Paracetamol use, availability, and knowledge of toxicity among British and American adolescents

Exploring public knowledge and perceptions regarding per os OTC pain-relieving medications: the case of paracetamol (acetaminophen)

BACKGROUND

Over-the-counter medications (OTC) are safe and effective when patients follow the patient's information leaflet (PIL) instructions and/or the instructions given by healthcare professionals (HCPs). However, OTC medications could be harmful and unsafe when individuals do not follow the given instructions and/or when their understanding about the proper use of OTC medications is incorrect. This study aimed to investigate the knowledge and perceptions of people regarding paracetamol use in the Republic of Cyprus.

METHODS

This cross-sectional study, which belongs to quantitative research methods, included participants visiting community pharmacies in the following three cities of the Republic of Cyprus: Nicosia, Limassol and Larnaca. Participation in the study was voluntary and anonymous. Participants responded to the survey-based questionnaire, which concerned their knowledge and views on paracetamol use. After the data collection, responses were tabulated and analysed statistically.

RESULTS

The original compound was shown to be more well-known compared to generics. A notable percentage of respondents-ranging between 13.0% (N = 49) and 29.8% (N = 112)-answered incorrectly that broadly used non-steroidal anti-inflammatory drugs (NSAIDs) contain paracetamol. Furthermore, a remarkable percentage of respondents (71.5%, N = 269 and 50.3%, N = 189, respectively) falsely believed that two widely used combination products in the market of Cyprus (Paracetamol and Hyoscine-N-butylbromide; Paracetamol and Codeine and Caffeine) did not contain paracetamol. A notable percentage of participants (27.6%, N = 100) believed that paracetamol causes low toxicity. More than a third of the respondents (40.2%, N = 149) drink alcohol together with or slightly after consuming paracetamol products. This viewpoint was linked with the participants' attitude towards consuming paracetamol medications after drinking alcohol (OR for consuming alcohol versus not consuming alcohol 0.100, 95% CI 0.044-0.225, p = 0.000).

CONCLUSIONS

To the best of our knowledge, this is the first study conducted in the Republic of Cyprus on this topic. Paracetamol is frequently consumed by individuals, both in its generic and original forms. However, the study showed that respondents often misperceive NSAIDs and paracetamol-containing medications. In addition, it is identified that there is a lack of education among people about the safe and effective use of paracetamol, namely, indications, potential side effects, maximum daily dose, alcohol consumption, and the potential risks of hepatotoxicity. The study contributed to the current published literature as it showed that there is a significant public health issue, for which appropriate measures can be established by the respective Authorities of Cyprus.

A Cross-Sectional Study to Investigate the Prevalence of Self-Medication of Non-Opioid Analgesics Among Medical Students at Qassim University, Saudi Arabia

Purpose

Self-medication (SM) using non-opioid analgesics (NOA) is contentious and increasingly recognized as a major public health concern with severe consequences, including masking of malignant and fatal diseases, risk of misdiagnosis, problems relating to over- and under-dosing, drug interactions, incorrect dosage, and choice of therapy. Herein, we aim to determine the prevalence of SM with NOA among pharmacy and medical students at Unaizah College, Qassim University, Saudi Arabia.

Patients and Methods

A cross-sectional study using a validated self-administered questionnaire was conducted on 709 pharmacy and medicine students belonging to an age group of 21-24 years from Unaizah Colleges. Data were statistically analyzed using SPSS version 21.

Results

Of 709 participants, 635 responded to the questionnaire. Our results showed a prevalence percentage of 89.6% using self-medicated NOA for pain management. The most common factor leading to SM in NOA was the mild nature of the illness (50.6%), and headache/migraine (66.8%) was the dominant health problem. Paracetamol (acetaminophen, 73.7%) was the most commonly used analgesic, followed by ibuprofen (16.5%). The most common and reliable sources of drug information were pharmacists (51.5%).

Conclusion

We observed a high rate of SM for NOA among undergraduate students. We believe that the adverse consequences of SM could be controlled through educational, regulatory, and administrative strategies by providing appropriate awareness sessions, and the role of pharmacists should be highlighted in preventing SM from NOA.

