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Padalhin A, Abueva C, Ryu HS, Yoo SH, Seo HH, Park SY, Chung PS, Woo SH. Impact of Thermo-Responsive N-Acetylcysteine Hydrogel on Dermal Wound Healing and Oral Ulcer Regeneration. Int J Mol Sci 2024; 25:4835. [PMID: 38732054 PMCID: PMC11084650 DOI: 10.3390/ijms25094835] [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: 04/02/2024] [Revised: 04/19/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
This study investigates the efficacy of a thermo-responsive N-acetylcysteine (NAC) hydrogel on wound healing and oral ulcer recovery. Formulated by combining NAC with methylcellulose, the hydrogel's properties were assessed for temperature-induced gelation and cell viability using human fibroblast cells. In vivo experiments on Sprague Dawley rats compared the hydrogel's effects against saline, NAC solution, and a commercial NAC product. Results show that a 5% NAC and 1% methylcellulose solution exhibited optimal outcomes. While modest improvements in wound healing were observed, significant enhancements were noted in oral ulcer recovery, with histological analyses indicating fully regenerated mucosal tissue. The study concludes that modifying viscosity enhances NAC retention, facilitating tissue regeneration. These findings support previous research on the beneficial effects of antioxidant application on damaged tissues, suggesting the potential of NAC hydrogels in improving wound care and oral ulcer treatment.
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Affiliation(s)
- Andrew Padalhin
- Beckman Laser Institute Korea, College of Medicine, Dankook University, Cheonan 31116, Republic of Korea; (A.P.); (C.A.); (H.S.R.); (S.Y.P.); (P.-S.C.)
| | - Celine Abueva
- Beckman Laser Institute Korea, College of Medicine, Dankook University, Cheonan 31116, Republic of Korea; (A.P.); (C.A.); (H.S.R.); (S.Y.P.); (P.-S.C.)
- Medical Laser Research Center, Dankook University, Cheonan 31116, Republic of Korea
| | - Hyun Seok Ryu
- Beckman Laser Institute Korea, College of Medicine, Dankook University, Cheonan 31116, Republic of Korea; (A.P.); (C.A.); (H.S.R.); (S.Y.P.); (P.-S.C.)
| | - Seung Hyeon Yoo
- School of Medical Lasers, Dankook University, Cheonan 31116, Republic of Korea; (S.H.Y.); (H.H.S.)
| | - Hwee Hyon Seo
- School of Medical Lasers, Dankook University, Cheonan 31116, Republic of Korea; (S.H.Y.); (H.H.S.)
| | - So Young Park
- Beckman Laser Institute Korea, College of Medicine, Dankook University, Cheonan 31116, Republic of Korea; (A.P.); (C.A.); (H.S.R.); (S.Y.P.); (P.-S.C.)
| | - Phil-Sang Chung
- Beckman Laser Institute Korea, College of Medicine, Dankook University, Cheonan 31116, Republic of Korea; (A.P.); (C.A.); (H.S.R.); (S.Y.P.); (P.-S.C.)
- Medical Laser Research Center, Dankook University, Cheonan 31116, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Dankook University, Cheonan 31116, Republic of Korea
| | - Seung Hoon Woo
- Beckman Laser Institute Korea, College of Medicine, Dankook University, Cheonan 31116, Republic of Korea; (A.P.); (C.A.); (H.S.R.); (S.Y.P.); (P.-S.C.)
- Medical Laser Research Center, Dankook University, Cheonan 31116, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Dankook University, Cheonan 31116, Republic of Korea
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2
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Alam MS, Hasan MN, Maowa Z, Khatun F, Nazir KHMNH, Alam MZ. N-acetylcysteine reduces severity and mortality in COVID-19 patients: A systematic review and meta-analysis. J Adv Vet Anim Res 2023; 10:157-168. [PMID: 37534078 PMCID: PMC10390689 DOI: 10.5455/javar.2023.j665] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/21/2023] [Accepted: 05/22/2023] [Indexed: 08/04/2023] Open
Abstract
Objectives Recent clinical studies suggest that oxidative stress is one of the key players in the pathogenesis of coronavirus disease 2019 (COVID-19), and N-acetylcysteine (NAC), a potent antioxidant, has been shown to improve clinical outcomes in COVID-19 patients. We conducted a systematic review and meta-analysis of the literature published on the therapeutic intervention of NAC on COVID-19 infection. Methods We searched PubMed, Google Scholar, and Science Direct. We identified and screened eight studies with 20,503 participants, including 2,852 in the NAC-treated group and 17,651 in the placebo group, which reported the effect of NAC on COVID-19 infection. A meta-analysis was performed using forest plots under fixed effect estimates based on the standardized mean difference (SMD) and risk ratio (RR). Results Pooled analysis showed that NAC was associated with lower mortality in patients with COVID-19 compared with the placebo group [RR, 0.65; (95% CI: 0.56 to 0.75); p < 0.0001]. Similarly, C-reactive protein (CRP) [SMD, -0.32; (95% CI: -56 to -0.09); p = 0.0070] and D-dimer [SMD, -0.35, (95% CI: -0.59 to -0.10; p = 0.0062] levels were significantly decreased, and the oxygenation marker, PaO2/FiO2 ratio, was increased in the NAC-treated group compared with the placebo group [SMD, 0.76; (95% CI: 0.48 to 1.03); p < 0.0001]. Conclusion Although the number of included studies was minimal, this meta-analysis suggests that NAC may have a positive effect on COVID-19 outcomes, specifically, a significant decrease in CRP and D-dimer levels and a significant increase in oxygen saturation, which decreased mortality. We have also presented a comprehensive review of the role and mechanisms of NAC in patients with COVID-19.
