Accidental and suicidal adolescent poisoning deaths in the United States, 1979-1994

Hospitalizations and deaths related to adverse drug events worldwide: Systematic review of studies with national coverage

PURPOSE

Adverse drug events are related to negative outcomes in healthcare, including hospitalization, increased duration of hospital stay and death. The aim of this study was to conduct a systematic review to evaluate hospitalizations and deaths related to adverse drug events worldwide, reported in studies with national coverage.

METHODS

The protocol was registered in PROSPERO (CRD42020157008). We performed a systematic search on Medline, Embase, CINAHL, LILACS, and the Cochrane Library (until March 2020) using pre-specified terms. We included published studies that reported data on hospitalizations and/or deaths related to adverse drug events from a national perspective and the use of secondary data as a source of information. Two reviewers independently extracted and synthesized data. The quality of the studies was assessed using an adapted version of the Joanna Briggs Institute critical appraisal checklist for prevalence studies. Narrative summaries of findings were undertaken.

RESULTS

Among 59,336 citations, 62 studies were included for data extraction and synthesis. Among these studies, 41 studies included the outcome of hospitalization, 16 included the death outcome, and five included both outcomes. Administrative databases regarding discharges and registries of vital statistics were the most common sources of information. The relative frequency of hospitalizations ranged from 0.03% to 7.3%, and from 9.7 to 383.0/100,000 population, whereas mortality rate ranged from 0.1 to 7.88/100,000 population.

CONCLUSION

Our study highlights information about adverse drug events using large administrative databases in a national scenario and provides an overview of databases and methods implemented to detect adverse drug events.

Mortality in a cohort of 3.1 million children, adolescents and young adults

BACKGROUND

Many youth deaths occur in the first year of life, from prematurity and anomalies. Detailing mortality after age 1 year may differentially guide preventive strategies in children, adolescents and young adults.

METHODS

A cohort study in Ontario, Canada comprised 3 139 698 children born from 1990 to 2016. Adjusted HR (aHR) for death between 1 and 24 years were generated, comparing demographic variables and parity.

RESULTS

After a median of 13.7 years of follow-up, 6930 deaths occurred between ages 1 and 24 years (incidence rate 17.0 per 100 000 person-years), peaking at age 23 years (43.7 per 100 000). The aHR for death was higher among males than females (1.44, 95% CI 1.37 to 1.51), rural versus urban areas (1.48, 95% CI 1.39 to 1.58), lowest versus highest income areas (1.39, 95% CI 1.29 to 1.51) and at parity 1 (1.16, 95% CI 1.10 to 1.23), parity 2 (1.34, 95% CI 1.23 to 1.45), parity 3+ (1.96, 95% CI 1.74 to 2.21), each relative to a child without an older sibling. Among males, the proportion of deaths due to injury jumped from 30% before age 15 years to 65% thereafter, and in females, from 28% to 51%. Intentional self-harm/assault explained 11% of injury-related deaths among males before age 15 years, and 20% thereafter, with respective figures of 18% and 17% for females. Deaths outside of hospital increased with age, from 35% at age 1 year, to 66% at age 22 years.

CONCLUSION

There is a heightened susceptibility of dying starting at age 15 years, especially among males, from injury, and arising outside of hospital.

Trend of years of life lost due to suicide in Iran (2006-2015)

OBJECTIVES

Suicide is a major global public health problem and much burden in the societies. This study aims to calculate the years of life lost (YLL) due to suicide and investigate its trend in Iran.

METHODS

Information on deaths due to suicide in Iran was extracted from Iran Legal Medicine Organization. The years of life lost was calculated in each year according to gender and age-groups. To examine the trend for different years, joinpoint regression was used.

RESULTS

The 35,297 deaths due to suicide were recorded in 2006-2015. The total YLL in the 10-year period was 34.52 per 1000 persons in males, 13.61 per 1000 persons in females and 23.35 per 1000 persons in both sexes. Hanging comprised the largest YLL of suicide. The annual percent change of YLL rate was 3.3%.

