Studying the Safety and Performance of Rapid Sequence Intubation: Data Collection Method Matters.

OBJECTIVE: We sought to describe and compare chart and video review as data collection sources for the study of emergency department (ED) rapid sequence intubation (RSI). METHODS: This retrospective cohort study compares the availability and content of key RSI outcome and process data from two sources: chart and video data from 12 months of pediatric ED RSI. Key outcomes included adverse effects (oxyhemoglobin desaturation, physiologic changes, inadequate paralysis, vomiting), process components (number of laryngoscopy attempts, end-tidal CO2 detection), and timing data (duration of preoxygenation and laryngoscopy attempts). RESULTS: We reviewed 566 documents from 114 cases with video data. Video review detected higher rates of adverse effects (67%) than did chart review (46%, p < 0.0001), identifying almost twice the rate of desaturation noted in the chart (34% vs. 18%, p = 0.0002). The performance and timing of key RSI processes were significantly more reliably available via video review (timing and duration of preoxygenation, as well as timing, duration, and number of laryngoscopy attempts, all p < 0.05). Video review identified 221 laryngoscopy attempts, whereas chart review only identified 187. CONCLUSIONS: When compared with video review for retrospective study of RSI in a pediatric ED, chart review significantly underestimated adverse effects, inconsistently contained data on important RSI process elements, rarely provided time data, and often conflicted with observations made on video review. Interpretation of and design of future studies of RSI should take into consideration the quality of the data source.

Risk Stratification to Decrease Unnecessary Diagnostic Imaging for Acute Appendicitis.

BACKGROUND: There has been an increase in the use of imaging modalities to diagnose appendicitis despite evidence that can help identify children at especially high or low risk of appendicitis who may not benefit. We hypothesized that the passive diffusion of a standardized care pathway (including diagnostic imaging recommendations) would improve the diagnostic workup of appendicitis by safely decreasing the use of unnecessary imaging when compared with historical controls and that an electronic, real-time decision support tool would decrease unnecessary imaging. METHODS: We used an interrupted time series trial to compare proportions of patients who underwent diagnostic imaging (computed tomography [CT] and ultrasound) between 3 time periods: baseline historical controls, after passive diffusion of a diagnostic workup clinical pathway, and after introduction of an electronic medical record-embedded clinical decision support tool that provides point-of-care imaging recommendations (active intervention). RESULTS: The moderate- and high-risk groups showed lower proportions of CT in the passive and active intervention time periods compared with the historical control group. Proportions of patients undergoing ultrasound in all 3 risk groups showed an increase from the historical baseline. Time series analysis confirmed that time trends within any individual time period were not significant; thus, incidental secular trends over time did not appear to explain the decreased use of CT. CONCLUSIONS: Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.

Utility of Pediatric Appendicitis Score in Female Adolescent Patients.

OBJECTIVES: Acute appendicitis is common in the pediatric population and is difficult to diagnose in adolescent females. The validated Pediatric Appendicitis Score (PAS) has unclear utility in female adolescents. The purpose of this study is to determine the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of the PAS for female adolescents compared to all other patients. METHODS: This study examined a retrospective observational cohort of patients ages 3 to 21 years in a pediatric emergency department with prospectively assigned PAS from an existing database. We compared the sensitivity, specificity, PPV, and NPV of the PAS for acute appendicitis among female adolescent patients (13 to 21 years) and all other patients. RESULTS: Of the 1,228 patients enrolled, 901 (73.4%) had a complete PAS. Among the 901 patients, 249 (27.6%) had pathology-proven appendicitis, 494 (54.8%) were female, and 272 (30.2%) were adolescent females. At a cutoff of ≥8, the PAS showed a specificity of 89% for adolescent females and 78% for all other patients (p < 0.001), although the specificities did not differ at a cutoff of ≥7. At both cutoffs, the PPVs were poor in both groups. At a cutoff of ≥3, the PAS showed similar sensitivities in both groups. At a cutoff of <3, the NPVs did not significantly differ between groups. CONCLUSION: At a cutoff of ≥8 (although not ≥7), the PAS demonstrated a higher specificity among female adolescents compared to all other patients. The PPV for both cutoffs in both groups were poor. At a cutoff of ≥3, sensitivities were equivalent. The NPV for a cutoff of <3 was acceptable but similar in both groups. While sensitivities were similar to previously reported, specificities in both groups were lower. This highlights the need for further investigation of the PAS's performance in specific subpopulations.

