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Mehrpour O, Saeedi F, Hoyte C. Decision tree outcome prediction of acute acetaminophen exposure in the United States: A study of 30,000 cases from the National Poison Data System. Basic Clin Pharmacol Toxicol 2021; 130:191-199. [PMID: 34649297 DOI: 10.1111/bcpt.13674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 10/08/2021] [Accepted: 10/12/2021] [Indexed: 12/25/2022]
Abstract
Acetaminophen is one of the most commonly used analgesic drugs in the United States. However, the outcomes of acute acetaminophen overdose might be very serious in some cases. Therefore, prediction of the outcomes of acute acetaminophen exposure is crucial. This study is a 6-year retrospective cohort study using National Poison Data System (NPDS) data. A decision tree algorithm was used to determine the risk predictors of acetaminophen exposure. The decision tree model had an accuracy of 0.839, an accuracy of 0.836, a recall of 0.72, a specificity of 0.86 and an F1_score of 0.76 for the test group and an accuracy of 0.848, a recall of 0.85, a recall of 0.74, a specificity of 0.87 and an F1_score of 0.78 for the training group. Our results showed that elevated serum levels of liver enzymes, other liver function test abnormality, anorexia, acidosis, electrolyte abnormality, increased bilirubin, coagulopathy, abdominal pain, coma, increased anion gap, tachycardia and hypotension were the most important factors in determining the outcome of acute acetaminophen exposure. Therefore, the decision tree model is a reliable approach in determining the prognosis of acetaminophen exposure cases and can be used in an emergency room or during hospitalization.
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Affiliation(s)
- Omid Mehrpour
- Data Science Institute, Southern Methodist University, Dallas, Texas, USA.,Rocky Mountain Poison and Drug Safety, Denver Health and Hospital Authority, Denver, Colorado, USA
| | - Farhad Saeedi
- Student Research Committee, Birjand University of Medical Sciences, Birjand, Iran.,Medical Toxicology and Drug Abuse Research Center (MTDRC), Birjand University of Medical Sciences (BUMS), Birjand, Iran
| | - Christopher Hoyte
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,University of Colorado Hospital, Aurora, Colorado, USA
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2
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Sattari M, Ostadi A, Hassani S, Mazloumi Z, Noshad H, Mirnia K, Salek Maghsoudi A. Plasma Concentration of Taurine Changes following Acetaminophen Overdose in Male Patients during Hospitalization. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2021; 20:297-306. [PMID: 34567163 PMCID: PMC8457743 DOI: 10.22037/ijpr.2020.113698.14435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Changes in plasma concentration of taurine during hospitalization of acetaminophen poisoned patients have not been studied. Hepatotoxicity is a common consequence of acetaminophen overdose that may lead to acute liver failure. Numerous biomarkers for drug-induced liver injury have been explored. All biomarkers are usually obtainable 48 h following acetaminophen overdose. We have already introduced taurine as a non-specific early biomarker of acetaminophen overdose. This study aimed to follow up changes in plasma concentration of taurine during the first three days of acetaminophen overdose. Sixty-four male patients suffering from acetaminophen overdose were selected for the study. Four blood samples were taken from the patients every 12 h. Sixty blood samples were also taken from sixty healthy humans. The plasma concentration of taurine in both groups was analyzed an already developed HPLC method. Analysis of regression showed a significant correlation between means of plasma concentrations of taurine and acetaminophen, aspartate aminotransferase, Alanine aminotransferase, glutathione peroxidase, and prothrombin time during hospitalization. The high plasma concentration of taurine, 6 h or more after acetaminophen overdose, could be a useful early indicator of liver damage.
