It also quite erroneously suggested that taking paracetamol pills in the instructed way is in itself dangerous. Most coverage failed to reassure the public that sticking to the recommended dose of paracetamol is a safe and effective method of pain relief. The researchers studied patients admitted to the Scottish Liver Transplantation Unit over a year period from to Information on paracetamol use was recorded on admission to the transplantation unit by asking the patients to recall their paracetamol use in the last seven days.
This included:. ALT is normally found within the liver cells, and high levels in the blood indicate that it has been released into the bloodstream due to liver cells becoming damaged. Patients with other causes of liver failure, such as viral hepatitis and liver cancer, were excluded from the study. The researchers then categorised patients by their self-reported paracetamol use. Patients were labelled as having had a staggered overdose if they had taken two or more paracetamol doses above the recommended level over more than eight hours resulting in a cumulative dose of greater than 4g a day.
The researchers compared the laboratory blood test results, liver transplant rates and survival of the patients in the different paracetamol groups. Of the patients admitted to the transplant unit, the majority Information on paracetamol use was available for patients; the majority of whom About one-quarter They found that the staggered group had taken significantly less paracetamol than the single point group.
The main finding was that a significantly lower proportion of the staggered overdose group survived 30 days after admittance to the unit This means that roughly 7 out of 10 survived in the single overdose group survived for 30 days, but only 6 out of every 10 patients in the staggered overdose group.
The group who did not get to a hospital in less than 24 hours following a single point overdose were more likely to develop worsening brain function due to liver damage during their stay at the transplant unit compared to those who came to hospital earlier.
Information on the reasons for overdose was available for patients. The most common reason given for overdose was for pain relief. Among patients with available data, about one-third The researchers also acknowledged that the patients admitted to the transplant unit represented the more severe cases of paracetamol-induced liver disease.
Ukraine too often loses veterans to suicide, and this problem needed to be addressed, Lifeline Ukraine was established to provide help for veterans and their family members first and foremost. Lifeline Ukraine was founded by Paul Niland, an Irish writer and commentator and businessman who has been a resident of Ukraine for almost 20 years.
The project was initiated in at the request of the then Acting Minister of Health, Dr. Ulana Suprun. The business community acknowledged Paul Niland, Founder of Lifeline Ukraine, for creating Ukraine's first national suicide prevention hotline, Lifeline Ukraine, to save people's lives, focused first and foremost on helping Ukraine's military veterans.
Conclusions: Further measures to reduce breaches of sales guidelines and the dangers of paracetamol overdose are required. Media and internet site producers should follow guidelines on reporting suicide. Paracetamol acetaminophen , an analgesic available over the counter, is the most common drug used for self-poisoning in the UK. Evidence from other countries indicates that restrictions on the quantity of paracetamol which may be purchased at one time may result in reduced case fatality when it is taken in overdose.
Warnings of the dangers of overdose are printed on the packets. Several research studies have evaluated the impact of the legislation, and generally found positive results, including reductions in mortality rates, admissions to liver units and liver transplantations, although these sometimes failed to reach statistical significance.
Although in law up to a maximum of tablets can be sold without a prescription to one person in one transaction, the Royal Pharmaceutical Society's Law and Ethics Bulletin recommends that pharmacists use their professional judgement in supplying more than 32 tablets, 29 and the Medicines and Healthcare products Regulatory Agency MHRA worked with trade organizations to agree on voluntary measures to comply with the intention of the legislation, including till bars on multiple purchases.
Many local trading standards offices published guidance recommending a general sales limit of one pack. We conducted an interview study to investigate the characteristics of larger paracetamol overdoses and the people who use this method of self-poisoning, and to assess whether the intention of the legislation to restrict sales of large numbers of tablets is being complied with by shops and pharmacies.
The overall purpose of the research was to provide information that could inform discussion of possible further initiatives to limit the dangers associated with paracetamol overdose, in view of the continuing high level of mortality associated with this problem. The study was based at the John Radcliffe Hospital in Oxford. We did not include patients who had taken overdoses of paracetamol-containing compounds unless they had also taken pure paracetamol , as we wanted to be sure that patients knew they were consuming paracetamol.
Patient knowledge of the paracetamol content of compound analgesics has been shown to be relatively poor. The research interview consisted of standardized and open-ended questions regarding the circumstances of the act, the number of tablets consumed, the number available, the source of the tablets, whether the patient had tried to buy more than the recommended amount and their expectations of the physical effects of overdose.
Patients were shown cards with common motives for overdoses written on them modified from Bancroft et al. They were also asked about previous paracetamol overdoses and potential influences on their decision to take the current overdose.
Scores on the Suicidal Intent Scale SIS , 38 a commonly used measure of severity of suicidal intent associated with an act of self-harm were recorded, using data collected by the clinician during the psychosocial assessment. This scale consists of 15 items rated 0—2, with higher scores indicating greater suicidal intent.
