Long term effect of reduced pack sizes of paracetamol on poisoning deaths and liver transplant activity in England and Wales: interrupted time series analyses

Assessment of the impact of Uber system implementation on mortality from traffic injuries in Brazilian capital cities

The rapid expansion of Uber Technologies, Inc.'s ride-sharing, courier service, and food delivery system and e-hailing applications has been transforming the logistics network and urban mobility around the world. We aimed to evaluate the impact of the Uber system on traffic injury (TI) mortality during its implementation in Brazilian capital cities. A quasiexperimental design of interrupted time series was used. The monthly mortality rates for TI standardized by age were analyzed. The date of availability of the Uber app, specific to each capital, was considered the start date. Data from the Brazilian Mortality Information System and the Brazilian Institute of Geography and Statistics were used. For the data analysis, from an interrupted time-series design, autoregressive integrated moving average (ARIMA) models with a transfer function were fitted. In 92.6% (n = 25) of Brazilian capitals, there was no impact of Uber system implementation, 12 months after the start of its activities, on TI mortality. A reduction in mortality from this cause was observed after the system was implemented in Belo Horizonte and Rio de Janeiro. The impact on TI mortality was progressive and continuous in both. More studies are needed to establish the factors associated with the inequalities observed in the impact of Uber system implementation between different locations and the heterogeneity of effects.

Quantifying sustained health system benefits of primary care-based integrated disease management for COPD: a 6-year interrupted time series study

BACKGROUND

Severe exacerbation of chronic obstructive pulmonary disease (COPD) is a trajectory-changing life event for patients and a major contributor to health system costs. This study evaluates the real-world impact of a primary care, integrated disease management (IDM) programme on acute health service utilisation (HSU) in the Canadian health system.

METHODS

Interrupted time series analysis using retrospective health administrative data, comparing monthly HSU event rates 3 years prior to and 3 years following the implementation of COPD IDM. Primary outcomes were COPD-related hospitalisation and emergency department (ED) visits. Secondary outcomes included hospital bed days and all-cause HSU.

RESULTS

There were 2451 participants. COPD-related and all-cause HSU rates increased in the 3 years prior to IDM implementation. With implementation, there was an immediate decrease (month 1) in COPD-related hospitalisation and ED visit rates of -4.6 (95% CI: -7.76 to -1.39) and -6.2 (95% CI: -11.88, -0.48) per 1000 participants per month, respectively, compared with the counterfactual control group. After 12 months, COPD-related hospitalisation rates decreased: -9.1 events per 1000 participants per month (95% CI: -12.72, -5.44) and ED visits -19.0 (95% CI: -25.50, -12.46). This difference nearly doubled by 36 months. All-cause HSU also demonstrated rate reductions at 12 months, hospitalisation was -10.2 events per 1000 participants per month (95% CI: -15.79, -4.44) and ED visits were -30.4 (95% CI: -41.95, -18.78).

CONCLUSIONS

Implementation of COPD IDM in a primary care setting was associated with a changed trajectory of COPD-related and all-cause HSU from an increasing year-on-year trend to sustained long-term reductions. This highlights a substantial real-world opportunity that may improve health system performance and patient outcomes.

Patterns of acetaminophen toxicity among patients with low-risk serum concentrations

OBJECTIVE

In 2012, the Commission on Human Medicines mandated lowering the acetaminophen toxicity nomogram treatment threshold in the UK to 100 µg/ml at 4 h post-ingestion. The present study aim was to evaluate biochemical and liver toxicity patterns in patients who presented with acetaminophen overdose and had low serum acetaminophen concentrations (<150 µg/ml).

METHODS

Patients admitted to the emergency department with a clear history of acute acetaminophen overdose with or without other medication or ethanol were consecutively enrolled into this retrospective cohort study. Patients with serum acetaminophen concentration >150 µg/ml or an unknown ingestion time were excluded. Data were extracted from electronic medical records and are presented as mean ± SD or median (interquartile range).

RESULTS

A total of 103 patients were included (median age, 17 [4-21] years) and 80 (78%) were female. The median ingested acetaminophen dose was 5000 (2850-7650) mg. At baseline, the median serum acetaminophen concentration was 42 (4.5-64.8) µg/ml, and median alanine aminotransferase and aspartate aminotransferase levels were 22 (17-28) and 27 (16-45) IU/L, respectively. Twenty patients were treated with acetylcysteine, with none developing adverse reactions. No patient developed hepatotoxicity, including patients with initial multiple product ingestion or other risk factors.

CONCLUSIONS

Patients presenting with an acute acetaminophen overdose with acetaminophen level <150 µg/ml, including patients with other risk factors, are at low risk of hepatotoxicity.

Profile and risk factors in farmer injuries: a review based on Haddon matrix and 5 E's risk reduction strategy

Farmers are considered a high-risk group for intentional and unintentional injuries. This review identified significant risk factors for agricultural injuries in farmers and explored injury prevention countermeasures based on the literature. Therefore, CiteSpace software was used to analyze the relevant literature in this field. Additionally, we identified both key risk factors and countermeasures using the Haddon matrix and the 5 E's risk reduction strategies conceptual framework, respectively. The risk factors were identified from four categories (host, agent, physical environment, and social environment) corresponding to three phases (pre-event, event, and post-event). Interventions of 5 E's risk reduction strategies including education, engineering, enforcement, economic, and emergency response have been proven effective in preventing injuries or reducing their severity. Our findings provide a comprehensive foundation and research direction for the study and prevention of injuries among farmers.

Suicide prevention: reflections on progress over the past decade

Interest in preventing suicides has increased greatly in recent years. In this Personal View, we consider the general global developments related to suicide prevention that have occurred in the decade since The Lancet Psychiatry was first published in 2014. We then review specific advances during this period, first, in relation to public health initiatives, and second, with regard to clinical developments. Finally, we examine some of the challenges that currently confront individuals and organisations responsible for designing and implementing suicide prevention measures.

Evaluating Population-Level Interventions and Exposures for Suicide Prevention

Evaluations of interventions targeting the population level are an essential component of the policy development cycle. Pre-post designs are widespread in suicide prevention research but have several significant limitations. To inform future evaluations, our aim is to explore the three most frequently used approaches for assessing the association between population-level interventions or exposures and suicide - the pre-post design, the difference-in-difference design, and Poisson regression approaches. The pre-post design and the difference-in-difference design will only produce unbiased estimates of an association if there are no underlying time trends in the data and there is no additional confounding from other sources. Poisson regression approaches with covariates for time can control for underlying time trends as well as the effects of other confounding factors. Our recommendation is that the default position should be to model the effects of population-level interventions or exposures using regression methods that account for time effects. The other designs should be seen as fall-back positions when insufficient data are available to use methods that control for time effects.

Effectiveness of a Suicide Prevention Lethal Means Training Program for the General Public

To evaluate the effectiveness of Conversations on Access to Lethal Means for the General Public (CALM-GP), a training for the public focusing on reducing access to lethal means during a crisis. The program adapted Counseling on Access to Lethal Means (CALM), developed for mental health practitioners and physicians. Participants completed pre/post surveys and follow-up surveys three months afterward. Measures included comfort and confidence in talking to a suicidal individual about access to lethal means, the likelihood of follow-up, and the number of lethal means conversations before and after the program. Surveys showed improvement in comfort and confidence talking about safely storing firearms and other lethal means and the likelihood of follow-up with that individual regarding access to lethal means. Results also indicated increased conversations participants had regarding suicide and lethal means at three-month follow-up. This evaluation suggests that CALM-GP is an effective suicide prevention and lethal means program for the public.

