The epidemiology and management of adult poisonings admitted to the short-stay ward of a large Scottish emergency department

Comparison of emergency transport for acute alcohol intoxication before and after the coronavirus disease 2019 pandemic: A retrospective observational study

The ongoing coronavirus disease 2019 (COVID-19) pandemic has had a broad effect on social, economic, educational, and political systems. We investigated the effect of COVID-19 on emergency transportation due to acute alcohol intoxication in the Kochi Prefecture in Japan, a region with high alcohol consumption. This retrospective observational study was conducted using the data of 62,138 patients from the Kochi-Iryo-Net database, Kochi Prefecture's emergency medical and wide-area disaster information system. Chi-square tests and multiple logistic regression analyses were performed to examine the association between emergency transportation and alcohol intoxication. This analysis compared the monthly number of transportations during 2019 (as reference) with that throughout 2020 and 2021. Approximately 1.5 % of all emergency transportation cases were related to acute alcohol intoxication. The number of emergency transportation cases due to acute alcohol intoxication declined by 0.5 % in 2020 and 0.7 % in 2021 compared with that in 2019. Moreover, compared with that in 2019, the number of cases of emergency transportation due to acute alcohol intoxication significantly decreased in 2020 (incidence rate ratio: 0.78; 95 % confidence interval: 0.67-0.91) and 2021 (incidence rate ratio: 0.73; 95 % confidence interval: 0.63-0.86). Lifestyle changes due to the COVID-19 pandemic affected the number of emergency transports due to acute alcohol intoxication in 2020 and 2021 (during the COVID-19 pandemic) compared to that in 2019 (before the pandemic).

Self-discharge during treatment for acute recreational drug toxicity: an observational study from emergency departments in seven European countries

BACKGROUND

Self-discharge is a risk factor for readmission and excess mortality. We assess the rate of self-discharge from the emergency department (ED) among presentations for acute recreational drug toxicity and identify factors associated with self-discharge.

METHODS

From the Euro-DEN Plus database of presentations to the ED with acute recreational drug toxicity, we extracted data from 11 centres in seven European countries from 2014 to 2017. Self-discharge was defined as taking one's own discharge or escaping from the ED before being medically cleared. We used multiple logistic regression analyses to look for factors associated with self-discharge.

RESULTS

Among 15,135 included presentations, 1807 (11.9%) self-discharged. Self-discharge rates varied from 1.7 to 17.1% between centres. Synthetic cannabinoids were associated with self-discharge, adjusted odds ratio 1.44 (95% confidence interval 1.10-1.89), as were heroin, 1.44 (1.26-1.64), agitation, 1.27 (1.10-1.46), and naloxone treatment, 1.27 (1.07-1.51), while sedation protected from self-discharge, 0.38 (0.30-0.48).

CONCLUSION

One in eight presentations self-discharged. There was a large variation in self-discharge rates across the participating centres, possibly partly reflecting different discharge procedures and practices. Measures to improve the management of agitation and cautious administration of naloxone to avoid opioid withdrawal symptoms may be approaches worth exploring to reduce self-discharge.

Association between psychotropic prescriptions and the total amount of psychotropics ingested during an intentional overdose: A single-center retrospective study

Aim

To investigate the association between psychotropic prescriptions and the total amount of psychotropics ingested during a subsequent intentional overdose and to examine factors related to the number of psychotropic prescriptions.

Methods

The initial sample comprised 69 patients who were admitted to the emergency department of a general hospital in Japan following an intentional overdose via psychotropic medications. We performed retrospective hierarchical multiple regression analysis with the total amount of psychotropics ingested at the overdose as a dependent variable and factors related to deliberate self‐harm or overdose identified in previous studies as independent variables. We compared two models, one that did not (Step 1) and one that did (Step 2) include the number of different prescribed psychotropic medications as an independent variable in the analysis.

Results

Forty‐seven patients were eligible for the analysis. The number of different prescribed psychotropic medications was associated with the total amount of psychotropics ingested at the overdose in Step 2 (β = 0.40, P = .01). There was a trend toward an association between the past number of deliberate self‐harm events and the total amount of psychotropics ingested at the overdose in Step 1 (β = 0.30, P = .05), but this trend was weakened in Step 2 (β = 0.15, P = .33).