CONCLUSIONS

The results revealed that male shows an increasing trend in YLL specifically among youth and adult, while there is no improvement in females. There is a national need to implement an effective health policy intervention in Iran.

Suicide and self-inflicted injury hospitalizations in Canada (1979 to 2014/15)

INTRODUCTION

The purpose of this paper is to describe the trends and patterns of self-inflicted injuries, available from Canadian administrative data between 1979 and 2014/15, in order to inform and improve suicide prevention efforts.

METHODS

Suicide mortality and hospital separation data were retrieved from the Public Health Agency of Canada (PHAC) holdings of Statistics Canada's Canadian Vital Statistics: Death Database (CVS:D) (1979 to 2012); Canadian Socio-Economic Information Management System (CANSIM 2011, 2012); the Hospital Morbidity Database (HMDB) (1994/95 to 2010/11); and the Discharge Abstract Database (2011/12 to 2014/15). Mortality and hospitalization counts and rates were reported by sex, 5-year age groups and method.

RESULTS

The Canadian suicide rate (males and females combined, all ages, age-sex standardized rate) has decreased from 14.4/100 000 (n = 3355) in 1979 to 10.4/100 000 (n = 3926) in 2012, with an annual percent change (APC) of -1.2% (95% CI: -1.3 to -1.0). However, this trend was not observed in both sexes: female suicide rates stabilized around 1990, while male rates continued declining over time-yet males still accounted for 75.7% of all suicides in 2012. Suffocation (hanging and strangulation) was the primary method of suicide (46.9%) among Canadians of all ages in 2012, followed by poisoning at 23.3%. In the 2014/15 fiscal year, there were 13 438 hospitalizations in Canada (excluding Quebec) associated with self-inflicted injuries-over 3 times the number of suicides. Over time females have displayed consistently higher rates of hospitalization for self-inflicted injury than males, with 63% of the total. Poisoning was reported as the most frequent means of self-inflicted harm in the fiscal year 2014/15, at 86% of all hospitalizations.

CONCLUSION

Suicides and self-inflicted injuries continue to be a serious - but preventable - public health problem that requires ongoing surveillance.

Aggressiveness across development and suicidal behavior in depressed patients

The objective of this study was to determine differences in the pathway of aggressiveness across development between depressive subjects and normal controls, and to examine males and females separately with regard to level of aggression and suicidal behavior among depressed subjects. Participants were classified into 5 groups: depressed suicide attempters (DSA; n = 339), depressed non-suicide attempters (DNSA; n = 92), psychiatric controls who had attempted suicide (PSA; n = 188), psychiatric controls who had not attempted suicide (PNSA; n = 222), and normal controls (NC; n = 532). The level of aggressiveness across development in the different groups was examined using a 5 (DSA vs. DNSA vs. PSA vs. PNSA vs. NC)×3 (Childhood, Adolescence, and Adulthood) MANCOVA. Adjusted and separate models for males and females were conducted. Depressed subjects differed in severity of aggressiveness. The level of aggressiveness in individuals in the NC group remained stable across development, while subjects in the DSA and DNSA groups showed significantly higher levels of aggressiveness. This finding was also observed in subjects of the PSA and PNSA groups. The level of aggressiveness in males with depression significantly increased over time. In women, increasing levels of aggressiveness across development were only observed in depressed suicide attempters. Limitations of this study included use of semi-structured interview for the assessment of risk factors. We found significant differences in severity and in the pathway of aggressiveness across development between depressive subjects and normal controls. In addition, sex differences regarding level of aggression and suicidal behavior among depressed subjects were found.

Antidotes for toxicological emergencies: a practical review

PURPOSE

Appropriate therapies for commonly encountered poisonings, medication overdoses, and other toxicological emergencies are reviewed, with discussion of pharmacists' role in ensuring their ready availability and proper use.

