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Parker W, Anderson LG, Jones JP, Anderson R, Williamson L, Bono-Lunn D, Konsoula Z. The Dangers of Acetaminophen for Neurodevelopment Outweigh Scant Evidence for Long-Term Benefits. CHILDREN (BASEL, SWITZERLAND) 2023; 11:44. [PMID: 38255358 PMCID: PMC10814214 DOI: 10.3390/children11010044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/20/2023] [Accepted: 12/27/2023] [Indexed: 01/24/2024]
Abstract
Based on available data that include approximately 20 lines of evidence from studies in laboratory animal models, observations in humans, correlations in time, and pharmacological/toxicological considerations, it has been concluded without reasonable doubt and with no evidence to the contrary that exposure of susceptible babies and children to acetaminophen (paracetamol) induces many, if not most, cases of autism spectrum disorder (ASD). However, the relative number of cases of ASD that might be induced by acetaminophen has not yet been estimated. Here, we examine a variety of evidence, including the acetaminophen-induced reduction of social awareness in adults, the prevalence of ASD through time, and crude estimates of the relative number of ASD cases induced by acetaminophen during various periods of neurodevelopment. We conclude that the very early postpartum period poses the greatest risk for acetaminophen-induced ASD, and that nearly ubiquitous use of acetaminophen during early development could conceivably be responsible for the induction in the vast majority, perhaps 90% or more, of all cases of ASD. Despite over a decade of accumulating evidence that acetaminophen is harmful for neurodevelopment, numerous studies demonstrate that acetaminophen is frequently administered to children in excess of currently approved amounts and under conditions in which it provides no benefit. Further, studies have failed to demonstrate long-term benefits of acetaminophen for the pediatric population, leaving no valid rationale for continued use of the drug in that population given its risks to neurodevelopment.
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Affiliation(s)
- William Parker
- Department of Psychology and Neuroscience, University of North Carolina, Chapel Hill, NC 27599, USA
- WPLab, Inc., Durham, NC 27707, USA
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | | | | | | | - Lauren Williamson
- Department of Biological Sciences, Northern Kentucky University, Highland Heights, KY 41099, USA;
| | - Dillan Bono-Lunn
- Department of Public Policy, University of North Carolina, Chapel Hill, NC 27599, USA;
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2
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Wright K, Craske J, Gill A, Jenson J, Arnold P. Evaluation of age-banded dosing of oral paracetamol in hospitalised children: a retrospective analysis using clinical data in a tertiary paediatric hospital. Arch Dis Child 2023:archdischild-2022-325267. [PMID: 37185173 DOI: 10.1136/archdischild-2022-325267] [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: 12/22/2022] [Accepted: 03/29/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To evaluate age-banded dosing in paediatric inpatients by determining the proportion of patients whose dose would fall outside the therapeutic range (by weight). DESIGN A retrospective observational study. Weight and height measurements and details of hospital admissions were matched from the electronic patient record of a single, tertiary paediatric hospital. Dosage which would be given according to age-banded dosing was then compared with their weight. PARTICIPANTS All children admitted to a single tertiary children's hospital aged 3 months to 16 years over a 5-year period. Data were cleaned to remove values likely to be erroneous and filtered to reduce bias due to patients who were admitted on multiple occasions. OUTCOMES The main outcome was the proportion of patients who would receive a subtherapeutic or supratherapeutic paracetamol dose if given a dose based on their age. Secondary outcomes were to examine this in children of different ages and to examine the impact of alternative size-based dosing strategies. RESULTS 100 047 admissions (in 68 310 patients) had a weight documented. If age-banded dosing had been used, a subtherapeutic dose (less than 10 mg/kg) would be given during 19 829 (20%) of the admissions and a supratherapeutic dose (over 18.75 mg/kg, 75 mg/kg/day in four doses) in 4289 (4.3%). The highest risk of a subtherapeutic dose occurred in infants just prior to reaching 6 months of age (83%) and in children just prior to reaching 8 years (66%). The highest risk of a supratherapeutic dose was at 12 years of age (35%). CONCLUSION Age-banded dosing is not suitable for an inpatient paediatric population as approximately a quarter of patients receive a dose outside the recommended range of 10.0-18.75 mg/kg.