Conclusion

The number of different prescribed psychotropics appeared to influence the risk of subsequent intentional overdose through increasing the total amount of psychotropics ingested. Cumulative psychotropic prescriptions, particularly those delivered after deliberate self‐harm, might be indirectly related to this risk.

The number of different prescribed psychotropics appeared to influence the risk of subsequent intentional overdose through increasing the total amount of psychotropics ingested. Cumulative psychotropic prescriptions, particularly those delivered after deliberate self‐harm, might be indirectly related to this risk.

Suicide attempts by drug overdose at Jichi Medical University Hospital emergency centre: A study of patient characteristics and quantity of drug overdose

OBJECTIVE

Patients attempted suicide by psychotropic drug overdose and require medical care have increased, becoming a serious problem in Japan. This study investigated the characteristics of patients who attempted suicide by overdose and required emergency care, with a focus on quantity of drugs taken.

METHODS

We conducted a clinical survey of 98 patients examined at the emergency centre of the psychiatric department of Jichi Medical University Hospital and hospitalized for attempted suicide by drug overdose from January 1, 2012 to December 31, 2014. Data were collected by chart review and subjected to statistical analysis.

RESULTS

Diagnoses were mainly mood disorder and neurosis in both genders. Also, 23.5% of the cases had multiple hospitalizations at the centre, and past overdose was significantly higher in these patients. The average total number of pills/sachets ingested was 84.4 ± 95.5, but no significant difference was noted in dosage according to psychiatric clinic visit history (P = 0.63). Of these patients, 45.1% returned to their previous hospital, and 12.2% were hospitalized in the psychiatric ward.

CONCLUSION

These results are consistent with reports in the literature. Psychiatric outpatient history does not seem to be a risk factor for attempted suicide by ingesting higher drug doses.

Mortality and repeated poisoning after self-discharge during treatment for acute poisoning by substances of abuse: a prospective observational cohort study

Background

Though substance use is a known risk factor for self-discharge, patients self-discharging during treatment for acute poisoning have not previously been described. We charted characteristics of patients self-discharging during treatment for acute poisoning by substances of abuse looking for associations between self-discharge, repeated poisoning, and death.

Methods

All patients 12 years and older treated for acute poisoning by substances of abuse at an emergency outpatient clinic in Oslo, Norway, were included consecutively from October 2011 through September 2012. We collected data on gender, age, main toxic agent, suicidal intention, homelessness, history of severe mental illness, and self-discharge. Information on deaths was retrieved from the National Cause of Death Register. We did a multiple logistic regression analysis to look for associations between self-discharge and repeated poisoning and a Cox regression analysis for associations between self-discharge and death.

Results

During one year, 1731 patients were treated for 2343 episodes of acute poisoning by substances of abuse. Two-hundred-and-sixty-six (15%) patients self-discharged during at least one poisoning episode. Self-discharging patients were older, median age 39 years vs 32 years (p <  0.001), more frequently homeless, 20/266 (8%) vs 63/1465 (4%) (p = 0.035), and the main toxic agent more frequently was an opioid, 82/266 (31%) vs 282/1465 (19%) (p <  0.001). Self-discharge was an independent risk factor for repeated poisoning. The adjusted odds ratio for two or more poisoning episodes during one year among self-dischargers was 3.0 (95% CI 2.2–4.1). The association was even stronger for three or more poisoning episodes, adjusted odds ratio 5.0 (3.3–7.5). In total, there were 34 deaths, 9/266 (3.4%) among self-discharging patients and 25/1465 (1.7%) among patients not self-discharging (p = 0.12). The adjusted hazard ratio for death among self-discharging patients was 1.6 (0.75–3.6).

Conclusions

Self-discharge was associated with frequent poisonings by substances of abuse. Short-term mortality was doubled among self-discharging patients, though this increase was not statistically significant. Still, the increased risk of repeated poisoning marks self-discharging patients as a vulnerable group who might benefit from targeted post-discharge follow-up measures.

Use of a 23-hour emergency department observation unit for the management of patients with toxic exposures

BACKGROUND

A significant proportion of patients with toxic exposures presenting to the ED require admission. However, most will improve within 24 hours, and so could potentially be managed in a short-stay observation unit. We describe the management and outcomes of these patients in a 23-hour ED observation unit (EDOU).