Loperamide cases reported to United States poison centers, 2010-2022

BACKGROUND

Intentional use of high doses of loperamide has been linked to serious cardiac toxicity. The objective of this study is to investigate the characteristics and trends of loperamide cases reported to United States (US) poison centers and to evaluate the changes in reported loperamide cases following US Food and Drug Administration (FDA) warnings, labeling requirements, and packaging restrictions for loperamide starting in 2016, with an emphasis on intentional exposures.

METHODS

Data from the National Poison Data System were analyzed.

RESULTS

There were 12,987 cases reported to US poison centers from 2010 to 2022, for which, loperamide was the most likely substance responsible for observed clinical effects. Although 46.1% of these cases were associated with minor or no effect, 13.4% resulted in a serious medical outcome, including 59 deaths (0.5%). Eight percent (8.1%) of cases were admitted to a critical care unit and 5.0% were admitted to a non-critical care unit. Among cases with a serious medical outcome, most were associated with loperamide abuse (38.0%), intentional-misuse (15.7%), or suspected suicide (27.5%). The majority (60.0%; n = 33) of fatalities were related to abuse, followed by suspected suicide (20.0%; n = 11) and intentional-misuse (5.5%, n = 3). The rate of loperamide cases per 100,000 US population reported to US PCs decreased from 0.44 in 2010 to 0.36 in 2015 (p = 0.0290), followed by an increase to 0.46 in 2017 (p = 0.0013), and then a trend reversal with a decrease to 0.28 in 2022 (p < 0.0001). The rate of serious medical outcomes related to loperamide increased from 0.03 in 2010 to 0.05 in 2015 (p = 0.0109), which subsequently increased rapidly to 0.11 in 2017 (p < 0.0001), and then demonstrated a trend reversal and decreased to 0.04 in 2022 (p < 0.0001).

CONCLUSIONS

FDA warnings, labeling requirements, and packaging restrictions may have contributed to the observed trend reversal and decrease in reports to US poison centers of loperamide cases related to intentional misuse, abuse, and suspected suicide. This demonstrates the potential positive effect that regulatory actions may have on public health. These findings contribute to the evidence supporting the application of similar prevention efforts to reduce poisoning from other medications associated with intentional misuse, abuse, and suicide.

Drug induced liver injury - a 2023 update

Drug-Induced Liver Injury (DILI) constitutes hepatic damage attributed to drug exposure. DILI may be categorized as hepatocellular, cholestatic or mixed and might also involve immune responses. When DILI occurs in dose-dependent manner, it is referred to as intrinsic, while if the injury occurs spontaneously, it is termed as idiosyncratic. This review predominately focused on idiosyncratic liver injury. The established molecular mechanisms for DILI include (1) mitochondria dysfunction, (2) increased reactive oxygen species levels, (3) presence of elevated apoptosis and necrosis, (4) and bile duct injuries associated with immune mediated pathways. However, it should be emphasized that the underlying mechanisms responsible for DILI are still unknown. Prevention strategies are critical as incidences occur frequently, and treatment options are limited once the injury has developed. The aim of this review was to utilize retrospective cohort studies from across the globe to gain insight into epidemiological patterns. This review considers (1) what is currently known regarding the mechanisms underlying DILI, (2) discusses potential risk factors and (3) implications of the coronavirus pandemic on DILI presentation and research. Future perspectives are also considered and discussed and include potential new biomarkers, causality assessment and reporting methods.

Paracetamol (acetaminophen) overdose and hepatotoxicity: mechanism, treatment, prevention measures, and estimates of burden of disease

INTRODUCTION

Paracetamol is one of the most used medicines worldwide and is the most common important poisoning in high-income countries. In overdose, paracetamol causes dose-dependent hepatotoxicity. Acetylcysteine is an effective antidote, however despite its use hepatotoxicity and many deaths still occur.

AREAS COVERED

This review summarizes paracetamol overdose and toxicity (including mechanisms, risk factors, risk assessment, and treatment). In addition, we summarize the epidemiology of paracetamol overdose worldwide. A literature search on PubMed for poisoning epidemiology and mortality from 1 January 2017 to 26 October 2022 was performed to estimate rates of paracetamol overdose, liver injury, and deaths worldwide.

EXPERT OPINION

Paracetamol is widely available and yet is substantially more toxic than other analgesics available without prescription. Where data were available, we estimate that paracetamol is involved in 6% of poisonings, 56% of severe acute liver injury and acute liver failure, and 7% of drug-induced liver injury. These estimates are limited by lack of available data from many countries, particularly in Asia, South America, and Africa. Harm reduction from paracetamol is possible through better identification of high-risk overdoses, and better treatment regimens. Large overdoses and those involving modified-release paracetamol are high-risk and can be targeted through legislative change.

Trends in suicide methods in Switzerland from 1969 to 2018: an observational study

BACKGROUND

Suicide is a serious societal and health problem. We examined changes in rates of completed suicides in Switzerland between 1969-2018 with particular regard to different methods of suicide used in different subgroups of the resident population.

METHODS

We used data of the Swiss cause of death statistics and Poisson regression models to analyse annual incidence rates and calendar time trends of specific suicide methods used in population subgroups by sex (men vs women), age (10-29, 30-64, >64 years), and nationality (Swiss vs other citizenship).

RESULTS

There were 64,996 registered suicides between 1969 and 2018. Across these 5 decades, the overall suicide rate was higher in men than in women (incidence rate ratio [IRR] 2.62, 95% confidence interval [CI] 2.58-2.67), in Swiss citizens than in foreigners (IRR 2.02; 95% CI 1.97-2.07), and in older residents (>64 years) than in the age groups 30-64 years (IRR 1.35, 95% CI 1.32-1.37) and 10-29 years (IRR 2.37, 95% CI 2.32-2.43). After peaking in the 1980s, the overall suicide rate had declined in all of these population subgroups, with flattening trends over most recent years. The most common specific methods of suicide were hanging (accounting for 26.7% of all suicides) and firearms (23.6%). The rates of the specific suicide methods were usually higher in men, in Swiss citizens and in older residents, and they had typically declined over most recent decades in the population subgroups examined. However, some methods diverged from this general pattern, at least in some population subgroups. For instance, railway suicides most recently increased in younger and in male residents whereas suicides by gas and by drowning were only at a low level after rapid declines in the last millennium.

CONCLUSIONS

Restricting access to lethal means (e.g., detoxification of domestic gas), improvements in health care and media guidelines for responsible reporting of suicides are possible explanations for the generally declining suicide rates in Switzerland. Whereas some methods (e.g., poisoning by gases or drowning) had become rare, others continue to account for many suicides every year, at least in some population subgroups (e.g., firearms in older Swiss men or railway suicides in younger and in male residents). As different methods of suicide are chosen by different people or subgroups of the population, preventive efforts should include differentiated strategies and targeted measures to further reduce suicides in Switzerland and elsewhere.