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Affiliation(s)
- Kirstie Wright
- Acute Medicine, Harrogate District Hospital, Harrogate, UK
| | - Jennie Craske
- Pain Service, Department of Anaesthesia, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Andrea Gill
- School of Pharmacy and Biomolecular Sciences, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - John Jenson
- Business Intelligence, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Philip Arnold
- Anesthesia, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
- Faculty of Medicine and Life Sciences, University of Liverpool, Liverpool, Merseyside, UK
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3
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Chamorro-Garcia A, Gerson J, Flatebo C, Fetter L, Downs AM, Emmons N, Ennis HL, Milosavić N, Yang K, Stojanovic M, Ricci F, Kippin TE, Plaxco KW. Real-Time, Seconds-Resolved Measurements of Plasma Methotrexate In Situ in the Living Body. ACS Sens 2023; 8:150-157. [PMID: 36534756 DOI: 10.1021/acssensors.2c01894] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Dose-limiting toxicity and significant patient-to-patient pharmacokinetic variability often render it difficult to achieve the safe and effective dosing of drugs. This is further compounded by the slow, cumbersome nature of the analytical methods used to monitor patient-specific pharmacokinetics, which inevitably rely on blood draws followed by post-facto laboratory analysis. Motivated by the pressing need for improved "therapeutic drug monitoring", we are developing electrochemical aptamer-based (EAB) sensors, a minimally invasive biosensor architecture that can provide real-time, seconds-resolved measurements of drug levels in situ in the living body. A key advantage of EAB sensors is that they are generalizable to the detection of a wide range of therapeutic agents because they are independent of the chemical or enzymatic reactivity of their targets. Three of the four therapeutic drug classes that have, to date, been shown measurable using in vivo EAB sensors, however, bind to nucleic acids as part of their mode of action, leaving open questions regarding the extent to which the approach can be generalized to therapeutics that do not. Here, we demonstrate real-time, in vivo measurements of plasma methotrexate, an antimetabolite (a mode of action not reliant on DNA binding) chemotherapeutic, following human-relevant dosing in a live rat animal model. By providing hundreds of drug concentration values, the resulting seconds-resolved measurements succeed in defining key pharmacokinetic parameters, including the drug's elimination rate, peak plasma concentration, and exposure (area under the curve), with unprecedented 5 to 10% precision. With this level of precision, we easily identify significant (>2-fold) differences in drug exposure occurring between even healthy rats given the same mass-adjusted methotrexate dose. By providing a real-time, seconds-resolved window into methotrexate pharmacokinetics, such measurements can be used to precisely "individualize" the dosing of this significantly toxic yet vitally important chemotherapeutic.
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Affiliation(s)
- Alejandro Chamorro-Garcia
- Department of Chemistry and Biochemistry, University of California Santa Barbara, Santa Barbara, California 93106, United States.,Dipartimento di Scienze e Tecnologie Chimiche, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Julian Gerson
- Department of Psychological and Brain Sciences, University of California Santa Barbara, Santa Barbara, California 93106, United States
| | - Charlotte Flatebo
- Institute for Collaborative Biotechnologies, University of California Santa Barbara, Santa Barbara, California 93106, United States
| | - Lisa Fetter
- Biomolecular Science and Engineering Program, University of California Santa Barbara, Santa Barbara, California 93106, United States
| | - Alex M Downs
- Department of Mechanical Engineering, University of California Santa Barbara, Santa Barbara, California 93106, United States
| | - Nicole Emmons
- Department of Psychological and Brain Sciences, University of California Santa Barbara, Santa Barbara, California 93106, United States
| | - Herbert L Ennis
- Center for Innovative Diagnostic and Therapeutic Approaches, Department of Medicine, Columbia University New York, New York, New York 10032, United States
| | - Nenad Milosavić
- Center for Innovative Diagnostic and Therapeutic Approaches, Department of Medicine, Columbia University New York, New York, New York 10032, United States
| | - Kyungae Yang
- Center for Innovative Diagnostic and Therapeutic Approaches, Department of Medicine, Columbia University New York, New York, New York 10032, United States
| | - Milan Stojanovic