Paracetamol poisoning: a population-based study from Iceland

OBJECTIVE

To examine the incidence and severity of paracetamol poisoning in a population-based cohort in Iceland. A previous study showed a decrease in the incidence during a financial crisis in Iceland, by approximately half (16/100,000 annually). The aims of the study were to assess the incidence and nature of paracetamol poisoning after economic recovery in Iceland and to compare intentional and accidental poisoning.

METHODS

Paracetamol serum concentrations were used to identify patients in this retrospective study from 2010-2017. A search was undertaken in laboratory databases for patients with serum paracetamol concentrations, which were grouped by <66 µmol/L (below detection limit) and ≥66 µmol/L. Medical records were reviewed and relevant laboratory and clinical information obtained to determine whether paracetamol poisoning had occurred.

RESULTS

Altogether 542 cases of paracetamol poisoning were identified. The mean annual incidence was 27/100,000 (range 22-33). Intentional poisoning was observed in 437/542 (81%) cases, most frequently among females 16-25 years of age. Males ≥65 years were more likely to overdose by accident, which was associated with worse outcomes. Twenty-five (4.6%) patients developed severe paracetamol-induced liver injury and coagulopathy. Overall, six (1.1%) cases were fatal in which paracetamol contributed to the cause of death, with accidental poisoning found in 67% (4/6).

CONCLUSIONS

The incidence of paracetamol poisoning has increased in recent years associated with economic recovery in Iceland. Most patients had favourable outcomes. Intentional overdose was most common in young females, whereas accidental overdose was more common in older males and more frequently associated with a fatal outcome.

Children's medicine: What do consumers really want to know?

AIM

This study explored consumer knowledge gaps and concerns regarding medication use in children.

METHODS

Calls concerning or made by people under 18 to the pharmacist-operated, national consumer medicines call centre National Prescribing Service Medicines Line (2002 to June 2010) were analysed. Calls were classified and narratively explored by age group: <1, 1-4, 5-14 and 15-17 years. Consumer Medication Information (CMI) and evidence-based resources were examined to determine information concordance for common questions.

RESULTS

There were 14 753 paediatric-related calls (mean age 4.1 years). Callers were predominantly female (91.5%), mean age was 35.8 years. Most (89.4%) phoned for a child and 2.2% for themselves. Main enquiry types were: lactation (22.1%), treatment/prophylaxis (11.1%), dose (10.2%), adverse reaction (10.0%), interaction (8.4%) and vaccination (8.4%). However, the primary enquiry differed by age group: lactation (<1 year), dosing (1-4, 5-14 years) and interactions (15-17 years). Global concerns were medication safety, with breastfeeding for infants <1 year and age/weight dose clarification for children 1-4 and 5-14 years. In contrast, interaction questions from adolescents concerned nervous system medicines, cold/flu products, contraceptives and recreational drugs. While paracetamol was the primary medication of interest across age groups, the remaining 'top two' differed significantly. Inconsistencies identified between CMI and evidence-based resources contribute to consumer uncertainty.

CONCLUSIONS

Care givers and older children use a call centre to address their information needs about frequently used and highly accessible medicines, and their concerns vary across paediatric age groups. Inconsistent information provided by CMI on medication use in children contributes to consumer uncertainty and help-seeking behaviour.

Identifying adults at risk of paracetamol toxicity in the acute dental setting: development of a clinical algorithm

Paracetamol is widely used and effective for the management of dental pain in the UK. Acute dental pain is a recognised precipitant of unintentional paracetamol overdose and in a small but significant number of cases this results in hepatotoxicity. Patients' understanding of the risks of excess paracetamol ingestion remains poor and risk of over-medication before presentation is increased due to a variety of factors including dental anxiety and fragmented provision of dental emergency services. Early recognition of overdose is crucial to preventing significant hepatotoxicity and death. Dentists have a role to play in recognising unintentional overdose cases and directing patients timeously to appropriate medical care. Guidelines on the treatment of paracetamol toxicity are readily available but our data suggests some dental settings may present a weak link in the care pathway and overdose may not be readily recognised. We have developed an algorithm and training package targeted at dentists in the acute dental setting with the aim of improving recognition of paracetamol toxicity in adults and directing onward referral appropriately. This paper also revises the key pharmacokinetics and pharmacodynamics of paracetamol and is intended to raise awareness of issues of toxicity for dentists.