[Suicide prevention in the context of assisted suicide]

The verdict of the German Federal Constitutional Court from 26 February 2020 made it clear that every person is granted the right to end his or her own life, provided it is the person's own free will. It is also within his or her rights to utilize assistance in doing so, if such assistance is offered. This freedom to end one's life and to utilize assistance is not limited to terminal illnesses or situations of unbearable suffering. However, the High Court has also demanded that lawmakers ensure the safety of vulnerable people by making certain that the decision for suicide is in fact made out of the person's own free will. This free decision-making capability can be substantially impaired by acute psychosocial stressors, by mental illnesses but also by third party influence. Therefore, a liberalization of assisted suicide must unconditionally be accompanied by a massive strengthening of suicide prevention measures, which clearly prioritize the help to live over the help to die. This article reviews the scientifically established methods for suicide prevention and makes demands to lawmakers to comprehensively implement such measures.

Suicide Prevention in Nigeria: Can Community Pharmacists Have a Role?

Suicide is a global public health problem and is among the leading causes of death worldwide. Over 700,000 people die by suicide globally each year, affecting all ages, genders, and regions. Community pharmacists are easily accessible and trusted frontline healthcare professionals. They provide pharmaceutical care to the community, yet their role is still yet to be fully optimised. With the expanding role of community pharmacists and their constant accessibility to the local population, they could have a potential role in suicide prevention and awareness in Nigeria through restriction of means, signposting to services, and conversations with patients built on trusting relationships. In this commentary, we review the literature on the involvement of community pharmacists in suicide prevention. In addition, we discuss the potential role of community pharmacists in Nigeria through establishing trusting relationships with patients, clinical counselling, and medication gatekeeping, given the existing gaps in knowledge and awareness of suicide prevention within community settings. This commentary also outlines potential barriers and solutions, making suggestions for future research.

Suicide Risk Assessments: A Scientific and Ethical Critique

There are widely held premises that suicide is almost exclusively the result of mental illness and there is "strong evidence for successfully detecting and managing suicidality in healthcare" (Hogan and Grumet, 2016). In this context, 'zero-suicide' policies have emerged, and suicide risk assessment tools have become a normative component of psychiatric practice. This essay discusses how suicide evolved from a moral to a medical problem and how, in an effort to reduce suicide, a paternalistic healthcare response emerged to predict those at high risk. The evidence for the premises is critiqued and shown to be problematic; and it is found that strong paternalistic interventions are being used more often than acknowledged. Using a Principles approach, the ethics of overriding autonomy in suicide prevention is considered. Ethical concerns are identified with the current approach which are potentially amplified by the use of these risk assessments. Furthermore, it is identified that the widespread use of risk assessments in health settings is equivalent to screening without regard to the ethical principles of screening. The essay concludes that this is unethical; that we should abandon the use of standardized suicide risk assessments and 'zero-suicide' policy; and that this may improve outcomes.

Near-Fatal Self-Harm Among Canadian Adolescents

OBJECTIVE

To evaluate the clinical features of Canadian adolescents admitted to the intensive care unit (ICU) for medically serious self-harm.

METHODS

2700 Canadian paediatricians were surveyed monthly over two years (January 2017 to December 2018) through the Canadian Paediatric Surveillance Program to ascertain data from eligible cases.

RESULTS

Ninety-three cases (73 female; age 15.2 ± 1.5) met the case definition. Four provinces reported the majority of cases: Quebec (n = 27), Ontario (n = 26), Alberta (n = 21), and British Columbia (n = 8). There were 10 deaths, 9 by hanging. Overdose and hanging were the most frequently reported methods of self-harm (74.2% and 19.4%, respectively). Overdose was more common in females (80.8% females vs. 50% males; χ² = 7.8 (1), p = .005), whereas hanging was more common in males (35% males vs. 15.1% females, χ² = 3.9 (1), p = .04). More females than males had a past psychiatric diagnosis (79% vs. 58%; χ² = 4.1 (1), p = .06), a previous suicide attempt (55.9% vs. 29.4%, χ² = 3.8 (1), p = .05), and prior use of mental health service (69.7% vs. 27.8%, χ² = 10.4 (1), p = .001). Family conflict was the most commonly identified precipitating factor (43%) of self-harm.

CONCLUSIONS

Among Canadian adolescents admitted to the ICU with medically serious self-harm, females demonstrate a higher rate of suicide attempts and prior mental health care engagement, whereas males are more likely to die by suicide. These findings are consistent with data from other adolescent samples, as well as data from working-age and older adults. Therefore, a sex-specific approach to suicide prevention is warranted as part of a national suicide prevention strategy; family conflict may be a specific target for suicide prevention interventions among adolescents.

Vaccination and Government Stringent Control as Effective Strategies in Preventing SARS-CoV-2 Infections: A Global Perspective

With the rapid implementation of global vaccination against the coronavirus disease 2019 (COVID-19), the threat posed by the disease has been mitigated, yet it remains a major global public health concern. Few studies have estimated the effects of vaccination and government stringent control measures on the disease transmission from a global perspective. To address this, we collected 216 countries' data on COVID-19 daily reported cases, daily vaccinations, daily government stringency indexes (GSIs), and the human development index (HDI) from the dataset of the World Health Organization (WHO) and the Our World in Data COVID-19 (OWID). We utilized the interrupted time series (ITS) model to examine how the incidence was affected by the vaccination and GSI at continental and country levels from 22 January 2020 to 13 February 2022. We found that the effectiveness of vaccination was better in Europe, North America, and Africa than in Asia, South America, and Oceania. The long-term effects outperformed the short-term effects in most cases. Countries with a high HDI usually had a high vaccination coverage, resulting in better vaccination effects. Nonetheless, some countries with high vaccination coverage did not receive a relatively low incidence due to the weaker GSI. The results suggest that in addition to increasing population vaccination coverage, it is crucial to maintain a certain level of government stringent measures to prevent and control the disease. The strategy is particularly appropriate for countries with low vaccination coverage at present.

Evaluating the policy of closing bars and restaurants in Cataluña and its effects on mobility and COVID19 incidence

The world has gone through unprecedented changes since the global pandemic hit. During the early phase of the pandemic, the absence of known drugs or pharmaceutical treatments forced governments to introduce different policies in order to help reduce contagion rates and manage the economic consequences of the pandemic. This paper analyses the causal impact on mobility and COVID19 incidence from policy makers in Cataluña, Spain. We use anonymized phone-based mobility data together with reported incidence and apply a series of causal impact models frequently used in econometrics and policy evaluation in order to measure the policies impact. We analyse the case of Cataluña and the public policy decision of closing all bars and restaurants down for a 5 week period between 2020-16-10 and 2020-23-11. We find that this decision led to a significant reduction in mobility. It not only led to reductions in mobility but from a behavioural economics standpoint, we highlight how people responded to the policy decision. Moreover, the policy of closing bars and restaurants slowed the incidence rate of COVID19 after a time lag has been taken into account. These findings are significant since governments worldwide want to restrict movements of people in order to slow down COVID19 incidence without infringing on their rights directly.

[Suicide prevention: How to act?]

