Emergency department visits for acetaminophen overdose: a Canadian population-based epidemiologic study (1997–2002)

Public health measures on COVID-19 in North Korea: a quantitative analysis of media programmes in 2020-2022

OBJECTIVES

Details regarding the management of COVID-19 in North Korea are unknown. The aim of this paper was to analyse media programmes in North Korea in order to understand public health measures and policies concerning COVID-19.

SETTING

State-run news agency in North Korea.

PRIMARY AND SECONDARY OUTCOME MEASURES

The classification of television programmes on COVID-19 broadcast in a state-run news agency, from January 2020 to May 2022, and public health measures introduced in the programmes.

RESULTS

A total of 2671 programmes concerning COVID-19 were included in the study. These programmes provided detailed clinical guidelines to laypeople without medical expertise, including instructions for the usage of medication and preventive measures. An association between the media concern regarding COVID-19 and trade volume, as a proxy of border closure according to the concern of the authorities, provided hints to understand the priorities and aims of the authorities.

CONCLUSIONS

The research outcomes provided significant insights into the effort to understand an impaired healthcare system and prevalent drug abuse behaviours in North Korea. Findings from further studies on the recently collected data might suggest additional implications on the North Korean policies on COVID-19.

Acute health care among Indigenous patients in Canada: a scoping review

A recent report by the Chief Public Health Officer of Canada demonstrates the inferior health status of Indigenous Peoples in Canada when compared to non-Indigenous populations. This scoping review maps out the available literature concerning acute health care for Indigenous Peoples in Canada in order to better understand the health care issues they face. All existing articles concerning health care provided to Indigenous Peoples in Canada in acute settings were included in this review. The targeted studied outcomes were access to care, health care satisfaction, hospital visit rates, mortality, quality of care, length of stay and cost per hospitalisation. 114 articles were identified. The most studied outcomes were hospitalisation rates (58.8%), length of stay (28.0%), mortality (25.4%) and quality of care (24.6%) Frequently studied topics included pulmonary disease, injuries, cardiovascular disease and mental illness. Indigenous Peoples presented lower levels of satisfaction and access to care although they tend to be over-represented in hospitalisation rates for acute care. Greater inclusion of Indigenous Peoples in the health care system and in the training of health care providers is necessary to ensure a better quality of care that is culturally safe for Indigenous Peoples.

Plasma Concentration of Taurine Changes following Acetaminophen Overdose in Male Patients during Hospitalization

Changes in plasma concentration of taurine during hospitalization of acetaminophen poisoned patients have not been studied. Hepatotoxicity is a common consequence of acetaminophen overdose that may lead to acute liver failure. Numerous biomarkers for drug-induced liver injury have been explored. All biomarkers are usually obtainable 48 h following acetaminophen overdose. We have already introduced taurine as a non-specific early biomarker of acetaminophen overdose. This study aimed to follow up changes in plasma concentration of taurine during the first three days of acetaminophen overdose. Sixty-four male patients suffering from acetaminophen overdose were selected for the study. Four blood samples were taken from the patients every 12 h. Sixty blood samples were also taken from sixty healthy humans. The plasma concentration of taurine in both groups was analyzed an already developed HPLC method. Analysis of regression showed a significant correlation between means of plasma concentrations of taurine and acetaminophen, aspartate aminotransferase, Alanine aminotransferase, glutathione peroxidase, and prothrombin time during hospitalization. The high plasma concentration of taurine, 6 h or more after acetaminophen overdose, could be a useful early indicator of liver damage.

The analysis of acetaminophen (paracetamol) and seven metabolites in rat, pig and human plasma by U(H)PLC-MS

A U(H)PLC-MS/MS method is described for the analysis of acetaminophen and its sulphate, glucuronide, glutathione, cysteinyl and N-acetylcysteinyl metabolites in plasma using stable isotope-labeled internal standards. P-Aminophenol glucuronide and 3-methoxyacetaminophen were monitored and semi-quantified using external standards. The assay takes 7.5 min/sample, requires only 5 μl of plasma and involves minimal sample preparation. The method was validated for rat plasma and cross validated for human and pig plasma and mouse serum. LOQ in plasma for these analytes were 0.44 μg/ml (APAP-C), 0.58 μg/ml (APAP-SG), 0.84 μg/ml (APAP-NAC), 2.75 μg/ml (APAP-S), 3.00 μg/ml (APAP-G) and 16 μg/ml (APAP). Application of the method is illustrated by the analysis of plasma following oral administration of APAP to male Han Wistar rats.