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Affiliation(s)
- Mohammadreza Sattari
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali Ostadi
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Internal Medicine, Sina Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Shokoufeh Hassani
- Toxicology and Diseases Group (TDG), Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran.,Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Zeynab Mazloumi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari, Iran
| | - Hamid Noshad
- Department of Nephrology, Sina Hospital, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kayvan Mirnia
- Department of Neonatology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Armin Salek Maghsoudi
- Toxicology and Diseases Group (TDG), Pharmaceutical Sciences Research Center (PSRC), The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran.,Department of Toxicology and Pharmacology, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
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3
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Reddoch-Cardenas KM, Cheppudira BP, Garza T, Hopkins CD, Bunker KD, Slee DH, Cap AP, Bynum JA, Christy RJ. Evaluation of KP-1199: a novel acetaminophen analog for hemostatic function and antinociceptive effects. Transfusion 2021; 61 Suppl 1:S234-S242. [PMID: 34269435 DOI: 10.1111/trf.16497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acetaminophen (APAP) is a widely self-prescribed analgesic for mild to moderate pain, but overdose or repeat doses can lead to liver injury and death. Kalyra Pharmaceuticals has developed a novel APAP analog, KP-1199, currently in Phase 1 clinical studies, which lacks hepatotoxicity. In this study, the authors evaluated the antinociceptive effect of KP-1199 on thermal injury-induced nociceptive behaviors as well as hemostatic parameters using human blood samples. METHODS Full-thickness thermal injury was induced in anesthetized adult male Sprague-Dawley rats. On day 7 post-injury, KP-1199 (30 and 60 mg/kg) or APAP (60 mg/kg) was administered orally. Antinociception of KP-1199 and APAP were assessed at multiple time points using Hargreaves' test. In separate experiments, human whole blood was collected and treated with either KP-1199, APAP, or Vehicle (citrate buffer) at 1× (214 μg/ml) and 10× (2140 μg/ml) concentrations. The treated blood samples were assessed for: clotting function, thrombin generation, and platelet activation. RESULTS APAP did not produce antinociceptive activity. KP-1199 treatment significantly increased the nociceptive threshold, and the antinociceptive activity persisted up to 3 h post-treatment. In human samples, 10× APAP caused significantly prolonged clotting times and increased platelet activation, whereas KP-1199 had caused no negative effects on either parameter tested. CONCLUSION These results suggest that KP-1199 possesses antinociceptive activity in a rat model of thermal injury. Since KP-1199 does not induce platelet activation or inhibit coagulation, it presents an attractive alternative to APAP for analgesia, especially for battlefield or surgical scenarios where blood loss and blood clotting are of concern.
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Affiliation(s)
| | - Bopaiah P Cheppudira
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Thomas Garza
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Chad D Hopkins
- Kalyra Pharmaceuticals, Inc., San Diego, California, USA
| | - Kevin D Bunker
- Kalyra Pharmaceuticals, Inc., San Diego, California, USA
| | | | - Andrew P Cap
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - James A Bynum
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
| | - Robert J Christy
- United States Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, Texas, USA
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Yen JS, Hu CC, Huang WH, Hsu CW, Yen TH, Weng CH. An artificial intelligence algorithm for analyzing acetaminophen-associated toxic hepatitis. Hum Exp Toxicol 2021; 40:1947-1954. [PMID: 33955253 DOI: 10.1177/09603271211014587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Very little artificial intelligence (AI) work has been performed to investigate acetaminophen-associated hepatotoxicity. The objective of this study was to develop an AI algorithm for analyzing weighted features for toxic hepatitis after acetaminophen poisoning. METHODS The medical records of 187 patients with acetaminophen poisoning treated at Chang Gung Memorial Hospital were reviewed. Patients were sorted into two groups according to their status of toxic hepatitis. A total of 40 clinical and laboratory features recorded on the first day of admission were selected for algorithm development. The random forest classifier (RFC) and logistic regression (LR) were used for artificial intelligence algorithm development. RESULTS The RFC-based AI model achieved the following results: accuracy = 92.5 ± 2.6%; sensitivity = 100%; specificity = 60%; precision = 92.3 ± 3.4%; and F1 = 96.0 ± 1.8%. The area under the receiver operating characteristic curve (AUROC) was approximately 0.98. The LR-based AI model achieved the following results: accuracy = 92.00 ± 2.9%; sensitivity = 100%; specificity = 20%; precision = 92.8 ± 3.4%; recall = 98.8 ± 3.4%; and F1 = 95.6 ± 1.5%. The AUROC was approximately 0.68. The weighted features were calculated, and the 10 most important weighted features for toxic hepatitis were aspartate aminotransferase (ALT), prothrombin time, alanine aminotransferase (AST), time to hospital, platelet count, lymphocyte count, albumin, total bilirubin, body temperature and acetaminophen level. CONCLUSION The top five weighted features for acetaminophen-associated toxic hepatitis were ALT, prothrombin time, AST, time to hospital and platelet count.