Prediction of Persistent Postconcussion Symptoms in Youth Using a Neuroimaging Decision Rule.

OBJECTIVE: To evaluate the ability of risk strata generated by a neuroimaging rule, developed to assess risk of clinically important traumatic brain injury (ciTBI), to predict postconcussive symptoms in youth with an acute mild traumatic brain injury. METHODS: We performed a prospective cohort study of youth aged 5 to 17 years presenting to an emergency department (ED) within 24 hours of mild traumatic brain injury. Risk strata (very low, intermediate, and at risk) of ciTBI were determined in ED by criteria set forth by the neuroimaging rule. Postconcussive symptoms were assessed using the Health and Behavior Inventory (HBI) in the ED and at 1, 2, and 4 weeks after injury. General linear models were used to examine the relationship between the HBI score at 1 week and risk strata. Repeated measures analysis was used to measure change in HBI over time. RESULTS: Of the 120 participants, 46 were categorized by the Pediatric Emergency Care Applied Research Network (PECARN) rule as very low risk, 39 as intermediate risk, and 35 as at risk for ciTBI. Adjusted mean HBI scores (95% confidence intervals) at 1 week were 18.0 (13.9, 22.2) for at risk, 13.8 (9.9, 17.6) for intermediate risk, and 17.1 (13.4, 20.8) for very low risk. Risk strata were not significantly associated with the adjusted HBI score at 1 week (P = .17). While adjusted HBI scores declined significantly over time (P < .0001), the trajectories of the HBI score over time did not differ significantly by risk strata (P = .68). CONCLUSIONS: Risk of ciTBI as determined by factors within a neuroimaging rule alone is insufficient to predict children with persistent postconcussive symptoms.

Can Computerized Neuropsychological Testing in the Emergency Department Predict Recovery for Young Athletes With Concussions?

OBJECTIVE: The objective of this study was to determine if computerized neurocognitive testing (Immediate Post-Concussion Assessment and Cognitive Testing [ImPACT]) in the emergency department (ED) can be used as a prognostic tool to detect young athletes at risk of having protracted concussive symptoms. METHODS: This was a prospective cohort study of athletes aged 11 to 18 years who presented to an ED less than 24 hours after sustaining a sports-related concussion. ImPACT was administered in the ED, and performance was categorized as "poor" if the athlete had 3 (of 4) or greater low domain scores. Participants completed the Post-Concussion Symptom Scale (PCSS) in the ED and by phone at 1 and 2 weeks after injury. Athletes were symptomatic if their PCSS score was more than 6 in males and more than 8 in females. RESULTS: One hundred nine patients were enrolled; 60% and 36% remained symptomatic at 1 and 2 weeks after injury, respectively. "Poor" ImPACT performance was not particularly useful in predicting athletes with protracted symptoms (at 1 week: positive predictive value, 70.8%; negative predictive value, 43.5%; at 2 weeks: positive predictive value, 47.8%; negative predictive value, 68.9%). In bivariate analysis, a higher ED PCSS score was associated with protracted symptoms (at 1 week: odds ratio, 1.1 [confidence interval, 1.0-1.1]; at 2 weeks: odds ratio, 1.0 [confidence interval, 1.0-1.1]). CONCLUSIONS: Computerized neurocognitive testing in the ED has limited usefulness in predicting protracted symptoms. Total acute symptom burden may be a useful prognostic tool in the ED evaluation of concussed young athletes, yet further research is necessary.

Impact of preseason concussion education on knowledge, attitudes, and behaviors of high school athletes.