Although being complex, suicide is a phenomenon considered as preventable, and its prevention has been made as a public health priority. Some interventions to prevent suicide have been evaluated, such as the education of the healthcare workers, especially in the suicidal assessment (suicidal risk and suicidal emergency/dangerousness), the diagnosis and management of common mental disorders, the care provided after a suicide attempt, the restriction access to common means of suicide, the use of websites to educate the public, or the appropriate reports of suicide in media. Other interventions, even not rigorously evaluated, are implemented in France as in many parts of the world. It is the case of interventions among identified high-risk groups. To be efficient, prevention programs should simultaneously include different strategies targeting several known risk factors for suicide. Clinicians play a crucial role in the suicide prevention strategies.

The Recent Rise of Suicide Mortality in the United States

Suicide is a major public health concern in the United States. Between 2000 and 2018, US suicide rates increased by 35%, contributing to the stagnation and subsequent decrease in US life expectancy. During 2019, suicide declined modestly, mostly owing to slight reductions in suicides among Whites. Suicide rates, however, continued to increase or remained stable among all other racial/ethnic groups, and little is known about recent suicide trends among other vulnerable groups. This article (a) summarizes US suicide mortality trends over the twentieth and early twenty-first centuries, (b) reviews potential group-level causes of increased suicide risk among subpopulations characterized by markers of vulnerability to suicide, and (c) advocates for combining recent advances in population-based suicide prevention with a socially conscious perspective that captures the social, economic, and political contexts in which suicide risk unfolds over the life course of vulnerable individuals.

Direct costs of hospital care of self-harm: A national register-based cohort study

OBJECTIVE

To estimate national direct hospital costs associated with treatment of self-harm and to analyse whether costs differ with respect to demographic and clinical characteristics.

METHODS

A cohort design was applied to register data on all people living in Denmark (5.8 million inhabitants) from Jan 1, 2012 to Dec 31, 2016. Self-harm presentations at all hospitals by persons aged 10 years and older were included. Total costs and costs related to somatic and psychiatric care and treatment setting (inpatient, emergency department and outpatient) were calculated (in US dollars). The association between specific characteristics and somatic inpatient costs was analysed adjusted using generalized linear models and expressed as Odds Ratios (OR).

RESULTS

In all, 42,634 (97.3%) self-harm presentations by 30,366 persons were included. Annual somatic and psychiatric costs amounted to $25,241,518 and $34,696,388, respectively, and the median cost per episode was $2248 (IQR: $1553-$4138). Predictors of high somatic inpatient costs were: admission to intensive care (OR = 15.6; 95% CI, 13.7-17.9), particularly dangerous methods of self-harm, such as being hit by moving objects (OR = 6.5; 95% CI, 2.7-15.7) and shooting (OR = 6.0; 95% CI, 3.4-10.7), and age ≥75 years (OR = 1.8; 95% CI, 1.5-2.2). A small group of persons (0.7%) with ≥10 presentations accounted for 8.2% of somatic and 15.3% of total hospital costs.

CONCLUSION

Substantial hospital costs were noted for inpatient treatment. Although one-time presenters accounted for the major share of costs, smaller patient groups accounted for considerable shares. Hospital costs of self-harm should be included in evaluation of initiatives for prevention and treatment.

[Management of suicidal crisis in general practice: evaluation of care practices according to patient age]

Nearly 800,000 people die by suicide each year worldwide. Up to 75% of suicidal patients consulted their general practitioner in the months preceding their attempt. A study, conducted among 167 practitioners in Champagne-Ardenne in 2016-2017, aims to evaluate the practices of general practitioners in the management of suicidal crisis, particularly according to the age of the patient. It provides elements for reflection on their role in suicide prevention.

Role of Firearm Ownership on 2001-2016 Trends in U.S. Firearm Suicide Rates

INTRODUCTION

In the U.S., state-level household firearm ownership is strongly associated with firearm suicide mortality rates. Whether the recent increases in firearm suicide are explained by state-level household firearm ownership rates and trends remains unknown.

METHODS

Mortality data from the U.S. National Vital Statistics System and an estimate of state-level household firearm ownership rate were used to conduct hierarchical age-period-cohort (random-effects) modeling of firearm suicide mortality between 2001 and 2016. Models were adjusted for individual-level race and sex and for state-level poverty rate, unemployment rate, median household income in U.S. dollars, population density, and elevation.

RESULTS

Between 2001 and 2016, the crude national firearm suicide mortality rate increased from 6.8 to 8.0 per 100,000, and household firearm ownership rate remained relatively stable, at around 40%. Both variables were markedly heterogeneous and correlated at the state level. Age-period-cohort models revealed period effects (affecting people across ages) and cohort effects (affecting specific birth cohorts) underlying the recent increases in firearm suicide. Individuals born after 2000 had higher firearm suicide rates than most cohorts born before. A 2001-2006 decreasing period effect was followed, after 2009, by an increasing period effect that peaked in 2015. State-level household firearm ownership rates and trends did not explain cohort effects and only minimally explained period effects.

CONCLUSIONS

State-level firearm ownership rates largely explain the state-level differences in firearm suicide but only marginally explain recent increases in firearm suicide. Although firearms in the home increase firearm suicide risk, the recent national rise in firearm suicide might be the result of broader, more distal causes of suicide risk.

Association Between Means Restriction of Poison and Method-Specific Suicide Rates

Question

Findings

Meaning

Importance

Objective

Evidence Review

Findings

Conclusions and Relevance

Liver Transplantation Society of India Guidelines for the Management of Acute Liver Injury Secondary to Yellow Phosphorus-Containing Rodenticide Poisoning Using the Modified Delphi Technique of Consensus Development

BACKGROUND

Acute liver failure caused by the ingestion of yellow phosphorus-containing rodenticide has been increasing in incidence over the last decade and is a common indication for emergency liver transplantation in Southern and Western India and other countries. Clear guidelines for its management are necessary, given its unpredictable course, potential for rapid deterioration and variation in clinical practice.

METHODS

A modified Delphi approach was used for developing consensus guidelines under the aegis of the Liver Transplantation Society of India. A detailed review of the published literature was performed. Recommendations for three areas of clinical practice, assessment and initial management, intensive care unit (ICU) management and liver transplantation, were developed.

RESULTS

The expert panel consisted of 16 clinicians, 3 nonclinical specialists and 5 senior advisory members from 11 centres. Thirty-one recommendations with regard to criteria for hospital admission and discharge, role of medical therapies, ICU management, evidence for extracorporeal therapies such as renal replacement therapy and therapeutic plasma exchange, early predictors of need for liver transplantation and perioperative care were developed based on published evidence and combined clinical experience.

CONCLUSION

Development of these guidelines should help standardise care for patients with yellow phosphorus poisoning and identify areas for collaborative research.