Estimating Consumers' Knowledge and Attitudes Towards Over-The-Counter Analgesic Medication in Greece in the Years of Financial Crisis: The Case of Paracetamol

Introduction

Non-prescription over-the-counter (OTC) drugs are widely used by patients to control aches, pain, and fever. One of the most frequently used OTC medications worldwide is paracetamol (acetaminophen). The aim of the present study was to fill the current knowledge gap regarding the beliefs and attitudes of people in Greece associated with the use of paracetamol during the years of financial crisis.

Methods

The present study employed a sample of individuals visiting community pharmacies in the second largest city of Greece, Thessaloniki. All participants anonymously answered a questionnaire regarding their beliefs and characteristics of paracetamol consumption. Their answers were then statistically analyzed.

Results

The generic paracetamol compound was shown to be more well known than the original. A significant percentage of participants, ranging between 9.9% and 33.7%, falsely believed that certain medications [mainly non-steroidal anti-inflammatory drugs (NSAIDs)] contained paracetamol. Participants’ age, level of education, and gender were shown to be predictive of this false belief. Additionally, 11.1% of participants believed that the maximum allowed daily dose of paracetamol was higher than the correct one. Better educated individuals were less likely to consume alcohol in parallel with paracetamol (odd ratio 0.230, 95% confidence interval 0.058–0.916, P = 0.037).

Conclusion

Paracetamol is commonly used, both in its original and generic forms. However, a significant number of individuals confuse it with NSAIDs. Age, level of education, and gender are important determinants of the characteristics of paracetamol consumption. It seems that patients prefer to take paracetamol on their own decision during the financial crisis.

Electronic supplementary material

The online version of this article (doi:10.1007/s40122-015-0042-x) contains supplementary material, which is available to authorized users.

Saudi school students' knowledge, attitude and practice toward medicines

The current study was aimed to assess Saudi school students' knowledge, attitude and practice about medicines. A pretested self-administered questionnaire was used anonymously among 15-20 year-old adolescents attending tertiary schools in Taif City, KSA. A total of 1022 students completed the questionnaires. Only 15.4% of the respondents knew the medicines' uses. Most of the students 79.6% affirmed that they used to take medicines after consulting physicians, and 45.1% of the students thought that tablet size affects the medicine's efficacy. More than half of the students knew that high temperatures affect the efficacy of medicines, there was a significant difference between rural and urban areas (P = 0.005). Physicians (50.6%) and community pharmacists (15.7%), were the main students' reliable sources of information about medicines. The majority of the students 70.5% were interested in learning more about medicines. The younger students ⩽18 years wish to learn more than the older ones (P < 0.014). The study showed that Saudi school students aged 15-20 years old have poor knowledge, misconception and negative attitudes about medicines. Low level of knowledge may expose adolescents to health-related problems. Educational efforts are important to improve students' practice toward medicines.

Overdosed prescription of paracetamol (acetaminophen) in a teaching hospital

INTRODUCTION

Paracetamol is the most commonly used analgesic and antipyretic. Reviews of hospital use of paracetamol are scarce. Little is known about the appropriateness of the dose of paracetamol prescribed for hospitalized adults. The aim of this study was to report on the nature and the frequency of the overdosed prescription of paracetamol observed in adult patients over a 4.5-year period in a teaching hospital.

METHODS

Prescription analysis by pharmacists was performed once a week in six medical and three surgical departments and daily in a post-emergency unit. In cases of prescription error, the pharmacist notified the physician through an electronic alert when a computerized prescription order entry system was available or otherwise by face-to-face discussion. For each drug-related problem detected, the pharmacists recorded relevant details in a database.