BACKGROUND: The benefit of preseason concussion education on athletes' knowledge, attitudes, and behaviors is unclear. The purpose of the study was to determine the influence of preseason concussion education on knowledge and self-reported attitudes and reporting behaviors. We hypothesized that preseason education would lead to better knowledge and self-reported attitudes and better reporting of concussion symptoms during the season. METHODS: This study involved a prospective cohort comparing the benefits of a preseason lectured-based concussion education session at one high school with a control school. Participants included males and females age 13 years to 18 years from two community high schools who were participating in higher concussion risk, fall or winter sports (football, soccer, wrestling, and basketball). The education school and control school included 234 and 262 participants, respectively. Outcomes were a preseason and postseason survey assessing knowledge and self-reported attitudes about concussions and an end-of-season questionnaire assessing concussion reporting behaviors during the season. RESULTS: Total scores on the combined (p < 0.0001), knowledge-based (p = 0.016), and behavioral-based (p < 0.0001) questions demonstrated statistically significant improvement in the education group. Scores peaked immediately after education but dissipated at the end of the season. There was a lower proportion in the education school (72%) compared with the control school (88%) that reported continued play despite having concussion symptoms during the season (p = 0.025). A similar proportion of athletes diagnosed with concussion during the season in the education (27%) and control schools (23%) reported returning to play before symptoms resolved (p = 0.81). CONCLUSION: These findings suggest that a didactic-based preseason concussion education likely has minimal benefits. Other factors besides knowledge are likely influencing student-athlete concussion reporting behavior. Future research focused on changing the culture of concussion reporting is needed. LEVEL OF EVIDENCE: Therapeutic study, level III.

A smoking cessation intervention for low-income smokers in the ED.

BACKGROUND: There is a high prevalence of smoking among caregivers who bring their children to the pediatric emergency department (PED) and even higher rates of tobacco smoke exposure (TSE) and related morbidity among their children. The PED visit presents an opportunity to intervene with caregivers, but it is unknown whether they are more likely to quit if their child has a TSE-related illness. We sought to examine a PED-based smoking cessation intervention and compare outcomes based on children's TSE-related illness. METHODS: A single-arm, prospective trial, with baseline, 3, and 6 month assessments was used in this study. Caregivers whose child had either a TSE-related (n=100) or non-TSE-related illness (n=100) were given a brief intervention consisting of counseling, referral to the Quitline, and free nicotine replacement therapy. RESULTS: Participants were 91.5% female, 50.5% African American, 100% Medicaid recipients, 30.8 years old, child age mean of 5.5 years, 90% highly nicotine dependent, and 60.3% and 75.8% allowed smoking in the home and car, respectively. At follow-up (65% retention), 80% reported quit attempts at 3 months and 89% between 3 and 6 months. There were significant decreases in number of cigarettes smoked, time to first cigarette, and smoking in the home and car. Quit rates were 12.2% at 3 months, 14.6% at 6 months, and 7.3% at both time points (50% biochemically confirmed). There were no significant differences in outcomes based on children's illness. CONCLUSIONS: A brief PED-based smoking cessation intervention resulted in quit attempts and successful quits. However, the presence of a TSE-related illness did not result in different cessation outcomes.

Factors associated with participation in research conducted in a pediatric emergency department.

OBJECTIVE: To examine the association of demographic and study characteristics in eligible subjects who agree to participate compared with those who did not participate in clinical research studies in a pediatric emergency department (PED). METHODS: Information for all families approached for participation in PED-based clinical research studies during a 6-year period was recorded in an electronic database. This included demographic factors, decision to participate, primary reason for not participating, and study characteristics. Forty studies were included in this analysis. Differences in participation rate among demographic and study characteristics were examined. Multivariable logistic regression was used to predict the likelihood of participation. RESULTS: Participation rates were similar with respect to sex (50.1% in male vs 49.9% in female), whereas families with younger children were more likely to participate (mean age, 8.5 years vs 10.2 years among nonparticipants P < 0.001). White patients were more likely to participate than African American patients (54.7% vs 45.6% in African Americans, P < 0.001). The presence of compensation, brief time requirement, and older children was negatively associated with participation for moderate to very invasive studies. However, for noninvasive and mildly invasive studies, the presence of compensation and the time required were not associated with participation. CONCLUSIONS: Study characteristics including invasiveness, time required of patients, and whether compensation is offered, along with demographic factors, influence participation in clinical studies conducted in the PED. When designing a research study in the PED, these, along with novel approaches to including all races and ethnicities in PED research, should be considered.

A computerized kiosk to teach injury prevention: is it as effective as human interaction?

