Patterns and trends of medicinal poisoning substances: a population-based cohort study of injuries in 0-11 year old children from 1998-2018.

BACKGROUND: There have been sharp increases in antidepressant and opioid prescriptions over the last 10 years, as well as increased over-the-counter medicine availability. However, the impact on childhood medicinal poisonings rates, particularly by socioeconomic deprivation is unclear. This study reports population level medicinal poisoning substance patterns in England among children aged 0-11 years, helping inform safety advice and poisoning prevention interventions. METHODS: An open cohort study of 1,489,620 0-11 year olds was conducted from 1998 to 2018, using the Clinical Practice Research Datalink, to examine inpatient hospital admissions for poisoning. Incidence rates and adjusted incidence rate ratios (aIRR) were calculated for poisoning substance groups by age, sex, socio-economic deprivation and year. RESULTS: 3,685 medicinal poisoning hospital admissions were identified. The most common substances were paracetamol (33.2%), dependence/withdrawal risk drugs (DWRD - antidepressants, opioids, gabapentinoids, benzodiazepines) (13.5%) and other over-the-counter (OTC) analgesics/anti-common cold drugs (13.0%). Over the study period DWRD poisonings decreased 33% (aIRR 0.67, 95%CI 0.50-0.90 comparing 2013/14-2017/18 to 1998/99-2002/03), while paracetamol poisonings increased 43% (aIRR 1.43, 95%CI 1.20-1.70 for the same periods), with no change in incidence rates for other OTC drugs (aIRR 0.82, 95% CI 0.60-1.12) or all medications combined (aIRR 0.97, 95%CI 0.88-1.07). A gradient in poisonings by area-level socioeconomic deprivation was shown for all medications (aIRR 1.32, 95%CI 1.18-1.47 for most deprived compared to least deprived quintile), and DWRDs (aIRR 2.03, 95%CI 1.42-2.88 for 4th most deprived quintile and aIRR 1.88, 95%CI 1.32-2.66 for 5th most deprived quintile, compared to least deprived quintile), but not for paracetamol or other OTC drug poisonings. CONCLUSIONS: Poisonings from DWRDs decreased by 33%, while paracetamol poisonings increased by 43% during the study period. There was a gradient by area-level socioeconomic deprivation in prescribed medication poisonings, including drugs with withdrawal/dependence risk, but not OTC medication poisonings. Households in more socioeconomically deprived areas have the potential to benefit most from measures to improve safe storage of medicines and are likely to require targeted interventions providing education and safety equipment. In addition, universal promotion of the safe storage of OTC and prescribed medicines must be provided by prescribers, community pharmacies and other outlets of such medication.

Comparison of the effectiveness of exclusively facilitated clinical teaching as an alternative to traditional practice-based primary care placements.

INTRODUCTION: COVID-19 presented major challenges to undergraduate GP placement capacity and there was an increased reliance on clinical training using facilitated simulation. The authors present a novel comparison of the effectiveness and cost-effectiveness of delivering a one-week primary care course using entirely GP-facilitated clinical teaching outside the GP setting against traditional practice-based GP clinical education. METHODS: A one-week GP placement was redeveloped from a traditional teaching model (TT-M) to an exclusively facilitated teaching model (FT-M) delivered outside the GP practice setting, using principles of blended learning, flipped classroom methods, e-learning and simulation. Both teaching models, delivered in different locations during 2022 to pre-clinical students, were evaluated using student feedback surveys for attainment of learning outcomes and course satisfaction. RESULTS: The students reported their consultation skills and clinical knowledge (amalgamated mean score 4.36 for FT-M versus 4.63 for TT-M; P = 0.05), as well as preparation for the clinical phases (mean scores 4.35 for FT-M versus 4.41 for TT-M; P = 0.68), were well developed and similar for both courses. Students reported similar enjoyment across both teaching models (FT-M mean score 4.31 versus 4.41 for TT-M; P = 0.49). The costs for delivering teaching per 4-h session for 100 students were £1,379 and £5,551 for FT-M and TT-M, respectively. CONCLUSION: Delivery of a one-week primary care attachment to third year medical students using an FT-M was similarly effective and more cost effective than delivering it by a TT-M. FT-M potentially offers an important adjunct to clinical learning and resilience to capacity challenges for GP placements.

Incident Type 2 Diabetes and Risk of Fracture: A Comparative Cohort Analysis Using U.K. Primary Care Records.

