Efficacy of fresh frozen plasma transfusion in comparison with conventional regimen in organophosphate poisoning treatment: a meta-analysis study

OBJECTIVE

To evaluating the efficacy of fresh frozen plasma (FFP) in comparison with conventional regimen in the treatment of organophosphate (OP) poisoning.

METHODS

PubMed, ScopeMed, Cochrane, Scopus, and Google Scholar databases were searched. The search strategy used the following key words "organophosphate" and "poisoning or toxicity", "(atropine and oxime)", "fresh frozen plasma", "clinical trial", "outcome". The treatment with atropine or/and oxime was considered conventional therapy. The length of hospitalization, the length of ICU admission, need for mechanical ventilation and its duration, clinical recovery point, choline esterase level, mortality rate, and intermediate syndrome (IMS) occurrence were the key outcomes of interest. Databases were searched during the period of 2003-2019. Five studies were included in the analysis.

RESULTS

Pooling of data showed that the relative risk (RR) of mortality in OP poisoning for five included trials comparing FFP-treated group with conventional regimen therapy was [0.563 (95% CI (0.252, 1.255)]. The summary of RR for IMS in two studies was [RR: 1.34, 95% CI (0.655, 2.742)]. In addition, there was a non-significant mean difference (MD) in hospital stay [MD: -0.106, 95% CI (-0.434, 0.223)] in three included trials. A significant MD was observed in the length of ICU admission in two trials between FFP-treated group compared to the conventional treatment group [MD: -2.672, 95% CI (-4.189, -1.154)], but after random effects meta-analysis, the changes were not significant [MD: -2.015, 95% CI (-6.308, 2.277)]. The summary of fixed-effect meta-analysis for choline esterase level in three trails was [MD: -0.117, 95% CI (-0.468, 0.234)]. The RR of ventilation requirement for two included trials in the FFP-treated group comparing to the conventional regimen therapy was [0.84, 95% CI (0.691, 1.022)] while for ventilation duration in two studies was [MD: -0.183, 95% CI (-0.567, 0.201)].

CONCLUSION

The addition of FFP to conventional therapy did not improve the outcomes of mortality, IMS, hospital length of stay, cholinesterase levels, need or duration of mechanical ventilation, and only the length of ICU stay could affect in the treated group.

Massive Citalopram Overdose Associated with Recurrent Seizures and Bilateral Shoulder Dislocations

Selective serotonin reuptake inhibitors (SSRIs) are widely used in the treatment of many types of mental disorders. Citalopram is commonly used as a new generation of SSRIs in this regard; however, unfortunately, its overdose is associated with seizure and heart disorders. The reported case in the present study indicated recurrent seizures, nonspecific ST-T changes, and prolonged QT interval due to the overuse of citalopram. The patient had bilateral anterior shoulder dislocation along with right proximal humerus fracture that was occurred during the seizure. The dislocation was initially reduced and then fixed. Moreover, the seizure was controlled with diazepam without any problems, and cardiac monitoring continued for 2 days. Massive citalopram overdose may be associated with recurrent seizures and QT prolongation. Complications postseizures, such as shoulder dislocations, should be examined for and managed appropriately.

Accuracy of maxillary repositioning surgery using CAD/CAM customized surgical guides and fixation plates

The advent of three-dimensional imaging and computer-aided surgical simulation (CASS) have brought about a paradigm shift in surgical planning. The aim of this study was to assess the accuracy of maxillary repositioning surgery using computer-aided design and manufacturing (CAD/CAM) customized titanium surgical guides and fixation plates. Thirty consecutive adult patients, 13 male and 17 female, with a mean age of 29.2 years and 25.5 years, respectively, requiring Le Fort I maxillary osteotomy, with or without simultaneous mandibular surgery, were evaluated retrospectively. All orthognathic surgeries were performed by one experienced surgeon. The pre-surgical and post-surgical volumetric imaging were superimposed to assess the linear and angular differences between the planned and actual positions of the maxilla following surgery. With the use of the CAD/CAM titanium surgical guides and fixation plates, all surgical movements were within 2mm and 4° of the planned movements, which is considered clinically insignificant. The overall root mean square error between the planned and actual surgical movements was 0.38mm in the transverse dimension, 0.64mm in the anteroposterior dimension, and 0.55mm in the vertical dimension. In regard to the centroid of the maxilla, the absolute angular difference of the maxillary centroid was 1.06° in pitch, 0.47° in roll, and 0.49° in yaw. Maxillary repositioning surgery can be performed with high accuracy using CAD/CAM titanium surgical guides and fixation plates.