- Center for Innovative Diagnostic and Therapeutic Approaches, Department of Medicine, Columbia University New York, New York, New York 10032, United States.,Department of Biomedical Engineering and Systems Biology, Columbia University New York, New York, New York 10032, United States
| | - Francesco Ricci
- Dipartimento di Scienze e Tecnologie Chimiche, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Tod E Kippin
- Department of Psychological and Brain Sciences, University of California Santa Barbara, Santa Barbara, California 93106, United States
| | - Kevin W Plaxco
- Department of Chemistry and Biochemistry, University of California Santa Barbara, Santa Barbara, California 93106, United States.,Biomolecular Science and Engineering Program, University of California Santa Barbara, Santa Barbara, California 93106, United States.,Department of Mechanical Engineering, University of California Santa Barbara, Santa Barbara, California 93106, United States.,Biological Engineering Graduate Program, University of California Santa Barbara, Santa Barbara, California 93106, United States
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4
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Yan J, Ni Y, Tan L, Zheng S, Zhang Y, Liu J, Wang Z. Efficacy and safety of Dazhui (GV 14) as a single acupoint for managing fever: A systematic review. Eur J Integr Med 2022. [DOI: 10.1016/j.eujim.2022.102196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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5
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Hepatic, Extrahepatic and Extracellular Vesicle Cytochrome P450 2E1 in Alcohol and Acetaminophen-Mediated Adverse Interactions and Potential Treatment Options. Cells 2022; 11:cells11172620. [PMID: 36078027 PMCID: PMC9454765 DOI: 10.3390/cells11172620] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/03/2022] [Accepted: 08/19/2022] [Indexed: 12/15/2022] Open
Abstract
Alcohol and several therapeutic drugs, including acetaminophen, are metabolized by cytochrome P450 2E1 (CYP2E1) into toxic compounds. At low levels, these compounds are not detrimental, but higher sustained levels of these compounds can lead to life-long problems such as cytotoxicity, organ damage, and cancer. Furthermore, CYP2E1 can facilitate or enhance the effects of alcohol-drug and drug-drug interactions. In this review, we discuss the role of CYP2E1 in the metabolism of alcohol and drugs (with emphasis on acetaminophen), mediating injury/toxicities, and drug-drug/alcohol-drug interactions. Next, we discuss various compounds and various nutraceuticals that can reduce or prevent alcohol/drug-induced toxicity. Additionally, we highlight experimental outcomes of alcohol/drug-induced toxicity and potential treatment strategies. Finally, we cover the role and implications of extracellular vesicles (EVs) containing CYP2E1 in hepatic and extrahepatic cells and provide perspectives on the clinical relevance of EVs containing CYP2E1 in intracellular and intercellular communications leading to drug-drug and alcohol-drug interactions. Furthermore, we provide our perspectives on CYP2E1 as a druggable target using nutraceuticals and the use of EVs for targeted drug delivery in extrahepatic and hepatic cells, especially to treat cellular toxicity.
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Piton GR, Augusto KKL, Wong A, Moraes FC, Fatibello‐Filho O. A Novel Electrochemical Glassy Carbon Electrode Modified with Carbon Black and Glyceline Deep Eutectic Solvent within a Crosslinked Chitosan Film for Simultaneous Determination of Acetaminophen and Diclofenac. ELECTROANAL 2021. [DOI: 10.1002/elan.202100325] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Gabriela R. Piton
- Department of Chemistry Federal University of São Carlos C.P. 676 13560-970 São Carlos SP Brazil
| | - Karen K. L. Augusto
- Department of Chemistry Federal University of São Carlos C.P. 676 13560-970 São Carlos SP Brazil
| | - Ademar Wong
- Department of Chemistry Federal University of São Carlos C.P. 676 13560-970 São Carlos SP Brazil
| | - Fernando C. Moraes
- Department of Chemistry Federal University of São Carlos C.P. 676 13560-970 São Carlos SP Brazil
| | - Orlando Fatibello‐Filho
- Department of Chemistry Federal University of São Carlos C.P. 676 13560-970 São Carlos SP Brazil
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Wu HM, Lee SG, Oh CS, Kim SG. Hypergravity Load Modulates Acetaminophen Nephrotoxicity via Endoplasmic Reticulum Stress in Association with Hepatic microRNA-122 Expression. Int J Mol Sci 2021; 22:4901. [PMID: 34063126 PMCID: PMC8124210 DOI: 10.3390/ijms22094901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/03/2021] [Accepted: 05/03/2021] [Indexed: 02/06/2023] Open
Abstract