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Affiliation(s)
- Mohammad Shah Alam
- Department of Anatomy and Histology, Bangabandhu Sheikh Mujibur Rahman Agricultural University, Gazipur, Bangladesh
| | - Mohammad Nazmol Hasan
- Department of Statistics, Bangabandhu Sheikh Mujibur Rahman Agricultural University, Gazipur, Bangladesh
| | - Zannatul Maowa
- Department of Anatomy and Histology, Bangabandhu Sheikh Mujibur Rahman Agricultural University, Gazipur, Bangladesh
| | - Fahima Khatun
- Department of Pathobiology, Bangabandhu Sheikh Mujibur Rahman Agricultural University, Gazipur, Bangladesh
| | | | - Mohammad Zahangeer Alam
- Department of Environmental Science, Bangabandhu Sheikh Mujibur Rahman Agricultural University, Gazipur, Bangladesh
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Rajaraman N, Gray L, Anderson M, Kelgeri C. Paracetamol overdose in children: management following an initial N-acetylcysteine regimen. Arch Dis Child Educ Pract Ed 2022; 108:200-204. [PMID: 36600476 DOI: 10.1136/archdischild-2022-324906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Nikitha Rajaraman
- Paediatrics and Neonatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, Birmingham, UK
| | - Laurence Gray
- National Poisons Information Service (Cardiff Unit), University Hospital Llandough, Llandough, UK
| | - Mark Anderson
- National Poisons Information Service (UK), Royal Victoria Infirmary, Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Chayarani Kelgeri
- Liver Unit, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, Birmingham, UK
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4
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Stewart A, Glaser E, Mott CA, Bailey WM, Sulllivan PG, Patel S, Gensel J. Advanced Age and Neurotrauma Diminish Glutathione and Impair Antioxidant Defense after Spinal Cord Injury. J Neurotrauma 2022; 39:1075-1089. [PMID: 35373589 PMCID: PMC9347421 DOI: 10.1089/neu.2022.0010] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Andrew Stewart
- University of Kentucky, Physiology, 741 S. Limestone Street, BBSRB B483, Lexington, Kentucky, United States, 40536-0509,
| | - Ethan Glaser
- University of Kentucky, Physiology, Lexington, Kentucky, United States,
| | - Caitlin A Mott
- University of Kentucky, Physiology, Lexington, Kentucky, United States,
| | - William M Bailey
- University of Kentucky, Spinal Cord and Brain Injury Research Center, Physiology, Lexington, Kentucky, United States
| | - Patrick G Sulllivan
- University of Kentucky College of Medicine, Spinal Cord & Brain Injury Research Cent, 475 BBSRB, Lexington, United States, 40536-0509,
| | - Samir Patel
- University of Kentucky, 4530, Spinal Cord and Brain Injury Research Center, Physiology, Lexington, Kentucky, United States
| | - John Gensel
- University of Kentucky, Physiology, 741 S. Limestone Street, B436 BBSRB, Lexington, Kentucky, United States, 40536-0509
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5
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Mohan S, Koziatek C, Swartz J, Howland MA, Su MK. Thromboelastography in the setting of acetaminophen-induced hepatotoxicity. Clin Toxicol (Phila) 2022; 60:651-653. [PMID: 35014913 DOI: 10.1080/15563650.2021.2016797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Severe acetaminophen (APAP) poisoning can result in fulminant hepatic failure and abnormal tests of coagulation. Although the international normalized ratio (INR) may be elevated, the actual hemostatic status of patients with APAP-induced hepatotoxicity is unknown. Few studies exist investigating the clinical use of thromboelastography (TEG) to evaluate the hemostatic status in the setting of APAP-induced hepatotoxicity. METHODS We performed a retrospective review of patients who were admitted for APAP toxicity and received TEG testing at a single transplant center. RESULTS Nine patients had detectable APAP concentrations and exhibited elevated aspartate and alanine aminotransferase activities. Seven had thrombocytopenia. TEG revealed a decreased median alpha angle and maximum amplitude but other values were within the normal reference range. DISCUSSION Based on our study of APAP-induced hepatotoxicity, TEG showed a decreased rate of fibrin formation and cross-linking, as well as reduced clot strength. These findings suggest that patients with APAP-induced hepatotoxicity and thrombocytopenia have a theoretically increased bleeding risk as demonstrated by both elevated INR and abnormal TEG values. However, these TEG findings are more likely related to thrombocytopenia rather than directly to APAP-induced hepatotoxicity. Further studies should be performed to elucidate the potential role of TEG in various stages of APAP-induced hepatotoxicity.