Trends in emergency department visits for acetaminophen-related poisonings: 2011-2019

We examined trends in emergency department (ED) presentation rates for acetaminophenrelated poisonings across Canada. A total of 27123 cases of poisoning were seen in the electronic Canadian Hospitals Injury Reporting and Prevention Program (eCHIRPP) sentinel sites between April 2011 and February 2019; of these, 13.7% were related to acetaminophen use. A significant decreasing trend for both sexes was observed for unintentional poisonings (males: -10.3%; females: -8.0%). For intentional poisonings, there was a significant decrease among females only (-5.9%). Females have consistently displayed higher rates of ED presentations for both unintentional and intentional poisoning.

Increased availability of paracetamol in Sweden and incidence of paracetamol poisoning: using laboratory data to increase validity of a population-based registry study

PURPOSE

To estimate the incidence trend and outcome of paracetamol poisoning, in relation to increased availability of paracetamol from non-pharmacy outlets in 2009.

METHOD

Patients' serum paracetamol results over 14 years (2000-2013) from 20 (out of 21) regions in Sweden were linked to national registers of hospital care, cause of death, and prescriptions. Paracetamol poisonings were defined by serum paracetamol levels, hospital diagnoses, or cause of death. The change in incidence of poisonings following increased availability of paracetamol was analysed by using segmental regression of time series.

RESULTS

Of the 12 068 paracetamol poisonings, 85% were classified as intentional self-harm. Following increased availability from non-pharmacy outlets, there was a 40.5% increase in the incidence of paracetamol poisoning, from 11.5/100 000 in 2009 to 16.2/100 000 in 2013. Regression analyses indicated a change in the trend (p < 0.0001) but not an immediate jump in the incidence (p = 0.5991) following the increased availability. Adjusting for trends in hospital episodes for self-harm, suicides, and the sales volume of paracetamol did not influence the result. All-cause mortality at 30 days (3.2%) did not change over time.

CONCLUSIONS

The incidence of paracetamol poisoning in Sweden has increased since 2009, contrasting the decreased incidence in the period of 2007-2009. The change in trend was temporally associated with the introduction of availability of paracetamol from non-pharmacy outlets but did not appear to be related to sales volume of paracetamol or general trends in self-harm or suicides. © 2017 Commonwealth of Australia. Pharmacoepidemiology and Drug Safety © 2017 John Wiley & Sons, Ltd.

Paracetamol overdose in Victoria remains a significant health-care burden

BACKGROUND AND AIM

Paracetamol is the most frequently used analgesic in Australia and can be purchased without a prescription. We aimed to investigate the epidemiology and outcome of paracetamol overdoses occurring in Victoria, Australia.

METHODS

The Victorian admitted episode dataset was examined for all patients who had a diagnosis of paracetamol poisoning (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification [ICD-10-AM]: T39.1) or paracetamol adverse effect in therapeutic use (Y45.5) from July 1, 2000 to June 30, 2007. Data extracted included all ICD-10 codes related to their admissions, gender, age range, date of admission, and cause of death (if applicable).

RESULTS

Over 7 years, there was a total of 14,662 hospital admissions for paracetamol overdose with a mean of 2095 cases per year. Accidental overdoses comprised 15% (n = 2149) of cases. The overdose rate fell from 46 cases per 100,000 in 2001 to 39 cases per 100,000 in 2006 (P < 0.001). Most overdoses occurred in women (71%), and patients between 15 and 50 years old comprised 78% of all cases. Complications and mortality were relatively uncommon, with only 26 deaths directly attributable to paracetamol overdose over the 7 years. No child under 15 years old died from their overdose.

CONCLUSION

Admission to Victorian hospitals with paracetamol overdose presents an enormous and in many cases preventable health-care burden. Fortunately, there has been a gradual fall in admissions, and most cases appear relatively benign. Further reductions in overdose could be achieved with increased awareness by physicians and the general public regarding the potential for accidental overdose, and increasing funding for mental health initiatives.

Paracetamol intoxications: a retrospective population-based study in Iceland

OBJECTIVE

Paracetamol is the most common cause of acute liver failure (ALF) in many countries. Much data on paracetamol toxicity originate from liver transplant centers and tertiary referral institutions. The authors analyzed the population-based annual incidence of paracetamol overdoses and ALF, and described the risk factors for hepatotoxicity.

METHODS

A search was undertaken for the diagnosis of paracetamol overdoses in the diagnoses registry of the National University Hospital of Iceland from 2004 to 2009 serving a population of 219,249 inhabitants. Relevant information was collected from medical records.