Hypergravity conditions may subject the kidney to intrinsic stress and lead to hemodynamic kidney dysfunction. However, the mechanisms underlying this phenomenon remain unclear. Accumulation of unfolded proteins in the endoplasmic reticulum (i.e., ER stress) is often observed in kidney diseases. Therefore, this study investigated whether hypergravity stress alters acetaminophen-induced renal toxicity in vivo, as well as the molecular mechanisms involved in this process. C57BL/6 mice were submitted to one or three loads of +9 Gx hypergravity for 1 h with or without acetaminophen (APAP) treatment. The protein levels of cell survival markers, including pAKT and pCREB, were decreased in the kidney after acetaminophen treatment with a single hypergravity load. Additionally, the combined treatment increased kidney injury markers, serum creatinine, and Bax, Bcl2, and Kim-1 transcript levels and enhanced ER stress-related markers were further. Moreover, multiple hypergravity loads enabled mice to overcome kidney injury, as indicated by decreases in serum creatinine content and ER stress marker levels, along with increased cell viability indices. Similarly, multiple hypergravity loads plus APAP elevated miR-122 levels in the kidney, which likely originated from the liver, as the levels of primary miR-122 increased only in the liver and not the kidney. Importantly, this phenomenon may contribute to overcoming hypergravity-induced kidney injury. Taken together, our results demonstrate that APAP-exposed mice submitted to a single load of hypergravity exhibited more pronounced kidney dysfunction due to increased ER stress, which may be overcome by repetitive hypergravity loads presumably due to increased production of miR-122 in the liver. Thus, our study provides novel insights into the mechanisms by which hypergravity stress plus APAP medication induce kidney injury, which may be overcome by repeated hypergravity exposure.
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Affiliation(s)
- Hong-Min Wu
- College of Pharmacy, Seoul National University, Seoul 08826, Korea; (H.-M.W.); (S.-G.L.)
| | - Sang-Gil Lee
- College of Pharmacy, Seoul National University, Seoul 08826, Korea; (H.-M.W.); (S.-G.L.)
| | - Choong-Sik Oh
- Aerospace Medical Center, ROKAF, Cheong-ju 360-842, Korea;
| | - Sang-Geon Kim
- College of Pharmacy and Integrated Research Institute for Drug Development, Dongguk University-Seoul, Goyang-si, Gyeonggi-Do 10326, Korea
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8
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Krampa FD, Aniweh Y, Kanyong P, Awandare GA. Graphene nanoplatelet-based sensor for the detection of dopamine and N-acetyl-p-aminophenol in urine. ARAB J CHEM 2020. [DOI: 10.1016/j.arabjc.2018.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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9
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Schuman SS, Regen RB, Stuart LH, Harrell C, Jones TL, Stewart BM, Berg AM, Longjohn M, Kink RJ. Reducing Time to Pain Medication Administration for Pediatric Patients with Long Bone Fractures in the Emergency Department. Pediatr Qual Saf 2019; 3:e120. [PMID: 31334452 PMCID: PMC6581474 DOI: 10.1097/pq9.0000000000000120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/28/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction Pain management is a critical aspect of effective long bone fracture treatment. Pediatric patients frequently report suboptimal pain management, which is an area of growing public concern. The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures ≤47 minutes of emergency department arrival. Methods A multidisciplinary team developed a standardized protocol for pain management of patients presenting with musculoskeletal pain utilizing acetaminophen as the first-line agent under a nurse-initiated order. Following education and implementation, weekly reports generated using the International Classification of Diseases codes of fractures were reviewed to assess compliance with the protocol. This study evaluates the frequency of a second pain medication administration and reduction in vital signs and pain scores. Results Implementation of a pain management protocol reduced median time to pain medication administration to 26 minutes. Overall, 63% (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second pain medication. No significant changes in pre and posttreatment vital signs were found between groups. Patients who initially received opioids experienced a greater reduction in posttreatment pain scores. Conclusions Using a standardized pain management protocol in combination with comprehensive education effectively reduces median time to pain medication administration in pediatric patients with long bone fractures. Acetaminophen is a rapid and effective first-line agent for managing pain in this population.