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Affiliation(s)
- Sanjay Mohan
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Christian Koziatek
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Jordan Swartz
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Mary Ann Howland
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA.,College of Pharmacy and Health Sciences, St. John's University, Queens, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
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6
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Dayasiri K, Rao S. Fifteen-minute update: International normalised ratio as the treatment end point in children with acute paracetamol poisoning. Arch Dis Child Educ Pract Ed 2021; 108:181-183. [PMID: 34880073 DOI: 10.1136/archdischild-2020-320190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/15/2021] [Indexed: 11/04/2022]
Abstract
Paracetamol is one of the most frequent reasons for poisonings across the UK with an estimated 90,000 patients and 150 deaths annually. International normalised ratio (INR) may be elevated due to hepatocellular damage and is frequently used to monitor progress on N-acetyl cysteine. N-acetyl cysteine is associated with reduced activity of vitamin K dependent clotting factors leading to a benign elevation of INR. In asymptomatic children with normal aspartate transaminase/alanine transaminase, isolated borderline elevation of INR following paracetamol overdose should be reviewed for possible N-acetyl cysteine induced elevation of INR. Due to these factors, in those with borderline persistent elevation of INR, N-acetyl cysteine can be safety stopped if INR is falling on two or more consecutive tests and is <3.0.
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Affiliation(s)
- Kavinda Dayasiri
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK.,Department of Paediatrics, Faculty of Medicine, University of Kelaniya, Kelaniya, Sri Lanka
| | - Sahana Rao
- Department of Paediatrics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK .,Paediatrics, University of Oxford, Oxford, Oxfordshire, UK
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7
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Minhaj FS, Leonard JB, Seung H, Anderson BD, Klein-Schwartz W, King JD. In vitro analysis of n-acetylcysteine (NAC) interference with the international normalized ratio (INR). Clin Toxicol (Phila) 2021; 60:489-492. [PMID: 34549665 DOI: 10.1080/15563650.2021.1979232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Previous literature suggests a laboratory interference of n-acetylcysteine (NAC) with prothrombin time (PT) and the international normalized ratio (INR). Early publications focused on this interaction in the setting of an acetaminophen overdose and evaluated the INR of patients receiving intravenous NAC. However, there is limited literature describing the concentration-effect relationship of NAC to INR measurement in the absence of acetaminophen-induced hepatotoxicity at therapeutic NAC concentrations. The purpose of the study is to quantify the degree of interference of NAC on INR values at therapeutic concentrations correlating to each infusion of the regimen (ex. bag 1: 550 mcg/mL, bag 2: 200 mcg/mL, bag 3: 35 mcg/mL, double bag 3: 70 mcg/mL) and at supratherapeutic concentrations in vitro. METHODS Blood samples were obtained from study volunteers. Each blood sample was transferred into vials containing 0.3 mL buffered sodium citrate 3.2% and spiked with various concentrations of NAC for final concentrations of 0, 35, 70, 200, 550, 1000, 2000, and 4000 mcg/mL. The samples were centrifuged and tested to determine PT and INR on two separate machines: Siemens CS-2500 and Stago SN1114559. We would require a sample size of 6 to achieve a power of 80% and a level of significance of 1.7% (two-sided). Differences between INRs at varying concentrations were determined by Friedman's test. For multiple comparisons, post hoc analysis was performed using Wilcoxon signed-rank test with Bonferroni adjustment. Analyses were performed with SAS version 9.4 (SAS Institute, Cary, NC). RESULTS Participants included 11 healthy subjects: 8 males, 3 females, median age 30 years (range 25 - 58). Median and interquartile ranges (IQR) INR for the baseline samples were 1.09 (IQR 1.05, 1.16) for Siemens and 1.03 (IQR 0.99, 1.11) for Stago analyzers. There was a significant difference in INR between the therapeutic concentrations (baseline, 35, 70,200, or 550 µg/mL) (Siemens p = .0008, Stago p < .0001). The 550 µg/mL concentration with the Siemens analyzer was the only one compared separately and found to be significantly greater than the baseline (1.07 vs 1.22, p = .02). For the Stago analyzer the 200 µg/mL and 500 µg/mL were compared and found to be significantly different from baseline (1.00 vs 1.07 and 1.19, adjusted p = .02 and p = .03, respectively). The largest INR increase seen was in one subject from a baseline of 1.07-1.32 with the 550 µg/mL concentration. Increases in concentrations to supratherapeutic levels resulted in a statistically significant non-linear increase in INR for all concentrations (Siemens p < .0001, Stago p < .0001). All of these concentrations were found to be significantly different from baseline (all adjusted p < .05). CONCLUSION Although it was found that at therapeutic concentrations the in vitro presence of NAC affects INR measurements on two different machines, the change is of little clinical relevance. Supratherapeutic concentrations of NAC affect INR significantly, but the clinical utility of those results is limited by the rarity of those concentrations being measured.