RESULTS

A total of 1913 drug-related poisoning episodes were identified and reviewed, 352 (18%) involved paracetamol overdoses. The annual incidence of paracetamol overdoses declined from 30.0 (2004) to 16.0/100,000 per year (2009) (p < 0.05). The female/male ratio was 3.0 and the largest age group was 16-25 years. After the initial examination, 26% were discharged home. Hospitalized index visits were 182 with accidental overdoses constituting 16 (9%) with no gender difference. Compared with intentional overdose the accidental group had higher aminotransferases (p < 0.005). ALF occurred in 3.8% (7/182) of the index visits and the incidence was 0.7/100,000 per year. In the intentional group, 1.2% (2/163) developed ALF versus 25% (4/16) of the accidental group (p = 0.001). Only one patient died from ALF and none underwent liver transplantation.

CONCLUSION

The annual incidence of paracetamol overdoses was high in this population-based study but declined. Young females with intentional overdose accounted for most of the cases, whereas accidental overdoses were more common in older patients. The occurrence of ALF was low and mostly associated with accidental overdose.

Population prevalence of high dose paracetamol in dispensed paracetamol/opioid prescription combinations: an observational study

Background

Paracetamol (acetaminophen) is generally considered a safe medication, but is associated with hepatotoxicity at doses above doses of 4.0 g/day, and even below this daily dose in certain populations.

Methods

The Nova Scotia Prescription Monitoring Program (NSPMP) in the Canadian province of Nova Scotia is a legislated organization that collects dispensing information on all out-of-hospital prescription controlled drugs dispensed for all Nova Scotia residents. The NSPMP provided data to track all paracetamol/opioids redeemed by adults in Nova Scotia, from July 1, 2005 to June 30, 2010. Trends in the number of adults dispensed these prescriptions and the numbers of prescriptions and tablets dispensed over this period were determined. The numbers and proportions of adults who filled prescriptions exceeding 4.0 g/day and 3.25 g/day were determined for the one-year period July 1, 2009 to June 30, 2010. Data were stratified by sex and age (<65 versus 65+).

Results

Both the number of prescriptions filled and the number of tablets dispensed increased over the study period, although the proportion of the adult population who filled at least one paracetamol/opioid prescription was lower in each successive one-year period. From July 2009 to June 2010, one in 12 adults (n = 59,197) filled prescriptions for over 13 million paracetamol/opioid tablets. Six percent (n = 3,786) filled prescriptions that exceeded 4.0 g/day and 18.6% (n = 11,008) exceeded 3.25 g/day of paracetamol at least once. These findings exclude non-prescription paracetamol and paracetamol–only prescribed medications.

Conclusions

A substantial number of individuals who redeem prescriptions for paracetamol/opioid combinations may be at risk of paracetamol-related hepatotoxicity. Healthcare professionals must be vigilant when prescribing and dispensing these medications in order to reduce the associated risks.

Paracetamol in therapeutic dosages and acute liver injury: causality assessment in a prospective case series

Background

Acute liver injury (ALI) induced by paracetamol overdose is a well known cause of emergency hospital admission and death. However, there is debate regarding the risk of ALI after therapeutic dosages of the drug.

The aim is to describe the characteristics of patients admitted to hospital with jaundice who had previous exposure to therapeutic doses of paracetamol. An assessment of the causality role of paracetamol was performed in each case.

Methods

Based on the evaluation of prospectively gathered cases of ALI with detailed clinical information, thirty-two cases of ALI in non-alcoholic patients exposed to therapeutic doses of paracetamol were identified. Two authors assessed all drug exposures by using the CIOMS/RUCAM scale. Each case was classified into one of five categories based on the causality score for paracetamol.

Results

In four cases the role of paracetamol was judged to be unrelated, in two unlikely, and these were excluded from evaluation. In seven of the remaining 26 cases, the RUCAM score associated with paracetamol was higher than that associated with other concomitant medications. The estimated incidence of ALI related to the use of paracetamol in therapeutic dosages was 0.4 per million inhabitants older than 15 years of age and per year (99%CI, 0.2-0.8) and of 10 per million paracetamol users-year (95% CI 4.3-19.4).

Conclusions

Our results indicate that paracetamol in therapeutic dosages may be considered in the causality assessment in non-alcoholic patients with liver injury, even if the estimated incidence of ALI related to paracetamol appears to be low.

Misuse of acetaminophen in the management of dental pain

PURPOSE

We highlight the risk associated with acetaminophen misuse in patients having dental pain in France based on a series of cases of unintentional acetaminophen overdose reported by the Emergency Dental Service of Nancy over a 9-month period.

METHODS

Data were collected by querying the French Pharmacovigilance database. Each retrieved clinical data were reviewed by a clinician.