BACKGROUND: An emergency department (ED) visit may be an effective place to screen and educate families about injury prevention. The purpose of this study was to determine if a computerized kiosk in a pediatric ED can screen families for injury risk and encourage them to make more safety changes at follow-up survey compared with an injury prevention specialist (IPS). METHODS: A prospective, randomized controlled study was performed with families of children younger than 14 years in an ED lobby. Families were screened for injury risk by computerized kiosk based on child's age category at triage (birth to 1 year, 1-4 years, 5-9 years, or 10-14 years). Families were randomized to receive either injury behavior instructions by kiosk printout or by IPS when answers to specific practices were deemed unsafe. Three weeks after intervention, families were telephoned to determine change in safety practices. RESULTS: Three hundred seventeen families completed ED kiosk screen at enrollment (172 kiosk, 145 IPS). On initial screen, kiosk families practiced 79.6% of behaviors safely versus 75.9% in the IPS group (p = 0.011). A total of 221 families (69.7%) were reached for follow-up (121 kiosk, 100 IPS). On average, IPS families improved their safe behavior responses by 8.3% versus 1.0% in the kiosk group (p < 0.0001). Significantly more families in the IPS group than in the kiosk group (36% vs. 23%, p < 0.03) used additional safety equipment after the intervention. CONCLUSION: A computerized kiosk based in a pediatric ED can help screen families for their injury risk. However, to elicit significant behavior change, an IPS discussing safety changes may be more effective.

Variation in suicide occurrence by day and during major American holidays.

BACKGROUND: Due to temporal variations in completed suicides, it has been suggested that impulsivity and environmental factors may influence suicide. STUDY OBJECTIVE: Our intent was to determine if particular days of the week, seasons, or holidays were associated with increased attempted and completed suicides by poisoning. METHODS: All calls recorded in the National Poison Database System coded as "suspected suicide" from 2006 through 2010 were included. Exposures were evaluated by day, season, and holidays, and compared to control dates. RESULTS: There were 1,065,067 exposures (63% female) related to suicide attempts, with completions in 0.4% of cases. Sundays and Mondays for adults, and Mondays and Tuesdays for age < 19 years were the most common. Spring and fall had higher numbers of exposures than summer and winter. New Year's Day had a higher number of exposures, whereas Independence Day, Thanksgiving, and Christmas had fewer exposures. CONCLUSIONS: The beginning of the week, spring and fall, and New Year's Day were associated with higher numbers of ingestions with suicidal intent. This has implications for clinicians advising potential victims and providing emergency care for these patients.

The contribution of housing renovation to children's blood lead levels: a cohort study.

BACKGROUND: Routine renovation of older housing is a risk factor for childhood lead poisoning, but the contribution to children's blood lead levels is poorly defined for children with lower exposure levels. METHODS: We examined a prospective cohort of 276 children followed from 6 to 24 months of age. We conducted surveys of renovation activities and residential lead hazards and obtained blood lead level (B-Pb) every six months. We analyzed B-Pb in a repeated measures design using a mixed effects linear model. RESULTS: Parent reported interior renovation ranged from 11 to 25% of housing units at the four, 6-month periods. In multivariable analysis, children whose housing underwent interior renovation had a 12% higher mean B-Pb by two years of age compared with children whose housing units were not renovated (p < 0.01). The time between renovation and the child blood lead sample was associated with higher B-Pb (p-value for trend <0.01); compared to children in non-renovated housing, children whose housing units underwent renovation in the prior month had a 17% higher mean B-Pb at two years of age, whereas children whose housing renovation occurred in the prior 2-6 months had an 8% higher mean B-Pb. We also found an association between higher paint lead loading, measured using an X-ray fluorescence (XRF) based paint lead index, and child B-Pb (p = 0.02); for every 10 mg/cm2 increase in paint lead loading index there was a 7.5% higher mean childhood B-Pb. CONCLUSIONS: In an analysis of data collected before the recent changes to Environmental Protection Agency's Lead, Renovation, Repair and Painting Rule, routine interior housing renovation was associated with a modest increase in children's B-Pb. These results are important for the provision of clinical advice, for housing and public health professionals, and for policymakers.

Can the reduction of pediatric injury rates be sustained using a community-based approach?