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Affiliation(s)
- Faisal Syed Minhaj
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - James B Leonard
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Hyunuk Seung
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Bruce D Anderson
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Wendy Klein-Schwartz
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Joshua D King
- Maryland Poison Center, University of Maryland School of Pharmacy, Baltimore, MD, USA.,University of Maryland School of Medicine, Baltimore, MD, USA
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8
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Gomez-Aparicio LS, Bernáldez-Sarabia J, Camacho-Villegas TA, Lugo-Fabres PH, Díaz-Martínez NE, Padilla-Camberos E, Licea-Navarro A, Castro-Ceseña AB. Improvement of the wound healing properties of hydrogels with N-acetylcysteine through their modification with methacrylate-containing polymers. Biomater Sci 2021; 9:726-744. [PMID: 33179647 DOI: 10.1039/d0bm01479f] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Hydrogels with antioxidant activity have shown to significantly improve the standard of care, because they promote efficient wound healing, i.e. regeneration. N-Acetylcysteine (NAC) is an antioxidant amino acid derivative that promotes complete tissue restoration. However, NAC has anticoagulant properties that may also hinder blood coagulation, which is crucial for hydrogels for wound healing applications. To take advantage of the regenerative activity of NAC while avoiding hampering the hemostasis stage during wound healing, we modified gelatin-NAC with the methacrylate-containing polymers 2-hydroxyethyl methacrylate (H) and poly(ethylene glycol) methyl ether methacrylate (P) to produce Gel-HP-NAC. These hydrogels clotted more blood and faster than Gel and Gel-NAC hydrogels, while maintaining fluid absorption properties adequate to promote wound healing. Similarly, there were more viable human skin fibroblasts after 10 days cultured in Gel-HP-NAC compared with Gel and Gel-NAC. A mouse full-thickness skin wound model demonstrated that Gel-HP-NAC hydrogels improved the wound healing process as compared to the untreated group as proved by the increased wound closure rates and re-epithelialization. Histology of the biopsied tissues indicated more organized collagen deposits on the wounds treated with either Gel-HP-NAC or Gel-NAC than untreated wounds. Our results show that modification of NAC-containing hydrogels through methacrylate-containing polymers improved their wound healing properties, including blood-clotting, and demonstrate the potential of Gel-HP-NAC hydrogels for wound treatment and tissue regeneration.
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Affiliation(s)
- Lesly S Gomez-Aparicio
- Departamento de Innovación Biomédica, Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico.
| | - Johanna Bernáldez-Sarabia
- Departamento de Innovación Biomédica, Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico.
| | - Tanya A Camacho-Villegas
- Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico and CONACYT-Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico
| | - Pavel H Lugo-Fabres
- Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico and CONACYT-Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico
| | - Néstor Emmanuel Díaz-Martínez
- Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico
| | - Eduardo Padilla-Camberos
- Unidad de Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco (CIATEJ), A.C., Av. Normalistas No. 800, Colinas de la Normal, C.P. 44270, Guadalajara, Jalisco, Mexico
| | - Alexei Licea-Navarro
- Departamento de Innovación Biomédica, Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico.