RESULTS

From October 2006 to April 2011, 44,404 prescriptions were reviewed and 480 alerts related to the overdosed prescription of paracetamol were made (1% of analyzed prescriptions). The extent of errors of dosage was within the intervals [90-120 mg/kg/d] and greater than 120 mg/kg/d for 87 and 11 patients respectively, who were prescribed a single non-combination paracetamol containing product. Sixty alerts concerned co-prescription of at least two paracetamol containing products with similar frequency for computerized (1.4/1000) or handwritten (1.2/1000) prescriptions.

DISCUSSION

Prescriptions of paracetamol for hospitalized adults frequently exceed the recommended dosage.

CONCLUSION

These results highlight the need for increased awareness of unintentional paracetamol overdose and support the initiation of an educational program aimed at physicians and nurses.

Misunderstanding and potential unintended misuse of acetaminophen among adolescents and young adults

Acetaminophen is highly accessible yet potentially dangerous when used incorrectly. In attempts to address concerns about acetaminophen, the U.S. Food and Drug Administration (FDA) has identified gaps in evidence about unintentional misuse among adolescents. Therefore, our objectives were to assess adolescents' (1) health literacy, (2) knowledge about acetaminophen, (3) recent use of over-the-counter (OTC) medicines, and (4) understanding of medication dosing (instructions for how to use the medicine, i.e., "acetaminophen skills"). We conducted a cross-sectional survey of adolescents and young adults (ages 16-23 years) recruited from education settings and health care sites in Monroe County, New York, from 11/08-9/09. Using structured in-person interviews, we assessed acetaminophen knowledge and recent use of over-the-counter (OTC) medicines. Through role-plays of everyday health scenarios, we assessed participants' abilities to identify acetaminophen in OTC products and answer questions about instructions for acetaminophen use. We measured health literacy with the Rapid Estimate of Adult Literacy in Medicine (REALM) for participants >18, and the REALM-Teen for those <18. Confusion about acetaminophen and its use was common. Limited health literacy was an independent risk factor for poor knowledge, misunderstanding, and potential unsafe use of acetaminophen-containing medicines; however, most participants at all health literacy levels erred dangerously in "unsafe" understanding of acetaminophen use from label instructions. Individuals with limited health literacy could face disproportionate risk of unsafe use of acetaminophen because of confusion and misunderstanding of label information. Better labeling, public health programs, and educational efforts could facilitate safer use of acetaminophen.

Knowledge and sources of information about medicines among adolescents in Malta

Objective

To investigate knowledge of medicines and sources of information about medicines among adolescents in Malta.

Methods

A self-administered questionnaire was used to survey knowledge of medicines and information sources among adolescents attending secondary schools in Malta. A random stratified sample design generated a sample size of 514 students. Knowledge of medicines was investigated by questions that included topics about the efficacy of medicines, proper communication during a medical consultation, the safety of medicines, antibiotic use and pictograms.

Results

The analytical sample, of which 53.8% were girls, was made up of 474 students, aged 1416 years. The students obtained a mean score of 22.92 points (SD = 4.31) out of a maximum of 32 points for medicine knowledge. More than 30.0% of the respondents did not mark the correct answer for 40.6% of the questions that investigated knowledge of medicines. The family physician, community pharmacist and parents were the sources of information that were mostly cited. A proportion of 4.4% had obtained information from the teacher. A quarter of the respondents (24.7%) had obtained information from friends/schoolmates, young relatives or the media, generally television (17.3%).

Conclusion

Although the level of knowledge about medicines among this study sample of Maltese students was good, there appeared to be particular misconceptions with regard to important aspects associated with the proper use of medicines. These findings highlight the need to educate adolescents about the proper use of medicines. The most important information providers about medicines appeared to be the physician, pharmacist and parents. It is being suggested that education campaigns should be organized in order to help parents guide adolescents on how to use medicines appropriately. In addition, adolescents would benefit if more information about the proper use of medicines would be disseminated by means of television programs and school-based health education curricula.

Knowledge of appropriate acetaminophen doses and potential toxicities in an adult clinic population

OBJECTIVE

To evaluate the knowledge of appropriate doses and potential toxicities of acetaminophen and assess the ability to recognize products containing acetaminophen in an adult outpatient setting.

DESIGN

Cross-sectional, prospective study.

SETTING

University adult general internal medicine (AGIM) clinic.

