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Koning T, Cordova F, Aguilar G, Sarmiento J, Mardones GA, Boric M, Varas-Godoy M, Lladser A, Duran WN, Ehrenfeld P, Sanchez FA. S-Nitrosylation in endothelial cells contributes to tumor cell adhesion and extravasation during breast cancer metastasis. Biol Res 2023; 56:51. [PMID: 37773178 PMCID: PMC10540418 DOI: 10.1186/s40659-023-00461-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 08/23/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND Nitric oxide is produced by different nitric oxide synthases isoforms. NO activates two signaling pathways, one dependent on soluble guanylate cyclase and protein kinase G, and other where NO post-translationally modifies proteins through S-nitrosylation, which is the modification induced by NO in free-thiol cysteines in proteins to form S-nitrosothiols. High levels of NO have been detected in blood of breast cancer patients and increased NOS activity has been detected in invasive breast tumors compared to benign or normal breast tissue, suggesting a positive correlation between NO biosynthesis, degree of malignancy and metastasis. During metastasis, the endothelium plays a key role allowing the adhesion of tumor cells, which is the first step in the extravasation process leading to metastasis. This step shares similarities with leukocyte adhesion to the endothelium, and it is plausible that it may also share some regulatory elements. The vascular cell adhesion molecule-1 (VCAM-1) expressed on the endothelial cell surface promotes interactions between the endothelium and tumor cells, as well as leukocytes. Data show that breast tumor cells adhere to areas in the vasculature where NO production is increased, however, the mechanisms involved are unknown. RESULTS We report that the stimulation of endothelial cells with interleukin-8, and conditioned medium from breast tumor cells activates the S-nitrosylation pathway in the endothelium to induce leukocyte adhesion and tumor cell extravasation by a mechanism that involves an increased VCAM-1 cell surface expression in endothelial cells. We identified VCAM-1 as an S-nitrosylation target during this process. The inhibition of NO signaling and S-nitrosylation blocked the transmigration of tumor cells through endothelial monolayers. Using an in vivo model, the number of lung metastases was inhibited in the presence of the S-nitrosylation inhibitor N-acetylcysteine (NAC), which was correlated with lower levels of S-nitrosylated VCAM-1 in the metastases. CONCLUSIONS S-Nitrosylation in the endothelium activates pathways that enhance VCAM-1 surface localization to promote binding of leukocytes and extravasation of tumor cells leading to metastasis. NAC is positioned as an important tool that might be tested as a co-therapy against breast cancer metastasis.
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Affiliation(s)
- T Koning
- Instituto de Inmunología, Facultad de Medicina, Universidad Austral de Chile, 511-0566, Valdivia, Chile
- Escuela de Graduados de Ciencias, Universidad Austral de Chile, 511-0566, Valdivia, Chile
| | - F Cordova
- Instituto de Inmunología, Facultad de Medicina, Universidad Austral de Chile, 511-0566, Valdivia, Chile
| | - G Aguilar
- Instituto de Inmunología, Facultad de Medicina, Universidad Austral de Chile, 511-0566, Valdivia, Chile
| | - J Sarmiento
- Instituto de Fisiología, Facultad de Medicina, Universidad Austral de Chile, 511-0566, Valdivia, Chile
| | - G A Mardones
- Instituto de Fisiología, Facultad de Medicina, Universidad Austral de Chile, 511-0566, Valdivia, Chile
- Escuela de Medicina, Facultad de Medicina y Ciencia, Universidad San Sebastián, Valdivia, Chile
| | - M Boric
- Departamento de Fisiología, Facultad de Ciencias Biológicas, Pontificia Universidad Católica de Chile, 8331150, Santiago, Chile
| | - M Varas-Godoy
- Cancer Cell Biology Lab., Centro de Biología Celular y Biomedicina (CEBICEM), Facultad de Medicina y Ciencia, Universidad San Sebastián, 7510157, Santiago, Chile
- Centro Ciencia & Vida, Fundación Ciencia & Vida, 7780272, Santiago, Chile
| | - A Lladser
- Centro Ciencia & Vida, Fundación Ciencia & Vida, 7780272, Santiago, Chile
- Facultad de Medicina y Ciencia, Universidad San Sebastián, Santiago, Chile
| | - W N Duran
- Department of Pharmacology, Physiology and Neuroscience, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, 07103, USA
| | - P Ehrenfeld
- Instituto de Anatomía, Histología y Patología, Facultad de Medicina, Universidad Austral de Chile, 511-0566, Valdivia, Chile.
- Centro Interdisciplinario de Estudios del Sistema Nervioso, Universidad Austral de Chile, 5110566, Valdivia, Chile.
| | - F A Sanchez
- Instituto de Inmunología, Facultad de Medicina, Universidad Austral de Chile, 511-0566, Valdivia, Chile.
- Centro Interdisciplinario de Estudios del Sistema Nervioso, Universidad Austral de Chile, 5110566, Valdivia, Chile.
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Hassan GS, Flores Molina M, Shoukry NH. The multifaceted role of macrophages during acute liver injury. Front Immunol 2023; 14:1237042. [PMID: 37736102 PMCID: PMC10510203 DOI: 10.3389/fimmu.2023.1237042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/15/2023] [Indexed: 09/23/2023] Open
Abstract
The liver is situated at the interface of the gut and circulation where it acts as a filter for blood-borne and gut-derived microbes and biological molecules, promoting tolerance of non-invasive antigens while driving immune responses against pathogenic ones. Liver resident immune cells such as Kupffer cells (KCs), a subset of macrophages, maintain homeostasis under physiological conditions. However, upon liver injury, these cells and others recruited from circulation participate in the response to injury and the repair of tissue damage. Such response is thus spatially and temporally regulated and implicates interconnected cells of immune and non-immune nature. This review will describe the hepatic immune environment during acute liver injury and the subsequent wound healing process. In its early stages, the wound healing immune response involves a necroinflammatory process characterized by partial depletion of resident KCs and lymphocytes and a significant infiltration of myeloid cells including monocyte-derived macrophages (MoMFs) complemented by a wave of pro-inflammatory mediators. The subsequent repair stage includes restoring KCs, initiating angiogenesis, renewing extracellular matrix and enhancing proliferation/activation of resident parenchymal and mesenchymal cells. This review will focus on the multifaceted role of hepatic macrophages, including KCs and MoMFs, and their spatial distribution and roles during acute liver injury.
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Affiliation(s)
- Ghada S. Hassan
- Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Manuel Flores Molina
- Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada
- Département de microbiologie, infectiologie et immunologie, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
| | - Naglaa H. Shoukry
- Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada
- Département de médecine, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
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Chiew AL, Isbister GK. Advances in the understanding of acetaminophen toxicity mechanisms: a clinical toxicology perspective. Expert Opin Drug Metab Toxicol 2023; 19:601-616. [PMID: 37714812 DOI: 10.1080/17425255.2023.2259787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/02/2023] [Accepted: 09/13/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Acetaminophen (paracetamol) is a commonly used analgesic and antipyretic agent, which is safe in therapeutic doses. Acetaminophen poisoning due to self-harm or repeated supratherapeutic ingestion is a common cause of acute liver injury. Acetylcysteine has been a mainstay of treatment for acetaminophen poisoning for decades and is efficacious if administered early. However, treatment failures occur if administered late, in 'massive' overdoses or in high-risk patients. AREAS COVERED This review provides an overview of the mechanisms of toxicity of acetaminophen poisoning (metabolic and oxidative phase) and how this relates to the assessment and treatment of the acetaminophen poisoned patient. The review focuses on how these advances offer further insight into the utility of novel biomarkers and the role of proposed adjunct treatments. EXPERT OPINION Advances in our understanding of acetaminophen toxicity have allowed the development of novel biomarkers and a better understanding of how adjunct treatments may prevent acetaminophen toxicity. Newly proposed adjunct treatments like fomepizole are being increasingly used without robust clinical trials. Novel biomarkers (not yet clinically available) may provide better assessment of these newly proposed adjunct treatments, particularly in clinical trials. These advances in our understanding of acetaminophen toxicity and liver injury hold promise for improved diagnosis and treatment.
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Affiliation(s)
- Angela L Chiew
- Department of Clinical Toxicology, Prince of Wales Hospital, Randwick, NSW, Australia
- Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Geoffrey K Isbister
- New South Wales Poisons Information Centre, Sydney Children's Hospital, Sydney, New South Wales, Australia
- Clinical Toxicology Research Group, University of Newcastle, Callaghan, NSW, Australia
- Department of Clinical Toxicology, Calvary Mater Newcastle, Waratah, NSW, Australia
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Popiolek I, Hydzik P, Jagielski P, Zrodlowska M, Mystek K, Porebski G. Risk Factors for Hepatotoxicity Due to Paracetamol Overdose in Adults. ACTA ACUST UNITED AC 2021; 57:medicina57080752. [PMID: 34440958 PMCID: PMC8402128 DOI: 10.3390/medicina57080752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 12/26/2022]
Abstract
Background and Objectives: Over-the-counter availability and a good safety profile make paracetamol one of the most common analgesics in developed countries but also the leading cause of liver failure due to overdose. The objectives of the study were to identify modifiable risk factors for severe hepatotoxicity following paracetamol overdose in adults. Materials and Methods: A retrospective cohort study involved the consecutive adult patients hospitalized in a toxicological center over a period of seven years due to paracetamol overdose. Complete medical datasets of laboratory and anamnestic variables were analyzed and validated by means of logistic regression model. Results: A total of 185 patients entered the study, including 25 individuals who developed severe hepatotoxicity (plasma aminotransferases levels above 1000 UI/L) and 31 individuals with mild to moderate liver injury (plasma aminotransferases levels above upper normal range, but below 1000 UI/L). In the univariable analysis, significant hepatotoxicity risk factors were male gender, alcohol abuse, an ingested paracetamol dose, and a timespan from ingestion to hospital admission. The later one was the only significant risk factor in the multivariable model (adjusted odds ratio 1.08; 95% CI: 1.03-1.12). Conclusions: A delay in hospital admission, resulting in a delayed administration of disease-specific treatment outweighs any other known risk factors of paracetamol-induced hepatotoxicity.
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Affiliation(s)
- Iwona Popiolek
- Toxicology Clinical Department, University Hospital in Krakow, Jakubowskiego 2, 30-688 Krakow, Poland; (I.P.); (P.H.)
- Department of Toxicology, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Piotr Hydzik
- Toxicology Clinical Department, University Hospital in Krakow, Jakubowskiego 2, 30-688 Krakow, Poland; (I.P.); (P.H.)
- Department of Toxicology, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Pawel Jagielski
- Department of Nutrition and Drug Research, Faculty of Health Science, Jagiellonian University Medical College, Skawińska 8, 31-066 Krakow, Poland;
| | - Monika Zrodlowska
- Faculty of Medicine, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland; (M.Z.); (K.M.)
| | - Karol Mystek
- Faculty of Medicine, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland; (M.Z.); (K.M.)
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
- Correspondence: ; Tel.: +48-12-424-86-38
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Muller R, Briantais A, Faucher B, Borentain P, Nafati C, Blasco V, Gregoire E, Bernit E, Seguier J, Meunier B, Harlé JR, Ebbo M, Schleinitz N. Acute severe hepatitis in adult-onset Still's disease: case report and comprehensive review of a life-threatening manifestation. Clin Rheumatol 2020; 40:2467-2476. [PMID: 32955629 DOI: 10.1007/s10067-020-05383-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/27/2020] [Accepted: 08/31/2020] [Indexed: 10/23/2022]
Abstract
Acute severe hepatitis is a rare complication of adult-onset Still's disease (AOSD). This condition is poorly characterized. We performed a review of the medical literature to describe clinical, biological, pathological, and treatment characteristics from AOSD patients with acute severe hepatitis. Their characteristics were compared with AOSD patients without severe hepatitis. Twenty-one cases were collected including a new case reported here. Patients with severe hepatitis were mostly young adults with a median age of 28 years (range: 20 to 55 years). Overall, patients with severe hepatitis had less arthritis, macular rash, sore throat, lymphadenopathy, or splenomegaly than patients without severe hepatitis. Cytopenia was more frequent in case of severe hepatitis. Most patients were treated with steroids, and the use of biotherapies has increased over the last decade. Despite treatment, 49% of patients required liver transplantation and 24% died. Key Points • Acute severe hepatitis in adult-onset Still's disease (AOSD) is associated with liver transplantation and/or death in, respectively, 43% and 24% of cases. • Severe hepatitis is the inaugural manifestation of AOSD in half of cases. Diagnosis is difficult when extra-hepatic clinical manifestations are lacking. • The mechanism of hepatic necrosis in AOSD with severe hepatitis is unknown. Liver biopsy is not specific and should not delay treatment initiation.