| | - Ana B Castro-Ceseña
- Departamento de Innovación Biomédica, Centro de Investigación Científica y de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico. and CONACYT- Departamento de Innovación Biomédica, Centro de Investigación Científica de Educación Superior de Ensenada (CICESE), Carretera Ensenada-Tijuana No. 3918, Zona Playitas, C.P. 22860, Ensenada, Baja California, Mexico
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Harmouche E, Fung F, Howland MA, Su MK. In response to “Coagulopathy and bleeding associated with salicylate toxicity”. Clin Toxicol (Phila) 2020; 58:431-432. [DOI: 10.1080/15563650.2019.1636061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Elie Harmouche
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- Department of Health & Mental Hygiene, New York City Poison Control Center, New York, NY, USA
| | - Filgen Fung
- Department of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Mary Ann Howland
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- Department of Health & Mental Hygiene, New York City Poison Control Center, New York, NY, USA
| | - Mark K Su
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU School of Medicine, New York, NY, USA
- Department of Health & Mental Hygiene, New York City Poison Control Center, New York, NY, USA
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10
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Morthorst BR, Erlangsen A, Chaine M, Eriksson F, Hawton K, Dalhoff K, Nordentoft M. Restriction of non-opioid analgesics sold over-the-counter in Denmark: A national study of impact on poisonings. J Affect Disord 2020; 268:61-68. [PMID: 32158008 DOI: 10.1016/j.jad.2020.02.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 02/14/2020] [Accepted: 02/26/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Self-poisoning with non-opioid analgesics presents a growing challenge to health care providers. We aimed to assess the impact of an 18-year age restriction of OTC sales and a pack size restriction of non-opioid analgesics sold OTC in pharmacies on hospital-treated poisonings and poisoning severity measured using biomarkers. METHODS We applied a before and after design using interrupted time series analysis. Data on all poisonings recorded as hospital admissions were obtained during 2002-2015 and biochemical parameters from laboratory databases during 2011-2015, both covering the entire Danish population. RESULTS The age restriction was followed by a 17% level reduction in admissions for non-opioid analgesic poisoning among young people age 10-17 years (RR 0.830; 95% CI 0.697-0.988; p < 0.036). After the pack size restriction, an instant level reduction of 18.5% (RR 0.815; 95% CI 0.729-0.912; p < 0.001) was observed for the entire population. A 27% decrease in the number of poisonings with alanine transaminase levels (ALT) ≥ 210 U/L was observed (RR 0.734; 95% CI 0.579-0.931; p = 0.011) followed by 40% decrease in biomarkers indicative of liver failure (RR 0.597; 95% CI 0.421-0.847; p = 0.004). We also observed similar reductions for other poisonings such as psychotropics. LIMITATIONS Although declines in poisonings were observed after implementation of means restrictive measures, a causal link cannot be inferred. CONCLUSION Age and pack size restriction were assiociated with a reduction in the numbers of poisonings. This was also observed for pharmaceutical poisonings in general, which might suggest a non-specific or spill-over effect.
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Affiliation(s)
- Britt Reuter Morthorst
- Institute of Clinical Medicine, Faculty of Medical and Health Science, University of Copenhagen, Copenhagen, Denmark; Danish Research Institute for Suicide Prevention, Copenhagen Research Center for Mental Health (CORE), mental Health Center Copenhagen, Copenhagen, Denmark; Child & Adolescent Mental Health Services Capital Region of Denmark, Gentofte Hospitalsvej 15, DK - 2900 Hellerup.
| | - Annette Erlangsen
- Danish Research Institute for Suicide Prevention, Copenhagen Research Center for Mental Health (CORE), mental Health Center Copenhagen, Copenhagen, Denmark; Department of Mental Health, Johns Hopkins School of Public Health, Baltimore, MD, USA; Center for Mental Health Research, College of Health and Medicine, Australian National University, Canberra, Australia
| | | | - Frank Eriksson
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Denmark
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Oxford University, Oxford, UK
| | - Kim Dalhoff
- Department of Clinical Pharmacology and Clinical Toxicology, Copenhagen University Hospital Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Merete Nordentoft
- Institute of Clinical Medicine, Faculty of Medical and Health Science, University of Copenhagen, Copenhagen, Denmark; Danish Research Institute for Suicide Prevention, Copenhagen Research Center for Mental Health (CORE), mental Health Center Copenhagen, Copenhagen, Denmark
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11
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Bismuth Subsalicylate Coagulopathy in a Patient with Chronic Liver Disease. J Med Toxicol 2019; 15:198-201. [PMID: 31062178 DOI: 10.1007/s13181-019-00709-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/21/2019] [Accepted: 04/03/2019] [Indexed: 10/26/2022] Open
Abstract
Bismuth subsalicylate (BSS) is the active ingredient in over-the-counter antacid and antidiarrheal medications. Coagulopathy in the setting of acetylsalicylic acid toxicity is well documented but not in setting of bismuth subsalicylate overuse. We present a case report of coagulopathy from BSS poisoning in a patient with underlying cirrhosis. The patient's high prothrombin time suggests inhibition of vitamin K-dependent coagulation factors. The patient had decreased factor V activity, which is responsible for converting prothrombin to thrombin. Patients with cirrhosis often have hypoprothrombinemia which may be exacerbated by salicylate-induced coagulopathy. Given the widespread use of BSS products, physicians should recognize coagulopathy as a possible manifestation of toxicity especially in patients with underlying liver disease.