PATIENTS

104 adult patients presenting to the clinic over consecutive weekdays in December 2003.

INTERVENTIONS

Three-page, written questionnaire.

MAIN OUTCOME MEASURES

Ability of patients to identify maximum daily doses and potential toxicities of acetaminophen and recognize products that contain acetaminophen.

RESULTS

A large percentage of participants (68.3%) reported pain on a daily or weekly basis, and 78.9% reported use of acetaminophen in the past 6 months. Only 2 patients correctly identified the maximum daily dose of regular acetaminophen, and just 3 correctly identified the maximum dose of extra-strength acetaminophen. Furthermore, 28 patients were unsure of the maximum dose of either product. Approximately 63% of participants either had not received or were unsure whether information on the possible danger of high doses of acetaminophen had been previously provided to them. When asked to identify potential problems associated with high doses of acetaminophen, 43.3% of patients noted the liver would be affected. The majority of the patients (71.2%) recognized Tylenol as containing acetaminophen, but fewer than 15% correctly identified Vicodin, Darvocet, Tylox, Percocet, and Lorcet as containing acetaminophen.

CONCLUSION

Although nearly 80% of this AGIM population reported recent acetaminophen use, their knowledge of the maximum daily acetaminophen doses and potential toxicities associated with higher doses was poor and appeared to be independent of education level, age, and race. This indicates a need for educational efforts to all patients receiving acetaminophen-containing products, especially since the ability to recognize multi-ingredient products containing acetaminophen was likewise poor.

Age and paracetamol self-poisoning

BACKGROUND

Whereas paracetamol poisoning is predominantly seen in adolescents and young adults, the majority of paracetamol associated deaths occur in an older population.

AIMS

The aim of the present study was to evaluate age as a risk factor for fulminant hepatic failure (FHF) and death in a large population of patients with paracetamol poisoning.

PATIENTS

A total of 746 patients transferred to a specialised unit with severe paracetamol poisoning and 273 unselected patients admitted from the local region over a 10 year period.

METHODS

A partly retrospective study based on hospital charts. The risk associated with age was evaluated by multivariate analysis.

RESULTS

Paracetamol poisoning most frequently occurred in the age group 15-24 years. Transferred patients were significantly older than local patients (median age 37 years v 29 years; p = 0.0006). In contrast, FHF and death from paracetamol poisoning most frequently occurred in patients aged 40 years or above. In a logistic regression analysis, "age >/=40 years" was associated with an excess risk of FHF (odds ratio (OR) 2.33 (95% confidence interval (CI) 1.50-3.64)) and death or liver transplantation (OR 4.18 (95% CI 2.17-8.05)). In addition, older age was associated with other risk factors for paracetamol hepatotoxicity such as regular alcohol abuse and late presentation.

CONCLUSIONS

Age 40 years or above was identified as a significant independent risk factor for FHF and mortality following paracetamol overdose. Patients aged 40 years or above should be considered as high risk patients, in particular when older age appears in combination with regular alcohol abuse or late presentation.

Television and Adolescent Use of Over-the-Counter Analgesic Agents

BACKGROUND:

Portrayals of the use of over-the-counter (OTC) analgesics on television may stimulate their use.

OBJECTIVE:

To explore the association between taking OTC analgesics and television viewing by adolescents.

METHODS:

A standardized self-administered questionnaire among first-year (mean age 13.16 y) and fourth-year (mean age 16.37 y) secondary students in Flanders, Belgium (n = 2546) was administered in a school setting. The independent variable was television viewing; control variables were school year, gender, drinking alcohol, days off sick, computer gaming, and Internet use. The main outcome variable was monthly use of OTC analgesics.

RESULTS:

On average, respondents watched 3 hours 18 minutes of television per day (boys more than girls, first-year students more than fourth-year students). Per additional hour of television per day, the odds that respondents were regular users of analgesics were 1.16 times higher (95% CI 1.08 to 1.24). For the 10% heaviest viewers, the odds were 2.30 times higher (95% CI 1.25 to 4.24) compared with the 10% lightest viewers. Odds of OTC analgesic use were higher for students reporting more sick days in the past year (OR 1.38, 95% CI 1.28 to 1.49), regular users of alcohol (OR 1.33, 95% CI 1.17 to 1.50), and girls (OR 1.92, 95% CI 1.35 to 2.73).