BACKGROUND: Injuries are the leading cause of morbidity and mortality in US residents aged 1 to 44 years. Community-based interventions are effective in reducing injuries. Using this approach, investigators significantly reduced injuries in Avondale, Ohio, between 1999 and 2004 compared with three control communities (42 vs. 15%, respectively). The objective of this study was to determine if injury reduction was sustained through the 5 years after initial implementation of injury prevention (IP) efforts in Avondale compared with the same three control communities. DESIGN/METHODS: Injury prevention interventions implemented in Avondale, Ohio, during previous study years were sustained. Two new playgrounds were built, but no other new interventions were introduced. Control communities had no programs introduced by the team during the study period. Data were obtained from the Hamilton County Injury Surveillance System from 2005 to 2009 for deaths, hospitalizations, and emergency department visits due to injury for children 0 to 19 years old. Data from the study community were compared with those of the same three control communities as in our previous work, with similar demographics and socioeconomic characteristics, as well as with data obtained previously from 1999 to 2004. Census data based on annual estimates were used to calculate injury rates. RESULTS: The injury rate in Avondale decreased from 17,073 to 11,284 injuries per 100,000 children per year during the 11-year period (33.9% reduction). The injury rate in the control communities decreased from 14,436 to 12,381 injuries per 100,000 children per year in the same period (14.2% reduction). The difference in the injury rate decrease between the intervention and control communities was statistically significant, p < 0.001. From 2005 to 2009, the lower injury rate was sustained in Avondale, p = 0.58. CONCLUSIONS: Community-based strategies to prevent injuries to children in high-risk communities can be successful in reducing overall injury rates. These efforts can result in sustained injury reduction over time despite no new interventions being introduced.

Inability of S100B to predict postconcussion syndrome in children who present to the emergency department with mild traumatic brain injury: a brief report.

OBJECTIVE: This study aimed to explore the ability of the serum marker S100B to predict the development and severity of postconcussion syndrome (PCS) at 3 months in children after mild traumatic brain injury (mTBI). METHODS: This is a retrospective analysis of a prospective observational study conducted in a pediatric emergency department (ED). Children were eligible for the study if they were between the ages 5 and 18 years, presented within 6 hours of injury, met the case definition of mTBI from American Congress of Rehabilitation Medicine, had a Glasgow Coma Scale score of greater than 13, consented to have blood drawn for S100B levels, and completed the 3-month telephone follow-up. At the follow-up, the Rivermead Postconcussion Questionnaire was conducted to determine the development and severity of PCS. RESULTS: A total of 76 children were included in this cohort. The children had a mean (SD) age of 14.0 (3.1) years, 60.5% were male, and 89.5% had a Glasgow Coma Scale of 15. Twenty-eight (36.8%) developed PCS. For the children who developed PCS, the mean (SD) S100B level was 0.092 (0.376) µg/L. For children who did not develop PCS (n = 48), the mean (SD) S100B level was 0.022 (0.031) µg/L. The analyses did not support an association between initial S100B levels measured in the ED and development of PCS or severity of PCS symptoms. CONCLUSIONS: In this small sample, S100B, measured immediately after injury in the ED, did not seem to predict those children with mTBI who will go on to develop PCS.

Maternal somatic symptoms, psychosocial correlates, and subsequent pediatric emergency department use.

BACKGROUND: Somatization is associated with increased health care use in adults. Whether mothers with somatic symptoms use more health care resources for their children has not been investigated. OBJECTIVE: This study aimed to explore the association of maternal somatic symptoms and emergency department (ED) use. DESIGN/METHODS: Mothers from a cohort of 319 mother-child dyads were screened for somatic symptoms using the Patient Health Questionnaire 15. Dyads were followed up for 3 years after the initial ED visit to record ED use. The outcome variable was ED use (lower ED use, 0-3 visits, higher ED use, 4+ visits). The primary independent variable was somatization, with a dichotomous variable analyzing the Patient Health Questionnaire 15 symptom count of less than 7 symptoms (lower somatization) and 7 or more symptoms (higher somatization [HISOM]). Secondary independent variables included demographic data, maternal major depression, and maternal difficulty in taking care of the child or themselves. Statistical analysis included bivariate and multivariate analyses. RESULTS: Mothers with HISOM symptoms did not demonstrate an increased use of the ED in bivariate analysis. Higher somatization mothers did show an increased (1) endorsement of maternal major depression symptoms and (2) maternal perception of difficulty in taking care of the child and themselves. When adjusted for these and other covariates, HISOM mothers were more likely to be in the higher ED use group (1.83; 95% confidence interval, 0.99-3.38) P = 0.055). CONCLUSIONS: Mothers with higher somatic symptom loads were more likely to screen positive for depression and to report difficulty caring for their child and for themselves. A trend toward higher use of the pediatric ED warrants further study.