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Wong A, McNulty R, Taylor D, Sivilotti M, Greene S, Gunja N, Koutsogiannis Z, Graudins A. The NACSTOP Trial: A Multicenter, Cluster-Controlled Trial of Early Cessation of Acetylcysteine in Acetaminophen Overdose. Hepatology 2019; 69:774-784. [PMID: 30125376 DOI: 10.1002/hep.30224] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 08/13/2018] [Indexed: 12/07/2022]
Abstract
Historically, intravenous acetylcysteine has been delivered at a fixed dose and duration of 300 mg/kg over 20 to 21 hours to nearly every patient deemed to be at any risk for hepatotoxicity following acetaminophen overdose. We investigated a 12-hour treatment regimen for selected low-risk patients. This was a multicenter, open-label, cluster-controlled trial at six metropolitan emergency departments. We enrolled subjects following single or staggered acetaminophen overdose with normal serum alanine transaminase (ALT) and creatinine on presentation and at 12 hours, and less than 20 mg/L acetaminophen at 12 hours. Patients were allocated to intervention (250 mg/kg over 12-hour) or control (300 mg/kg over 20-hour) regimens by site. The primary outcome was incidence of "hepatic injury" 20 hours following initiation of acetylcysteine treatment, defined as ALT doubling and peak ALT greater than 100 IU/L, indicating the need for further antidotal treatment. Secondary outcomes included incidence of hepatotoxicity (ALT > 1,000 IU/L), peak international normalized ratio (INR), and adverse drug reactions. Of the 449 acetaminophen overdoses receiving acetylcysteine, 100 were recruited to the study. Time to acetylcysteine (median 7 hours [interquartile ratio 6,12] versus 7 hours [6,10]) and initial acetaminophen (124 mg/L [58,171] versus 146 mg/L [66,204]) were similar between intervention and control groups. There was no difference in ALT (18 IU/L [13,22] versus 16 IU/L [13,21]) or INR (1.2 versus 1.2) 20 hours after starting acetylcysteine between groups. No patients developed hepatic injury or hepatotoxicity in either group (odds ratio 1.0 [95% confidence interval 0.02, 50]). No patients represented with liver injury, none died, and 96 of 96 were well at 14-day telephone follow-up. Conclusion: Discontinuing acetylcysteine based on laboratory testing after 12 hours of treatment is feasible and likely safe in selected patients at very low risk of liver injury from acetaminophen overdose.
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Affiliation(s)
- Anselm Wong
- School of Clinical Sciences, Monash University, Victoria, Australia.,Victorian Poisons Information Center and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
| | - Richard McNulty
- Department of Emergency Medicine, Blacktown and Mount Druitt Hospitals, Western Sydney Toxicology Service, NSW, Australia
| | - David Taylor
- Emergency Department and Department of Medicine, Austin Hospital, Heidelberg, Australia
| | - Marco Sivilotti
- Departments of Emergency and Biomedical & Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Shaun Greene
- Victorian Poisons Information Center and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
| | - Naren Gunja
- Western Sydney Toxicology Service, Sydney Medical School, NSW, Australia
| | - Zeff Koutsogiannis
- Victorian Poisons Information Center and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
| | - Andis Graudins
- Monash Toxicology Service and Monash Emergency Research Collaborative, Dandenong Hospital, School of Clinical Sciences, Monash University, Victoria, Australia
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Abstract
The effect and mechanisms of Myristica fragrans on blood clotting were evaluated by evaluating blood coagulation time and the fibrinolytic system. The compounds 2 and 5 were isolated from the herbal extract and their activities were assessed for the first time. None of the tested compounds had fibrinolytic activity, but could inhibit the fibrinolytic activity of urokinase. Compound 2 showed the highest inhibitory activity (IC50 = 1.747 mg·mL-1) followed by compounds 4 (IC50 = 1.818 mg·mL-1) and 1 (IC50 = 2.407 mg·mL-1), which were higher than that of the compound in Danshen drug tablets (IC50 = 6.577 mg·mL-1) used in China. Moreover, compounds 1 and 2 showed strong α-glucosidase inhibitory activity in a dose-dependent manner with IC50 values 21.76 ± 0.59 and 21.31 ± 0.00 μg·mL-1, respectively. These results demonstrated that the compounds are promising candidates as procoagulant and antidiabetic agents.