SUMMARY

Poisoning is the second leading cause of injury-related morbidity and mortality in the United States, with more than 2.4 million toxic exposures reported each year. Recently published national consensus guidelines recommend that hospitals providing emergency care routinely stock 24 antidotes for a wide range of toxicities, including toxic-alcohol poisoning, exposure to cyanide and other industrial agents, and intentional or unintentional overdoses of prescription medications (e.g., calcium-channel blockers, β-blockers, digoxin, isoniazid). Pharmacists can help reduce morbidity and mortality due to poisonings and overdoses by (1) recognizing the signs and symptoms of various types of toxic exposure, (2) guiding emergency room staff on the appropriate use of antidotes and supportive therapies, (3) helping to ensure appropriate monitoring of patients for antidote response and adverse effects, and (4) managing the procurement and stocking of antidotes to ensure their timely availability.

CONCLUSION

Pharmacists can play a key role in reducing poisoning and overdose injuries and deaths by assisting in the early recognition of toxic exposures and guiding emergency personnel on the proper storage, selection, and use of antidotal therapies.

Analysis of suspected suicides using poison center data

Although there has been extensive research into the epidemiology and prevention of suicide, there continues to be a paucity of research on non-fatal suicides, in particular persons not treated in hospitals following a suicide attempt. In this study, we analyzed call data from the Illinois Poison Center from 2002 to 2007, which primarily comprises of non-fatal hospitalized and non-hospitalized attempts. We analyzed 43,057 calls by persons suspected of attempting suicide. The three most common groups of substances used were analgesics, antidepressants, and sedative/hypnotics/antipsychotics. The Poisson regression model showed significant declines in calls for suspected suicides during periods of holidays and vacations, and was more pronounced among youths. This study provides a current and detailed description of substances used primarily in non-fatal suicide attempts.

Gender-specific risk factors for suicidality among high school students

This study examined differences in three major risk areas associated with suicidality (suicidal ideation and suicide attempts) separately by gender: 1) substance use, 2) aggression/victimization, and 3) risky sexual behaviors. This study is a secondary data analysis of the Youth Risk Behavior Surveillance (YRBS) survey, consisting of data collected from a nationally representative sample of high school students. Early alcohol onset, having had sex before age 13, injection drug use, and being forced to have sex were associated with suicidality across gender. Smoking in girls was associated with making a plan to attempt suicide and actual suicide attempts. Fighting was related to suicidality for girls, while fighting in school was related to suicidality for boys. The importance of examining risk factors for suicidality separately for boys and girls is discussed.

Poisoning deaths among Finnish children from 1969 to 2003

AIM

Trends in paediatric deaths due to poisoning are little studied. The aim of this study was to investigate the cause and secular trend of poisoning deaths among Finnish children.

METHODS

Death certificates of all Finnish children aged 0-15 who died due to poisoning between 1969 and 2003 were obtained from the Statistics of Finland and analysed.

RESULTS

During the study period, altogether 121 children aged 0-15 years died from poisoning in Finland. Among 0- to 4-year olds, the incidence of poisoning deaths declined to practically zero by the beginning of 1980s. Most of these deaths were unintentional poisonings. Among 5- to 15-year olds, the incidence of poisoning deaths varied during the study period. In this age group, up to 53% of the deaths were suicides among girls compared with 20% among boys (p = 0.017). The corresponding figures for substance abuse were 54% among boys and 9% among girls (p < 0.001).

CONCLUSION

Despite the declining secular trend seen in paediatric poisoning deaths in Finland from 1969 to 2003, the risk of death from both intentional and unintentional poisoning persists in children. Health programmes should be continued especially to promote well-being in families and to prevent teenage suicides and substance abuse.

Homicidal poisoning deaths in the United States 1999-2005

OBJECTIVES

Homicidal poisoning is an intriguing but poorly described phenomenon. This study describes homicidal poisoning deaths in the United States during 1999-2005.