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Affiliation(s)
- Romain Muller
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Antoine Briantais
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Benoit Faucher
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Patrick Borentain
- Service d'hépato-gastro-entérologie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Cyril Nafati
- Réanimation polyvalente et des pathologies du foie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Valery Blasco
- Réanimation polyvalente et des pathologies du foie, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Emilie Gregoire
- Service de chirurgie digestive, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Emmanuelle Bernit
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Julie Seguier
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Benoit Meunier
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Jean-Robert Harlé
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Mikael Ebbo
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France
| | - Nicolas Schleinitz
- Service de médecine interne, Aix Marseille Université, APHM, Hôpital La Timone, Marseille, France.
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Li R, Hasan N, Armstrong L, Cockings J. Impaired consciousness, hypokalaemia and renal tubular acidosis in sustained Nurofen Plus abuse. BMJ Case Rep 2019; 12:12/11/e231403. [DOI: 10.1136/bcr-2019-231403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Ibuprofen-induced renal tubular acidosis is a rare but important diagnosis which should be considered in patients presenting with hypokalaemia and metabolic acidosis. This case report details the case of a 33-year-old woman presenting with reduced conscious state, metabolic acidosis and profound hypokalaemia without an obvious cause. With correction of the patient’s electrolyte and acid-base disturbance, her conscious state improved allowing disclosure of her use of Nurofen Plus for its euphoric opiate effects. The diagnosis of renal tubular acidosis had been considered and subsequent disclosure of excessive chronic ingestion of ibuprofen suggested this to be the underlying cause. The striking feature of our patient was the insidious development of the problem and delayed accurate drug history. An important safety message arising from our case is the composite risk of dependence on the opiate component of over the counter analgesics, such as Nurofen Plus, and adverse events related to the ibuprofen component.
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Pu S, Liu Q, Li Y, Li R, Wu T, Zhang Z, Huang C, Yang X, He J. Montelukast Prevents Mice Against Acetaminophen-Induced Liver Injury. Front Pharmacol 2019; 10:1070. [PMID: 31620001 PMCID: PMC6759817 DOI: 10.3389/fphar.2019.01070] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/22/2019] [Indexed: 02/05/2023] Open
Abstract
Acetaminophen (APAP) is a widely used over-the-counter antipyretic and analgesic drug. Overdose of APAP is the leading cause of hospital admission for acute liver failure. Montelukast is an antagonist of cysteinyl leukotriene receptor 1 (Cysltr1), which protects from inflammation and oxidative stress. However, the function of montelukast in APAP-induced hepatotoxicity remains unknown. In this study, we examined whether pharmacological inhibition of Cystlr1 could protect mice against APAP-induced hepatic damage. We found that APAP treatment upregulated messenger RNA and protein levels of Cysltr1 both in vitro and in vivo. Pharmacological inhibition of Cysltr1 by montelukast ameliorated APAP-induced acute liver failure. The hepatoprotective effect of montelukast was associated with upregulation of hepatic glutathione/glutathione disulfide level, reduction in c-Jun-NH2-terminal kinase activation and oxidative stress. In mouse primary hepatocytes, inhibition of Cysltr1 by montelukast ameliorated the expression of inflammatory-related genes and APAP-induced cytotoxicity. We conclude that montelukast may be used to treat APAP-induced acute hepatic injury.
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Affiliation(s)
- Shiyun Pu
- Department of Pharmacy, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Qinhui Liu
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Yanping Li
- Laboratory of Clinical Pharmacy and Adverse Drug Reaction, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Rui Li
- Department of Pharmacy, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Tong Wu
- Department of Pharmacy, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Zijing Zhang
- Molecular Medicine Research Center, State Key Laboratory of Biotherapy and Cancer Center, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Cuiyuan Huang
- Department of Pharmacy, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Xuping Yang
- Department of Pharmacy, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
| | - Jinhan He
- Department of Pharmacy, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China.,Laboratory of Clinical Pharmacy and Adverse Drug Reaction, West China Hospital of Sichuan University and Collaborative Innovation Center of Biotherapy, Chengdu, China
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Woodhead K, Foex BA. BET 1: In paracetamol overdose, is oral N-acetylcysteine as effective as intravenous N-acetylcysteine? Emerg Med J 2018; 35:643-645. [PMID: 30249712 DOI: 10.1136/emermed-2018-208093.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A short-cut review was carried out to establish whether oral N-acetylcysteine is as effective as intravenous N-acetylcysteine in the management of paracetamol overdose. Seven studies were directly relevant to the question. The author, year and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that oral N-acetylcysteine is a safe alternative in patients for whom the intravenous route is not an option.
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Affiliation(s)
- Kathryn Woodhead
- University of Manchester and Manchester Royal Infirmary, Manchester, UK
| | - Bernard A Foex
- University of Manchester and Manchester Royal Infirmary, Manchester, UK
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Athersuch TJ, Antoine DJ, Boobis AR, Coen M, Daly AK, Possamai L, Nicholson JK, Wilson ID. Paracetamol metabolism, hepatotoxicity, biomarkers and therapeutic interventions: a perspective. Toxicol Res (Camb) 2018; 7:347-357. [PMID: 30090586 PMCID: PMC6062253 DOI: 10.1039/c7tx00340d] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/07/2018] [Indexed: 12/28/2022] Open
Abstract
After over 60 years of therapeutic use in the UK, paracetamol (acetaminophen, N-acetyl-p-aminophenol, APAP) remains the subject of considerable research into both its mode of action and toxicity. The pharmacological properties of APAP are the focus of some activity, with the role of the metabolite N-arachidonoylaminophenol (AM404) still a topic of debate. However, that the hepatotoxicity of APAP results from the production of the reactive metabolite N-acetyl-p-benzoquinoneimine (NAPQI/NABQI) that can deplete glutathione, react with cellular macromolecules, and initiate cell death, is now beyond dispute. The disruption of cellular pathways that results from the production of NAPQI provides a source of potential biomarkers of the severity of the damage. Research in this area has provided new diagnostic markers such as the microRNA miR-122 as well as mechanistic biomarkers associated with apoptosis, mitochondrial dysfunction, inflammation and tissue regeneration. Additionally, biomarkers of, and systems biology models for, glutathione depletion have been developed. Furthermore, there have been significant advances in determining the role of both the innate immune system and genetic factors that might predispose individuals to APAP-mediated toxicity. This perspective highlights some of the progress in current APAP-related research.
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Affiliation(s)
- Toby J Athersuch
- Division of Computational and Systems Medicine , Department of Surgery and Cancer , Faculty of Medicine , Imperial College London , South Kensington , London SW7 2AZ , UK .
| | - Daniel J Antoine
- MRC Centre for Inflammation Research , The University of Edinburgh , Edinburgh , EH16 4TJ , UK
| | - Alan R Boobis
- Department of Medicine , Imperial College London , London W12 0NN , UK
| | - Muireann Coen
- Division of Computational and Systems Medicine , Department of Surgery and Cancer , Faculty of Medicine , Imperial College London , South Kensington , London SW7 2AZ , UK .
| | - Ann K Daly
- Institute of Cellular Medicine , Newcastle University , Newcastle upon Tyne NE2 4HH , UK
| | - Lucia Possamai
- Department of Hepatology , St Mary's Hospital , Imperial College London , London W2 1NY , UK
| | - Jeremy K Nicholson
- Division of Computational and Systems Medicine , Department of Surgery and Cancer , Faculty of Medicine , Imperial College London , South Kensington , London SW7 2AZ , UK .
| | - Ian D Wilson
- Division of Computational and Systems Medicine , Department of Surgery and Cancer , Faculty of Medicine , Imperial College London , South Kensington , London SW7 2AZ , UK .
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Abstract
BACKGROUND Paracetamol (acetaminophen) is the most widely used non-prescription analgesic in the world. Paracetamol is commonly taken in overdose either deliberately or unintentionally. In high-income countries, paracetamol toxicity is a common cause of acute liver injury. There are various interventions to treat paracetamol poisoning, depending on the clinical status of the person. These interventions include inhibiting the absorption of paracetamol from the gastrointestinal tract (decontamination), removal of paracetamol from the vascular system, and antidotes to prevent the formation of, or to detoxify, metabolites. OBJECTIVES To assess the benefits and harms of interventions for paracetamol overdosage irrespective of the cause of the overdose. SEARCH METHODS We searched The Cochrane Hepato-Biliary Group Controlled Trials Register (January 2017), CENTRAL (2016, Issue 11), MEDLINE (1946 to January 2017), Embase (1974 to January 2017), and Science Citation Index Expanded (1900 to January 2017). We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov database (US National Institute of Health) for any ongoing or completed trials (January 2017). We examined the reference lists of relevant papers identified by the search and other published reviews. SELECTION CRITERIA Randomised clinical trials assessing benefits and harms of interventions in people who have ingested a paracetamol overdose. The interventions could have been gastric lavage, ipecacuanha, or activated charcoal, or various extracorporeal treatments, or antidotes. The interventions could have been compared with placebo, no intervention, or to each other in differing regimens. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included trials. We used fixed-effect and random-effects Peto odds ratios (OR) with 95% confidence intervals (CI) for analysis of the review outcomes. We used the Cochrane 'Risk of bias' tool to assess the risks of bias (i.e. systematic errors leading to overestimation of benefits and underestimation of harms). We used Trial Sequential Analysis to control risks of random errors (i.e. play of chance) and GRADE to assess the quality of the evidence and constructed 'Summary of findings' tables using GRADE software. MAIN RESULTS We identified 11 randomised clinical trials (of which one acetylcysteine trial was abandoned due to low numbers recruited), assessing several different interventions in 700 participants. The variety of interventions studied included decontamination, extracorporeal measures, and antidotes to detoxify paracetamol's toxic metabolite; which included methionine, cysteamine, dimercaprol, or acetylcysteine. There were no randomised clinical trials of agents that inhibit cytochrome P-450 to decrease the activation of the toxic metabolite N-acetyl-p-benzoquinone imine.Of the 11 trials, only two had two common outcomes, and hence, we could only meta-analyse two comparisons. Each of the remaining comparisons included outcome data from one trial only and hence their results are presented as described in the trials. All trial analyses lack power to access efficacy. Furthermore, all the trials were at high risk of bias. Accordingly, the quality of evidence was low or very low for all comparisons. Interventions that prevent absorption, such as gastric lavage, ipecacuanha, or activated charcoal were compared with placebo or no intervention and with each other in one four-armed randomised clinical trial involving 60 participants with an uncertain randomisation procedure and hence very low quality. The trial presented results on lowering plasma paracetamol levels. Activated charcoal seemed to reduce the absorption of paracetamol, but the clinical benefits were unclear. Activated charcoal seemed to have the best risk:benefit ratio among gastric lavage, ipecacuanha, or supportive treatment if given within four hours of ingestion. There seemed to be no difference between gastric lavage and ipecacuanha, but gastric lavage and ipecacuanha seemed more effective than no treatment (very low quality of evidence). Extracorporeal interventions included charcoal haemoperfusion compared with conventional treatment (supportive care including gastric lavage, intravenous fluids, and fresh frozen plasma) in one trial with 16 participants. The mean cumulative amount of paracetamol removed was 1.4 g. One participant from the haemoperfusion group who had ingested 135 g of paracetamol, died. There were no deaths in the conventional treatment group. Accordingly, we found no benefit of charcoal haemoperfusion (very low quality of evidence). Acetylcysteine appeared superior to placebo and had fewer adverse effects when compared with dimercaprol or cysteamine. Acetylcysteine superiority to methionine was unproven. One small trial (low quality evidence) found that acetylcysteine may reduce mortality in people with fulminant hepatic failure (Peto OR 0.29, 95% CI 0.09 to 0.94). The most recent randomised clinical trials studied different acetylcysteine regimens, with the primary outcome being adverse events. It was unclear which acetylcysteine treatment protocol offered the best efficacy, as most trials were underpowered to look at this outcome. One trial showed that a modified 12-hour acetylcysteine regimen with a two-hour acetylcysteine 100 mg/kg bodyweight loading dose was associated with significantly fewer adverse reactions compared with the traditional three-bag 20.25-hour regimen (low quality of evidence). All Trial Sequential Analyses showed lack of sufficient power. Children were not included in the majority of trials. Hence, the evidence pertains only to adults. AUTHORS' CONCLUSIONS These results highlight the paucity of randomised clinical trials comparing different interventions for paracetamol overdose and their routes of administration and the low or very low level quality of the evidence that is available. Evidence from a single trial found activated charcoal seemed the best choice to reduce absorption of paracetamol. Acetylcysteine should be given to people at risk of toxicity including people presenting with liver failure. Further randomised clinical trials with low risk of bias and adequate number of participants are required to determine which regimen results in the fewest adverse effects with the best efficacy. Current management of paracetamol poisoning worldwide involves the administration of intravenous or oral acetylcysteine which is based mainly on observational studies. Results from these observational studies indicate that treatment with acetylcysteine seems to result in a decrease in morbidity and mortality, However, further evidence from randomised clinical trials comparing different treatments are needed.