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Affiliation(s)
- J-S Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou
| | - C-C Hu
- College of Medicine, Chang Gung University, Taoyuan.,Department of Hepatogastroenterology and Liver Research Unit, Chang Gung Memorial Hospital, Keelung
| | - W-H Huang
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
| | - C-W Hsu
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
| | - T-H Yen
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou
| | - C-H Weng
- Department of Nephrology and Clinical Poison Center, Chang Gung Memorial Hospital, Linkou.,College of Medicine, Chang Gung University, Taoyuan.,Kidney Research Center, Chang Gung Memorial Hospital, Linkou
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5
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Mullins ME, Seger DL. Authors’ reply to Comment on antidotal use of lipid emulsion. Clin Toxicol (Phila) 2020; 58:1357-1358. [DOI: 10.1080/15563650.2020.1775243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Michael E. Mullins
- Section of Medical Toxicology, Department of Emergency Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Donna L. Seger
- Tennessee Poison Center, Vanderbilt University Medical Center, Nashville, TN, USA
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Abualhasan MN, Al- Masri MY, Manasara R, Yadak L, Abu-Hasan NS. Anti-Inflammatory and Anticoagulant Activities of Synthesized NSAID Prodrug Esters. SCIENTIFICA 2020; 2020:9817502. [PMID: 33093967 PMCID: PMC7271289 DOI: 10.1155/2020/9817502] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 03/30/2020] [Accepted: 04/30/2020] [Indexed: 06/11/2023]
Abstract
Paracetamol with ibuprofen or with naproxen are frequently prescribed by doctors in combination. It was found that patients using a combination of NSAID like acetaminophen and ibuprofen experienced less pain. Patients are more compliant if these two drugs are combined in an ester form and given in one dosage form. The esterified prodrugs are hydrolyzed in humans to their active forms. In this study, two esters of paracetamol combined with ibuprofen and naproxen were synthesized as prodrugs. The physiochemical properties of these products were identified. Moreover, the bioactivities of these prodrugs were tested for its anti-inflammatory and anticoagulant activities. The results showed an improved COX inhibition and anticoagulant activity compared with their parent drugs. The synthesized drugs are expected to improve patient's compliance in terms of administration frequency and will have better pharmacokinetic properties with fewer side effects.
