Impact of reducing the threshold for acetylcysteine treatment in acute paracetamol poisoning: the recent United Kingdom experience

BACKGROUND

On 3 September 2012, the licensed indication for acetylcysteine was changed in the United Kingdom (UK) so that all patients with a plasma paracetamol concentration above a "100 mg/L" (4 h post ingestion) nomogram treatment line after an acute paracetamol (acetaminophen) overdose should be treated. This is a lower threshold than that used in the United States, Canada, Australia, and New Zealand. Here we report the impact of this change in the UK on the management of patients with acute overdose in different paracetamol concentration ranges.

METHODS

This is a cohort study, consisting of a retrospective analysis conducted on prospectively collected audit data in three UK hospitals. Following appropriate ethical and data protection authority approval, data for patients presenting within 24 h of an acute timed single paracetamol overdose were extracted. Numbers of admissions and use of antidote in relation to different paracetamol concentration bands (< 100 mg/L; 100-149 mg/L; 150-199 mg/L; and ≥ 200 mg/L at 4 h) were analyzed for one-year periods before and after the change.

RESULTS

Comparing the year before with the year after the change, there was no change in the numbers of patients presenting to hospital within 24 h of acute timed paracetamol overdose (1246 before and 1251 after), but more patients were admitted (759 before and 849 after) and treated with acetylcysteine (389 before and 539 after). Of the 150 additional patients treated with acetylcysteine in the year following the change, 114 (76%, 95% CI: 68.4-82.6) were in the 100-149 group and 9 (6.0%, 95% CI: 2.8-11.1) in the 150-199 group.

CONCLUSIONS

Changes to national guidelines for managing paracetamol poisoning in the UK have increased the numbers of patients with acute overdose treated with acetylcysteine, with most additional treatments occurring in patients in the 100-149 mg/L dose range, a group at low risk of hepatotoxicity and higher risk of adverse reactions.

National radon programmes and policies: the RADPAR recommendations

Results from epidemiological studies on lung cancer and radon exposure in dwellings and mines led to a significant revision of recommendations and regulations of international organisations, such as WHO, IAEA, Nordic Countries, European Commission. Within the European project RADPAR, scientists from 18 institutions of 14 European countries worked together for 3 y (2009-12). Among other reports, a comprehensive booklet of recommendations was produced with the aim that they should be useful both for countries with a well-developed radon programme and for countries with little experience on radon issues. In this paper, the main RADPAR recommendations on radon programmes and policies are described and discussed. These recommendations should be very useful in preparing a national action plan, required by the recent Council Directive 2013/59/Euratom.

The suspected scaphoid injury: resource implications in the absence of magnetic resonance imaging

INTRODUCTION

Undiagnosed and untreated scaphoid fractures have poorer outcomes and many patients are unnecessarily immobilised for prolonged periods of time to avoid missing occult injuries. Magnetic resonance imaging has a high sensitivity and specificity in detecting occult scaphoid fractures, but many units do not routinely use this imaging modality in the diagnostic pathway. We aimed to determine the patterns of suspected scaphoid injuries, report the process of care, and calculate the costs involved in their management.

METHODS

We prospectively identified all adult patients referred to fracture clinic at the Royal Infirmary of Edinburgh with a scaphoid-related injury, between October 2007 and September 2008. Clinical notes were examined retrospectively. We defined three injury groups: true fractures, occult fractures, and suspected scaphoid injuries. We analysed patient demographics, treatment timelines, and the treatment costs involved.

RESULTS

Fracture clinic received 537 scaphoid-related referrals. There were 87 true fractures, 43 occult fractures, and 407 suspected injuries, incurring average treatment costs of £1,173, £773, and £384 respectively. Occult fractures accounted for 33% of all confirmed scaphoid fractures. The majority of scaphoid-related referrals (76%) were never proven to have a scaphoid fracture, and many were unnecessarily immobilised. The costs involved in the treatment of suspected scaphoid injuries were found to be higher than the cost of magnetic resonance imaging (£97).

CONCLUSION

In this group of suspected scaphoid injury, we believe the introduction of an early magnetic resonance imaging protocol would lead to an earlier definitive diagnosis and potentially a more cost-effective service.

Protocol for the United Kingdom Rotator Cuff Study (UKUFF): a randomised controlled trial of open and arthroscopic rotator cuff repair

This protocol describes a pragmatic multicentre randomised controlled trial (RCT) to assess the clinical and cost effectiveness of arthroscopic and open surgery in the management of rotator cuff tears. This trial began in 2007 and was modified in 2010, with the removal of a non-operative arm due to high rates of early crossover to surgery. Cite this article: Bone Joint Res 2014;3:155-60.

Edible gardens in early childhood education settings in Aotearoa, New Zealand

ISSUE ADDRESSED

This paper aims to explore the presence and role of edible gardens in Aotearoa/New Zealand Early Childhood Education Services (ECES).

METHODS

Participant ECES providers were identified from the Ministry of Education database of Early Childhood Education Services (March 2009). These include Education and Care and Casual Education and Care, Kindergarten, Home-based Education and Care services, Playcentres, Te Kōhanga Reo. A structured, self-administered questionnaire was sent to the Principal or Head Teacher of the service.