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Affiliation(s)
- Angela L Chiew
- Prince of Wales HospitalEmergency Department and Clinical Toxicology UnitBarker StreetRandwickNSWAustralia2031
- University of SydneyDepartment of PharmacologyCamperdownNSWAustralia
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Jesper Brok
- RigshospitaletPaediatric Department 4072Blemdagsvej 9CopenhagenDenmark2100 Ø
| | - Nick A Buckley
- University of SydneyDepartment of PharmacologyCamperdownNSWAustralia
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11
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Yarema M, Chopra P, Sivilotti MLA, Johnson D, Nettel-Aguirre A, Bailey B, Victorino C, Gosselin S, Purssell R, Thompson M, Spyker D, Rumack B. Anaphylactoid Reactions to Intravenous N-Acetylcysteine during Treatment for Acetaminophen Poisoning. J Med Toxicol 2018; 14:120-127. [PMID: 29423816 DOI: 10.1007/s13181-018-0653-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/15/2018] [Accepted: 01/18/2018] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Anaphylactoid reactions to intravenous (IV) N-acetylcysteine (NAC) are well-recognized adverse events during treatment for acetaminophen (APAP) poisoning. Uncertainty exists regarding their incidence, severity, risk factors, and management. We sought to determine the incidence, risk factors, and treatment of anaphylactoid reactions to IV NAC in a large, national cohort of patients admitted to hospital for acetaminophen overdose. METHODS This retrospective medical record review included all patients initiated on the 21-h IV NAC protocol for acetaminophen poisoning in 34 Canadian hospitals between February 1980 and November 2005. The primary outcome was any anaphylactoid reaction, defined as cutaneous (urticaria, pruritus, angioedema) or systemic (hypotension, respiratory symptoms). We examined the incidence, severity and timing of these reactions, and their association with patient and overdose characteristics using multivariable analysis. RESULTS An anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses, of which 398 (75.4%) were cutaneous. Five hundred four (95.4%) reactions occurred during the first 5 h. Of 403 patients administered any medication for these reactions, 371 (92%) received an antihistamine. Being female (adjusted OR 1.24 [95%CI 1.08, 1.42]) and having taken a single, acute overdose (1.24 [95%CI 1.10, 1.39]) were each associated with more severe reactions, whereas higher serum APAP concentrations were associated with fewer reactions (0.79 [95%CI 0.68, 0.92]). CONCLUSION Anaphylactoid reactions to the 21-h IV NAC protocol were uncommon and involved primarily cutaneous symptoms. While the protective effects of higher APAP concentrations are of interest in understanding the pathophysiology, none of the associations identified are strong enough to substantially alter the threshold for NAC initiation.
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Affiliation(s)
- Mark Yarema
- Poison and Drug Information Service, Foothills Medical Centre, 1403-29th St NW, Calgary, Alberta, T2N 2T9, Canada. .,Section of Clinical Pharmacology and Toxicology, Alberta Health Services, Calgary, AB, Canada. .,Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada.
| | - Puja Chopra
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine, and of Biomedical and Molecular Sciences, Queen's University, Kingston, ON, Canada.,Ontario Poison Centre, Toronto, ON, Canada
| | - David Johnson
- Poison and Drug Information Service, Foothills Medical Centre, 1403-29th St NW, Calgary, Alberta, T2N 2T9, Canada.,Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Alberto Nettel-Aguirre
- Department of Pediatrics, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.,Alberta Children's Hospital Research Institute for Child and Maternal Health, Calgary, AB, Canada
| | - Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte Justine, Montréal, Quebec, Canada
| | | | | | - Roy Purssell
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Daniel Spyker
- Department of Emergency Medicine, Oregon Health Sciences University, Portland, OR, USA
| | - Barry Rumack
- Department of Pediatrics, University of Colorado School of Medicine, Denver, CO, USA
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12
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Hypoxia-induced reactive oxygen species mediate N-cadherin and SERPINE1 expression, EGFR signalling and motility in MDA-MB-468 breast cancer cells. Sci Rep 2017; 7:15140. [PMID: 29123322 PMCID: PMC5680275 DOI: 10.1038/s41598-017-15474-7] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 10/26/2017] [Indexed: 12/30/2022] Open
Abstract
One of the hallmarks of the tumour microenvironment is hypoxia resulting from increased oxygen consumption by proliferative cancer cells and altered vasculature. Hypoxic tension initiates various cellular signals and can drive epithelial to mesenchymal transition (EMT), a process important in cancer progression. In this study, using the antioxidant N-acetylcysteine (NAC), we show that hypoxia-induced reactive oxygen species (ROS) in MDA-MB-468 breast cancer cells, selectively regulate hypoxia-induced increases in N-cadherin and SERPINE1, two proteins involved in cell adhesion. Treatment of cells with NAC also attenuated hypoxia-mediated activation of EGFR, but did not have any effect on hypoxia-mediated induction of HIF1α. Exogenous hydrogen peroxide phenocopied the effects of hypoxia on N-cadherin and SERPINE1 expression and EGFR activation, suggesting its possible involvement in these hypoxia-mediated events. Reflective of their effect on cell adhesion proteins and EGFR (associated with migratory phenotypes), NAC also reduced cell migration under hypoxic conditions, a crucial event in metastasis. Our findings suggest a selective role for redox signalling in the regulation of specific components of the responses to hypoxia and induction of EMT in breast cancer cells. This study provides new evidence supporting the potential of targeting ROS as a therapeutic strategy for the control of breast cancer metastasis.
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13
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Calvo PL, Tandoi F, Haak TB, Brunati A, Pinon M, Olio DD, Romagnoli R, Spada M. NBAS mutations cause acute liver failure: when acetaminophen is not a culprit. Ital J Pediatr 2017; 43:88. [PMID: 28946922 PMCID: PMC5613325 DOI: 10.1186/s13052-017-0406-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/13/2017] [Indexed: 01/25/2023] Open
Abstract
Background Pediatric acute-liver-failure due to acetaminophen (APAP) administration at therapeutic dosage is rare, while viral infections and metabolic defects are the prevalent causes. Yet, as acetaminophen is routinely used in febrile illnesses, it may be mistakenly held responsible for the acute liver damage. Case presentation An 11 month old boy had been on acetaminophen for 10 days (total dose 720 mg = 72 mg/kg) when he developed acute-liver-failure with encephalopathy. As he rapidly improved on N-acetylcysteine (NAC) infusion, it was concluded that chronic acetaminophen administration in an infant had lead to acute-liver-failure even at therapeutic doses, that N-acetylcysteine infusion had been life-saving and should be immediately started in similar circumstances. The child, however, had two further episodes of acute liver damage over a 34-month period, without having been given acetaminophen, as the parents carefully avoided using it. His clinical, laboratory and radiological findings between the acute episodes were unremarkable. His features and skeletal surveys were not suggestive of a syndromic condition. He then went on to suffer another episode of acute-liver-failure with multi-organ failure, necessitating an urgent liver transplant. All efforts to come to a diagnosis for the causes of his recurrent episodes of liver failure had been unsuccessful, until a biallelic mutation in the NBAS gene was reported to be associated with recurrent acute-liver-failure in children. The boy’s DNA analysis revealed compound heterozygous pathogenic mutations in the NBAS gene. Liver failure episodes in these patients are triggered and worsened by fever, most likely due to thermal susceptibility of hepatocytes, hence APAP, rather than being a culprit, is part of the supportive treatment. Conclusions We suggest that, in acute-liver-failure with a history of acetaminophen exposure at therapeutic dosage, clinicians should not be contented with administering NAC, but should consider an alternative etiology, above all if the episodes are recurrent, and actively start supportive and antipyretic treatment while seeking the advice of a specialist unit.
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Affiliation(s)
- Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia 94, 10126, Torino, Italy.
| | - Francesco Tandoi
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Tobias B Haak
- Institute of Human Genetics, Technische Universität München, 81675, Munich, Germany.,Institute of Human Genetics, Helmholtz Zentrum München, 85764, Neuherberg, Germany
| | - Andrea Brunati
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia 94, 10126, Torino, Italy
| | - Dominic Dell Olio
- Regional Transplant Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Renato Romagnoli
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Marco Spada
- Department of Pediatrics, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
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14
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Mignani S, Bryszewska M, Zablocka M, Klajnert-Maculewicz B, Cladera J, Shcharbin D, Majoral JP. Can dendrimer based nanoparticles fight neurodegenerative diseases? Current situation versus other established approaches. Prog Polym Sci 2017. [DOI: 10.1016/j.progpolymsci.2016.09.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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15
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Rabinowich L, Wendon J, Bernal W, Shibolet O. Clinical management of acute liver failure: Results of an international multi-center survey. World J Gastroenterol 2016; 22:7595-7603. [PMID: 27672280 PMCID: PMC5011673 DOI: 10.3748/wjg.v22.i33.7595] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/03/2016] [Accepted: 03/30/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the practice of caring for acute liver failure (ALF) patients in varying geographic locations and medical centers.
METHODS Members of the European Acute Liver Failure Consortium completed an 88-item questionnaire detailing management of ALF. Responses from 22 transplantation centers in 11 countries were analyzed, treating between 300 and 500 ALF cases and performing over 100 liver transplants (LT) for ALF annually. The questions pertained to details of the institution and their clinical activity, standards of care, referral and admission, ward- based care versus intensive care unit (ICU) as well as questions regarding liver transplantation - including criteria, limitations, and perceived performance. Clinical data was also collected from 13 centres over a 3 mo period.
