Mean vitamin D intake was 360 +/- 141 (SD) IU/day in the control group and 2170 +/- 144 (SD) IU/day in the experimental group. Median 6-week serum 25-hydroxyvitamin D levels were 24 ng/ml (range 3 to 60 ng/ml) in the control group and 68 ng/ml (range 9 to 150 ng/ml) in the experimental group (p less than 0.001). Overall, 20% of the infants had evidence of moderate radiographic bone disease and only 2% were severely affected. The radiographic bone score (median = 2.5) and serum osteocalcin concentration (mean = 21.7 +/- 8.7 ng/ml) in the control subjects did not differ significantly from those in the experimental group (median bone score = 2.0; mean osteocalcin level = 24.1 +/- 7.9 ng/ml). Although there may be a subset of very low birth weight infants who would benefit from high doses of vitamin D, we conclude that no generalized clinical improvement can be attributed to this regimen alone.

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We report two infants with bone deformities and multiple fractures reminiscent of osteogenesis imperfecta, but also having ocular proptosis with orbital craniosynostosis, hydrocephalus, and distinctive facial features. Both infants were normal at birth, but multiple compression fractures of the long bones were noted shortly thereafter, followed by extensive demineralization and culminating in recurrent diaphyseal fractures of the weight-bearing bones before the first birthday. The striking similarity of both the distinctive dysmorphic features and the unique pattern of fractures in two unrelated individuals suggests that this is a previously unrecognized form of osteogenesis imperfecta. Despite the craniosynostosis and hydrocephalus, intellectual performance is unimpaired in both individuals. Bone biopsy in one patient revealed decreased bone volume and increased bone resorption without compensatory new bone formation. Extensive laboratory investigations have not identified a cause, nor have they clarified pathogenesis; further elucidation will require the identification and study of new cases.

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We surveyed both normal children and patient populations to identify the effects of metabolic bone disease and impaired renal function on serum levels of osteocalcin, a vitamin K-dependent protein synthesized in bone. Cord blood osteocalcin was nearly double that of maternal osteocalcin, but there was no correlation between the two. Infants with Apgar scores less than or equal to 7 had a lower mean serum osteocalcin value (8.7 ng/ml, n = 8) than did those with scores of 8 to 10 (16.6 ng/ml, n = 38). Serum osteocalcin elevation coincided with the pubertal growth spurt. In boys, levels decreased to adult values by 18 years of age, as do other indices of bone metabolism; in girls, the levels decreased earlier and had a less pronounced maximum. In children with renal failure, osteocalcin was substantially increased, presumably because of diminished renal clearance of the protein. Children receiving peritoneal dialysis, however, had mean serum concentrations less than half of those seen in children receiving hemodialysis (117 vs 328 ng/ml). The peritoneal dialysate contained significant amounts of osteocalcin, but none was detectable in hemodialysate. Correlation between bone disease and serum osteocalcin was evident in a longitudinal study of one patient with renal failure. Children with various forms of rickets had elevated osteocalcin levels; hypoparathyroidism and osteoporosis were accompanied by variable changes. Serum osteocalcin holds promise as a useful marker of subacute changes in bone metabolism.

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