METHODS

A trend analysis of homicidal poisoning death was performed using Vital Statistics data. The National Mortality Statistics database was queried using "homicide" as injury intent and "poisoning" as mechanism for the years 1999-2005. Counts and rates were obtained for subgrouping by using demographic data and ICD-10 codes. Chi-square analysis calculated subgroup odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

A total of 523 homicidal poisoning deaths were identified. The overall rate for the period was 0.26/million/year. Males were significantly (OR 1.34, CI 1.13-1.59) more likely to victims than females. Death was more likely at extremes of age. Rates were 2.05/million (OR 8.72, CI 6.63-11.49) in children <1 year and 0.56/million (OR 2.20, CI 1.38-3.52) at ages >or=85 years. Rates also varied by race and were more common among Blacks (0.43/million; OR 1.83, CI 1.47-2.26). The greatest rate was observed in Black infants (5.3/million; OR 21.34, CI 14.17-32.15). ICD-10 codes indicated that medications were the most common poison. Rates were significantly higher in the West and lower in the Northeast.

CONCLUSION

The overall homicidal poisoning death rate was low between 1999 and 2005. The most common type of poison used was medications. Substantially higher rates were observed in vulnerable populations at extremes of age, particularly infants, and among Blacks. This challenges common notions of the victims of homicidal poisoning and the underlying motivation of their poisoners.

Secular trends in poisonings leading to hospital admission among Finnish children and adolescents between 1971 and 2005

OBJECTIVE

To investigate the secular trends in childhood poisonings leading to hospitalization in Finland.

STUDY DESIGN

All children and adolescents age 0 to 19 years hospitalized in Finland with the primary diagnosis of poisoning between 1971 and 2005 were identified using the International Classification of Diseases.

RESULTS

During the study period, there were 41 862 hospitalizations with 96 427 hospital bed days for poisoning in 38 582 children and adolescents. The incidence of hospitalization declined from 91.3 admissions per 100 000 person-years in boys and 105.2 per person-years in girls in 1971 to 64.8 in boys and 83.5 in girls in 2005. In the 0- to 4-year age group, admissions declined by 51%. Hospitalizations for alcohol poisoning increased 1.7-fold (95% confidence interval = 1.4 to 2.2) in boys and 2.4-fold (95% confidence interval = 1.8 to 3.3) in girls. Alcohol poisoning was the primary diagnosis in 53% of those in the 10- to 14-year age group.

CONCLUSIONS

Poisoning remains an important cause of morbidity in Finnish children and adolescents despite the decreased overall incidence of poisonings leading to hospitalization between 1971 and 2005. The increasing trend of hospital admissions for alcohol poisoning, especially in 10- to 14-year-olds, is noteworthy. Effective primary prevention programs and adult supervision should be targeted at reducing alcohol consumption and alcohol-related poisonings in youth.

Paediatric poisonings treated in one Finnish main university hospital between 2002 and 2006

AIM

Acute poisonings are a major cause of morbidity among children. This study aims to describe the incidence and nature of emergency visits for acute paediatric poisoning among Finnish children.

METHODS

All patients younger than 16 years admitted to the Tampere University Hospital's emergency department with a diagnosis of poisoning during 2002-2006 were identified from the Hospital Information System using the International Classification of Diseases (ICD-10).

RESULTS

Altogether 369 emergency visits were diagnosed with poisoning, the overall incidence being 8.1 per 10 000 person-years (95% CI 7.3-9.0). A majority of patients were adolescents aged 10-15 years (48%) and children under 5 years (45%). Boys represented 55% of the cases. Nonpharmaceutical agents were suspected to be the cause in 60.4% and pharmaceuticals in 30.6% of the intoxications. Multiple agents were involved in 8.4% of the cases. Ethanol was the agent in 30.9% of the poisonings. Most patients (78.9%) were hospitalized (median length of stay 1 day). Overall mortality was 0.3%.