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Affiliation(s)
- Murad N. Abualhasan
- Faculty of Medicine and Health Sciences, Department of Pharmacy, An-Najah National University, Nablus, State of Palestine
| | - Motasem Y. Al- Masri
- Faculty of Science, Department of Biology, An-Najah National University, Nablus, State of Palestine
| | - Rufaida Manasara
- Faculty of Medicine and Health Sciences, Department of Pharmacy, An-Najah National University, Nablus, State of Palestine
| | - Lana Yadak
- Faculty of Medicine and Health Sciences, Department of Pharmacy, An-Najah National University, Nablus, State of Palestine
| | - Nael S. Abu-Hasan
- Faculty of Science, Department of Biology, An-Najah National University, Nablus, State of Palestine
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7
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Stefanello ST, de Carvalho NR, Reis SB, Soares FAA, Barcelos RP. Acetaminophen Oxidation and Inflammatory Markers - A Review of Hepatic Molecular Mechanisms and Preclinical Studies. Curr Drug Targets 2020; 21:1225-1236. [PMID: 32386489 DOI: 10.2174/1389450121666200510014418] [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: 11/01/2019] [Revised: 01/06/2020] [Accepted: 02/21/2020] [Indexed: 11/22/2022]
Abstract
Acetaminophen is a widely used analgesic for pain management, especially useful in chronic diseases, such as rheumatoid arthritis. However, easy access to this medicine has increased the occurrence of episodes of poisoning. Patients often develop severe liver damage, which may quickly lead to death. Consequently, numerous studies have been conducted to identify new biomarkers that allow the prediction of the degree of acetaminophen intoxication and thus intervene in a timely manner to save patients' lives. This review highlights the main mechanisms of the induction and progression of liver damage arising from acetaminophen poisoning. In addition, we have discussed the possibility of using new clinical biomarkers for detecting acetaminophen poisoning.
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Affiliation(s)
- Silvio Terra Stefanello
- Programa de Pos-Graduacao em Bioquimica Toxicologica, Centro de Ciencias Naturais e Exatas (CCNE), Universidade Federal de Santa Maria, Brazil
| | | | - Simone Beder Reis
- Institudo de Ciencias Biologicas (ICB), Programa de Posgraduacao em Bioexperimentacao, Universidade de Passo Fundo, Passo Fundo, Brazil
| | - Felix Alexandre Antunes Soares
- Programa de Pos-Graduacao em Bioquimica Toxicologica, Centro de Ciencias Naturais e Exatas (CCNE), Universidade Federal de Santa Maria, Brazil
| | - Rômulo Pillon Barcelos
- Programa de Pos-Graduacao em Bioquimica Toxicologica, Centro de Ciencias Naturais e Exatas (CCNE), Universidade Federal de Santa Maria, Brazil
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Abstract
Drug-induced liver injury (DILI) is a major clinical and regulatory challenge. As a result, interest in DILI biomarkers is growing. So far, considerable progress has been made in identification of biomarkers for diagnosis (acetaminophen-cysteine protein adducts), prediction (genetic biomarkers), and prognosis (microRNA-122, high mobility group box 1 protein, keratin-18, glutamate dehydrogenase, mitochondrial DNA). Many of those biomarkers also provide mechanistic insight. The purpose of this chapter is to review major advances in DILI biomarker research over the last decade, and to highlight some of the challenges involved in implementation. Although much work has been done, more liver-specific biomarkers, more DILI-specific biomarkers, and better prognostic biomarkers for survival are all still needed. Furthermore, more work is needed to define reference intervals and medical decision limits.
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Affiliation(s)
- Mitchell R McGill
- Department of Environmental and Occupational Health, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, United States; Department of Pharmacology and Toxicology, University of Arkansas for Medical Sciences, Little Rock, AR, United States.
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, KS, United States
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9
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Hegarty R, Dhawan A. Fifteen-minute consultation: The child with an incidental finding of elevated aminotransferases. Arch Dis Child Educ Pract Ed 2018; 103:228-230. [PMID: 29434022 DOI: 10.1136/archdischild-2016-311935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 12/18/2017] [Accepted: 01/17/2018] [Indexed: 01/19/2023]
Abstract
It is not unusual to encounter abnormal liver enzyme levels on routine blood tests. When the abnormal elevation in aminotransferases persist, they require prompt and appropriate investigations as liver diseases in children are often insidious in onset and clinically silent. This article aims to provide (1) an explanation to the aetiologies of elevated aminotransferases; (2) an investigational approach to these children and (3) an insight into further investigations performed at a liver centre.