RESULTS The interval between referral and admission of ALF patients to specialized units was usually less than 24 h and once admitted, treatment was provided by a multidisciplinary team. Principles of care of patients with ALF were similar among centers, particularly in relation to recognition of severity and care of the more critically ill. Centers exhibited similarities in thresholds for ICU admission and management of severe hepatic encephalopathy. Over 80% of centers administered n-acetyl-cysteine to ICU patients for non-paracetamol-related ALF. There was significant divergence in the use of prophylactic antibiotics and anti-fungals, lactulose, nutritional support and imaging investigations in admitted patients and in the monitoring and treatment of intra-cranial pressure (ICP). ICP monitoring was employed in 12 centers, with the most common indications being papilledema and renal failure. Most patients listed for transplantation underwent surgery within an average waiting time of 1-2 d. Over a period of 3 mo clinical data from 85 ALF patients was collected. Overall patient survival at 90-d was 76%. Thirty six percent of patients underwent emergency LT, with a 90% post transplant survival to hospital discharge, 42% survived with medical management alone.
CONCLUSION Alongside similarities in principles of care of ALF patients, major areas of divergence were present in key areas of diagnosis, monitoring, treatment and decision to transplant.
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16
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Skvarc DR, Dean OM, Byrne LK, Gray LJ, Ives K, Lane SE, Lewis M, Osborne C, Page R, Stupart D, Turner A, Berk M, Marriott AJ. The Post-Anaesthesia N-acetylcysteine Cognitive Evaluation (PANACEA) trial: study protocol for a randomised controlled trial. Trials 2016; 17:395. [PMID: 27502769 PMCID: PMC4977889 DOI: 10.1186/s13063-016-1529-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 07/26/2016] [Indexed: 12/18/2022] Open
Abstract
Background Some degree of cognitive decline after surgery occurs in as many as one quarter of elderly surgical patients, and this decline is associated with increased morbidity and mortality. Cognition may be affected across a range of domains, including memory, psychomotor skills, and executive function. Whilst the exact mechanisms of cognitive change after surgery are not precisely known, oxidative stress and subsequent neuroinflammation have been implicated. N-acetylcysteine (NAC) acts via multiple interrelated mechanisms to influence oxidative homeostasis, neuronal transmission, and inflammation. NAC has been shown to reduce oxidative stress and inflammation in both human and animal models. There is clinical evidence to suggest that NAC may be beneficial in preventing the cognitive decline associated with both acute physiological insults and dementia-related disorders. To date, no trials have examined perioperative NAC as a potential moderator of postoperative cognitive changes in the noncardiac surgery setting. Methods and design This is a single-centre, randomised, double-blind, placebo-controlled clinical trial, with a between-group, repeated-measures, longitudinal design. The study will recruit 370 noncardiac surgical patients at the University Hospital Geelong, aged 60 years or older. Participants are randomly assigned to receive either NAC or placebo (1:1 ratio), and groups are stratified by age and surgery type. Participants undergo a series of neuropsychological tests prior to surgery, 7 days, 3 months, and 12 months post surgery. It is hypothesised that the perioperative administration of NAC will reduce the degree of postoperative cognitive changes at early and long-term follow-up, as measured by changes on individual measures of the neurocognitive battery, when compared with placebo. Serum samples are taken on the day of surgery and on day 2 post surgery to quantitate any changes in levels of biomarkers of inflammation and oxidative stress. Discussion The PANACEA trial aims to examine the potential efficacy of perioperative NAC to reduce the severity of postoperative cognitive dysfunction in an elderly, noncardiac surgery population. This is an entirely novel approach to the prevention of postoperative cognitive dysfunction and will have high impact and translatable outcomes if NAC is found to be beneficial. Trial registration The PANACEA trial has been registered with the Therapeutic Goods Administration, and the Australian New Zealand Clinical Trials Registry: ACTRN12614000411640; registered on 15 April 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1529-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David R Skvarc
- School of Psychology, Deakin University, 221 Burwood Highway, Burwood, 3215, VIC, Australia.,Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Olivia M Dean
- Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Linda K Byrne
- School of Psychology, Deakin University, 221 Burwood Highway, Burwood, 3215, VIC, Australia
| | - Laura J Gray
- School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Kathryn Ives
- Department of Anaesthesia, Perioperative Medicine and Pain Management, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Stephen E Lane
- School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,Biostatistics Unit, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Matthew Lewis
- Aged Psychiatry Service, Caulfield Hospital, Alfred Health, 260 Kooyong Road, Caulfield, 3162, Victoria, Australia
| | - Cameron Osborne
- Department of Anaesthesia, Perioperative Medicine and Pain Management, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Richard Page
- School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,Barwon Orthopaedic Research Unit, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Douglas Stupart
- Department of General Surgery, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia
| | - Alyna Turner
- Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Michael Berk
- Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia
| | - Andrew J Marriott
- Department of Anaesthesia, Perioperative Medicine and Pain Management, Barwon Health, Bellarine Street, Geelong, 3220, VIC, Australia. .,Innovations in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, Deakin University/Barwon Health Clinical School, Pigdons Road, Waurn Ponds, 3216, VIC, Australia. .,School of Medicine, Deakin University, Pigdons Road, Waurn Ponds, 3216, VIC, Australia.
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17
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Nayyer NV, Byers J, Marney C. Identifying adults at risk of paracetamol toxicity in the acute dental setting: development of a clinical algorithm. Br Dent J 2016; 216:229-35. [PMID: 24603244 DOI: 10.1038/sj.bdj.2014.146] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/01/2013] [Indexed: 11/09/2022]
Abstract
Paracetamol is widely used and effective for the management of dental pain in the UK. Acute dental pain is a recognised precipitant of unintentional paracetamol overdose and in a small but significant number of cases this results in hepatotoxicity. Patients' understanding of the risks of excess paracetamol ingestion remains poor and risk of over-medication before presentation is increased due to a variety of factors including dental anxiety and fragmented provision of dental emergency services. Early recognition of overdose is crucial to preventing significant hepatotoxicity and death. Dentists have a role to play in recognising unintentional overdose cases and directing patients timeously to appropriate medical care. Guidelines on the treatment of paracetamol toxicity are readily available but our data suggests some dental settings may present a weak link in the care pathway and overdose may not be readily recognised. We have developed an algorithm and training package targeted at dentists in the acute dental setting with the aim of improving recognition of paracetamol toxicity in adults and directing onward referral appropriately. This paper also revises the key pharmacokinetics and pharmacodynamics of paracetamol and is intended to raise awareness of issues of toxicity for dentists.
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Affiliation(s)
- N V Nayyer
- Department of Oral Surgery, Dundee Dental Hospital, 2 Park Place, Dundee, DD1 4HN
| | - J Byers
- Department of Oral Surgery and Oral Medicine, Glasgow Dental Hospital, 378 Sauchiehall Street, Glasgow, G2 3JZ, Scotland
| | - C Marney
- Department of Oral Surgery and Oral Medicine, Glasgow Dental Hospital, 378 Sauchiehall Street, Glasgow, G2 3JZ, Scotland
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18
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Chughlay MF, Kramer N, Spearman CW, Werfalli M, Cohen K. N-acetylcysteine for non-paracetamol drug-induced liver injury: a systematic review. Br J Clin Pharmacol 2016; 81:1021-9. [PMID: 26757427 DOI: 10.1111/bcp.12880] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/22/2015] [Accepted: 01/01/2016] [Indexed: 01/08/2023] Open
Abstract
AIMS N-acetylcysteine (NAC) may be useful in the management of non-paracetamol drug-induced liver injury (DILI). Our objective was to review systematically evidence for the use of NAC as a therapeutic option for non-paracetamol DILI. METHODS We searched for randomized controlled trials (RCTs) and prospective cohort studies. We searched several bibliographic databases, grey literature sources, conference proceedings and ongoing trials. Our pre-specified primary outcomes were all cause and DILI related mortality, time to normalization of liver biochemistry and adverse events. Secondary outcomes were proportion receiving liver transplant, time to transplantation, transplant-free survival and hospitalization duration. RESULTS We identified one RCT of NAC vs. placebo in patients with non-paracetamol acute liver failure. There was no difference in the primary outcomes of overall survival at 3 weeks between NAC [70%, 95% confidence interval (CI) = 60%, 81%, n = 81] and placebo (66%, 95% CI = 56%, 77%, n = 92). NAC significantly improved the secondary outcomes of transplant-free survival compared with placebo: 40% NAC (95% CI = 28%, 51%) vs. 27% placebo (95% CI = 18%, 37%). A subgroup analysis according to aetiology found improved transplant-free survival in patients with non-paracetamol DILI, NAC (58%, n = 19) vs. placebo (27%, n = 26), odds ratio (OR) 0.27 (95% CI = 0.076, 0.942). Overall survival was similar, NAC (79%) vs. placebo (65%);, OR 0.50 (95% CI = 0.13, 1.98). CONCLUSION Current available evidence is limited and does not allow for any firm conclusions to be made regarding the role of NAC in non-paracetamol DILI. We therefore highlight the need for further research in this area.
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Affiliation(s)
- Mohamed Farouk Chughlay
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town
| | - Nicole Kramer
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town
| | - Mahmoud Werfalli
- Division of Endocrinology and Diabetes, Chronic Disease Initiative in Africa (CDIA) Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town
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19
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Awodele O, Yemitan O, Ise PU, Ikumawoyi VO. Modulatory potentials of aqueous leaf and unripe fruit extracts of Carica papaya Linn. (Caricaceae) against carbon tetrachloride and acetaminophen-induced hepatotoxicity in rats. JOURNAL OF COMPLEMENTARY MEDICINE RESEARCH 2016; 5:27-35. [PMID: 27069723 PMCID: PMC4805144 DOI: 10.5455/jice.20160124113528] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Accepted: 01/18/2016] [Indexed: 12/21/2022]
Abstract
Introduction: Carica papaya Linn is used in a traditional medicine for hepatobiliary disorders. This study investigated the hepatomodulatory effects of aqueous extracts of C. papaya leaf (CPL) and unripe fruit (CPF) at doses of 100 and 300 mg/kg on carbon tetrachloride (CCl4) and acetaminophen (ACM)-induced liver toxicities in rats. Materials and Methods: Rats were administered CCl4 (3 ml/kg in olive oil, i.p.) followed by oral administration of CPL and CPF at 2, 6 and 10 h intervals. The ACM model proceeded with the same method but inclusive of animals treated with N-acetyl cysteine (3 ml/kg i.p). At the end of the study, serum levels of liver biomarkers and antioxidant enzymes were assessed and histology of the liver tissues determined. Results: There was a significant (P < 0.05) reduction in CCl4 and ACM-induced increases in serum levels of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase and direct bilirubin at 100 and 300 mg/kg, respectively. The levels of catalase (CAT), superoxide dismutase and reduced GSH were decreased in both models with corresponding significantly (P < 0.05) elevated level of malondialdehyde. However, these antioxidant enzymes were significantly (P < 0.05) increased in CPL and CPF-treated rats. Histopathological assessment of the liver confirmed the protective effects of CPL and CPF on CCl4 and ACM-induced hepatic damage evidenced by the normal presentation of liver tissue architecture. Conclusion: These results indicate that aqueous extracts of C. papaya may be useful in preventing CCl4 and ACM-induced liver toxicities.