RESULTS

Thirteen cases of acetaminophen overdose were reported to the Regional Pharmacovigilance Center of Lorraine, Nancy, France. Most cases (10/13) concerned men aged 20-40 years old. Mild, unspecific clinical symptoms were observed in seven of 13 patients. The median value of the supposed ingested dose was 137 mg/kg/24 h. Liver enzyme activity was tested in 10 patients and was abnormal in four patients. N-acetylcysteine treatment was administered to four patients.

CONCLUSIONS

We propose that even patients with mild clinical symptoms with a supposed ingested dose of acetaminophen greater than 150 mg/kg/24 h should be referred to an emergency department and that liver enzyme activity should be analyzed. No case of liver failure was observed during our short survey. However, hepatotoxicity of repeated supratherapeutic ingestion of acetaminophen was suspected in four patients. Patients and practitioners should thus be better informed about the risk of unintentional acetaminophen overdose following supratherapeutic acetaminophen ingestion.

Characterization of acetaminophen overdose-related emergency department visits and hospitalizations in the United States

PURPOSE

To estimate the number of acetaminophen overdose-related emergency department (ED) visits and hospitalizations in the United States, characterize these by intentionality, age, and gender, and compare the strengths and limitations of the utilized databases.

METHODS

We used data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Electronic Injury Surveillance System (NEISS) to estimate the number of relevant ED visits in the United States between 2000 and 2007, and the National Hospital Discharge Survey (NHDS) to estimate the number of relevant hospitalizations in the United States between 1991 and 2006. National estimates and their standard errors were calculated using information provided in each database. We used the standard United States population in 2000 to calculate age-adjusted rates.

RESULTS

We estimate an annual average of 44,348 (NHAMCS, 2000-2007) or 78,414 (NEISS, 2006-2007) acetaminophen overdose-related ED visits and 33,520 (NHDS, 2000-2006) hospitalizations. For 2000-2006 we calculated an age-adjusted rate of 13.9 acetaminophen overdose-related hospitalizations per 100,000 US population, with the highest rate (15.7) occurring from 2005 to 2006. Between 1991 and 2006, there was no decrease noted in hospitalizations for intentional or unintentional overdoses. The majority of overdoses reported in NEISS (69.8%) and NHDS (74.2%) were classified as intentional (suicides or suicidal gestures), whereas in NHAMCS, intentionality was evenly distributed.

CONCLUSIONS

Our results suggest that acetaminophen overdose, both intentional and unintentional, remains a significant public health concern. With an understanding of their methodological characteristics and limitations, these national databases can be useful tools to characterize acetaminophen overdose-related ED visits and hospitalizations.

Comparison of the 20-hour intravenous and 72-hour oral acetylcysteine protocols for the treatment of acute acetaminophen poisoning

STUDY OBJECTIVE

To compare outcomes after acute acetaminophen poisoning in 2 large cohorts of patients treated with either the 20-hour intravenous or 72-hour oral acetylcysteine protocol.

METHODS

We conducted a retrospective cohort study with historical control comparing patients treated with one of 2 acetylcysteine regimens. Data for the 20-hour group were obtained from a medical record review of patients on whom the 20-hour intravenous protocol was initiated in Canadian hospitals from 1980 to 2005. The 72-hour group consisted of a historical cohort of patients treated in US hospitals with the 72-hour oral protocol from 1976 to 1985. The primary outcome was hepatotoxicity (aminotransferase levels >1,000 IU/L).

RESULTS

Of the 4,048 patients analyzed, 2,086 were in the 20-hour group and 1,962 were in the 72-hour group. The incidence of hepatotoxicity was 13.9% in the 20-hour group and 15.8% in the 72-hour group (-1.9% absolute difference; 95% confidence interval [CI] -4.2 to 0.3). The relative risk of hepatotoxicity was lower in the 20-hour group when acetylcysteine was initiated within 12 hours of ingestion. The relative risk was lower in the 72-hour group when acetylcysteine was initiated later than 18 hours after ingestion. There was no significant risk difference between groups when acetylcysteine treatment was started 12 to 18 hours after ingestion. One patient in the 20-hour group received a liver transplant and died because of acetaminophen toxicity compared with no liver transplants and 3 deaths in the 72-hour group. Anaphylactoid reactions to intravenous acetylcysteine were reported in 148 of 2,086 patients (7.1%; 95% CI 6.1% to 8.3%). This study is limited by comparison of 2 separate data sets from different countries and study years.

CONCLUSION

The risk of hepatotoxicity differed between the 20-hour and 72-hour protocols according to the time to initiation of acetylcysteine. It favored the 20-hour protocol for patients presenting early and favored the 72-hour protocol for patients presenting late after acute acetaminophen overdose.