Predicting postconcussion syndrome after mild traumatic brain injury in children and adolescents who present to the emergency department.

OBJECTIVE: To determine the acute predictors associated with the development of postconcussion syndrome (PCS) in children and adolescents after mild traumatic brain injury. DESIGN: Retrospective analysis of a prospective observational study. SETTING: Pediatric emergency department (ED) in a children's hospital. PARTICIPANTS: Four hundred six children and adolescents aged 5 to 18 years. MAIN EXPOSURE: Closed head trauma. MAIN OUTCOME MEASURES: The Rivermead Post Concussion Symptoms Questionnaire administered 3 months after the injury. RESULTS: Of the patients presenting to the ED with mild traumatic brain injury, 29.3% developed PCS. The most frequent PCS symptom was headache. Predictors of PCS, while controlling for other factors, were being of adolescent age, headache on presentation to the ED, and admission to the hospital. Patients who developed PCS missed a mean (SD) of 7.4 (13.9) days of school. CONCLUSIONS: Adolescents who have headache on ED presentation and require hospital admission at the ED encounter are at elevated risk for PCS after mild traumatic brain injury. Interventions to identify this population and begin early treatment may improve outcomes and reduce the burden of disease.

Is an emergency department encounter for a motor vehicle collision truly a teachable moment?

BACKGROUND: Some have suggested that a pediatric emergency department (PED) visit for an injury represents a "teachable moment." Our aim was to determine if a motor vehicle collision (MVC) instigates greater change in booster seat use compared with children presenting for non-injury-related complaints. METHODS: A prospective pilot study of children 4 years to 8 years who never used a booster seat and were in a minor MVC were compared with children presenting to the PED for non-injury-related complaints. After completing a survey of demographics and knowledge about booster seats, all parents received brief, standardized counseling about booster seats. Two weeks after the PED visit, follow-up telephone calls were made to assess behavior change. RESULTS: Sixty-seven youth were enrolled (37 MVC group, 30 controls). Initially, 65 (97%) used a seat belt alone (36 MVC, 29 controls); the rest were unrestrained. There was no difference between the groups in mean age, sex of child, or insurance type. Significantly more families in the MVC group claimed that they would get a booster seat after their PED encounter (46% vs. 19%, p = 0.02) and their child would consistently use a booster seat (54% vs. 23%, p = 0.01). At follow-up, 45 families (67%) were reached (25 cases [68%] and 20 controls [67%]). There was no significant difference between the groups in having a booster seat at follow-up (12 cases [48%] and 9 controls [45%]) and reports of booster seat use more than 75% of the time (9 cases [36%] and 7 controls [35%]). CONCLUSION: A minor MVC did not serve as a teachable moment to entice families to consistently use a booster seat more than families presenting to a PED for non-injury-related complaints. However, more than one third of the families who learned about booster seats in the PED reported using a booster seat regularly. LEVEL OF EVIDENCE: Therapeutic study, level II.

Monitoring a toxicological outbreak using Internet search query data.

BACKGROUND: A novel group of drugs of abuse colloquially known as "bath salts" had a dramatic rise in exposures recently noted in Europe and the United States. Internet search query data have been shown to be correlated with office visits for influenza-like illnesses. The purpose of this study was to determine whether internet search query data could have been used as a surveillance method for this outbreak. METHODS: This was a retrospective database review of the National Poison Database System and internet search query data provided by Google Insights for Search (GIS) comparing exposures reported to "bath salts" with internet searches for "bath salts". RESULTS: 1072 cases of exposures to "bath salts" were reported to US poison centers from 7/1/10 to 2/28/11. GIS data for the search term "bath salts" had a correlation of 0.84 with exposures to bath salts reported to US poison centers over the study period. Poison center exposures and GIS data did not differ significantly in detecting a change from the baseline (p = 0.85). When comparing exposures by state to search volumes by state for "bath salts", the correlation was 0.79. Symptoms and treatments were typical of an exposure to a sympathomimetic drug. CONCLUSIONS: Internet search data correlated very well with exposures reported to US poison centers for a novel drug of abuse. In this particular outbreak, it is possible that using internet search data may have provided a means for public health officials to monitor the rise in usage on a national and regional basis.

The growing impact of pediatric pharmaceutical poisoning.