Analyses of Child and Youth Self-Poisoning Hospitalizations by Substance and Socioeconomic Status

Child and youth self-poisoning is a growing public health issue in many regions of the world, including British Columbia (BC), Canada, where 15–19-year-olds have the highest rates of self-poisoning hospitalizations compared with those of all other ages. The purpose of this study was to identify what substances children and youth commonly used to poison themselves in BC and how socioeconomic status may impact self-poisoning risk. Self-poisoning hospitalization rates among 10–14 and 15–19-year-olds from 1 April 2012 to 31 March 2020 were calculated by substance using ICD-10-CA codes X60-X69 and T36-T65, as well as by socioeconomic status using the Institut National de Santé Publique du Québec’s Deprivation Index. Nonopioid analgesics, antipyretics, and antirheumatics were the most common substances involved, with rates of 27.6 and 74.3 per 100,000 population among 10–14 and 15–19-year-olds, respectively, followed by antiepileptic, sedative–hypnotic, antiparkinsonism, and psychotropic drugs, with rates of 20.2 and 68.1 per 100,000 population among 10–14 and 15–19-year-olds, respectively. In terms of socioeconomic status, rates were highest among 10–19-year-olds living in neighbourhoods with the fewest social connections (243.7 per 100,000 population). These findings can inform poisoning prevention strategies and relevant policies, thereby reducing the number of self-poisoning events among children and youth.

Pulverizing medication as a harm reduction and intentional drug overdose prevention strategy: Two case studies

Aims

We explored the use of pulverized medication as a new method to prevent intentional drug overdose.

Methods

This case study presents data obtained from the medical records of two female patients, aged 19 and 27 years, who presented with schizophrenia and neurodevelopmental disorder, respectively. Both patients provided written informed consent. Medication was administered to the two patients in powdered form, as opposed to in tablet form, in an attempt to prevent intentional drug overdose.

Results

This administration method successfully prevented intentional drug overdose for 3 and 5 years in each case, respectively. However, case‐control or prospective cohort studies are needed to rule out biases, including cognitive bias.

Conclusion

Pulverizing medication is a simple and effective means of preventing intentional drug overdose by restricting access to the means of suicide, regardless of the type of mental disorder.

This case study presents two female patients, who repeated intentional drug overdose. Medication was administered to the two patients in powdered form, as opposed to in tablet form, in an attempt to prevent intentional drug overdose.

Medicine storage, wastage, and associated determinants among urban households: a systematic review and meta-analysis of household surveys

Background

Irrational household storage of medicines is a world-wide problem, which triggers medicine wastage as well as its associated harms. This study aimed to include all available evidences from literature to perform a focused examination of the prevalence and factors associated with medicine storage and wastage among urban households. This systematic review and meta-analysis mapped the existing literature on the burden, outcomes, and affective socio-economic factors of medicine storage among urban households. In addition, this study estimated pooled effect sizes for storage and wastage rates.

Methods

Household surveys evaluating modality, size, costs, and affective factors of medicines storage at home were searched in PubMed, EMBASE, OVID, SCOPUS, ProQuest, and Google scholar databases in 2019. Random effect meta-analysis and subgroup analysis were used to pool effect sizes for medicine storage and wastage prevalence among different geographical regions.

Results

From the 2604 initial records, 20 studies were selected for systematic review and 16 articles were selected for meta-analysis. An overall pooled-prevalence of medicine storage and real wastage rate was 77 and 15%, respectively. In this regard, some significant differences were observed between geographical regions. Southwest Asia region had the highest storage and wastage rates. The most common classes of medicines found in households belonged to the Infective agents for systemic (17.4%) and the Nervous system (16.4%). Moreover, income, education, age, the presence of chronic illness, female gender, and insurance coverage were found to be associated with higher home storage. The most commonly used method of disposal was throwing them in the garbage.

Conclusions

Factors beyond medical needs were also found to be associated with medicine storage, which urges effective strategies in the supply and demand side of the medicine consumption chain. The first necessary step to mitigate home storage is establishing an adequate legislation and strict enforcement of regulations on dispensing, prescription, and marketing of medicines. Patient’s pressure on excessive prescription, irrational storage, and use of medicines deserve efficient community-centered programs, in order to increase awareness on these issues. So, hazardous consequences of inappropriate disposal should be mitigated by different take back programs, particularly in low and middle income countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11100-4.

Can synthetic controls improve causal inference in interrupted time series evaluations of public health interventions?

Interrupted time series designs are a valuable quasi-experimental approach for evaluating public health interventions. Interrupted time series extends a single group pre-post comparison by using multiple time points to control for underlying trends. But history bias-confounding by unexpected events occurring at the same time of the intervention-threatens the validity of this design and limits causal inference. Synthetic control methodology, a popular data-driven technique for deriving a control series from a pool of unexposed populations, is increasingly recommended. In this paper, we evaluate if and when synthetic controls can strengthen an interrupted time series design. First, we summarize the main observational study designs used in evaluative research, highlighting their respective uses, strengths, biases and design extensions for addressing these biases. Second, we outline when the use of synthetic controls can strengthen interrupted time series studies and when their combined use may be problematic. Third, we provide recommendations for using synthetic controls in interrupted time series and, using a real-world example, we illustrate the potential pitfalls of using a data-driven approach to identify a suitable control series. Finally, we emphasize the importance of theoretical approaches for informing study design and argue that synthetic control methods are not always well suited for generating a counterfactual that minimizes critical threats to interrupted time series studies. Advances in synthetic control methods bring new opportunities to conduct rigorous research in evaluating public health interventions. However, incorporating synthetic controls in interrupted time series studies may not always nullify important threats to validity nor improve causal inference.

Paracetamol-related intentional drug overdose among young people: a national registry study of characteristics, incidence and trends, 2007-2018

PURPOSE

Incidence rates of hospital-presenting self-harm are highest in people under 25 years and are reportedly increasing in some countries. Intentional drug overdose (IDO) is the most common self-harm method among young people, with paracetamol the drug most frequently used. This study aimed to describe the characteristics, incidence, and temporal trends in paracetamol-related IDO among young people.

METHODS

Data from the National Self-Harm Registry Ireland on hospital-presenting self-harm by individuals aged 1024 years during 2007-2018 were examined. Annual IDO rates per 100,000 were calculated by age and gender. Joinpoint regression analyses and incidence rate ratios were used to examine trends in the incidence of paracetamol-related IDO.

RESULTS

During the study, 10,985 paracetamol-related IDOs were recorded. The incidence of paracetamol-related IDO among young people increased by 9% between 2007 and 2018 (IRR 1.09 95% CI 1.00-1.19), with the highest annual percentage change (APC) in females aged 18-24 years (APC 1.2%). Conversely, rates of paracetamol-related IDO among males aged 18-24 years decreased significantly (APC 1.6%). Between 2013 and 2018, excesses of 386 and 151 paracetamol-related IDOs were observed in females aged 10-17 and 18-24 years, respectively, and 42 excess presentations were observed for males aged 10-17 years. There were 107 fewer presentations than expected for males aged 18-24 years.

CONCLUSION

The increase in paracetamol-related IDO among specific groups of young people, particularly young females is an issue of growing concern. Interventions targeting IDO among young people are needed, incorporating measures to address the availability of paracetamol and aftercare following IDO.