Intussusception in 2 Children With Severe Acute Respiratory Syndrome Coronavirus-2 Infection

We note that intussusception was likely associated with severe acute respiratory syndrome coronavirus-2 infection in 2 infants in Wuhan and London. The intussusception was reduced by enemas in Wuhan; the outcome was fatal. The intussusception was not reduced by enemas in London and required surgery; the outcome was favorable.

COVID-19 and toxicity from potential treatments: Panacea or poison

Since December 2019, coronavirus disease (COVID‐19) has been increasingly spreading from its origin in Wuhan, China to many countries around the world eventuating in morbidity and mortality affecting millions of people. This pandemic has proven to be a challenge given that there is no immediate cure, no vaccine is currently available and medications or treatments being used are still undergoing clinical trials. There have already been examples of self‐medication and overdose. Clearly, there is a need to further define the efficacy of treatments used in the management of COVID‐19. This evidence needs to be backed by large randomised‐controlled clinical trials. In the meantime, there will no doubt be further off‐label use of these medications by patients and practitioners and possibly related toxicity.

Comparative Analysis of Gait Speed Estimation Using Wideband and Narrowband Radars, Thermal Camera, and Motion Tracking Suit Technologies

Research has shown that cognitive and physical functioning of older adults can be reflected in indicators such as walking speed. While changes in cognition, mobility, or health cause changes in gait speed, often gradual variations in walking speed go undetected until severe problems arise. Discrete clinical assessments during clinical consultations often fail to detect changes in day-to-day walking speeds and do not reflect walking speeds in everyday environments, where most of the mobility issues happen. In this paper, we compare four walking speed measurement technologies to a GAITRite mat (gold standard): (1) an ultra wideband radar (covering the band from 3.3 GHz to 10 GHz), (2) a narrow band 24-GHz radar (with a bandwidth of 250 MHz), (3) a perception Neuron Motion Tracking suit, and (4) a thermal camera. Data were collected in parallel using all sensors at the same time for 10 healthy adults for normal and slow walking paces. A comparison of the sensors indicates better performance at lower gait speeds, with offsets (when compared to GAITRite) between 0.1 and 20% for the ultra wideband radar, 1.9 and 17% for the narrowband radar, 0.1 and 38% for the thermal camera, and 1.7 and 38% for the suit. This paper supports the potential of unobtrusive radar-based sensors and thermal camera technologies for ambient autonomous gait speed monitoring for contextual, privacy-preserving monitoring of participants in the community.

Where ferroptosis inhibitors and paraquat detoxification mechanisms intersect, exploring possible treatment strategies

Paraquat (PQ) is a fast-acting and effective herbicide that is used throughout the world to eliminate weeds. Over the past years, PQ was considered one of the most popular poisoning substances for suicide, and PQ poisoning accounts for about one-third of suicides around the world. Poisoning with PQ may cause multiorgan failure, pulmonary fibrosis, and ultimately death. Exposure to PQ results in the accumulation of PQ in the lungs, causing severe damage and, eventually, fibrosis. Until now, no effective antidote has been found to treat poisoning with PQ. In general, the toxicity of PQ is due to the formation of high energy oxygen free radicals and the peroxidation of unsaturated lipids in the cell. Ferroptosis is the result of the loss of glutathione peroxidase 4 (GPX4) activity that transforms iron-dependent lipid hydroperoxides to lipid alcohols, which are inert in the biological environment. Impaired iron metabolism and lipid peroxidation are increasingly known as the driving agents of ferroptosis. The contribution of ferroptosis to the development of cell death during poisoning with PQ has not yet been addressed. There is growing evidence about the relationship between PQ poisoning and ferroptosis. This raises the possibility of using ferroptosis inhibitors for the treatment of PQ poisoning. In this hypothesis-driven review article, we elaborated how ferroptosis inhibitors might circumvent the toxicity induced by PQ and may be potentially useful for the treatment of PQ toxicity.