CONCLUSIONS:

A relationship was found between watching television and the use of OTC analgesics, even after controlling for gender and lifestyle measures. More research is needed to establish whether this relationship is causal.

Patients' knowledge and perceptions of the side-effects of OTC medication

OBJECTIVE

To investigate the knowledge of patients with regard to the side-effects of over-the-counter medicines.

METHOD

This took the form of ethnographic interviews and focus groups.

RESULTS

Patients generally had poor knowledge of the potential side-effects of their medication. However, this appeared not to affect their ability to identify adverse drug reactions (ADRs). A number of the patients had experienced ADRs, and they identified a medicine as the cause because of the timing or unexpected nature of the symptom. The patients obtained information about medicines from many sources, including health care professionals, friends and family. Despite wide availability, patient information leaflets were rarely used by the patients. The leaflets were usually only read if the medicine was new or if a side-effect was experienced. Negative views of the leaflets included poor design and long lists of side-effects.

CONCLUSION

Accurate information and advice from health care professionals could serve to reassure patients and to ensure they are well informed about the medicines they take.

Ease of access is a principal factor in the frequency of paracetamol overdose

BACKGROUND

In Ireland, 30% of non-fatal overdoses involve paracetamol.

AIMS

To determine how and where patients obtained paracetamol, to assess awareness of toxicity and examine the relationship between dose and suicidal intent.

METHODS

A prospective study of patients admitted following a paracetamol overdose recording their reasons for using paracetamol, their knowledge of its toxicity and their suicidal intent scale (SIS).

RESULTS

Of 100 patients, 66% obtained paracetamol in non-pharmacy outlets, 82% cited ease of availability as the reason, 55% were aware of its toxicity, 31% of liver damage and 68% did not read the warning on packets. The mean number of tablets taken was 51.3 for males and 37.2 for females (p < 0.01). Males presented later than females for medical attention (12.5 versus seven hours [p < 0.02]) and more males than females took alcohol (p < 0.03). The mean SIS score was 14.71 for males and 12.38 for females. There was a significant correlation between the SIS and the amount of paracetamol consumed (r = 0.28; p < 0.01).

CONCLUSION

The majority obtained paracetamol in local shops or at home. Knowledge of toxicity and the need for early antidote was poor. There was a significant relationship between suicidal intent and number of tablets consumed. Limiting availability could reduce number of overdoses.

Deliberate self-harm in adolescents in Oxford, 1985-1995

Deliberate self-harm (DSH) has been one of the major health problems of adolescents in the U.K. for many years. Any changes in rates of DSH or the demographic characteristics of the patient population are likely to have important implications for clinical services and for future suicidal behaviour. Following a decline in rates in the late 1970s and mid 1980s, there were signs in the late 1980s that rates were beginning to increase again. We have used data collected by the Oxford Monitoring System for Attempted Suicide on the basis of patients presenting to the general hospital in Oxford to review trends in DSH in under 20-year-olds between 1985 and 1995. There was a substantial increase in the numbers of teenage DSH patients during the 11-year study period, with an increase between 1985-1986 and 1994-1995 of 27.7% in males, 28.3% in females, and 28.1% overall. There were no demographic changes within the catchment area to explain a change of this size. As rates of repetition of DSH also increased in both sexes during the study period the overall number of episodes of DSH rose even more between 1985-1986 and 1994-1995 (+56.9% in males, +46.3% in females, and +49.4% overall). As in previous studies the majority of adolescents had interpersonal problems and/or difficulties with studying or employment. Self-poisoning with paracetamol and paracetamol compounds became increasingly common such that by 1995 these were used in almost two-thirds of overdoses. The recent increase in DSH in adolescents has important implications for general hospital and adolescent psychiatric services. The greater frequency of repetition of DSH may herald increased future suicide rates. The case for restricting the amount of paracetamol available is overwhelming. Evaluative trials of specific interventions following adolescent DSH are urgently required.