OBJECTIVE: To estimate risk of fracture in men and women with recent diagnosis of type 2 diabetes compared with individuals without diabetes. RESEARCH DESIGN AND METHODS: In this cohort study, we used routinely collected U.K. primary care data from The Health Improvement Network. In adults (>35 years) diagnosed with type 2 diabetes between 2004 and 2013, fractures sustained until 2019 were identified and compared with fractures sustained in individuals without diabetes. Multivariable models estimated time to first fracture following diagnosis of diabetes. Annual prevalence rates included at least one fracture in a given year. RESULTS: Among 174,244 individuals with incident type 2 diabetes and 747,290 without diabetes, there was no increased risk of fracture among males with diabetes (adjusted hazard ratio [aHR] 0.97 [95% CI 0.94, 1.00]) and a small reduced risk among females (aHR 0.94 [95% CI 0.92, 0.96]). In those aged ≥85 years, those in the diabetes cohort were at significantly lower risk of incident fracture (males: aHR 0.85 [95% CI 0.71, 1.00]; females: aHR 0.85 [95% CI 0.78, 0.94]). For those in the most deprived areas, aHRs were 0.90 (95% CI 0.83, 0.98) for males and 0.91 (95% CI 0.85, 0.97) for females. Annual fracture prevalence rates, by sex, were similar for those with and without type 2 diabetes. CONCLUSIONS: We found no evidence to suggest a higher risk of fracture following diagnosis of type 2 diabetes. After a diagnosis of type 2 diabetes, individuals should be encouraged to make positive lifestyle changes, including undertaking weight-bearing physical activities that improve bone health.

Poisoning substances taken by young people: a population-based cohort study.

BACKGROUND: Globally, poisonings account for most medically-attended self-harm. Recent data on poisoning substances are lacking, but are needed to inform self-harm prevention. AIM: To assess poisoning substance patterns and trends among 10-24-year-olds across England DESIGN AND SETTING: Open cohort study of 1 736 527 young people, using linked Clinical Practice Research Datalink, Hospital Episode Statistics, and Office for National Statistics mortality data, from 1998 to 2014. METHOD: Poisoning substances were identified by ICD-10 or Read Codes. Incidence rates and adjusted incidence rate ratios (aIRR) were calculated for poisoning substances by age, sex, index of multiple deprivation, and calendar year. RESULTS: In total, 40 333 poisoning episodes were identified, with 57.8% specifying the substances involved. The most common substances were paracetamol (39.8%), alcohol (32.7%), non-steroidal anti-inflammatory drugs (NSAIDs) (11.6%), antidepressants (10.2%), and opioids (7.6%). Poisoning rates were highest at ages 16-18 years for females and 19-24 years for males. Opioid poisonings increased fivefold from 1998-2014 (females: aIRR 5.30, 95% confidence interval (CI) = 4.08 to 6.89; males: aIRR 5.11, 95% CI = 3.37 to 7.76), antidepressant poisonings three-to fourfold (females: aIRR 3.91, 95% CI = 3.18 to 4.80, males: aIRR 2.70, 95% CI = 2.04 to 3.58), aspirin/NSAID poisonings threefold (females: aIRR 2.84, 95% CI = 2.40 to 3.36, males: aIRR 2.76, 95% CI = 2.05 to 3.72) and paracetamol poisonings threefold in females (aIRR 2.87, 95% CI = 2.58 to 3.20). Across all substances poisoning incidence was higher in more disadvantaged groups, with the strongest gradient for opioid poisonings among males (aIRR 3.46, 95% CI = 2.24 to 5.36). CONCLUSION: It is important that GPs raise awareness with families of the substances young people use to self-harm, especially the common use of over-the-counter medications. Quantities of medication prescribed to young people at risk of self-harm and their families should be limited, particularly analgesics and antidepressants.

Differing patterns in intentional and unintentional poisonings among young people in England, 1998-2014: a population-based cohort study.