CONCLUSION

Acute paediatric poisonings represent a relatively frequent problem in Finland, and remain a life-threatening problem. The high proportion of alcohol poisonings highlights the necessity to develop more effective primary prevention programs.

Role of hydroxocobalamin in acute cyanide poisoning

OBJECTIVE

To review the recently approved cyanide antidote, hydroxocobalamin, and describe its role in therapy.

DATA SOURCES

Relevant publications were identified through a systematic search of PubMed using the MeSH terms and key words hydroxocobalamin and cyanide. This search was then limited to human studies published since 2000. Systematic searches were conducted through January 2008. References from identified articles were reviewed for additional pertinent human studies.

STUDY SELECTION AND DATA EXTRACTION

The literature search retrieved 7 studies on the safety and/or efficacy of hydroxocobalamin in humans. Four new studies were identified by the search and 3 studies were identified from the references.

DATA SYNTHESIS

Studies of antidote efficacy in humans are ethically and logistically difficult. A preclinical study demonstrated that intravenous doses of hydroxocobalamin 5 g are well tolerated by volunteer subjects. Hydroxocobalamin has been shown to reduce cyanide concentrations in controlled studies of nitroprusside therapy and in heavy smokers. A retrospective study of 14 acute cyanide poisonings also demonstrated hydroxocobalamin's safety and efficacy. Two studies examining hydroxocobalamin for smoke inhalation-associated cyanide poisoning indicated a possible benefit, but they are insufficient to establish definitive criteria for use in this setting. Randomized controlled trials of hydroxocobalamin and traditional cyanide antidotes (nitrites/thiosulfate) are lacking.

CONCLUSIONS

Cyanide poisoning can rapidly cause death. Having an effective antidote readily available is essential for facilities that provide emergency care. In cases of cyanide ingestion, both the nitrite/thiosulfate combination and hydroxocobalamin are effective antidotes. Hydroxocobalamin offers an improved safety profile for children and pregnant women. Hydroxocobalamin also appears to have a better safety profile in the setting of cyanide poisoning in conjunction with smoke inhalation. However, current data are insufficient to recommend the empiric administration of hydroxocobalamin to all victims of smoke inhalation.

The epidemiology of intentional non-fatal self-harm poisoning in the United States: 2001-2004

INTRODUCTION

Suicide attempts through intentional poisoning are an important public health concern. This investigation sought to determine the different US incident rates of poisonings (with intent to do self-harm) by race, sex, and gender.

METHODS

We used data from the National Electronic Injury Surveillance System--All Injury Program (NEISS-AIP) to describe differences in incidence rates of non-fatal, self-harm poisonings evaluated in US emergency departments (ED) from 2001 to 2004. WISQARS defines self-harm as "either confirmed or suspected from injury or poisoning resulting from a deliberate act inflicted on oneself with the intent to take one's own life or harm oneself."

RESULTS

From 2001 to 2004, there were 976,974 (95% Confidence Interval (CI) 772,884 - 1,181,065) non-fatal self-harm poisonings reported in US Emergency Departments. Young white females between 15 to 19 years of age were at highest risk with an incidence rate of 248 per 100,000 (95% CI 180 - 315). Females had higher rates of self-harm poisonings than males: the rate for females was 101 per 100,000 (95% CI 81 - 123); the rate for males was 66 per 100,000 (95% CI 51 - 81), p < 0.001. Whites had slightly higher rates than blacks, and significantly higher rates than Hispanics: whites rates were 71 per 100,000 (95% 51 - 91); black rates were 65 per 100,000 (95% CI 35 - 96), and Hispanic rates were 23 per 100,000 (95% 10 - 37). There was a significant increase in the incidence rate from 2002 to 2003 (p < 0.001). Incident rates decreased for females and males older than 19 years of age (p < 0.001 for males and females).