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Affiliation(s)
- Yong Zhang
- 1 Institute of Chinese Materia Medica, Pharmaceutical College, Henan University , Kaifeng, China
| | - Pingyao Xie
- 1 Institute of Chinese Materia Medica, Pharmaceutical College, Henan University , Kaifeng, China
| | - Xiuchun Guo
- 1 Institute of Chinese Materia Medica, Pharmaceutical College, Henan University , Kaifeng, China
- 2 Kaifeng Key Laboratory of Functional Components in Health Food , Kaifeng, China
| | - Wenyi Kang
- 1 Institute of Chinese Materia Medica, Pharmaceutical College, Henan University , Kaifeng, China
- 2 Kaifeng Key Laboratory of Functional Components in Health Food , Kaifeng, China
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14
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Levine M, O'Connor AD, Padilla-Jones A, Gerkin RD. Comparison of Prothrombin Time and Aspartate Aminotransferase in Predicting Hepatotoxicity After Acetaminophen Overdose. J Med Toxicol 2016; 12:100-6. [PMID: 26341088 PMCID: PMC4781795 DOI: 10.1007/s13181-015-0504-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Despite decades of experience with acetaminophen (APAP) overdoses, it remains unclear whether elevated hepatic transaminases or coagulopathy develop first. Furthermore, comparison of the predictive value of these two variables in determining hepatic toxicity following APAP overdoses has been poorly elucidated. The primary objective of this study is to determine the test characteristics of the aspartate aminotransferase (AST) and the prothrombin time (PT) in patients with APAP toxicity. A retrospective chart review of APAP overdoses treated with IV N-acetylcysteine at a tertiary care referral center was performed. Of the 304 subjects included in the study, 246 with an initial AST less than 1000 were analyzed to determine predictors of hepatic injury, defined as an AST exceeding 1000 IU/L. The initial AST >50 was 79.5 % sensitive and 82.6 % specific for predicting hepatic injury. The corresponding negative and positive predictive values were 95.5 and 46.3 %, respectively. In contrast, an initial abnormal PT had a sensitivity of 82.1 % and a specificity of 63.6 %. The negative and positive predictive values for initial PT were 94.9 and 30.2 %, respectively. Although the two tests performed similarly for predicting a composite endpoint of death or liver transplant, neither was a useful predictor. Initial AST performed better than the initial PT for predicting hepatic injury in this series of patients with APAP overdose.
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Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, Division of Medical Toxicology, University of Southern California, Los Angeles, CA, USA.
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ, USA.
| | - Ayrn D O'Connor
- Department of Medical Toxicology, Banner Good Samaritan Medical Center, Phoenix, AZ, USA
- Center for Toxicology and Pharmacology, Education, and Research, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
| | | | - Richard D Gerkin
- Center for Toxicology and Pharmacology, Education, and Research, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, USA
- Banner Research Institute, Phoenix, AZ, USA
- Department of Internal Medicine, Banner Good Samaritan Medical Center, Phoenix, AZ, USA
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15
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Handigund M, Bae TW, Lee J, Cho YG. Evaluation of in vitro storage characteristics of cold stored platelet concentrates with N acetylcysteine (NAC). Transfus Apher Sci 2016; 54:127-38. [PMID: 26847865 DOI: 10.1016/j.transci.2016.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/30/2015] [Accepted: 01/06/2016] [Indexed: 10/22/2022]
Abstract
Platelets play a vital role in hemostasis and thrombosis, and their demand and usage has multiplied many folds over the years. However, due to the short life span and storage constraints on platelets, it is allowed to store them for up to 7 days at room temperature (RT); thus, there is a need for an alternative storage strategy for extension of shelf life. Current investigation involves the addition of 50 mM N acetylcysteine (NAC) in refrigerated concentrates. Investigation results revealed that addition of NAC to refrigerated concentrates prevented platelet activation and reduced the sialidase activity upon rewarming as well as on prolonged storage. Refrigerated concentrates with 50 mM NAC expressed a 23.91 ± 6.23% of CD62P (P-Selectin) and 22.33 ± 3.42% of phosphotidylserine (PS), whereas RT-stored platelets showed a 46.87 ± 5.23% of CD62P and 25.9 ± 6.48% of phosphotidylserine (PS) after 5 days of storage. Further, key metabolic parameters such as glucose and lactate accumulation indicated reduced metabolic activity. Taken together, investigation and observations indicate that addition of NAC potentially protects refrigerated concentrates by preventing platelet activation, stabilizing sialidase activity, and further reducing the metabolic activity. Hence, we believe that NAC can be a good candidate for an additive solution to retain platelet characteristics during cold storage and may pave the way for extension of storage shelf life.