Suizidalitäts-Barometer: Ursachen und Behandlung suizidalen Erlebens und Verhaltens aus Laienperspektive

<b><i>Hintergrund:</i></b> Ziel der vorliegenden Untersuchung war es, ein Meinungsbild über Ursachen und Behandlungsmöglichkeiten suizidalen Erlebens und Verhaltens aus Laiensicht zu erstellen. <b><i>Probanden:</i></b> Insgesamt nahmen 879 Personen (58,2% weiblich; Alter (Jahre): Mittelwert = 32,28, SD = 8,41) an einer internetbasierten Fragebogenstudie teil. <b><i>Ergebnisse:</i></b> Mehr als 90% der Befragten messen psychischen Erkrankungen, schwerwiegenden Lebensereignissen sowie den Wahrnehmungen keine Hoffnung zu haben, eine Last für andere und sozial isoliert zu sein, ursächliche Bedeutung für das Verständnis von Suiziden bei. Nahezu 100% halten eine Psychotherapie für eine angemessene Behandlung suizidalen Erlebens und Verhaltens. Die Zustimmungsraten zu verschiedenen Mythen über Suizidalität sind vergleichsweise niedrig (&#x3c;20%). <b><i>Diskussion und Schlussfolgerung:</i></b> Die Gesamtbefundlage stellt sich als positiv heraus: Sowohl bedeutsame Risikofaktoren für suizidales Erleben und Verhalten als auch zentrale Behandlungsmöglichkeiten sind den Befragten weitgehend bekannt.

Gatekeeper training needs of community pharmacy staff

OBJECTIVE

To develop an online suicide prevention gatekeeper training program to prepare community pharmacy staff to communicate with patients who exhibit warning signs of suicide.

METHOD

A convenience sample of 17 community pharmacy staff members completed a 1-hr semi-structured interview during which they viewed content from an existing gatekeeper training program and provided suggestions for improvement. Once thematic saturation was achieved, interviews were digitally recorded, transcribed, and analyzed by two independent coders who reached consensus on the themes present in each transcript.

RESULTS

Participants noted barriers to communicating about suicide, including lack of time and privacy, discomfort with using the word "suicide" and limited referral options. Participants wanted gatekeeper training to include local suicide prevention referral resources, take less than 30 min to complete, and incorporate 3-4 realistic role play scenarios, including a phone interaction.

CONCLUSIONS

Many environmental, interpersonal, and individual-level barriers complicate pharmacy staff members' ability to act as gatekeepers and communicate about suicide with at-risk patients. To maximize the public health impact of pharmacy staff, skills-based training on how to identify, communicate with, and refer at-risk patients is needed. Gatekeeper training should model brief, realistic interactions with patients and provide pharmacy staff with local referral resources.

The Impact of the Social Distancing Policy on COVID-19 Incidence Cases and Deaths in Iran from February 2020 to January 2021: Insights from an Interrupted Time Series Analysis

Background: In December 2019, a viral outbreak occurred in China, and rapidly spread out worldwide. Due to the lack of immediately available vaccines and effective drugs, many policy- and decision-makers have focused on non-pharmacological methods, including social distancing. This study was aimed at assessing the effects of the implementation of this policy in Iran, one of the countries most affected by COVID-19. We conducted a quasi-experimental study, utilizing the interrupted time series analysis (ITSA) approach. Methods: We collected daily data between February 20, 2020 and January 29, 2021, through governmental websites from 954 public hospitals and healthcare settings. The Iranian government launched the social distancing policy on March 27, 2020. Statistical analyses, including ITSA, were carried out with R software Version 3.6.1 (London, UK). Results: During the study period, 1,398,835 confirmed incidence cases and 57,734 deaths occurred. We found a decrease of -179.93 (95% CI: -380.11 to -20.25, P-value=0.078) confirmed incidence cases following the implementation of the social distancing policy, corresponding to a daily decrease in the trend of -31.17 (95% CI: -46.95 to -15.40, P-value=0.08). Moreover, we found a decrease of -28.28 (95% CI: -43.55 to -13.01, P-value=0.05) deaths, corresponding to a daily decrease in the trend of -4.52 (95% CI: -5.25 to -3.78, P-value=0.003). Conclusion: The growth rate of confirmed incidence cases and deaths from COVID-19 in Iran has decreased from March 27, 2020 to January 29, 2021, after the implementation of social distancing. By implementing this policy in all countries, the burden of COVID-19 may be mitigated.

Antihistamine-related deaths in England: Are the high safety profiles of antihistamines leading to their unsafe use?

AIMS

Antihistamines are routinely taken to control allergic reactions or sedation to induce sleep. There are, however, growing concerns regarding sedating antihistamine misuse. This research aims to evaluate deaths related to antihistamines in England occurring during 2000-2019.

METHODS

Cases reported to the National Programme on Substance Abuse Deaths from England occurring in 2000-2019 with antihistamine detections at postmortem were extracted for analysis.

RESULTS

In total, 1666 antihistamine postmortem detections were identified from 1537 cases. Sedating antihistamines available for purchase under pharmacist supervision but without need for a prescription (pharmacy-only medications) were present in a significant majority of cases (85.2%, P < .01). Despite an increasing trend for antihistamine-related deaths over time, the proportion of deaths where an antihistamine was implicated declined over the same period. Specific concerns with regards to the misuse of these pharmacy-only sedating antihistamines are raised with regards to the significant proportion of cases that were concluded as suicide (20.9%, P < .01), and the high prevalence of their use in combination with other central nervous system depressants (94.8% of cases).

CONCLUSION

This is the first report in over 40 years regarding antihistamine-related mortality from England. The rising trend in sedating antihistamine-related deaths may be contributed to by their increasing availability and the perceived negligible dangers associated with antihistamines, both from the general public and learned professionals. Awareness of the dangerous sedative properties that some antihistamines possess is, however, heightened in individuals deliberately seeking these effects. Urgent review of sedating antihistamines currently assigned under the pharmacy-only classification is needed to achieve antihistamine harm reduction.

Increased rates of diphenhydramine overdose, abuse, and misuse in the United States, 2005-2016

OBJECTIVES

To describe trends in abuse, misuse, and suicide attempts involving diphenhydramine (DPH).

METHODS

We analyzed intentional DPH exposures of individuals ≥10 years old reported to U.S. Poison Control Centers using data from the National Poison Data System, 2005-2016.

RESULTS

There were 158,774 intentional DPH exposures in our dataset. The rate of intentional exposures increased 63% over the 12-year study period for all ages combined. Suicide attempts involving DPH showed a bimodal distribution-increasing 263% among children 10-14 years of age, and 126 and 143% among those 55-64 and ≥65 years of age, respectively. Older adults in both the 55-64 and ≥65-year-old age groups had about a 230% increase in rates of misuse. Major adverse clinical effects increased by 91%. There were 745 total reported deaths with a 3.6% increase across all age groups.

CONCLUSIONS

Intentional DPH exposures among individuals ≥10 years old have been increasing since 2005. Increasing rates of suicide attempts among children ages 10-14 and increasing misuse among individuals ≥65, coupled with a trend toward greater severity of overdoses, highlight the significant public health impact of this commonly available over-the-counter drug.

The cost-effectiveness of banning highly hazardous pesticides to prevent suicides due to pesticide self-ingestion across 14 countries: an economic modelling study

BACKGROUND

Reducing suicides is a key Sustainable Development Goal target for improving global health. Highly hazardous pesticides are among the leading causes of death by suicide in low-income and middle-income countries. National bans of acutely toxic highly hazardous pesticides have led to substantial reductions in pesticide-attributable suicides across several countries. This study evaluated the cost-effectiveness of implementing national bans of highly hazardous pesticides to reduce the burden of pesticide suicides.