CONCLUSION

Recently, the incidence of self-harm poisoning has risen considerably. It rose from 75 (CI 53-98) per 100,000 in 2002 to 94 (CI 74-115) per 100,000 in 2003; incidence remained relatively steady in 2004. Whites have higher incidence rates than blacks and significantly higher incidence rates than Hispanics. Females are at higher risk than males, and adolescent white females are at highest risk. An understanding of the demographic factors associated with self-harm poisoning may provide useful information to improve prevention and treatment strategies.

The spectrum of intoxication and poisonings among adolescents: surveillance in an urban population

AIM

Among adolescents, poisoning is a leading cause of injury mortality in the United States. This study describes the epidemiology of poisonings, intoxication, and maladaptive effects of drugs among adolescents age 10-19 years in a large city.

METHODS

An injury surveillance system used records at seven hospitals, medical examiner records, and vital records over a two year period.

RESULTS

Of 633 cases (618 injuries/100 000/year), 6% were unintentional, 36% self-inflicted, 41% alcohol intoxication, and 15% maladaptive effects of drugs. Alcohol was involved in 45% of cases, 23% illegal drugs, 23% non-prescription drugs, 19% prescription drugs; 19% involved more than one substance. Hospitalization was required in 20%; 8% transferred to another hospital; one died from intoxication. The authors found high rates of self-inflicted poisoning, intoxication, and maladaptive effects of drugs among this urban population.

CONCLUSION

The study highlights the need to broadly define poisonings among adolescents and the challenge of assessing intent in some cases.

Intoxications de l’enfant : données des centres antipoison et de toxicovigilance (CAP-TV) français (2002)

MATERIALS AND METHODS

Data for 2002 from a number of French poison control centres were analysed in terms of several age groups; 87 678 possible or established poisoning cases were counted, including 49 355 cases in the 0- to 18-year age group.

RESULTS

The 0- to 3-year age group accounted for 71.7% of cases of childhood poisoning. Accidental poisoning was predominant up to 12 years, while from 13 to 18 years poisoning was essentially deliberate. The principal route of exposure was oral and involved liquids for babies and solid products for older children. The toxic agents most often implicated were pharmaceuticals and domestic products. The place of poisoning was mainly the home. A 'no-risk' evaluation was performed, and varied between 41.6% before the age of 3 years to 18.0% for the 13- to 18-year age group. The oldest children were more often managed in medical facilities.

DISCUSSION

Fortunately, most of these poisoning cases were not serious (death rate: 0.026%). The poison control centres' information system is continuing to expand: it will allow an improvement in medical health monitoring associated with poisoning.

Trends in adolescent suicide: misclassification bias?

OBJECTIVES

This study investigated the effect of misclassification of accidental deaths and undetermined deaths on age-, sex-, and race/ethnicity-specific adolescent suicide rates from 1979 through 1994.

METHODS

Official mortality data were used to present suicide mortality trends. Two estimates of misclassified suicides in other death categories were applied to calculate "corrected" trends of adolescent suicide.

RESULTS

The corrected trends showed a downward adjustment for Black adolescent males and young adolescents. This result does not, however, substantially alter the trend toward a recent increase in suicide in these groups.

CONCLUSIONS

Despite misclassification, the true direction of trends in adolescent suicide is reflected in recent official data. However, suicide rates should continuously be tested for misclassification, mainly in populations with proportionately high accidental and undetermined death rates.

Childhood injury prevention at home and play

Unintentional injuries are the leading cause of death for children and adolescents in the United States, and they create a significant burden of disability and financial cost. If motor vehicle-associated injuries are not considered, children are most commonly injured in their home and play environments. The reduction over the past 20 years in childhood deaths related to motor vehicle injury has been significant, but rates of childhood death due to other causes, such as firearms, have increased. This review focuses on several categories of injuries other than motor vehicle injuries and highlights a few recent successful community- and practice-based injury-prevention programs. In addition, recent epidemiologic studies describing risk factors for injury-related death are discussed. Injuries due to interpersonal violence and motor vehicles are covered elsewhere.