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Affiliation(s)
- Sarah S Schuman
- Department of Pharmacy, Le Bonheur Children's Hospital, Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center
| | - Rebecca B Regen
- Department of Pharmacy, Le Bonheur Children's Hospital, Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center
| | - Lindsay H Stuart
- Department of Pharmacy, Le Bonheur Children's Hospital, Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center
| | - Camden Harrell
- Children's Foundation Research Institute, Le Bonheur Children's Hospital
| | - Tamekia L Jones
- Children's Foundation Research Institute, Le Bonheur Children's Hospital, Department of Pediatrics, Department of Preventative Medicine, The University of Tennessee Health Science Center
| | | | - Allyson M Berg
- Department of Pharmacy, Le Bonheur Children's Hospital, Department of Clinical Pharmacy and Translational Science, The University of Tennessee Health Science Center
| | - Mindy Longjohn
- Division of Pediatric Emergency Medicine, Department of Pediatric Medicine, Le Bonheur Children's Hospital, The University of Tennessee Health Science Center
| | - Rudy J Kink
- Division of Pediatric Emergency Medicine, Department of Pediatric Medicine, Le Bonheur Children's Hospital, The University of Tennessee Health Science Center
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10
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Lubrano R, Paoli S, Bonci M, Di Ruzza L, Cecchetti C, Falsaperla R, Pavone P, Matin N, Vitaliti G, Gentile I. Acetaminophen administration in pediatric age: an observational prospective cross-sectional study. Ital J Pediatr 2016; 42:20. [PMID: 26920747 PMCID: PMC4769520 DOI: 10.1186/s13052-016-0219-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/18/2016] [Indexed: 12/03/2022] Open
Abstract
Background Parents often do not consider fever as an important physiological response and mechanism of defense against infections that leads to inappropriate use of antipyretics and potentially dangerous side effects. This study is designed to evaluate the appropriateness of antipyretics dosages generally administered to children with fever, and to identify factors that may influence dosage accuracy. Results In this cross-sectional study we analyzed the clinical records of 1397 children aged >1 month and < 16 years, requiring a primary care (ambulatory) outpatient visit due to fever. We evaluated the number of children who had received >90 mg/kg/day of acetaminophen, the prescriber, the medication formula and the educational level of the caregiver who administered acetaminophen. Among those children included in our study, 74 % were administered acetaminophen for body temperature ≤ 38.4 °C. 24.12 % of children received >90 mg/kg/day of acetaminophen. Parents with university qualifications most commonly self-administered acetaminophen to their children, in a higher than standard dose. Self medication was also described in 60 % of children, whose acetaminophen was administered for temperatures < 38 °C. Acetaminophen over-dosage was also favored by the use of drug formulations as drops or syrup. Conclusions Our study shows that preventive action should be taken regarding the use of acetaminophen as antipyretic drug in children in order to reduce the fever phobia and self-prescription, especially of caregivers with higher educational levels. It is also necessary to promote a more appropriate use of acetaminophen in those parents using drops or syrup formulations.
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Affiliation(s)
- Riccardo Lubrano
- Department of Pediatrics, La Sapienza University of Rome, Rome, Italy.
| | - Sara Paoli
- Department of Pediatrics, La Sapienza University of Rome, Rome, Italy.
| | - Marco Bonci
- Paediatrics Operative Unit, Grassi Hospital, Rome, Italy.
| | - Luigi Di Ruzza
- Paediatrics Operative Unit, Policlinico Umberto I, Frosinone, Italy.
| | - Corrado Cecchetti
- Acute and Emergency Operative Unit, Bambino Gesù Paediatric Hospital, Rome, Italy.
| | - Raffaele Falsaperla
- General Paediatrics and Acute and Emergency Paediatrics Operative Unit, Vittorio Emanuele University Hospital, Catania, Italy.
| | - Piero Pavone
- General Paediatrics and Acute and Emergency Paediatrics Operative Unit, Vittorio Emanuele University Hospital, Catania, Italy.
| | - Nassim Matin
- University Medical Science of Teheran, University of Teheran, Teheran, Italy.
| | - Giovanna Vitaliti
- Department of Pediatrics, La Sapienza University of Rome, Rome, Italy. .,AOU Policlinico-OVE, University of Catania, Via Plebiscito n. 628, 95100, Catania, Italy.
| | - Isotta Gentile
- Department of Pediatrics, La Sapienza University of Rome, Rome, Italy.