Efficacy of a two bag acetylcysteine regimen to treat paracetamol overdose (2NAC study)

BACKGROUND

Previous studies of paracetamol overdose treatment show that a 2-bag, 20-h intravenous (IV) acetylcysteine regimen decreased the incidence of non-allergic anaphylactic reactions compared to the 3-bag, 21 h IV regimen, but have not examined efficacy of the 20-h 2 bag regimen.

METHODS

This was a multi-centre observational study of paracetamol overdose presentations treated with a 2-bag IV acetylcysteine regimen (200 mg/kg over 4 h, 100 mg/kg over 16 h) compared to a 3-bag regimen, performed from 2009 to 2019. Patients were referred from the emergency department to the inpatient toxicology units for continued management. For the primary non-inferiority analysis: subjects had single, acute ingestions, a serum paracetamol-concentration performed 4 to 8-h post-ingestion. The primary outcome was development of acute liver injury (ALI), defined as peak ALT>150 U/L; and > double admission baseline ALT (for presentations within 24 h post-overdose). Secondary outcomes included adverse reactions to acetylcysteine (cutaneous and systemic).

FINDING

Out of 6419 paracetamol overdoses, 2763 received acetylcysteine. For the primary analysis, 1003 received the 2-bag and 783 the 3-bag acetylcysteine regimen. When presentation bloods were performed 4 to 8-h post-overdose, 21 (3.1%) developed ALI with the 2-bag regimen vs 16 (2.9%) with the 3-bag regimen (Difference: 0.2%, 95%CI:-1.6 to 2.2). The incidence of hepatotoxicity was: 1.2% (n = 8) with the two-bag regimen and 1.6% (n = 9) with the three-bag regimen (Difference -0.4%, 95%CI -1.75, 0.91). When presentation bloods were performed 8 to 24-h post-overdose, 70 (21%) developed ALI with the 2-bag regimen vs 46 (23%) with the 3-bag regimen (Difference: -2%, 95%CI -9.12 to 5.36). There were significantly less cutaneous and systemic non-allergic anaphylactic reactions recorded after treatment with the two-bag than the three-bag regimen (1.3% [n = 17] and 7.1% [n = 65], Difference: -5.8%, 95%CI -7.6 to -4.0, p < 0.0001), respectively.

INTERPRETATION

A two-bag intravenous acetylcysteine regimen was found to be non-inferior to the three-bag regimen with regards to efficacy in preventing acute liver injury for early presentations of paracetamol overdose. No important differences were seen for any other presentations. The two-bag regimen also decreased the incidence of both non-allergic anaphylactic reactions and gastrointestinal adverse events from acetylcysteine treatment.

FUNDING

AW is funded by a National Health and Medical Research Council (NHMRC) Early Career Fellowship ID 1159907. GI is funded by a NHMRC Senior Research Fellowship ID 1061041. The NHMRC had no role in the design, writing of this manuscript. The corresponding author (AW) had full access to all the data in the study and final responsibility for the decision to submit the manuscript for publication.

Adducts Post Acetaminophen Overdose Treated with a 12-Hour vs 20-Hour Acetylcysteine Infusion

INTRODUCTION

Acetaminophen protein adducts in the circulation are a specific biomarker of acetaminophen oxidation, and may be a more sensitive measure of impending hepatic injury following overdose than alanine transaminase (ALT). We performed an exploratory analytical substudy of adducts during a clinical trial (NACSTOP) of abbreviated (12-hour) versus control (20-hour) acetylcysteine to identify any signal of diminished antidotal effectiveness with shortened therapy.