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Affiliation(s)
- Olufunsho Awodele
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Omoniyi Yemitan
- Department of Pharmacology, College of Medicine, Lagos State University, Lagos, Nigeria
| | - Peter Uduak Ise
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Victor Olabowale Ikumawoyi
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine, University of Lagos, Lagos, Nigeria
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Mund ME, Quarcoo D, Gyo C, Brüggmann D, Groneberg DA. Paracetamol as a toxic substance for children: aspects of legislation in selected countries. J Occup Med Toxicol 2015; 10:43. [PMID: 26664414 PMCID: PMC4674926 DOI: 10.1186/s12995-015-0084-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/22/2015] [Indexed: 12/21/2022] Open
Abstract
Paracetamol is used widely in pediatrics because it has a high drug safety when used in therapeutic dosages. In case of overdose the majority of paracetamol is metabolized to N-acetyl-p-benzoquinone imine (NAPQI), which is responsible for the severe toxic effects. The covalent connection between NAPQI and hepatic proteins leads to hepatocellular damage and possibly to severe liver failure. The antidote for paracetamol is N-acetylcysteine (NAC). It is a precursor of glutathione and aids to fill glutathione stores. The Rumack-Matthew nomogram should be used to decide on antidote treatment. Pediatric drug metabolism differs from adult metabolism. Children have a larger liver size compared to their body weight than adults, resulting in a higher metabolism rate. Young children seem to be less sensitive to acute intoxication than adults. One hypothesis to explain the lower rate refers to the larger liver size. The acute toxic dosage for children is more than 200 mg/kg body weight. There seems to be a global increase in accidental pediatric paracetamol overdose. Governmental websites of various European Union (EU) countries were searched for legal information on paracetamol availability in pharmacies and non-pharmacy stores. Various EU countries permit prescription-free sales of paracetamol in pharmacies and non-pharmacy stores. In Sweden paracetamol 500 mg may be sold in both pharmacies and non-pharmacies in a maximum pack size of 20 units. In the United Kingdom (UK) paracetamol 500 mg is listed in the general sales list with a maximum pack size of 30 effervescent tablets or 16 tablets. In Ireland paracetamol 500 mg may be sold in a maximum pack size of 12 units in a non-pharmacy. In the Netherlands paracetamol 500 mg is legal to be sold in a maximum pack size of 50 units in a drug store and with a maximum of 20 units in any other non-pharmacy. Several countries in the European Union are permitted to offer paracetamol prescription-free in pharmacies and non-pharmacy stores without legal guidance on the storage position within the store. Further research is needed to investigate whether paracetamol is located directly accessible to young children within the stores in EU countries which permit prescription-free sales of paracetamol.
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Affiliation(s)
- Menen E Mund
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany
| | - David Quarcoo
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany
| | - Christoph Gyo
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany
| | - Dörthe Brüggmann
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany ; Department of Obstetrics and Gynecology, Keck School of Medicine of USC, Los Angeles, California USA
| | - David A Groneberg
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany
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21
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Nance E, Porambo M, Zhang F, Mishra MK, Buelow M, Getzenberg R, Johnston M, Kannan RM, Fatemi A, Kannan S. Systemic dendrimer-drug treatment of ischemia-induced neonatal white matter injury. J Control Release 2015; 214:112-20. [PMID: 26184052 PMCID: PMC4732874 DOI: 10.1016/j.jconrel.2015.07.009] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 06/29/2015] [Accepted: 07/06/2015] [Indexed: 01/09/2023]
Abstract
Extreme prematurity is a major risk factor for perinatal and neonatal brain injury, and can lead to white matter injury that is a precursor for a number of neurological diseases, including cerebral palsy (CP) and autism. Neuroinflammation, mediated by activated microglia and astrocytes, is implicated in the pathogenesis of neonatal brain injury. Therefore, targeted drug delivery to attenuate neuroinflammation may greatly improve therapeutic outcomes in models of perinatal white matter injury. In this work, we use a mouse model of ischemia-induced neonatal white matter injury to study the biodistribution of generation 4, hydroxyl-functionalized polyamidoamine dendrimers. Following systemic administration of the Cy5-labeled dendrimer (D-Cy5), we demonstrate dendrimer uptake in cells involved in ischemic injury, and in ongoing inflammation, leading to secondary injury. The sub-acute response to injury is driven by astrocytes. Within five days of injury, microglial proliferation and migration occurs, along with limited differentiation of oligodendrocytes and oligodendrocyte death. From one day to five days after injury, a shift in dendrimer co-localization occurred. Initially, dendrimer predominantly co-localized with astrocytes, with a subsequent shift towards microglia. Co-localization with oligodendrocytes reduced over the same time period, demonstrating a region-specific uptake based on the progression of the injury. We further show that systemic administration of a single dose of dendrimer-N-acetyl cysteine conjugate (D-NAC) at either sub-acute or delayed time points after injury results in sustained attenuation of the 'detrimental' pro-inflammatory response up to 9days after injury, while not impacting the 'favorable' anti-inflammatory response. The D-NAC therapy also led to improvement in myelination, suggesting reduced white matter injury. Demonstration of treatment efficacy at later time points in the postnatal period provides a greater understanding of how microglial activation and chronic inflammation can be targeted to treat neonatal brain injury. Importantly, it may also provide a longer therapeutic window.
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Affiliation(s)
- Elizabeth Nance
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States; Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, United States
| | - Michael Porambo
- Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD 21205, United States
| | - Fan Zhang
- Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, United States; Department of Materials Science and Engineering, Johns Hopkins University, Baltimore, MD 21218, United States
| | - Manoj K Mishra
- Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, United States; Ophthalmology, Wilmer Eye Institute at Johns Hopkins School of Medicine, 21205, United States
| | - Markus Buelow
- Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD 21205, United States
| | - Rachel Getzenberg
- Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD 21205, United States
| | - Michael Johnston
- Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD 21205, United States; Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
| | - Rangaramanujam M Kannan
- Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, United States; Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD 21205, United States; Ophthalmology, Wilmer Eye Institute at Johns Hopkins School of Medicine, 21205, United States
| | - Ali Fatemi
- Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD 21205, United States; Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD 21205, United States
| | - Sujatha Kannan
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, United States; Center for Nanomedicine, Johns Hopkins University School of Medicine, Baltimore, MD21205, United States; Kennedy Krieger Institute, Johns Hopkins University, Baltimore, MD 21205, United States.
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22
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Chughlay MF, Kramer N, Werfalli M, Spearman W, Engel ME, Cohen K. N-acetylcysteine for non-paracetamol drug-induced liver injury: a systematic review protocol. Syst Rev 2015; 4:84. [PMID: 26066646 PMCID: PMC4470061 DOI: 10.1186/s13643-015-0075-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 06/05/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Drug-induced liver injury (DILI) refers to acute or chronic liver injury that may occur as a consequence of using drugs and herbal or dietary supplements. Specific therapies for DILI are limited. There is considerable evidence for efficacy and safety of N-acetylcysteine (NAC) in management of paracetamol-induced liver injury. More recently, research has explored the use of NAC in non-paracetamol drug-induced liver injury. It is important to summarise the evidence of NAC for non-paracetamol DILI to determine if NAC may be considered a therapeutic option in this condition. METHODS/DESIGN We will conduct a systematic review of the benefit and harm of NAC in non-paracetamol drug-induced liver injury. Primary and secondary outcomes of interest are pre-specified. Primary outcomes include all-cause mortality, mortality due to DILI, time to normalisation of liver biochemistry (e.g. return of alanine transaminase to <100 U/l and/or international normalized ratio (INR) <1.5) and adverse events. Secondary outcomes include transplantation rate, time to transplantation, transplant-free survival and duration of hospitalisation. We will include randomized controlled trials (RCTs) and prospective cohort studies. RCTs will contribute to the evaluation of safety and efficacy of NAC, whereas, the cohort studies will contribute exclusively to the evaluation of safety. We will search several bibliographic databases (including PubMed, Scopus, CINAHL, CENTRAL), grey literature sources, conference proceedings and ongoing trials. Following data extraction and assessment of the risk of bias, we will conduct a meta-analysis if feasible, as well as subgroup analyses. We will assess and explore clinical and statistical heterogeneity. DISCUSSION The aim of this review is to provide evidence on the effectiveness and safety of NAC in non-paracetamol DILI. We anticipate that the results could aid health care practitioners, researchers and policymakers in the decision-making regarding the use of NAC in patients with non-paracetamol DILI. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42014008771.
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Affiliation(s)
- Mohamed Farouk Chughlay
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| | - Nicole Kramer
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| | - Mahmoud Werfalli
- Division of Endocrinology and Diabetes, Chronic Disease Initiative in Africa (CDIA) Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| | - Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| | - Mark Emmanuel Engel
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa.
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa.
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Gulmez SE, Larrey D, Pageaux GP, Bernuau J, Bissoli F, Horsmans Y, Thorburn D, McCormick PA, Stricker B, Toussi M, Lignot-Maleyran S, Micon S, Hamoud F, Lassalle R, Jové J, Blin P, Moore N. Liver transplant associated with paracetamol overdose: results from the seven-country SALT study. Br J Clin Pharmacol 2015; 80:599-606. [PMID: 26017643 DOI: 10.1111/bcp.12635] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 02/24/2015] [Accepted: 03/03/2015] [Indexed: 02/05/2023] Open
Abstract
AIMS Acute drug overdose, especially with paracetamol, may cause acute liver failure leading to registration for transplantation (ALFT). Population statistics and between-country differences for ALFT related to overdose have been poorly described. The aim of the present study was to evaluate overdose ALFT in the multi-country Study of Acute Liver Transplantation (SALT). METHODS All adult overdose-related ALFT, with or without suicidal intent, in France, Greece, Ireland, Italy, the Netherlands, Portugal and the UK between 2005 and 2007 were identified from liver transplant registries and hospital records. These were compared with whole-country and per capita use of paracetamol. RESULTS Six hundred cases of ALFT were identified in 52 of 57 eligible transplant centres, of which 114 involved overdose (72 intentional, 10 non-intentional, 32 uncertain). Overdose represented 20% of all-cause ALFT: Ireland 52%, UK 28%, France 18%, the Netherlands 8%, and Italy 1%. Overdose ALFT were mostly females (61%), mean age 33.6 ± 10.9 years. A total of 111 (97%) of the overdoses involved paracetamol. Event rates ranged from one ALFT for 20.7 tons of paracetamol in Ireland, to one for 1074 tons in Italy and one case in 60 million inhabitants over 3 years in Italy to one case in 286 000 inhabitants per year in Ireland. Per-country event rates for non-overdose ALFT exposed to paracetamol were between 2.5 and 4.0 per million treatment-years sold. CONCLUSIONS Paracetamol overdose was found to represent one-sixth of all-cause ALFT. There was a 50-fold difference in Europe in the rates of paracetamol overdose ALFT, and a 200-fold difference per million inhabitants.
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Affiliation(s)
- Sinem Ezgi Gulmez
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | | | | | | | - Franco Bissoli
- Department of Internal Medicine, Clinica San Gaudenzio, Novara, Italy
| | - Yves Horsmans
- Department of Gastroenterology, Louvain Catholic University, Louvain, Belgium
| | | | - P Aiden McCormick
- Liver Unit, St Vincent's University Hospital and University College Dublin, Dublin, Ireland
| | - Bruno Stricker
- Department of Epidemiology, Erasmus University, Rotterdam, Netherlands
| | | | | | - Sophie Micon
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Fatima Hamoud
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Régis Lassalle
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Jérémy Jové
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Patrick Blin
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
| | - Nicholas Moore
- CIC Bordeaux CIC1401 Pharmaco-épidémiologie, Université de Bordeaux, F-33076, Bordeaux, France
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24
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Hepatotoxicity induced by acute and chronic paracetamol overdose in adults. Where do we stand? Regul Toxicol Pharmacol 2015; 72:370-8. [PMID: 25985715 DOI: 10.1016/j.yrtph.2015.05.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 05/10/2015] [Accepted: 05/11/2015] [Indexed: 12/24/2022]
Abstract
Paracetamol (Acetaminophen) poisoning data can reveal the potential deficiencies of paracetamol poisoning management guidelines. We conducted a retrospective cohort study of patients >18years who were attended in the emergency department (ED) of a Spanish tertiary hospital, from 2005 to 2010 for suspected paracetamol overdose and who had measurable paracetamol concentrations. 208 patients suspected of paracetamol poisoning were identified. The annual incidence in the ED increased from 2.0 (95%-CI: 0.2-7.2) cases per 10,000 patients in 2005 to 3.4 (95%-CI: 1.1-8.8) in 2010. Only 7 of 98 patients (7.14%) with acute poisoning at toxic doses showed hepatotoxicity signs, 4 (57.1%) of whom presented acute liver failure (ALF) criteria, while 8 of 10 patients (80%) with chronic paracetamol poisoning at toxic doses presented hepatotoxicity and 3 (37.5%) with ALF criteria. The time required to find medical care was 9.0h for acute poisoning and 49.6h for chronic poisoning (p<0.001). We conclude that the incidence of suspected cases of paracetamol poisoning at our hospital is increasing. The majority of toxicity cases, including ALF, associated with the ingestion of paracetamol were due to chronic poisoning. This finding constitutes an important warning regarding paracetamol chronic poisoning, and clinicians should have a higher index of clinical suspicion for this entity.