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Affiliation(s)
- Mallikarjun Handigund
- Department of Laboratory Medicine, Chonbuk National University Medical School and Hospital, Jeonju 561180, Republic of Korea
| | - Tae Won Bae
- Department of Laboratory Medicine, Chonbuk National University Medical School and Hospital, Jeonju 561180, Republic of Korea
| | - Jaehyeon Lee
- Department of Laboratory Medicine, Chonbuk National University Medical School and Hospital, Jeonju 561180, Republic of Korea; Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju 561180, Republic of Korea
| | - Yong Gon Cho
- Department of Laboratory Medicine, Chonbuk National University Medical School and Hospital, Jeonju 561180, Republic of Korea; Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju 561180, Republic of Korea; Chonbuk National University Hospital branch of National Culture Collection for Pathology, Jeonju 561180, Republic of Korea.
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Karthivashan G, Arulselvan P, Fakurazi S. Pathways involved in acetaminophen hepatotoxicity with specific targets for inhibition/downregulation. RSC Adv 2015. [DOI: 10.1039/c5ra07838e] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Insights on molecular/immunological mechanisms involve in APAP hepatotoxicity and pave way for researchers/clinicians/pharma bodies to identify novel biomarkers, effective bioactive candidates and fruitful therapy against APAP hepatotoxicity.
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Affiliation(s)
- Govindarajan Karthivashan
- Laboratory of Vaccines and Immunotherapeutics
- Institute of Bioscience
- Universiti Putra Malaysia
- Serdang
- Malaysia
| | - Palanisamy Arulselvan
- Laboratory of Vaccines and Immunotherapeutics
- Institute of Bioscience
- Universiti Putra Malaysia
- Serdang
- Malaysia
| | - Sharida Fakurazi
- Laboratory of Vaccines and Immunotherapeutics
- Institute of Bioscience
- Universiti Putra Malaysia
- Serdang
- Malaysia
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17
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Zhang W, Sun YL, Chen DH. Effects of chitin and sepia ink hybrid hemostatic sponge on the blood parameters of mice. Mar Drugs 2014; 12:2269-81. [PMID: 24727395 PMCID: PMC4012435 DOI: 10.3390/md12042269] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 03/18/2014] [Accepted: 03/25/2014] [Indexed: 11/23/2022] Open
Abstract
Chitin and sepia ink hybrid hemostatic sponge (CTSH sponge), a new biomedical material, was extensively studied for its beneficial biological properties of hemostasis and stimulation of healing. However, studies examining the safety of CTSH sponge in the blood system are lacking. This experiment aimed to examine whether CTSH sponge has negative effect on blood systems of mice, which were treated with a dosage of CTSH sponge (135 mg/kg) through a laparotomy. CTSH sponge was implanted into the abdominal subcutaneous and a laparotomy was used for blood sampling from abdominal aortic. Several kinds of blood parameters were detected at different time points, which were reflected by coagulation parameters including thrombin time (TT), prothrombin time (PT), activated partial thromboplatin time (APTT), fibrinogen (FIB) and platelet factor 4 (PF4); anticoagulation parameter including antithrombin III (AT-III); fibrinolytic parameters including plasminogen (PLG), fibrin degradation product (FDP) and D-dimer; hemorheology parameters including blood viscosity (BV) and plasma viscosity (PV). Results showed that CTSH sponge has no significant effect on the blood parameters of mice. The data suggested that CTSH sponge can be applied in the field of biomedical materials and has potential possibility to be developed into clinical drugs of hemostatic agents.
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Affiliation(s)
- Wei Zhang
- Zhanjiang Normal University, Round Beibu Gulf Institute for the Protection and Utilization of Marine Animals in Medicine, Zhanjiang 524048, China.
| | - Yu-Lin Sun
- Zhanjiang Normal University, Round Beibu Gulf Institute for the Protection and Utilization of Marine Animals in Medicine, Zhanjiang 524048, China.
| | - Dao-Hai Chen
- Zhanjiang Normal University, Round Beibu Gulf Institute for the Protection and Utilization of Marine Animals in Medicine, Zhanjiang 524048, China.
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