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Affiliation(s)
- Robert Hegarty
- Paediatric Liver, GI, Nutrition Centre and MowatLabs, King's College Hospital, London, United Kingdom
| | - Anil Dhawan
- Paediatric Liver, GI, Nutrition Centre and MowatLabs, King's College Hospital, London, United Kingdom
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Ozarda Y, Sikaris K, Streichert T, Macri J. Distinguishing reference intervals and clinical decision limits - A review by the IFCC Committee on Reference Intervals and Decision Limits. Crit Rev Clin Lab Sci 2018; 55:420-431. [PMID: 30047297 DOI: 10.1080/10408363.2018.1482256] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Reference Intervals (RIs) and clinical decision limits (CDLs) are a vital part of the information supplied by laboratories to support the interpretation of numerical clinical pathology results. RIs describe the typical distribution of results seen in a healthy reference population while CDLs are associated with a significantly higher risk of adverse clinical outcomes or are diagnostic for the presence of a specific disease. However, as the two concepts are sometimes confused, there is a need to clarify the differences between these terms and to ensure they are easily distinguished, especially because CDLs have a clinical association with specific diseases and risks, thereby implying that effective clinical interventions are available. It is important to note that, because population-based RIs are derived from the range of values expected in a typical community population, laboratory results that fall outside a RI do not necessarily indicate a disease but rather that additional medical follow-up and/or treatment may be warranted. In contrast, CDLs are associated with a risk of specific adverse outcomes, and are commonly used to interpret laboratory test results, including lipid parameters, glucose, hemoglobin A1c (HbA1c), and tumor markers, to determine risk of disease, to diagnose or to treat. In recent years, the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) Committee on Reference Intervals and Decision Limits (C-RIDL) has focused primarily on RIs and has performed multicenter studies to obtain common RIs. However, the broader responsibility of the Committee, from its name, includes "decision limits". C-RIDL now aims to emphasize the importance of the correct use of both RIs and CDLs and to encourage laboratories to specify the appropriate information to clinicians as needed. This review discusses RIs and CDLs in detail, describes the similarities and the differences between these two important tools in laboratory medicine, and clearly explains the processes used to define them. C-RIDL encourages the involvement of laboratory professionals in the establishment of both RIs and CDLs.
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Affiliation(s)
- Yesim Ozarda
- a Department of Medical Biochemistry , Uludag University School of Medicine , Bursa , Turkey
| | - Ken Sikaris
- b Department of Pathology , Melbourne University , Parkville , Melbourne , Australia
| | - Thomas Streichert
- c Institute for Laboratory Medicine , Klinikum Bremen-Mitte , Bremen , Germany
| | - Joseph Macri
- d Hamilton General Hospital , Hamilton , Ontario , Canada
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Wong A, Graudins A. Risk prediction of hepatotoxicity in paracetamol poisoning. Clin Toxicol (Phila) 2017; 55:879-892. [DOI: 10.1080/15563650.2017.1317349] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Anselm Wong
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
- Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Clinical Toxicology Service, Program of Emergency Medicine, Monash Health, Clayton, Australia
| | - Andis Graudins
- Victorian Poisons Information Centre and Austin Toxicology Service, Austin Hospital, Heidelberg, Australia
- Monash Emergency Research Collaborative, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- Clinical Toxicology Service, Program of Emergency Medicine, Monash Health, Clayton, Australia
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12
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Levine M, O’Connor AD, Padilla-Jones A, Gerkin R. Comparison of Prothrombin Time and Aspartate Aminotransferase in Predicting Hepatotoxicity After Acetaminophen Overdose: a Response. J Med Toxicol 2016; 12:218. [DOI: 10.1007/s13181-015-0514-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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13
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In Response to: “Comparison of Prothrombin Time and Aspartate Aminotransferase in Predicting Hepatotoxicity After Acetaminophen Overdose.”. J Med Toxicol 2016; 12:217. [DOI: 10.1007/s13181-015-0513-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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