METHODS

A retrospective chart review of all patients with toxic exposures admitted to the EDOU in Singapore between 1 April 2013 and 31 March 2015 was performed. Patient demographics, exposure patterns, clinical presentation and interventions received were abstracted. The poisoning severity score (PSS) was retrospectively determined. Outcomes were length of stay and disposition.

RESULTS

A total of 286 patients were analysed, of which 78.0% had intentional self-poisoning, 12.2% had bites/stings and 9.8% had unintentional or occupational toxic exposures. Analgesics (29.4%), sedatives (12.3%) and antidepressants (6.8%) were the most common drugs encountered. The majority of patients had a mild (68.9%) or moderate (15.4%) PSS, but 4.2% were graded as severe. Most patients with deliberate self-poisoning were reviewed by psychiatry (88.8%) and social services (74.9%). Most patients (92.0%) were medically cleared during their stay in EDOU, including all 12 with a severe PSS. Of these, 200 (69.9%) were discharged and 63 (22.0%) were transferred directly to a psychiatric unit. The median length of stay in the EDOU was 18 hours (IQR 13-23).

CONCLUSION

Most patients admitted to the EDOU were successfully managed and medically cleared within 23 hours, including those with a severe PSS. The EDOU appears to be a suitable alternative to inpatient admission for selected patients.

Ethanol consumption produces a small increase in circulating miR-122 in healthy individuals

INTRODUCTION

MicroRNA 122 (miR-122) is a new circulating biomarker for liver injury, which increases earlier than conventional markers in patients with acetaminophen hepatotoxicity. However, as co-ingestion of ethanol is common with drug overdose, a confounding effect of acute ethanol consumption on serum miR-122 must be examined.

METHODS

Blood was collected from healthy volunteers before and after recreational consumption of ethanol. Routine biochemistry and haematology measurements were performed, and serum miR-122 was measured by qPCR. The primary outcome was the difference in serum miR-122 with ethanol consumption.

RESULTS

We recruited 18 participants (72% male). Their mean serum ethanol concentration was 113 mg/dl (95% confidence interval [CI] 91-135 mg/dl) after consuming ethanol. Serum miR-122 increased from a mean of 71.3 million (95% CI 29.3-113.2 million) to 139.1 million (95% CI 62.6-215.7 million) copies/ml (2.2-fold increase). There was no significant difference in serum alanine aminotransferase activity before and after ethanol consumption.

CONCLUSION

miR-122 increased with moderate ethanol consumption, but the fold change was modest. As increases with acetaminophen toxicity are 100- to 10 000-fold, moderate ethanol intoxication is unlikely to confound the use of this biomarker of hepatotoxicity.

Liver transplant associated with paracetamol overdose: results from the seven-country SALT study

AIMS

Acute drug overdose, especially with paracetamol, may cause acute liver failure leading to registration for transplantation (ALFT). Population statistics and between-country differences for ALFT related to overdose have been poorly described. The aim of the present study was to evaluate overdose ALFT in the multi-country Study of Acute Liver Transplantation (SALT).

METHODS

All adult overdose-related ALFT, with or without suicidal intent, in France, Greece, Ireland, Italy, the Netherlands, Portugal and the UK between 2005 and 2007 were identified from liver transplant registries and hospital records. These were compared with whole-country and per capita use of paracetamol.

RESULTS

Six hundred cases of ALFT were identified in 52 of 57 eligible transplant centres, of which 114 involved overdose (72 intentional, 10 non-intentional, 32 uncertain). Overdose represented 20% of all-cause ALFT: Ireland 52%, UK 28%, France 18%, the Netherlands 8%, and Italy 1%. Overdose ALFT were mostly females (61%), mean age 33.6 ± 10.9 years. A total of 111 (97%) of the overdoses involved paracetamol. Event rates ranged from one ALFT for 20.7 tons of paracetamol in Ireland, to one for 1074 tons in Italy and one case in 60 million inhabitants over 3 years in Italy to one case in 286 000 inhabitants per year in Ireland. Per-country event rates for non-overdose ALFT exposed to paracetamol were between 2.5 and 4.0 per million treatment-years sold.

CONCLUSIONS

Paracetamol overdose was found to represent one-sixth of all-cause ALFT. There was a 50-fold difference in Europe in the rates of paracetamol overdose ALFT, and a 200-fold difference per million inhabitants.