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11
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Sorell TL. Approaches to the Development of Human Health Toxicity Values for Active Pharmaceutical Ingredients in the Environment. AAPS J 2016; 18:92-101. [PMID: 26338232 PMCID: PMC4706294 DOI: 10.1208/s12248-015-9818-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 08/14/2015] [Indexed: 01/30/2023] Open
Abstract
Management of active pharmaceutical ingredients (API) in the environment is challenging because these substances represent a large and diverse group of compounds. Advanced wastewater treatment technologies that can remove API tend to be costly. Because of the potential resources required to address API in the environment, there is a need to establish environmental benchmarks that can serve as targets for treatment and release. To date, there are several different approaches that have been taken to derive human health toxicity values for API. These methods include traditional risk assessment approaches that calculate "safe" doses using experimental data and uncertainty (safety) factors; point of departure (POD), which starts from a therapeutic human dose and applies uncertainty factors; and threshold of toxicological concern (TTC), a generic approach that establishes threshold values across broad classes of chemicals based on chemical structure. To evaluate the use of these approaches, each of these methods was applied to three API commonly encountered in the environment: acetaminophen, caffeine, and chlorpromazine. The results indicate that the various methods of estimating toxicity values produce highly varying doses. Associated doses are well below typical intakes, or toxicity thresholds cannot be derived due to a lack of information. No uniform approach can be applied to establishing thresholds for multiple substances. Rather, an individualized approach will need to be applied to each target API.
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Affiliation(s)
- Tamara L Sorell
- Brown and Caldwell, One Tech Drive, Suite 310, Andover, Massachusetts, 01810, USA.
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12
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Dudas RA, Barone MA. Can medical students identify a potentially serious acetaminophen dosing error in a simulated encounter? a case control study. BMC MEDICAL EDUCATION 2015; 15:13. [PMID: 25889566 PMCID: PMC4335408 DOI: 10.1186/s12909-015-0288-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 01/09/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND In an effort to assess medical students' abilities to identify a medication administration error in an outpatient setting, we designed and implemented a standardized patient simulation exercise which included a medication overdose. METHODS Fourth year medical students completed a standardized patient (SP) simulation of a parent bringing a toddler to an outpatient setting. In this case-control study, the majority of students had completed a patient safety curriculum about pediatric medication errors prior to their SP encounter. If asked about medications, the SP portraying a parent was trained to disclose that she was administering acetaminophen and to produce a package with dosing instructions on the label. The administered dose represented an overdose. Upon completion, students were asked to complete an encounter note. RESULTS Three hundred forty students completed this simulation. Two hundred ninety-one students previously completed a formal patient safety curriculum while 49 had not. A total of two hundred thirty-four students (69%) ascertained that the parent had been administering acetaminophen to their child. Thirty-seven students (11%) determined that the dosage exceeded recommended dosages. There was no significant difference in the error detection rates of students who completed the patient safety curriculum and those who had not. CONCLUSIONS Despite a formal patient safety curriculum concerning medication errors, 89% of medical students did not identify an overdose of a commonly used over the counter medication during a standardized patient simulation. Further educational interventions are needed for students to detect medication errors. Additionally, 31% of students did not ask about the administration of over the counter medications suggesting that students may not view such medications as equally important to prescription medications. Simulation may serve as a useful tool to assess students' competency in identifying medication administration errors.
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Affiliation(s)
- Robert A Dudas
- Department of pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Michael A Barone
- Department of pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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13
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O'Donnell FT, Rosen KR. Pediatric pain management: a review. MISSOURI MEDICINE 2014; 111:231-237. [PMID: 25011346 PMCID: PMC6179554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Although the occurrence of pain in hospitalized children is common, assessment and treatment of pain presents unique challenges to practitioners who care for pediatric patients. Knowledge of drug mechanisms as well as metabolic differences in infants and children compared with adults is necessary for the successful treatment of acute and chronic pain syndromes. Recent reports of adverse events in children receiving both opioid and non-opioid analgesics have prompted re-examination of some long standing pain medication regimens and prescribing practices. We review advances in diagnosis and management of pain in pediatric populations.
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