At the end of the research interview patients completed the Hospital Anxiety and Depression Scale HADS , a item measure of symptoms of anxiety and depression within the last week specifically designed for use in general hospital patients. A pilot study consisting of interviews with four patients was conducted before the interview schedule was finalized.
All the interviewers were inducted in the interview procedure to ensure standardized delivery. Clinical staff identified patients who met the study criteria from their daily list of referrals from the Emergency Department. After completing a psychosocial assessment, the clinician asked the patient if they were willing to be approached about the study. If they agreed, they were given an information sheet and the study was explained to them, either by SS, LW or by the clinical assessor if the latter was to carry out the research interview.
The interview then took place before the patient left the hospital. Sixty patients were interviewed for the study. The interview data were entered on a Microsoft Access database Microsoft Office Quantitative data were transferred to SPSS for Windows v14 40 and analysed using descriptive statistics, including chi-squared and Mann—Whitney tests.
Themes were identified by SS from the written comments and reviewed and approved by KH. During the study period, overdoses involving pure paracetamol taken by individuals were identified. Of the remaining episodes, Thus, One hundred and fifty-nine further cases could not be included because they did not meet the study criteria e. Of the 48 patients who presented more than once following a paracetamol overdose, 8 patients had taken more than 5 overdoses and one patient had taken 22, but was not eligible for inclusion in the study proper as he had been interviewed for the pilot study.
Patients whose overdose met the study criteria were invited to take part in the study, even if they had declined on a previous occasion. Once a patient had been interviewed for the study, they were not approached again if they took a subsequent overdose. One hundred and five episodes met the study criteria.
In five cases, more than one overdose by the same patient was eligible for inclusion. Two patients refused to take part on both occasions, one patient agreed following her second overdose and another patient refused on two occasions and agreed on the third. In order to compare the 60 patients who were interviewed for the study with the 40 patients who were eligible but not included, we counted the first episode for the two patients who refused on both occasions, and the episode at which the other two patients entered the interview sample.
To compare the groups, we used information gathered for the Oxford Monitoring System for Attempted Suicide, 41 through which data are collected on all deliberate self-harm presentations to the hospital. No significant differences were found for sex, age, number of tablets taken in overdose, suicide intent score, previous self-harm episodes, and alcohol taken at the time of the act. The study sample included 35 females mean age For 24 patients Over half The Suicide Intent Scale was completed for 59 patients.
The median suicide intent score was At the time of the research interview, 43 patients Over a third of the patients had taken alcohol at the time of the overdose Table 2 ; this was slightly more common in males 11, The majority 50, Seventeen patients took one or more other drugs in their overdose. These included other analgesics seven NSAIDs, three opiate analgesics, three paracetamol compounds and three aspirin ; antidepressants [five SSRIs, one tricyclic-related trazodone ]; two antipsychotic drugs; two benzodiazepines; one antibiotic; one antihistamine and one betablocker.
The number of paracetamol tablets taken ranged from 18 to Over three-quarters of the patients took fewer than 50 tablets, but over half 35, Males were more likely to take larger overdoses: Half of the patients had taken the overdose impulsively, within an hour of first thinking about it Table 2. More of these took tablets already available in the household than people who had considered an overdose for over an hour 19, However, seven people had considered the overdose for more than a week.
In many cases 32, Three people had boxes of tablets, which had been prescribed after operations, or for back pain. Over half 35, Eleven of these Most purchases were made from a supermarket or pharmacy Table 2. Other outlets included four garages and an online pharmacy site. Thirty-seven people including some who had bought the tablets specifically for the overdose identified the place in their house where the tablets were kept.
The kitchen was the most common storage place 14, Ten people tried to buy more than 32 tablets in one transaction. Four succeeded: of these, one was able to buy in bulk from a cash and carry outlet, one purchased 14 packs of 16 tablets from an online pharmacy and one obtained multiple packs by telling pharmacy staff that he was going away on holiday and needed supplies to take with him.
The fourth bought three packs of 16 tablets from a supermarket. Another person bought two packs of 16 tablets at self-checkout tills in the same supermarket three times in one day. Others who wanted to buy more than the recommended amount went to several different shops, or to the same shop on different days. Eighteen had bought paracetamol from at least two different outlets. Nine patients commented that they were aware of the limit on sales and had therefore bought supplies in more than one transaction.
When asked what they had thought the physical effects of the overdose would be if untreated, the majority 53, Over three-quarters 48, However, 42 Over half of these 23, I thought I'd be sicker than I was — the chlorpromazine put me to sleep. Fourteen patients, including seven of those who had taken a previous paracetamol overdose, said that at the time they took the tablets they did not think about the possible physical effects.
The patients were asked how many tablets they thought would cause death. Twelve Of the rest, the number chosen ranged from 7 to ; five people thought that 16 or fewer tablets could kill, and a further 17 thought that 17—32 tablets would be lethal.
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