METHODS

We measured adducts at 0, 12, and 20 hours from a convenience sample of subjects enrolled in the cluster-controlled NACSTOP trial evaluating a 12-hour ("abbreviated"; 200 mg/kg over 4 hours, 50 mg/kg over 8 hours) vs 20-hour acetylcysteine regimen ("control"; 200 mg/kg over 4 hours, 100 mg/kg over 16 hours). Adducts were assayed using high-performance liquid chromatography/mass spectrometry.

RESULTS

Median ALT 20 hours after the initiation of acetylcysteine was 12 U/L (IQR 8,14) in the abbreviated 12-hour regimen group (N = 8), compared with the control group 16 U/L (IQR 11,21; N = 21) (p = 0.46). Adduct concentrations were similarly low in both groups: abbreviated [(0.005 μmol/L, IQR (0,0.14)] and control [(0.005 μmol/L, IQR (0,0.05)] (p = 0.61).

CONCLUSIONS

There were minimal to no acetaminophen protein adducts detected. These findings further support discontinuing acetylcysteine when acetaminophen concentrations are low and liver function tests normal after 12 hours of treatment.

A nurse-led paediatric oncology fast-track clinic proves a successful ambulatory intervention for patients

AIM

To assess the impact of a pilot nurse-led paediatric oncology fast-track clinic (OFTC) for complications and side effects following chemotherapy within a paediatric tertiary hospital.

METHODS

Prospective clinical data from the first 100 patients seen in the OFTC were compared with retrospective data of oncology patient presentations to the emergency department (ED) (over a 1-year period, n = 196) who would have been eligible for review in the OFTC. Parent and patient satisfaction of clinical care were also assessed via surveys pre- and post-OFTC implementation.

RESULTS

Analysis which achieved statistical difference was a reduction in the number of blood tubes taken in OFTC (average 1.9 for those discharged from clinic, 2.9 for those admitted from clinic) in comparison to those seen in the ED (average 3.2) (p = 0.0027). The average number of interventions per patient seen in the ED were 2.1 (standard deviation 1.64) compared with 1.7 (standard deviation 1.55) interventions per patient seen in the OFTC, and who were not admitted following review. This result approached statistical significance with p = 0.0963. Other results which did not meet statistical significance included a reduction in treatment times, hospital admissions and medical oncology reviews.

CONCLUSION

Our pilot study implementing an OFTC for the triage and assessment of chemotherapy-related complications has proven successful from an operational and consumer perspective. The clinic improved care by ensuring expedited review, more streamlined interventions, and less overall hospital admissions. The improvements in efficiency were also mirrored by increased parent and patient satisfaction.

The Global Educational Toxicology Toolkit (GETKIT): A 1-Day Course for Teaching Poisoning Essentials in Low- and Middle-Income Countries (LMIC): Course Development and Pilot Data Analysis

INTRODUCTION

Worldwide an estimated one million deaths occur annually as a result of poisoning. Internationally there is a lack of toxicology training programs, especially in resource poor settings. We developed a one-day, interactive toxicology curriculum for healthcare practitioners in countries lacking clinical toxicology training and evaluated its feasibility and effectiveness for knowledge dissemination.

METHODS

GETKIT was developed with 3 sections: didactics, hands on toxicology case lab, and technology clinic. The investigators, who are medical toxicologists,created 23 didactic lectures and 42 workshop cases. All materials were peer reviewed by 5 senior medical toxicologists for content validity. Participants atpilot sites were given pre-course, post-course, and 3-month follow-up tests and surveys.

RESULTS

GETKIT was delivered internationally at 7 sites between November 2017 and April 2018. There were 186 total participants. One hundred and ten participants (59%) reported their hospital lacked a clinical toxicology service. The median post course score 12 (60%), IQR (6,14) was significantly higher compared to the pre-course score 9 (45%), IQR (6,11) (p < 0.0001). There was a significantly higher median 3-month post course score 13 (65%), IQR (8,14) vs. a median pre course score of 9 (45%), IQR (6,11) (p 0.0005). At 3-month follow up 86% of participants reported GETKIT had changed their clinical practice.

CONCLUSIONS

An improvement in and retention of medical toxicology knowledge was demonstrated with the GETKIT course. It also conferred improvement in selfreportedpoisoning management practices in participants from low resource settings.