Background: Accurate and up to date data on changes in poisoning incidence among young people are lacking. Recent linkage of UK primary care, hospital and mortality data allows these to be quantified to inform service delivery. Methods: An open cohort study of 1 736 527 young people aged 10-24 between 1998 and 2014 was conducted using linked data from the Clinical Practice Research Datalink, Hospital Episode Statistics and Office for National Statistics deaths. Incidence rates (IRs) by poisoning intent were calculated by age, sex, deprivation and year. Results: Total poisoning IRs increased by 25% from 1998/99 to 2013/14 [adjusted incidence rate ratio (aIRR) 1.25, 95% CI: 1.20-1.30]. Patterns differed markedly by intent. Intentional poisoning rates increased by 52% while unintentional rates remained unchanged. Intentional rates increased almost exclusively among females, gradually between 1998/99 and 2013/14 among 16-18 (88% increase) and 19-24 (36% increase) year olds but only increased among 10-15 year olds in the last 2 years (79% increase). A 2-fold increased risk of poisoning for the most compared to least deprived quintile existed (aIRR 2.21, 95% CI: 2.02-2.23) and remained over time. Conclusions: Commissioning of primary and secondary prevention services needs to address the growing problem of intentional poisonings among young people.

Changes in poisonings among adolescents in the UK between 1992 and 2012: a population based cohort study.

BACKGROUND: Poisonings are a common cause of morbidity and mortality among adolescents. Yet surveillance data indicating current incidence rates (IRs) and time trends are lacking, making policy development and service planning difficult. We utilised population based primary care data to estimate adolescent poisoning rates according to intent across the UK. METHODS: A cohort study of 1 311 021 adolescents aged 10-17 years, between 1992 and 2012, was conducted using routine primary care data from The Health Improvement Network. IRs and adjusted IRRs with 95% CIs were calculated for all poisonings, intentional, unintentional, unknown intent and alcohol related poisonings, by age, sex, calendar time and socioeconomic deprivation. RESULTS: Overall poisoning incidence increased by 27% from the period 1992-1996 to 2007-2012, with the largest increases in intentional poisonings among females aged 16-17 years (IR 391.4/100 000 person years (PY), CI 328.9 to 465.7 for age 17 years in 1992-1996; 767.0/100 000 PY, CI 719.5 to 817.7 in 2007-2012) and alcohol related poisonings in females aged 15-16 years (IR 65.7/100 000 PY, CI 43.3 to 99.8 rising to 130.0/100 000 PY, CI 110.0 to 150.0 for age 15 years). A strong socioeconomic gradient for all poisonings persisted over time, with higher rates among the more deprived (IRR 2.63, CI 2.41 to 2.88 for the most vs least deprived quintile in 2007-2012). CONCLUSIONS: Adolescent poisonings, especially intentional poisonings, have increased substantially over time and remain associated with health inequalities. Social and psychological support for adolescents should be targeted at more deprived communities, and child and adolescent mental health and alcohol support service provision should be commissioned to reflect the changing need.

Children at risk of medicinal and non-medicinal poisoning: a population-based case-control study in general practice.

BACKGROUND: Preschool children have a high risk of poisoning. While medicines prescribed by primary care are potential poisoning agents, the risk factors for poisoning from medication are not well described. AIM: To identify risk factors for medicinal and non-medicinal poisoning in preschool children. DESIGN AND SETTING: Population-based nested case-control study using The Health Improvement Network primary care database 1988-2004. METHOD: Conditional logistic regression was used to identify child, maternal, and social risk factors for medicinal (1316 cases) and non-medicinal poisoning (503 cases), using 17 709 controls matched on general practice. RESULTS: Poisoning by medicines was independently associated with deprivation (test for trend P<0.001), maternal age (P<0.001), birth order (P<0.001), maternal alcohol misuse (odds ratio [OR] = 5.44, 95% confidence interval [CI] = 1.99 to 14.91), and perinatal depression (OR = 1.54, 95% CI = 1.26 to 1.88). Living in a household with two or more adults lowered the odds of injury compared to single-parent households (OR = 0.85, 95% CI = 0.74 to 0.96) and the odds varied by age, being highest in 2 year olds (OR = 9.61, 95% CI = 7.73 to 11.95). Non-medicinal poisoning was associated with deprivation (P = 0.001), maternal age (P<0.001), and birth order (P<0.001). The odds were raised in 1 year olds (OR = 5.44, 95% CI = 4.07 to 7.26) and 2 year olds (OR = 5.07, 95% CI = 3.73 to 6.90) compared to those aged <1 year. CONCLUSION: Primary care data can be used to target interventions to children at risk of poisoning. This is pertinent when prescribing for children/family members, as prescribed medications may become poisoning agents. Prompt identification of maternal depression and alcohol misuse, and delivery of poisoning-prevention interventions at this stage may help prevent poisonings.