METHODS

A Markov model was developed to examine the costs and health effects of implementing a national ban of highly hazardous pesticides to prevent suicides due to pesticide self-poisoning, compared with a null comparator. We used WHO cost-effectiveness and strategic planning (WHO-CHOICE) methods to estimate pesticide-attributable suicide rates for 100 years from 2017. Country-specific costs were obtained from the WHO-CHOICE database and denominated in 2017 international dollars (I$), discounted at a 3% annual rate, and health effects were measured in healthy life-years gained (HLYGs). We used a demographic projection model beginning with the country population in the baseline year (2017), split by 1-year age group and sex. Country-specific data on overall suicide rates were obtained for 2017 by age and sex from the Global Burden of Disease Study 2017 Data Resources. The analysis involved 14 countries spanning low-income to high-income settings, and cost-effectiveness ratios were analysed at the country-specific level and aggregated according to country income group and the proportion of suicides due to pesticides.

FINDINGS

Banning highly hazardous pesticides across the 14 countries studied could result in about 28 000 (95% uncertainty interval [UI] 24 000-32 000) fewer suicide deaths each year at an annual cost of I$0·007 per capita (95% UI 0·006-0·008). In the population-standardised results for the base case analysis, national bans produced cost-effectiveness ratios of $94 per HLYG (95% UI 73-123) across low-income and lower-middle-income countries and $237 per HLYG (95% UI 191-303) across upper-middle-income and high-income countries. Bans were more cost-effective in countries where a high proportion of suicides are attributable to pesticide self-poisoning, reaching a cost-effectiveness ratio of $75 per HLYG (95% UI 58-99) in two countries with proportions of more than 30%.

INTERPRETATION

National bans of highly hazardous pesticides are a potentially cost-effective and affordable intervention for reducing suicide deaths in countries with a high burden of suicides attributable to pesticides. However, our study findings are limited by imperfect data and assumptions that could be improved upon by future studies.

FUNDING

WHO.

Assessing the Impact on Health of Pharmacovigilance Activities: Example of Four Safety Signals

INTRODUCTION

The impact of pharmacovigilance activities on public health remains under-investigated, and measuring the impact on health of pharmacovigilance activities for a specific safety signal is challenging.

OBJECTIVE

To gain more insight into the methodological challenges and the data required, we assessed the impact of pharmacovigilance on public health for four identified product-specific safety signals using publicly available data in the Netherlands. The assessment was on the impact of the intertwined and complementary steps of the pharmacovigilance pathways.

METHODS

The impact of pharmacovigilance on public health was assessed using the assessment support tool and 'open data' from the Netherlands for four different types of pharmacovigilance safety signals: (1) off-label use of cyproterone acetate/ethinyloestradiol (CPA/EE) and thrombotic risk after pharmacovigilance measures after 2014; (2) pergolide and the risk of cardiac valvulopathy after pharmacovigilance activities in 2003; (3) proton pump inhibitors and the risk of hypomagnesaemia after pharmacovigilance activities in 2011; (4) rosiglitazone withdrawal from the market because of cardiovascular effects in 2010.

RESULTS

For the signals on CPA/EE and pergolide, a crude estimation of the impact could be made with varying degrees of assumptions based on the risk described in the literature and utilisation data.

CONCLUSION

This article highlights the methodological challenges and the data required to assess the impact of product-specific safety signals. A structured assessment support tool can be used as a guide for the necessary data elements and steps needed for the measurement or estimation of impact of pharmacovigilance activities on public health, provided that the appropriate data are available.

The Medium-Term Impact of COVID-19 Lockdown on Referrals to Secondary Care Mental Health Services: A Controlled Interrupted Time Series Study

To date, there is a paucity of information regarding the effect of COVID-19 or lockdown on mental disorders. We aimed to quantify the medium-term impact of lockdown on referrals to secondary care mental health clinical services. We conducted a controlled interrupted time series study using data from Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), UK (catchment population ~0.86 million). The UK lockdown resulted in an instantaneous drop in mental health referrals but then a longer-term acceleration in the referral rate (by 1.21 referrals per day per day, 95% confidence interval [CI] 0.41-2.02). This acceleration was primarily for urgent or emergency referrals (acceleration 0.96, CI 0.39-1.54), including referrals to liaison psychiatry (0.68, CI 0.35-1.02) and mental health crisis teams (0.61, CI 0.20-1.02). The acceleration was significant for females (0.56, CI 0.04-1.08), males (0.64, CI 0.05-1.22), working-age adults (0.93, CI 0.42-1.43), people of White ethnicity (0.98, CI 0.32-1.65), those living alone (1.26, CI 0.52-2.00), and those who had pre-existing depression (0.78, CI 0.19-1.38), severe mental illness (0.67, CI 0.19-1.15), hypertension/cardiovascular/cerebrovascular disease (0.56, CI 0.24-0.89), personality disorders (0.32, CI 0.12-0.51), asthma/chronic obstructive pulmonary disease (0.28, CI 0.08-0.49), dyslipidemia (0.26, CI 0.04-0.47), anxiety (0.21, CI 0.08-0.34), substance misuse (0.21, CI 0.08-0.34), or reactions to severe stress (0.17, CI 0.01-0.32). No significant post-lockdown acceleration was observed for children/adolescents, older adults, people of ethnic minorities, married/cohabiting people, and those who had previous/pre-existing dementia, diabetes, cancer, eating disorder, a history of self-harm, or intellectual disability. This evidence may help service planning and policy-making, including preparation for any future lockdown in response to outbreaks.

Paracetamol self-poisoning: Epidemiological study of trends and patient characteristics from the multicentre study of self-harm in England

BACKGROUND

Paracetamol is frequently used for intentional self-poisoning, especially in the UK, despite pack size restrictions introduced in 1998. Knowing more about paracetamol self-poisoning may identify further approaches to prevention.

METHODS

We used data from the Multicentre Study of Self-harm in England for 2004-2014 to calculate incidence rates of presentations to Emergency Departments following self-poisoning with pure paracetamol alone. National estimates for England for 2011-2014 were extrapolated using indirect age-standardised rates. The characteristics of individuals taking paracetamol overdoses and the size of the overdoses were investigated.

RESULTS

A third of 54,863 intentional overdoses presenting to the five Emergency Departments involved paracetamol without other drugs (N = 18,011), taken by 13,171 individuals (63.4% female).  The proportion of paracetamol self-poisonings was similar in the three centres. Extrapolation suggested there were approximately 50,000 paracetamol overdoses in England annually during 2011-2014. Females had higher rates of paracetamol overdose than males.  Males and older individuals took larger overdoses.  Nearly a quarter of individuals (24.2%) consumed more than 32 tablets. Alcohol was involved in 53.7% of paracetamol overdoses.

LIMITATIONS

Data were collected in three centres with predominantly urban populations. Extrapolation from local to national rates should be interpreted with caution.

CONCLUSIONS

Paracetamol overdose remains a major problem in the UK. It is more common in females and younger patients, but males and older patients consume larger overdoses. Consideration should be given to further restriction in pack sizes and sources of sales, in keeping with those of several other European countries.