The Effects of Concurrent Training Order on Satellite Cell-Related Markers, Body Composition, Muscular and Cardiorespiratory Fitness in Older Men with Sarcopenia

OBJECTIVES

Concurrent Training (CT) is described as a combination of resistance training (RT) and endurance training (ET) in a periodized program to maximize all aspects of physical performance. To date, effects of CT order on muscular and cardiorespiratory fitness adaptations are controversial. Owing to the age-related decrement in satellite cells (SC) which are critical for fiber repair, conservation, muscle hypertrophy as well as cardiorespiratory fitness, the present study examined the response of SC related markers to CT order in older sarcopenic men.

PARTICIPANTS

Thirty older men (age= 64.3 ± 3.5 years) were randomly assigned into one of 3 groups, ET followed by RT (E+R; n=10), RT followed by ET (R+E; n= 10) or a control (C; n=10).

INTERVENTION

The training protocol consisted of 3 exercise sessions per week for 8 weeks. Blood samples were obtained at baseline and 48 hours after the final training session.

RESULTS

Weight, skeletal muscle mass, lower and upper body power, maximal oxygen consumption (VO2max), Paired Box 7 (Pax7), and Myogenic factor 5 (Myf5) significantly increased, while were percent body fat significantly decreased following E+R and R+E compared to C. Importantly, the improvement in skeletal muscle mass, lower and upper body power, Myf5 and Pax7 in the E+R was significantly greater than the R+E group. Myogenin (Myog) and Paired Box 3 (Pax3) significantly increased (P < 0.01) in both training groups compared to no changes in C.

CONCLUSION

An 8-week CT intervention improves SC related markers, body composition and enhances power and VO2max in older sarcopenic participants, regardless of the order of RT and ET. However, performing ET before RT may be more effective at enhancing skeletal muscle mass, Myf5 and Pax7, in addition to both lower and upper body power. While both CT programs produced notable physiological and performance benefits, performing ET before RT during CT may provide the greatest therapeutic benefits for aging individuals.

In vitro study of pharmacobezoar formation in simulated acetaminophen overdose

Objectives: There have been few studies of pharmacobezoar formation, but they can be an important contributor to overdose toxicity. Pharmacobezoars may explain the delayed peak or "double hump" pharmacokinetics, which were noted in previous case reports with delayed toxicity of acetaminophen (APAP). We validated the presence of APAP bezoar formation in a controlled modified in vitro environment simulating acute APAP overdose.Methods: This study involved the APAP and control groups (ferrous sulfate and chlorpheniramine). The APAP study group contained three subgroups of APAP with different dosage, i.e., 25 g (50 tabs)/37.5 g (75 tabs)/50 g (100 tabs). The positive control group containing ferrous sulfate, i.e., 15 g (50 tabs), has been reported previously to form pharmacobezoars in overdose. The negative control group containing chlorpheniramine, i.e., 200 mg (50 tabs), has not been reported to form pharmacobezoars in previous case studies. Tablets from each study group were placed into a separate pig stomach. Each stomach contained 28 ml USP standard simulated gastric acid. The stomach was placed in a plastic box filled with water maintaining at 37 °C. Each test group was examined for 4 h in the stomach. The primary outcome was the presence of clump formation. Positive clump formation was defined as tablets sticking together and the ability to maintain shape upon dissecting the pig stomach and lifting with fingers. Tablet clumps would then undergo dissolution testing with subsequent analysis of dissolution profiles.Results: Formation of tablets clumps was confirmed in APAP overdose in the in vitro environment. Clumps were noted to be present in the 37.5 g and 50 g APAP groups, while 25 g APAP was unlikely to form clumps. The dissolution profile of clump demonstrated slower release without reaching plateau at 60 min, as compared to corresponding individual tabs of APAP. f1 and f2 analyses showed the dissolution profile of clump was different compared to that of referenced individual tab.Conclusions: APAP clump formation was confirmed in acute overdose of 37.5 g or more. Dissolution tests revealed delayed and steady release of tablet residue from the clumps, which could explain prolonged or delayed toxicity in large APAP overdose.