RESULTS

Of the 211 ECES that responded (55% response rate), 71% had edible gardens, incorporating vegetables, berry fruit, tree fruit, edible flowers and nut trees. Garden activities were linked with teaching across all strands of the New Zealand early childhood curriculum. In addition, 34% provided guidance on using garden produce and 30% linked the garden with messages on fruit and vegetable consumption. Most gardens were established recently (past 2 years) and relied on financial and non-financial support from parents, teachers and community organisations. Barriers included a lack of funding, space, time and staff support.

CONCLUSIONS/IMPLICATIONS

Study findings suggest that gardens are already being used as a versatile teaching tool in many ECES settings. Most gardens are new, with a need to support the sustainability and workforce development among teachers and parents in order to be able to maintain these resources for future generations. SO WHAT?: Given the inherent links between gardening and healthy food and exercise, there seem to be extensive opportunities for health promotion aligned with the edible garden movement.

Regional heritability advanced complex trait analysis for GPU and traditional parallel architectures

MOTIVATION

Quantification of the contribution of genetic variation to phenotypic variation for complex traits becomes increasingly computationally demanding with increasing numbers of single-nucleotide polymorphisms and individuals. To meet the challenges in making feasible large-scale studies, we present the REgional heritability advanced complex trait analysis software. Adapted from advanced complex trait analysis (and, in turn, genome-wide complex trait analysis), it is tailored to exploit the parallelism present in modern traditional and graphics processing unit (GPU)-accelerated machines, from workstations to supercomputers.

RESULTS

We adapt the genetic relationship matrix estimation algorithm to remove limitations on memory, allowing the analysis of large datasets. We build on this to develop a version of the code able to efficiently exploit GPU-accelerated systems for both the genetic relationship matrix and REstricted maximum likelihood (REML) parts of the analysis, offering substantial speedup over the traditional central processing unit version. We develop the ability to analyze multiple small regions of the genome across multiple compute nodes in parallel, following the 'regional heritability' approach. We demonstrate the new software using 1024 GPUs in parallel on one of the world's fastest supercomputers.

AVAILABILITY

The code is freely available at http://www.epcc.ed.ac.uk/software-products CONTACT: a.gray@ed.ac.uk.

Prediction of mortality and macrovascular complications in type 2 diabetes: validation of the UKPDS Outcomes Model in the Casale Monferrato Survey, Italy

AIMS/HYPOTHESIS

The United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model can be used to estimate the lifetime occurrence of major diabetes-related complications in order to calculate health economic outcomes. The aim of the study was to assess the performance of the model by comparing the predicted and observed mortality and the incidence of macrovascular complications in an Italian population-based cohort with type 2 diabetes.

METHODS

We used data from the Casale Monferrato Survey, a cohort enrolled in 1988 and surveyed in 1991 (n = 1,967) to assess the prevalence of cardiovascular risk factors. In 2000, a new survey included all the members of the original cohort who were still alive (n = 860), and in addition all individuals identified with a new diagnosis of type 2 diabetes since 1993 (n = 2,389). We compared the mortality predicted by the model for the 1991 survey over the subsequent 17-year period with the observed risk. The following outcomes were analysed in the 2000 survey: myocardial infarction (MI), other ischaemic heart disease, stroke, congestive heart failure (CHF) and amputation.

RESULTS

For all-cause mortality, the predictions from the model at 5 and 10 years (23% and 47%, respectively) were identical to the observed risks. At 15 years, the risk of death was slightly overestimated (an estimate of 67% vs 64% observed, 95% CI 61%, 66%). The performance of the model was best for patients with a recent history of disease (duration <6 years). Among the complications, the predicted cumulative incidences of MI and CHF were very close to those observed.

CONCLUSIONS/INTERPRETATION

External validation is essential to assess the accuracy of simulation models. The UKPDS Outcomes Model satisfactorily predicted a set of actual incidences of mortality and complications in an Italian diabetes cohort up to a duration of approximately 12 years. The longer term performance of such models should be carefully evaluated.

Five-year results of a randomised controlled trial comparing mobile and fixed bearings in total knee replacement

There is conflicting evidence about the merits of mobile bearings in total knee replacement, partly because most randomised controlled trials (RCTs) have not been adequately powered. We report the results of a multicentre RCT of mobile versus fixed bearings. This was part of the knee arthroplasty trial (KAT), where 539 patients were randomly allocated to mobile or fixed bearings and analysed on an intention-to-treat basis. The primary outcome measure was the Oxford Knee Score (OKS) plus secondary measures including Short Form-12, EuroQol EQ-5D, costs, cost-effectiveness and need for further surgery. There was no significant difference between the groups pre-operatively: mean OKS was 17.18 (sd 7.60) in the mobile-bearing group and 16.49 (sd 7.40) in the fixed-bearing group. At five years mean OKS was 33.19 (sd 16.68) and 33.65 (sd 9.68), respectively. There was no significant difference between trial groups in OKS at five years (-1.12 (95% confidence interval -2.77 to 0.52) or any of the other outcome measures. Furthermore, there was no significant difference in the proportion of patients with knee-related re-operations or in total costs. In this appropriately powered RCT, over the first five years after total knee replacement functional outcomes, re-operation rates and healthcare costs appear to be the same irrespective of whether a mobile or fixed bearing is used.