Acetaminophen (paracetamol) levels in human tears

This study was designed to measure acetaminophen (paracetamol) levels in tears, and to compare it to serum levels. Paracetamol levels were measured in 20 paired tears and serum samples from 10 healthy volunteers, 1 and 2 hours after ingesting 1.5 g paracetamol. Tears were collected using glass microcapillary tubes while stimulating the conjunctiva with a small sponge placed in the lower fornix. Blood samples were taken simultaneously. The samples were analyzed for paracetamol levels using homogeneous enzyme immunoassay. Tears and serum paracetamol levels 1 hour after ingestion were 16.3 microg/mL +/- 7.2 (mean +/- SD), and 21.4 microg/mL +/- 7.7 (mean +/- SD) respectively. Tears and serum levels 2 hours after ingestion were 14.4 microg/mL +/- 7.8 (mean +/- SD), and 17 microg/mL +/- 7.6 (mean +/- SD) respectively. Tears and serum paracetamol levels of all the 20 paired samples (1 h and 2 h after ingestion) were 15.35 microg/mL +/- 7.4, and 19.25 microg/mL +/- 7.8, respectively (mean +/- SD). There was a strong and highly significant correlation between paracetamol levels in serum and in tears 1 and 2 hours after ingestion (r = 0.8, p = 0.005, r = 0.85, p = 0.002 respectively). Mean +/- SD ratio of tears/serum paracetamol levels 1 hour and 2 hours after ingestion were 0.77 +/- 0.21 and 0.81 +/- 0.25 respectively. Delta tears (difference in mean levels at 1 and 2 hours) paracetamol levels is significantly correlated with delta serum levels (r = 0.7, p = 0.025). A reliable, convenient, and feasible noninvasive method is described for measuring paracetamol in tears. There is no information in the literature about tears paracetamol secretion, and little information of tears drugs concentration.

Suicidal behavior among young people in Singapore

The purpose of this study was to investigate suicidal behavior among young people in an Asian community. Tracing records of all patients below 21 years of age who attempted suicide and were managed in a teaching hospital, the authors found the incidence increased sixfold between 1991 and 1995. Young females of Indian origin were found to be a risk group. Differences in suicidal behavior among the three main ethnic communities appear to be influenced by various sociocultural factors. The most common diagnosis was adjustment disorder stemming from interpersonal losses and conflicts. Schizophrenia, alcohol, and other substance abuse were rarely reported.

Use of ondansetron and other antiemetics in the management of toxic acetaminophen ingestions

BACKGROUND

Patients presenting with acetaminophen toxicity and vomiting are often treated with antiemetics so that orally administered N-acetylcysteine can be retained. The policy at the West Virginia Poison Center is to reserve ondansetron, an antiemetic with a higher cost than other antiemetics, as a second line agent for patients presenting within 8 hours of an acetaminophen ingestion.

METHODS

A retrospective study of cases between January 1993 and December 1995, in which the primary or secondary drug ingested was an adult-strength, acetaminophen-only formulation and the ingestion resulted in vomiting. Seventy-eight patients with laboratory-verified acetaminophen toxicity and vomiting were evaluated for the type of antiemetics used and the antiemetic's effectiveness.

RESULTS

Of the 78 acetaminophen toxic patients with vomiting, 17/51 patients (33.3%) who received a nonondansetron antiemetic failed therapy and required IV ondansetron. Of the 24 patients who received ondansetron, 4 patients (16.7%) failed therapy. All four patients who failed ondansetron therapy had previously failed other antiemetic therapy.

DISCUSSION

Although ondansetron had a lower failure rate than nonondansetron antiemetics, almost two-thirds of acetaminophen toxic patients with vomiting did not require ondansetron to control their vomiting. Health care costs would have been higher had these patients received ondansetron as their initial therapy. Antiemetics were found to be highly effective as only 3/78 patients (4%) required IV N-acetylcysteine secondary to antiemetic failure.

CONCLUSIONS

Ondansetron should be utilized as a second-line agent in the management of acetaminophen toxic patients with vomiting. Because of its lower failure rate, ondansetron should be administered as a first-line agent in patients with a delay in N-acetylcysteine administration approaching 8 or more hours.