Acetaminophen Toxicity: A History of Serendipity and Unintended Consequences

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National Poison Center Calls Before vs After Availability of High-Dose Acetaminophen (Paracetamol) Tablets in Switzerland

IMPORTANCE

Acetaminophen (paracetamol) is among the most widely used pain medications worldwide; while safe within the therapeutic range, intake exceeding 4000 mg/d can lead to hepatotoxicity. Prior evidence suggests that limiting the availability of large quantities of acetaminophen is associated with decreased acetaminophen-related poisonings and mortality; in Switzerland, 500-mg tablets are available over-the-counter (OTC) and, as of October 2003, 1000-mg tablets are available with prescription.

OBJECTIVE

To evaluate the association of adding 1000-mg acetaminophen tablets to the Swiss market with utilization and poisonings.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a quasi-experimental interrupted time series analysis to evaluate 15 790 acetaminophen poison records from January 1, 2000, to December 31, 2018. All calls for acetaminophen-related poisonings identified from the National Swiss Poisons Centre and all sales for oral acetaminophen tablets (prescription and OTC) dispensed between January 2000 and December 2018 were included.

EXPOSURE

October 3, 2003 (Q4 2003), was defined as the intervention date, corresponding to the date of market entry for 1000-mg acetaminophen tablets in Switzerland.

MAIN OUTCOMES AND MEASURES

The primary outcome was the number of quarterly acetaminophen-related poison calls to the National Poison Centre. Additional outcomes included quarterly sales for acetaminophen and change in poisoning circumstances, stratified by preintervention and postintervention periods and by formulation (ie, 500-mg and 1000-mg tablets).

RESULTS

Between 2000 and 2018, 15 790 acetaminophen-related poisoning calls were identified, of which 10 628 (67.3%) were regarding women, and the mean (SD) age of patients was 25.2 (18.2) years. The interrupted time series analysis identified a significant increase in the slope for the number of reported poisonings following the intervention point, particularly for accidental circumstances (z score, -3.62; P < .001). In the preintervention period, 120 of 961 poisonings (15.3%) involved a dose greater than 10 000 mg, while for the postintervention period, 1140 of 5696 (30.6%) had a dose larger than 10 000 mg (P < .001). There was a rapid uptake in 1000-mg acetaminophen sales, while sales of the 500-mg tablet decreased slightly. Since 2012, a mean (SD) of 20.7 million (1.4 million) 1000-mg tablets were dispensed quarterly compared with 2.7 million (0.5 million) 500-mg tablets.

CONCLUSIONS AND RELEVANCE

This study found a significant increase in acetaminophen dispensing and acetaminophen-related poisonings in Switzerland following the approval of 1000-mg tablets in 2003. The availability of 1000-mg acetaminophen should be re-evaluated to minimize the potential for accidental poisonings.

Repeat Self-Harm Following Hospital-Presenting Intentional Drug Overdose among Young People-A National Registry Study

Background: The incidence of hospital-presenting self-harm peaks among young people, who most often engage in intentional drug overdose (IDO). The risk of self-harm repetition is high among young people and switching methods between self-harm episodes is common. However, little is known about their patterns of repetition and switching following IDO. This study aimed to investigate repeat self-harm and method-switching following hospital-presenting IDO among young people. Methods: Data from the National Self-Harm Registry Ireland on hospital-presenting self-harm by individuals aged 10–24 years during 2009–2018 were examined. Cox proportional hazards regression models with associated hazard ratios (HRs), survival curves and Poisson regression models with risk ratios (RRs), were used to examine risk factors for repetition and method-switching. Results: During 2009–2018, 16,800 young people presented following IDO. Within 12 months, 2136 young people repeated self-harm. Factors associated with repetition included being male (HR = 1.13, 95% CI: 1.03–1.24), aged 10–17 years (HR = 1.29, 95% CI: 1.18–1.41), consuming ≥ 50 tablets (HR = 1.27, 95% CI: 1.07–1.49) and taking benzodiazepines (HR = 1.67, 95% CI: 1.40–1.98) or antidepressants (HR = 1.36, 95% CI: 1.18–1.56). The cumulative risk for switching method was 2.4% (95% CI: 2.2–2.7). Method-switching was most likely to occur for males (RR = 1.36; 95% CI: 1.09–1.69) and for those who took illegal drugs (RR = 1.63; 95% CI: 1.19–2.25). Conclusion: Young males are at increased risk of repeat self-harm and method-switching following IDO and the type and quantity of drugs taken are further indicators of risk. Interventions targeting IDO among young people are needed that ensure that mental health assessments are undertaken and which address access to drugs.

Prevalence and Characteristics Associated with Chronic Noncancer Pain in Suicide Decedents: A National Study

OBJECTIVE

The aims were to estimate the prevalence of CNCP in suicide decedents, and compare sociodemographic and clinical characteristics of people who die by suicide (i) with and without a history of CNCP and (ii) among decedents with CNCP who are younger (<65 years) and older (65 + years).

METHOD

We examined all closed cases of intentional deaths in Australia in 2014, utilizing the National Coronial Information System.

RESULTS

We identified 2,590 closed cases of intentional deaths in Australia in 2014 in decedents over 18 years of age. CNCP was identified in 14.6% of cases. Decedents with CNCP were more likely to be older, have more mental health and physical health problems, and fewer relationship problems, and were more likely to die by poisoning from drugs, compared with decedents without CNCP. Comparisons of older and younger decedents with CNCP found that compared to younger (<65 years) decedents with CNCP, older decedents (65 + years) were less likely to have mental health problems.

CONCLUSIONS

This is the first national study to examine the characteristics of suicide deaths with a focus on people with CNCP. Primary care physicians should be aware of the increased risk for suicide in people living with CNCP, and it may be useful for clinicians to screen for CNCP among those presenting with suicidal behaviors.

Restriction of non-opioid analgesics sold over-the-counter in Denmark: A national study of impact on poisonings

OBJECTIVE

Self-poisoning with non-opioid analgesics presents a growing challenge to health care providers. We aimed to assess the impact of an 18-year age restriction of OTC sales and a pack size restriction of non-opioid analgesics sold OTC in pharmacies on hospital-treated poisonings and poisoning severity measured using biomarkers.

METHODS

We applied a before and after design using interrupted time series analysis. Data on all poisonings recorded as hospital admissions were obtained during 2002-2015 and biochemical parameters from laboratory databases during 2011-2015, both covering the entire Danish population.

RESULTS

The age restriction was followed by a 17% level reduction in admissions for non-opioid analgesic poisoning among young people age 10-17 years (RR 0.830; 95% CI 0.697-0.988; p < 0.036). After the pack size restriction, an instant level reduction of 18.5% (RR 0.815; 95% CI 0.729-0.912; p < 0.001) was observed for the entire population. A 27% decrease in the number of poisonings with alanine transaminase levels (ALT) ≥ 210 U/L was observed (RR 0.734; 95% CI 0.579-0.931; p = 0.011) followed by 40% decrease in biomarkers indicative of liver failure (RR 0.597; 95% CI 0.421-0.847; p = 0.004). We also observed similar reductions for other poisonings such as psychotropics.

LIMITATIONS

Although declines in poisonings were observed after implementation of means restrictive measures, a causal link cannot be inferred.

CONCLUSION

Age and pack size restriction were assiociated with a reduction in the numbers of poisonings. This was also observed for pharmaceutical poisonings in general, which might suggest a non-specific or spill-over effect.