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25
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Messerer B, Grögl G, Stromer W, Jaksch W. [Pediatric perioperative systemic pain therapy: Austrian interdisciplinary recommendations on pediatric perioperative pain management]. Schmerz 2015; 28:43-64. [PMID: 24550026 DOI: 10.1007/s00482-013-1384-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Many analgesics used in adult medicine are not licensed for pediatric use. Licensing limitations do not, however, justify that children are deprived of a sufficient pain therapy particularly in perioperative pain therapy. The treatment is principally oriented to the strength of the pain. Due to the degree of pain caused, intramuscular and subcutaneous injections should be avoided generally. NON-OPIOIDS The basis of systemic pain therapy for children are non-opioids and primarily non-steroidal anti-inflammatory drugs (NSAIDs). They should be used prophylactically. The NSAIDs are clearly more effective than paracetamol for acute posttraumatic and postoperative pain and additionally allow economization of opioids. Severe side effects are rare in children but administration should be carefully considered especially in cases of hepatic and renal dysfunction or coagulation disorders. Paracetamol should only be taken in pregnancy and by children when there are appropriate indications because a possible causal connection with bronchial asthma exists. To ensure a safe dosing the age, body weight, duration of therapy, maximum daily dose and dosing intervals must be taken into account. Dipyrone is used in children for treatment of visceral pain and cholic. According to the current state of knowledge the rare but severe side effect of agranulocytosis does not justify a general rejection for short-term perioperative administration. OPIOIDS In cases of insufficient analgesia with non-opioid analgesics, the complementary use of opioids is also appropriate for children of all age groups. They are the medication of choice for episodes of medium to strong pain and are administered in a titrated form oriented to effectiveness. If severe pain is expected to last for more than 24 h, patient-controlled anesthesia should be implemented but requires a comprehensive surveillance by nursing personnel. KETAMINE Ketamine is used as an adjuvant in postoperative pain therapy and is recommended for use in pediatric sedation and analgosedation.
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Affiliation(s)
- B Messerer
- Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinische Universität Graz, LKH-Universitätsklinikum Graz, Auenbruggerplatz 29, 8036, Graz, Österreich,
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26
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Mahmoudi GA, Astaraki P, Mohtashami AZ, Ahadi M. N-acetylcysteine overdose after acetaminophen poisoning. Int Med Case Rep J 2015; 8:65-9. [PMID: 25767408 PMCID: PMC4354467 DOI: 10.2147/imcrj.s74563] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
N-acetylcysteine (NAC) is used widely and effectively in oral and intravenous forms as a specific antidote for acetaminophen poisoning. Here we report a rare case of iatrogenic NAC overdose following an error in preparation of the solution, and describe its clinical symptoms. Laboratory results and are presented and examined. A 23-year-old alert female patient weighing 65 kg presented to the emergency ward with weakness, lethargy, extreme fatigue, nausea, and dizziness. She had normal arterial blood gas and vital signs. An excessive dosage of NAC over a short period of time can lead to hemolysis, thrombocytopenia, and acute renal failure in patients with normal glucose-6-phosphate dehydrogenase, and finally to death. Considering the similarity between some of the clinical symptoms of acetaminophen overdose and NAC overdose, it is vitally important for the administration phases and checking of the patient’s symptoms to be carried out attentively and cautiously.
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Affiliation(s)
- Ghafar Ali Mahmoudi
- Faculty of Medicine, Department of Internal Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Peyman Astaraki
- Faculty of Medicine, Department of Internal Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Azita Zafar Mohtashami
- Faculty of Medicine, Department of Internal Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Maryam Ahadi
- Legal Medicine Research Center of Lorestan, Khorramabad, Iran
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Affiliation(s)
| | - Estabrak Jiad
- Senior House Officer in Stroke Medicine in the Department of Stroke Medicine, National Hospital for Neurology and Neurosurgery, London
| | - Jacob F de Wolff
- Consultant Acute Physician in the Department of Acute Medicine, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ
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28
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Bhat S, Kenchetty KP. N-acetyl cysteine in the management of rodenticide consumption - life saving? J Clin Diagn Res 2015; 9:OC10-3. [PMID: 25738016 DOI: 10.7860/jcdr/2015/11484.5455] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 11/25/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND AIM OF STUDY Rodenticide is a commonly ingested poison in India. Many rodenticides contain hepatotoxic agents and can cause acute liver failure (ALF). There is no antidote for rodenticide poison, and consumption is often fatal. The Role of N acetyl cysteine (NAC) in acetaminophen induced ALF is well established. Additionally some studies have shown that it may be useful in non-acetaminophen induced ALF also. Cases with ALF secondary to suicidal rodenticide consumption have been reported, and some reports show that NAC is beneficial in these cases. Our study was a retrospective analysis of patients admitted with rodenticide consumption, comparing outcomes in those receiving standard of care management and those who were treated with NAC also. MATERIALS AND METHODS Case sheets of all inpatients of a tertiary medical college hospital between January 2010 and December 2012 admitted with an alleged history of rodenticide consumption were surveyed and data was extracted and analysed. STATISTICAL ANALYSIS Patients were analysed with respect to age, sex, mode of presentation, interval between consumption of rodenticide and starting NAC; the outcome in patients treated with acetylcysteine was compared to outcomes in those not treated with acetylcysteine RESULTS A total of 100 patients were studied out of which 18 died. Sixteen of the deaths were in patients who had not been treated with NAC. We found that patients who had received NAC had lower mortality, lower peak values of AST/ALT, and shorter hospital stay. CONCLUSION NAC may have a role in the management of ALF associated with rodenticide consumption.
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Affiliation(s)
- Smitha Bhat
- Professor, Department of Medicine, Father Muller Medical College , Mangalore, India
| | - Kumar P Kenchetty
- Post Graduate Resident, Department of Medicine, Father Muller Medical College , Mangalore, India
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Descatha A. The physician, the patient and the student: a 'win-win-win' process in the outpatient clinic. Br J Hosp Med (Lond) 2014; 75:716. [PMID: 25488540 DOI: 10.12968/hmed.2014.75.12.716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alexis Descatha
- Head, Occupational Health Unit, CHU Poincaré, 92380 Garches, France
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30
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Bateman DN, Dear JW, Thanacoody HKR, Thomas SHL, Eddleston M, Sandilands EA, Coyle J, Cooper JG, Rodriguez A, Butcher I, Lewis SC, Vliegenthart ADB, Veiraiah A, Webb DJ, Gray A. Reduction of adverse effects from intravenous acetylcysteine treatment for paracetamol poisoning: a randomised controlled trial. Lancet 2014; 383:697-704. [PMID: 24290406 DOI: 10.1016/s0140-6736(13)62062-0] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Paracetamol poisoning is common worldwide. It is treated with intravenous acetylcysteine, but the standard regimen is complex and associated with frequent adverse effects related to concentration, which can cause treatment interruption. We aimed to ascertain whether adverse effects could be reduced with either a shorter modified acetylcysteine schedule, antiemetic pretreatment, or both. METHODS We undertook a double-blind, randomised factorial study at three UK hospitals, between Sept 6, 2010, and Dec 31, 2012. We randomly allocated patients with acute paracetamol overdose to either the standard intravenous acetylcysteine regimen (duration 20·25 h) or a shorter (12 h) modified protocol, with or without intravenous ondansetron pretreatment (4 mg). Masking was achieved by infusion of 5% dextrose (during acetylcysteine delivery) or saline (for antiemetic pretreatment). Randomisation was done via the internet and included a minimisation procedure by prognostic factors. The primary outcome was absence of vomiting, retching, or need for rescue antiemetic treatment at 2 h. Prespecified secondary outcomes included a greater than 50% increase in alanine aminotransferase activity over the admission value. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov (identifier NCT01050270). FINDINGS Of 222 patients who underwent randomisation, 217 were assessable 2 h after the start of acetylcysteine treatment. Vomiting, retching, or need for rescue antiemetic treatment at 2 h was reported in 39 of 108 patients assigned to the shorter modified protocol compared with 71 of 109 allocated to the standard acetylcysteine regimen (adjusted odds ratio 0·26, 97·5% CI 0·13-0·52; p<0·0001), and in 45 of 109 patients who received ondansetron compared with 65 of 108 allocated placebo (0·41, 0·20-0·80; p=0·003). Severe anaphylactoid reactions were recorded in five patients assigned to the shorter modified acetylcysteine regimen versus 31 who were allocated to the standard protocol (adjusted common odds ratio 0·23, 97·5% CI 0·12-0·43; p<0·0001). The proportion of patients with a 50% increase in alanine aminotransferase activity did not differ between the standard (9/110) and shorter modified (13/112) regimens (adjusted odds ratio 0·60, 97·5% CI 0·20-1·83); however, the proportion was higher with ondansetron (16/111) than with placebo (6/111; 3·30, 1·01-10·72; p=0·024). INTERPRETATION In patients with paracetamol poisoning, a 12 h modified acetylcysteine regimen resulted in less vomiting, fewer anaphylactoid reactions, and reduced need for treatment interruption. This study was not powered to detect non-inferiority of the shorter protocol versus the standard approach; therefore, further research is needed to confirm the efficacy of the 12 h modified acetylcysteine regimen. FUNDING Chief Scientist Office of the Scottish Government.
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Affiliation(s)
- D Nicholas Bateman
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - James W Dear
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK; British Heart Foundation Centre for Cardiovascular Science, Edinburgh University, Edinburgh, UK
| | - H K Ruben Thanacoody
- Institute of Cellular Medicine, Newcastle University, and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Simon H L Thomas
- Institute of Cellular Medicine, Newcastle University, and Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michael Eddleston
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK; British Heart Foundation Centre for Cardiovascular Science, Edinburgh University, Edinburgh, UK
| | - Euan A Sandilands
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Judy Coyle
- Emergency Medicine Research Group, Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jamie G Cooper
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Aryelly Rodriguez
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Isabella Butcher
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Steff C Lewis
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Aravindan Veiraiah
- National Poisons Information Service, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David J Webb
- British Heart Foundation Centre for Cardiovascular Science, Edinburgh University, Edinburgh, UK
| | - Alasdair Gray
- Emergency Medicine Research Group, Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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Abstract
Acetaminophen (APAP) is the leading worldwide cause of drug overdose and acute liver failure (ALF). Single overdose ingestion and therapeutic misadventure may cause hepatotoxicity. Several factors, such as concomitant alcohol use or abuse, concurrent medications, genetic factors, and nutritional status, can influence the susceptibility and severity of APAP hepatotoxicity. Early manifestations of APAP hepatotoxicity are nonspecific, but require prompt recognition by physicians. Patients with repeated overdose tend to present late, and in such hepatotoxicity may have already evolved. N-acetylcysteine is a very effective antidote when giving within 8 hours, and is also recommended after a presentation of hepatotoxicity and ALF. The prognosis of patients with APAP-induced ALF is better than other causes of ALF. Liver transplantation should be offered to those who are unlikely to survive.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Ratchathewi, Bangkok 10400, Thailand
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Abstract
Cerebral palsy is a chronic childhood disorder that can have diverse etiologies. Injury to the developing brain that occurs either in utero or soon after birth can result in the motor, sensory, and cognitive deficits seen in cerebral palsy. Although the etiologies for cerebral palsy are variable, neuroinflammation plays a key role in the pathophysiology of the brain injury irrespective of the etiology. Currently, there is no effective cure for cerebral palsy. Nanomedicine offers a new frontier in the development of therapies for prevention and treatment of brain injury resulting in cerebral palsy. Nanomaterials such as dendrimers provide opportunities for the targeted delivery of multiple drugs that can mitigate several pathways involved in injury and can be delivered specifically to the cells that are responsible for neuroinflammation and injury. These materials also offer the opportunity to deliver agents that would promote repair and regeneration in the brain, resulting not only in attenuation of injury, but also enabling normal growth. In this review, the current advances in nanotechnology for treatment of brain injury are discussed with specific relevance to cerebral palsy. Future directions that would facilitate clinical translation in neonates and children are also addressed.
