Non-accidental non-fatal poisonings attended by emergency ambulance crews: an observational study of data sources and epidemiology.

BACKGROUND: Non-accidental non-fatal poisoning (NANFP) is associated with high risk of repeat episodes and fatality. This cross-sectional study aims to describe the data sources and epidemiology of non-fatal poisonings (NFPs) presenting to the emergency ambulance service. METHODS: We assessed incidents of NFP across Wales from electronic ambulance call centre records and paper records completed by attending ambulance crews, December 2007 to February 2008. We descriptively analysed data completed by attending crews. RESULTS: 92 331 calls were made to the ambulance call centre, of which 3923 (4.2%) were coded as 'overdose' or 'poisoning'. During the same period, ambulance crews recorded 1827 attended NANFP incidents in those categories, of which 1287 (70.4%) had been identified in the call centre. 76.1% (1356/1782) were aged 15-44 years and 54.2% (991/1827) were female. 75.0% (1302/1753) of incidents occurred in areas from the lower 2 quintiles of deprivation in Wales. Substance taken was reported in 90% of cases (n=1639). Multiple ingestion was common (n=886, 54.1%). Psychotropic was the most frequently taken group of substances (n=585, 32.0%) and paracetamol (n=484, 26.5%) was the most frequently taken substance prehospital. Almost half of patients had taken alcohol alongside other substances (n=844, 46.2%). Naloxone was the most frequently administered treatment (n=137, 7.5%). Only 142/1827 (7.8%) patients were not transported to hospital, of whom 4 were recorded to have been given naloxone. CONCLUSIONS: We report new data on the epidemiology of NFP across substance types at national level, highlighting deficiencies in information systems and high levels of multiple ingestion. In order to develop policy and practice for this patient group prehospital and further along the care pathway, information systems need to be developed to allow accurate routine monitoring of volume, presentation and outcomes.

A Retrospective Evaluation of Inpatient Transfer from High-Dose Methadone to Buprenorphine Substitution Therapy.

The product license of buprenorphine/naloxone for opioid substitution therapy indicates reducing methadone concentrations to 30 mg or less per day for a minimum of 1 week before transferring patients to buprenorphine and no sooner than 24 hours after the last methadone dose, because of the risk of precipitated withdrawal and a corresponding high risk of relapse to opioid use. There are few studies describing high-dose methadone transfers. This retrospective case review assessed the feasibility of transferring patients on methadone doses above 30 mg/day to buprenorphine or buprenorphine/naloxone in the inpatient setting. Six of seven patients on 60-120 mg/day of methadone successfully completed the transfer, and four cases tested negative for opiates at long-term follow-up (6-15 months). This suggests that methadone transfer to buprenorphine can be performed rapidly without the need to taper methadone doses in patients indicated for a therapeutic switch. This small study is hypothesis-generating; larger, well-designed trials are needed to define a protocol that can be used routinely to improve and widen transfers to buprenorphine when indicated.

Paramedic-supplied 'Take Home' Naloxone: protocol for cluster randomised feasibility study.

INTRODUCTION: 'Take Home' Naloxone (THN) kits for use by peers in the event of an opioid overdose may reduce further overdose and deaths, but distribution through Drugs Services may not reach those at highest risk. Attendance by paramedics at emergency calls for patients who have suffered an overdose presents an opportunity to distribute THN kits. In this feasibility study we will assess the acceptability of this intervention, and gather data to inform definitive trial planning. METHODS AND ANALYSIS: Cluster randomised trial with staggered allocation of paramedics (clusters) to groups. We will invite paramedics in an urban area of south Wales, UK to take part. We will randomly allocate those that accept to training sessions during the first 4 months of the trial. Patients attended by paramedics who have been trained and issued THN kits will fall into the intervention group. Patients attended by paramedics following usual practice (until they receive their training and THN kits) will fall into the control group. We will gather data about processes and outcomes of care: numbers of patients eligible for intervention, offered and accepted THN, attended emergency department, suffered further overdose, died within 3 months and about follow-up rates: numbers of patients consented, completed (postal or telephone) questionnaire. We will gather qualitative data about acceptability to patients and paramedics through interviews and focus groups. ETHICS AND DISSEMINATION: Ethical approval for this study was granted on 7 December 2011, by South East Wales Research Ethics Committee, Panel C. Results of this study will be reported through peer-reviewed scientific journals, conference presentations and internal organisational report. We will also seek to report our findings through local and national substance misuse networks and publications. TRIAL REGISTRATION NUMBER: ISRCTN98216498.

Is there an association between life events, postnatal depression and thyroid dysfunction in thyroid antibody positive women?

BACKGROUND: Postnatal depression is more common in women positive for thyroid autoantibodies, independent of thyroid hormone dysfunction, but the basis of this association is unclear. AIMS: The objective of the work reported here has been to investigate from data obtained from previously published research, a possible association between life events, postnatal depression and the development of thyroid dysfunction in women who are positive for thyroid autoantibodies. METHOD: A cohort of pregnant women whose thyroid antibody status was positive (N = 115), was identified at antenatal booking (approximately 16 weeks). These, and a group of women negative for thyroid antibodies (N = 123), were assessed for depression at six to eight weeks postpartum and then at 12, 20 and 28 weeks postpartum according to Research Diagnostic Criteria (RDC). The number and type of life events over the preceding year were also assessed at eight weeks postpartum using Paykel's Life Event Schedule. At four weekly intervals post-partum until six months, thyroid antibody levels and thyroid function (plasma T3 T4 and TSH) were measured. RESULTS: As anticipated, the thyroid antibody status remained the same throughout the study, and there was no difference in the number or type of life events reported in the preceding year, between antibody positive and antibody negative women. Postnatal depression was associated with an excess of both total and negative life events, independent of thyroid antibody status or actual thyroid hormonal status. Women who developed thyroid dysfunction did not report an excess of life events (total, negative or neutral) in the preceding year. CONCLUSION: There was an excess of reported total and negative life events in women with postnatal depression, but this was independent of thyroid antibody status or function.

Randomised trial of thyroxine to prevent postnatal depression in thyroid-antibody-positive women.

BACKGROUND: Women who are positive for thyroid antibodies in early gestation are prone to post-partum depression, apparently independent of thyroid dysfunction, as measured by serum levels of free thyroxine, free triodothyroxine and thyroid-stimulating hormone. This finding may be due to infrequent monitoring of thyroid function, because hyperthyroidism, hypothyroidism and combinations of both may occur post-partum. AIMS: To test the hypothesis that stabilising thyroid function post-partum by administering daily thyroxine reduces the rate of occurrence and severity of associated depression. METHOD: In a randomised double-blind placebo-controlled trial, 100 microg of thyroxine or placebo was given daily to 446 thyroid-antibody-positive women (342 of whom were compliant) from 6 weeks to 6 months post-partum, assessing their psychiatric and thyroid status at 4-weekly intervals. RESULTS: There was no evidence that thyroxine had any effect on the occurrence of depression. The 6-month period prevalence of depression was similar to that reported previously. CONCLUSIONS: The excess of depression in thyroid-antibody-positive women in the post-partum period is not corrected by daily administration of thyroxine.