OBJECTIVE: To understand which medications, under which circumstances, are responsible for the noted increase in pediatric medication poisonings, resource use, and morbidity. STUDY DESIGN: Patient records from 2001-2008 were obtained from the National Poison Data System of the American Association of Poison Control Centers for children aged ≤5 years evaluated in a health care facility following exposure to a potentially toxic dose of a pharmaceutical agent. Pharmaceutical agents were classified as over-the-counter or prescription and by functional category. Exposures were classified as child self-ingested the medication or as therapeutic error. For the 8-year period, emergency visits, admissions, significant injuries, and trends in these events were calculated for each substance category. RESULTS: We evaluated 453 559 children for ingestion of a single pharmaceutical product. Child self-exposure was responsible for 95% of visits. Child self-exposure to prescription products dominated the health care impact with 248 023 of the visits (55%), 41 847 admissions (76%), and 18 191 significant injuries (71%). The greatest resource use and morbidity followed self-ingestion of prescription products, particularly opioids, sedative-hypnotics, and cardiovascular agents. CONCLUSIONS: Prevention efforts have proved to be inadequate in the face of rising availability of prescription medications, particularly more dangerous medications.

Trends in hepatic injury associated with unintentional overdose of paracetamol (Acetaminophen) in products with and without opioid: an analysis using the National Poison Data System of the American Association of Poison Control Centers, 2000-7.

BACKGROUND: Unintended hepatic injury associated with the use of paracetamol (acetaminophen)-containing products has been growing. OBJECTIVE: The aim of the study was to seek a better understanding of the causes of this observation in order to evaluate the potential impact of proposed preventive measures. STUDY DESIGN: Retrospective analysis of a large database containing prospectively collected patient exposure data, clinical symptomatology and outcome. SETTING: The National Poison Data System database for 2000-7 involving exposures to paracetamol and an opioid was obtained and analysed. This dataset was limited to non-suicidal cases in patients 13 years of age and older. For comparison, the parallel, mutually exclusive dataset involving exposures to one or more non-opioid containing paracetamol products was analysed. OUTCOME MEASURE: Trends in the numbers of patients exposed, treated, and mildly and severely injured were obtained and compared with each other and with trends calculated from publicly available data on sales and population. The association of injury with the number of paracetamol-containing products and the reason for taking them were also assessed. RESULTS: Comparators: During the study period, the US population of those 15 years of age and over rose 8.5%; all pharmaceutical-related calls to all US poison centres rose 25%. For the 8-year period from 2001 to 2008, sales of over-the-counter paracetamol products rose 5% (single-ingredient products fell 3%; paracetamol-containing combination cough and cold products rose 11%) and prescription paracetamol combination products rose 67%. Opioids with paracetamol: A total of 119 731 cases were identified, increasing 70% over the period. The exposure merited acetylcysteine treatment in 8995 cases (252% increase). In total, 2729 patients (2.3%) experienced some hepatic injury (500% increase). Minor injuries rose faster than severe injuries (833% vs 280%) and most injuries (73.0%) were from overuse of a single combination product only, but the injury rate increased with use of more than one paracetamol-containing product. Abuse and misuse accounted for 34% of cases but 58% of the severe injuries. Paracetamol without opioid: A total of 126 830 cases were identified, increasing 44%, and 15 706 cases merited acetylcysteine (70% increase). A total of 4674 patients (3.7%) experienced some hepatic injury (134% increase). [corrected] Use of more than one non-opioid paracetamol product occurred in 7.3% of patients and was associated with a lower injury rate. CONCLUSIONS: Hepatic injury associated with paracetamol use is increasing significantly faster than population, paracetamol product sales and poison centre use. This suggests a growing portion of consumers is self-dosing paracetamol beyond the toxic threshold. This is true for paracetamol with and without opioids, but the increase in hepatic injury is greater when paracetamol is taken with an opioid. This disproportionate rise is greatest with misuse and abuse of paracetamol products in combination with opioids. Increasing self-dosage of the opioid combination products for the opioid effect is likely to result in more cases of toxic exposure to paracetamol. In contrast, cases of exposure to paracetamol-containing cough and cold products are underrepresented among those injured. In the absence of opioid-containing products, consumption of more than one paracetamol-containing product did not contribute to injury. Efforts to modulate unintentional paracetamol-related hepatic injury should consider these associations.