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Affiliation(s)
- Bindu Balakrishnan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University; Baltimore, MD, USA
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Pateria P, de Boer B, MacQuillan G. Liver abnormalities in drug and substance abusers. Best Pract Res Clin Gastroenterol 2013; 27:577-96. [PMID: 24090944 DOI: 10.1016/j.bpg.2013.08.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Drug and substance abuse remains a major medical problem. Alcohol use, abuse and dependence are highly prevalent conditions. Alcohol related liver disease can present as simple steatosis, steatohepatitis, alcoholic hepatitis or liver cirrhosis. Paracetamol hepatotoxicity secondary to accidental or deliberate overdose is another common problem. While the adverse cardiovascular, neurological, renal and psychiatric consequences of various illicit substance abuses are widely studied and publicized, less attention has been directed towards possible hepatotoxic effects. Illicit drug abuse can cause a range of liver abnormalities ranging from asymptomatic derangement of liver function tests to fulminant hepatic failure. This article reviews the epidemiology, risk factors, clinical manifestations, pathogenesis, investigations, management and prognostic factors of alcohol related liver disease and paracetamol hepatotoxicity as well as the current knowledge pertaining to hepatotoxicity of the more commonly used illicit substances including cannabis, amphetamine type stimulants, cocaine, khat chewing and complementary and alternate medicine.
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Affiliation(s)
- Puraskar Pateria
- Western Australian Liver Transplant Service, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia 6009, Australia.
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Sceneay J, Liu MCP, Chen A, Wong CSF, Bowtell DDL, Möller A. The antioxidant N-acetylcysteine prevents HIF-1 stabilization under hypoxia in vitro but does not affect tumorigenesis in multiple breast cancer models in vivo. PLoS One 2013; 8:e66388. [PMID: 23840457 PMCID: PMC3688768 DOI: 10.1371/journal.pone.0066388] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 05/05/2013] [Indexed: 12/13/2022] Open
Abstract
Intratumoral hypoxia is a poor prognostic factor associated with reduced disease-free survival in many cancer types, including breast cancer. Hypoxia encourages tumor cell proliferation, stimulates angiogenesis and lymphangiogenesis, and promotes epithelial-mesenchymal transition and metastasis. Tumor cells respond to a hypoxic state by stabilizing the Hif-1α subunit of the Hypoxia-Inducible Factor (HIF) transcription factor to promote expression of various tumor- and metastasis-promoting hypoxic response genes. The antioxidant N-acetylcysteine (NAC) was recently shown to prevent Hif-1α stabilization under hypoxia, and has been identified as a potential alternative method to target the hypoxic response in tumors. We utilized three orthotopic syngeneic murine models of breast cancer, the PyMT, EO771 and 4T1.2 models, to investigate the ability of NAC to modulate the hypoxic response in vitro and in vivo. While NAC prevented Hif-1α stabilization under hypoxia in vitro and increased levels of glutathione in the blood of mice in vivo, this did not translate to a difference in tumor growth or the hypoxic state of the tumor compared to untreated control mice. In addition, NAC treatment actually increased metastatic burden in an experimental metastasis model. This work raises questions regarding the validity of NAC as an anti-tumorigenic agent in breast cancer, and highlights the need to further investigate its properties in vivo in different cancer models.
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MESH Headings
- Acetylcysteine/pharmacology
- Animals
- Antineoplastic Agents/pharmacology
- Antioxidants/pharmacology
- Apoptosis/drug effects
- Carcinogenesis
- Cell Hypoxia
- Cell Line, Tumor
- Cell Proliferation/drug effects
- Drug Screening Assays, Antitumor
- Epithelial-Mesenchymal Transition
- Female
- Glutathione/blood
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Lung Neoplasms/blood supply
- Lung Neoplasms/drug therapy
- Lung Neoplasms/metabolism
- Lung Neoplasms/secondary
- Mammary Neoplasms, Experimental/blood supply
- Mammary Neoplasms, Experimental/drug therapy
- Mammary Neoplasms, Experimental/metabolism
- Mammary Neoplasms, Experimental/pathology
- Mice
- Mice, Inbred BALB C
- Mice, Inbred C57BL
- Neoplasm Transplantation
- Neovascularization, Pathologic/metabolism
- Neovascularization, Pathologic/pathology
- Neovascularization, Pathologic/prevention & control
- Phenotype
- Protein Stability
- Tumor Burden/drug effects
- Vascular Endothelial Growth Factor A/metabolism
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Affiliation(s)
- Jaclyn Sceneay
- Cancer Genomics and Genetics Laboratory, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
- Department of Pathology, The University of Melbourne, Parkville, Victoria, Australia
- Tumour Microenvironment Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
| | - Mira C. P. Liu
- Cancer Genomics and Genetics Laboratory, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
| | - Anna Chen
- Cancer Genomics and Genetics Laboratory, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
- Department of Pathology, The University of Melbourne, Parkville, Victoria, Australia
| | - Christina S. F. Wong
- Tumour Microenvironment Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
| | - David D. L. Bowtell
- Cancer Genomics and Genetics Laboratory, Peter MacCallum Cancer Centre, East Melbourne, Victoria, Australia
- Department of Pathology, The University of Melbourne, Parkville, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Andreas Möller
- Tumour Microenvironment Laboratory, Queensland Institute of Medical Research, Herston, Queensland, Australia
- * E-mail:
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Green JL, Heard KJ, Reynolds KM, Albert D. Oral and Intravenous Acetylcysteine for Treatment of Acetaminophen Toxicity: A Systematic Review and Meta-analysis. West J Emerg Med 2013; 14:218-26. [PMID: 23687539 PMCID: PMC3656701 DOI: 10.5811/westjem.2012.4.6885] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 03/08/2012] [Accepted: 04/23/2012] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION There are few reports summarizing the effectiveness of oral and intravenous (IV) acetylcysteine. We determined the proportion of acetaminophen poisoned patients who develop hepatotoxicity (serum transaminase > 1000 IU/L) when treated with oral and IV acetylcysteine. METHODS Studies were double abstracted by trained researchers. We determined the proportions of patients who developed hepatotoxicity for each route using a random effects model. Studies were further stratified by early and late treatment. RESULTS We screened 4,416 abstracts; 16 articles, including 5,164 patients, were included in the meta-analysis. The overall rate of hepatotoxicity for the oral and IV routes were 12.6% and 13.2%, respectively. Treatment delays are associated with a higher rate of hepatotoxicity. CONCLUSION Studies report similar rates of hepatotoxicity for oral and IV acetylcysteine, but direct comparisons are lacking. While it is difficult to disentangle the effects of dose and duration from route, our findings suggest that the rates of hepatotoxicity are similar for oral and IV administration.
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Affiliation(s)
- Jody L Green
- Rocky Mountain Poison and Drug Center, Denver Health Medical Center, University of Colorado, Denver, Colorado ; Vanderbilt University School of Nursing, Nashville, Tennessee
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Thanacoody HKR, Gray A, Dear JW, Coyle J, Sandilands EA, Webb DJ, Lewis S, Eddleston M, Thomas SH, Bateman DN. Scottish and Newcastle antiemetic pre-treatment for paracetamol poisoning study (SNAP). BMC Pharmacol Toxicol 2013; 14:20. [PMID: 23556549 PMCID: PMC3626543 DOI: 10.1186/2050-6511-14-20] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 02/07/2013] [Indexed: 11/10/2022] Open
Abstract
Background Paracetamol (acetaminophen) poisoning remains the commonest cause of acute liver injury in Europe and North America. The intravenous (IV) N-acetylcysteine (NAC) regimen introduced in the 1970s has continued effectively unchanged. This involves 3 different infusion regimens (dose and time) lasting over 20 hours. The same weight-related dose of NAC is used irrespective of paracetamol dose. Complications include frequent nausea and vomiting, anaphylactoid reactions and dosing errors. We designed a randomised controlled study investigating the efficacy of antiemetic pre-treatment (ondansetron) using standard NAC and a modified, shorter, regimen. Methods/Design We designed a double-blind trial using a 2 × 2 factorial design involving four parallel groups. Pre-treatment with ondansetron 4 mg IV was compared against placebo on nausea and vomiting following the standard (20.25 h) regimen, or a novel 12 h NAC regimen in paracetamol poisoning. Each delivered 300 mg/kg bodyweight NAC. Randomisation was stratified on: paracetamol dose, perceived risk factors, and time to presentation. The primary outcome was the incidence of nausea and vomiting following NAC. In addition the frequency of anaphylactoid reactions and end of treatment liver function documented. Where clinically necessary further doses of NAC were administered as per standard UK protocols at the end of the first antidote course. Discussion This study is primarily designed to test the efficacy of prophylactic anti-emetic therapy with ondansetron, but is the first attempt to formally examine new methods of administering IV NAC in paracetamol overdose. We anticipate, from volunteer studies, that nausea and vomiting will be less frequent with the new NAC regimen. In addition as anaphylactoid response appears related to plasma concentrations of both NAC and paracetamol anaphylactoid reactions should be less likely. This study is not powered to assess the relative efficacy of the two NAC regimens, however it will give useful information to power future studies. As the first formal randomised clinical trial in this patient group in over 30 years this study will also provide information to support further studies in patients in paracetamol overdose, particularly, when linked with modern novel biomarkers of liver damage, patients at different toxicity risk. Trial registration EudraCT number 2009-017800-10, ClinicalTrials.gov IdentifierNCT01050270
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Besouw M, Masereeuw R, van den Heuvel L, Levtchenko E. Cysteamine: an old drug with new potential. Drug Discov Today 2013; 18:785-92. [PMID: 23416144 DOI: 10.1016/j.drudis.2013.02.003] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 12/28/2012] [Accepted: 02/08/2013] [Indexed: 01/23/2023]
Abstract
Cysteamine is an amino thiol with the chemical formula HSCH2CH2NH2. Endogenously, cysteamine is derived from coenzyme A degradation, although its plasma concentrations are low. Most experience with cysteamine as a drug originates from the field of the orphan disease cystinosis, in which cysteamine is prescribed to decrease intralysosomal cystine accumulation. However, over the years, the drug has been used for several other applications both in vitro and in vivo. In this article, we review the different applications of cysteamine, ending with an overview of ongoing clinical trials for new indications, such as neurodegenerative disorders and nonalcoholic fatty liver disease (NAFLD). The recent development of an enteric-coated cysteamine formulation makes cysteamine more patient friendly and will extend its applicability for both old and new indications.
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Affiliation(s)
- Martine Besouw
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium.
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Ehsani M, Moghadamnia AA, Zahedpasha S, Maliji G, Haghanifar S, Mir SMA, Kani NM. The role of prophylactic ibuprofen and N-acetylcysteine on the level of cytokines in periapical exudates and the post-treatment pain. ACTA ACUST UNITED AC 2012; 20:30. [PMID: 23351387 PMCID: PMC3555796 DOI: 10.1186/2008-2231-20-30] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 07/19/2012] [Indexed: 12/29/2022]
Abstract
Background Periapical lesions are inflammatory diseases that result in periapical bone destruction because of host defensive–microbial disturbances. Objective To evaluate the role of prophylactic ibuprofen and N-acetylcysteine (NAC) on the levels of tumor necrosis factor alpha (TNF- α), interleukin- 6(IL-6) and IL-17 and post-treatment pain level in chronic periapical lesions. Materials and methods Eighty patients with chronic apical lesions less than 1 cm were randomly assigned to receive NAC tablets (400 mg), ibuprofen tablets (400 mg), NAC (400 mg)/ibuprofen (200 mg) combination and placebo 90 minutes prior to sampling. Periapical exudates were collected from root canals. TNF- α, IL-6 and IL-17 levels were determined by ELISA and post-treatment pain was assessed using a visual analog scale (VAS). Results There was a significant difference in IL-6 level between ibuprofen group and placebo (p = 0.019). Significant difference in IL-17 level was observed between NAC/ibuprofen combination group and placebo (p = 0.043). Four hours after treatment, a significant difference was observed in VAS pain score between ibuprofen group and placebo (p = 0.017). Eight hours post-treatment, VAS pain score for NAC group was statistically lower than placebo group (p = 0.033). After 12 hours VAS pain score showed a significant decrease in NAC group compared to placebo (p = 0.049). Conclusion The prophylactic ibuprofen and NAC failed to clearly reflect their effect on cytokines levels in exudates of chronic periapical lesions. On the other hand it seems that NAC can be a substitute for ibuprofen in the management of post endodontic pain.
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Affiliation(s)
- Maryam Ehsani
- Department of Endodontics, Dental Material Research Center, Faculty of Dentistry, Babol University of Medical Sciences, Babol, Iran.
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Kannan S, Dai H, Navath RS, Balakrishnan B, Jyoti A, Janisse J, Romero R, Kannan RM. Dendrimer-based postnatal therapy for neuroinflammation and cerebral palsy in a rabbit model. Sci Transl Med 2012; 4:130ra46. [PMID: 22517883 DOI: 10.1126/scitranslmed.3003162] [Citation(s) in RCA: 270] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cerebral palsy (CP) is a chronic childhood disorder with no effective cure. Neuroinflammation, caused by activated microglia and astrocytes, plays a key role in the pathogenesis of CP and disorders such as Alzheimer's disease and multiple sclerosis. Targeting neuroinflammation can be a potent therapeutic strategy. However, delivering drugs across the blood-brain barrier to the target cells for treating diffuse brain injury is a major challenge. We show that systemically administered polyamidoamine dendrimers localize in activated microglia and astrocytes in the brain of newborn rabbits with CP, but not healthy controls. We further demonstrate that dendrimer-based N-acetyl-l-cysteine (NAC) therapy for brain injury suppresses neuroinflammation and leads to a marked improvement in motor function in the CP kits. The well-known and safe clinical profile for NAC, when combined with dendrimer-based targeting, provides opportunities for clinical translation in the treatment of neuroinflammatory disorders in humans. The effectiveness of the dendrimer-NAC treatment, administered in the postnatal period for a prenatal insult, suggests a window of opportunity for treatment of CP in humans after birth.
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Affiliation(s)
- Sujatha Kannan
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Detroit, MI 48201, USA.
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Kalsi SS, Dargan PI, Waring WS, Wood DM. A review of the evidence concerning hepatic glutathione depletion and susceptibility to hepatotoxicity after paracetamol overdose. Open Access Emerg Med 2011; 3:87-96. [PMID: 27147856 PMCID: PMC4753970 DOI: 10.2147/oaem.s24963] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Indexed: 01/10/2023] Open
Abstract
Paracetamol (acetaminophen) poisoning is common throughout the world. The management of nonstaggered (acute) paracetamol overdose is based on the plasma paracetamol concentration plotted on a treatment nomogram. In the UK there are two treatment lines on this nomogram, with the lower treatment line used for individuals felt to be at ‘high risk’ of paracetamol-related hepatotoxicity either as a result of induction of cytochrome P450 isoenzymes or reduction of intrahepatic glutathione. In this article we review the risk factors that, in current guidelines, are felt to increase risk due to a reduction in intrahepatic glutathione concentrations. Based on our review of the published literature, we feel that cystic fibrosis, acute viral illness, malnutrition, and eating disorders such as anorexia nervosa are likely to be associated with reduction in intrahepatic glutathione concentrations, and that this risk is likely to be related to malnutrition secondary to the disease. Chronic hepatitis C infection is also associated with reduced glutathione concentrations, although this appears to be independent of any associated malnutrition. Ageing and acute fasting are not associated with an increased risk of paracetamol-related hepatotoxicity due to reductions in glutathione concentrations. Finally, the evidence for HIV infection is inconclusive, particularly as the majority of studies were conducted in the pre-anti-viral treatment (HAART) era; however it is likely that patients with symptomatic HIV/AIDS have reduced glutathione concentrations due to associated malnutrition. Although there have been few studies which have specifically investigated whether there is an association between reduced intrahepatic glutathione concentrations and increased risk of paracetamol-related hepatotoxicity, in our opinion, it is likely that the above conditions that are associated with reduced glutathione concentrations, will be associated with an increased risk of paracetamol-related hepatotoxicity.
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Affiliation(s)
- Sarbjeet S Kalsi
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust, London, UK;; Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Kalsi SS, Wood DM, Waring WS, Dargan PI. Does cytochrome P450 liver isoenzyme induction increase the risk of liver toxicity after paracetamol overdose? Open Access Emerg Med 2011; 3:69-76. [PMID: 27147854 PMCID: PMC4753969 DOI: 10.2147/oaem.s24962] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Indexed: 01/13/2023] Open
Abstract
Paracetamol (acetaminophen, N-acetyl-p-aminophenol, 4-hydroxyacetanilide) is the most common cause of acute liver failure in developed countries. There are a number of factors which potentially impact on the risk of an individual developing hepatotoxicity following an acute paracetamol overdose. These include the dose of paracetamol ingested, time to presentation, decreased liver glutathione, and induction of cytochrome P450 (CYP) isoenzymes responsible for the metabolism of paracetamol to its toxic metabolite N-acetyl-p-benzoquinoneimine (NAPQI). In this paper, we review the currently published literature to determine whether induction of relevant CYP isoenzymes is a risk factor for hepatotoxicity in patients with acute paracetamol overdose. Animal and human in vitro studies have shown that the CYP isoenzyme responsible for the majority of human biotransformation of paracetamol to NAPQI is CYP2E1 at both therapeutic and toxic doses of paracetamol. Current UK treatment guidelines suggest that patients who use a number of drugs therapeutically should be treated as “high-risk” after paracetamol overdose. However, based on our review of the available literature, it appears that the only drugs for which there is evidence of the potential for an increased risk of hepatotoxicity associated with paracetamol overdose are phenobarbital, primidone, isoniazid, and perhaps St John’s wort. There is no evidence that other drugs often quoted as increasing risk, such as carbamazepine, phenytoin, primidone, rifampicin, rifabutin, efavirenz, or nevirapine, should be considered risk factors for hepatotoxicity in patients presenting with acute paracetamol overdose.
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Affiliation(s)
- Sarbjeet S Kalsi
- Emergency Department, Guy's and St Thomas' NHS Foundation Trust, London;; Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London
| | | | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London
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Sundaram V, Shaikh OS. Acute liver failure: current practice and recent advances. Gastroenterol Clin North Am 2011; 40:523-39. [PMID: 21893272 DOI: 10.1016/j.gtc.2011.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
ALF is an important cause of liver-related morbidity and mortality. Advances in the management of ICH and SIRS, and cardiorespiratory, metabolic, and renal support have improved the outlook of such patients. Early transfer to a liver transplant center is essential. Routine use of NAC is recommended for patients with early hepatic encephalopathy, irrespective of the etiology. The role of hypothermia remains to be determined. Liver transplantation plays a critical role, particularly for those with advanced encephalopathy. Several detoxification and BAL support systems have been developed to serve as a bridge to transplantation or to spontaneous recovery. However, such systems lack sufficient reliability and efficacy to be applied routinely in clinical practice. Hepatocyte and stem cell transplantation may provide valuable adjunctive therapy in the future.
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Affiliation(s)
- Vinay Sundaram
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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van Hoving D, Veale D, Müller G. WITHDRAWN: Emergency management of acute poisoning. Afr J Emerg Med 2011. [DOI: 10.1016/j.afjem.2011.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Bebarta VS, Kao L, Froberg B, Clark RF, Lavonas E, Qi M, Delgado J, McDonagh J, Arnold T, Odujebe O, O'Malley G, Lares C, Aguilera E, Dart R, Heard K, Stanford C, Kokko J, Bogdan G, Mendoza C, Mlynarchek S, Rhyee S, Hoppe J, Haur W, Tan HH, Tran NN, Varney S, Zosel A, Buchanan J, Al-Helial M. A multicenter comparison of the safety of oral versus intravenous acetylcysteine for treatment of acetaminophen overdose. Clin Toxicol (Phila) 2010; 48:424-30. [PMID: 20524832 DOI: 10.3109/15563650.2010.486381] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED Oral and intravenous (IV) N-acetylcysteine (NAC) are used for the treatment of acetaminophen poisoning. The objective of this multicenter study was to compare the safety of these two routes of administration. METHODS We conducted a multicenter chart review of all patients treated with NAC for acetaminophen poisoning. The primary safety outcome was the percentage of patients with NAC-related adverse events. RESULTS A total of 503 subjects were included in the safety analysis (306 IV-only, 145 oral-only, and 52 both routes). There were no serious adverse events related to NAC for either route. Nausea and vomiting were the most common related adverse events and were more common with oral treatment (23 vs. 9%). Anaphylactoid reactions were more common with IV administration (6 vs. 2%). CONCLUSIONS IV and oral NAC are generally mild adverse drug reactions.
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Affiliation(s)
- Vikhyat S Bebarta
- Toxicology Investigator Network Authorship Group Wilford Hall Medical Center, USA
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Buckley NA, Eddleston M, Li Y. IV versus Oral Acetylcysteine. Ann Emerg Med 2010; 55:393-4; author reply 394-5. [DOI: 10.1016/j.annemergmed.2009.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2009] [Revised: 10/25/2009] [Accepted: 11/03/2009] [Indexed: 10/19/2022]
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Turner TJ, Barnes H, Reid J, Garrubba M. Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help? BMC Public Health 2010; 10:170. [PMID: 20350326 PMCID: PMC3091544 DOI: 10.1186/1471-2458-10-170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 03/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid. METHODS Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings. RESULTS Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid. CONCLUSIONS We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.
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Affiliation(s)
- Tari J Turner
- Monash Institute of Health Services Research, Monash University, Locked Bag 29, Clayton 3168 Australia
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Hayley Barnes
- previously of the Australasian Cochrane Centre, Monash University, Locked Bag 29, Clayton 3168 Australia
| | - Jane Reid
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
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Diener MK, Wolff RF, von Elm E, Rahbari NN, Mavergames C, Knaebel HP, Seiler CM, Antes G. Can decision making in general surgery be based on evidence? An empirical study of Cochrane Reviews. Surgery 2009; 146:444-61. [DOI: 10.1016/j.surg.2009.02.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Accepted: 02/20/2009] [Indexed: 10/20/2022]
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Life-threatening hyponatremia due to intravenous n-acetylcysteine treatment in an infant: a case report. CASES JOURNAL 2009; 2:8347. [PMID: 19918421 PMCID: PMC2769431 DOI: 10.4076/1757-1626-2-8347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 08/17/2009] [Indexed: 11/30/2022]
Abstract
Introduction N-acetylcysteine has proven to be effective in paracetamol intoxications, but there is no consensus regarding its way of administration. Here, we report a case to highlight the importance of careful management of intravenous n-acetylcysteine. Case presentation A two-month old infant was seen in our paediatric emergency department due to paracetamol poisoning after repeated supratherapeutic doses. She was treated with intravenous n-acetylcysteine diluted with dextrose 5%, according to the 20-hour standard protocol. Eight hours later she developed two tonic-clonic seizures and was subsequently intubated. By that time, she had received almost 1 liter of 5% dextrose, and serum sodium was 114 mg/dL. A rapid correction was done with hypertonic saline and the child experienced a good outcome, without any sequelae. Conclusion Intravenous n-acetylcysteine administration must be done carefully. Amount of liquid administrated and sodium monitoring should be kept in mind, with special care in small children.
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