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Catumbela CSG, Morales R. Elderly mice with history of acetaminophen intoxication display worsened cognitive impairment and persistent elevation of astrocyte and microglia burden. Sci Rep 2024; 14:14205. [PMID: 38902507 PMCID: PMC11190293 DOI: 10.1038/s41598-024-65185-z] [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: 03/16/2024] [Accepted: 06/18/2024] [Indexed: 06/22/2024] Open
Abstract
Acetaminophen (APAP) is a leading cause of acute liver failure. The effect of APAP metabolite's effects in the periphery are well characterized; however, associated consequences in the brain remain poorly understood. Animal studies on this subject are few and reveal that frequent APAP intake can trigger cerebral abnormalities that vary depending on the subject's age. Alarmingly, experimental efforts have yet to examine associated consequences in elderly hosts, who correspond to the highest risk of medication overload, impaired drug clearance, and cognitive deficits. Here, we interrogated the cerebral and peripheral pathology of elderly mice submitted to monthly episodes of APAP intoxication since a young adult age. We found that weeks after the final episode of recurrent APAP exposure, mice exhibited worsened non-spatial memory deficit whereas spatial memory performance was unaltered. Interestingly, one month after the period of APAP intoxication, these mice showed increased glial burden without associated drivers, namely, blood-brain barrier disruption, cholesterol accumulation, and elevation of inflammatory molecules in the brain and/or periphery. Our experimental study reveals how recurrent APAP exposure affects the cognitive performance and cellular events in elderly brains. These data suggest that APAP-containing pharmacological interventions may foreshadow the elevated risk of neuropsychiatric disorders that afflict elderly populations.
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Affiliation(s)
- Celso S G Catumbela
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA
| | - Rodrigo Morales
- Department of Neurology, The University of Texas Health Science Center at Houston, Houston, TX, 77030, USA.
- Centro Integrativo de Biologia y Quimica Aplicada (CIBQA), Universidad Bernardo O'Higgins, Santiago, Chile.
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Farah R, Carpenter JE, Morgan BW. Oral potassium poisoning: a retrospective review of the National Poison Data System 2010-2021. Clin Toxicol (Phila) 2024; 62:46-52. [PMID: 38421360 DOI: 10.1080/15563650.2024.2308730] [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: 05/31/2023] [Accepted: 01/17/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Oral potassium poisoning can be life-threatening. The study aimed to describe patterns of oral potassium poisoning in adult and pediatric populations and characterize its clinical presentation and management as reported by United States poison centers. METHODS This is a retrospective review of the National Poison Data System from 1 January 2010 through 30 June 2021. We descriptively analyzed cases involving single substance, oral potassium salts. In a second step, we requested a subset of case-specific narratives for cases that resulted in major outcome or death, as well as cases where patients received any of the following therapies: whole bowel irrigation, sodium bicarbonate, calcium, insulin or hemodialysis. We classified hyperkalemia by expected toxicity: mild (peak potassium concentration <6.5 mEq/L), moderate (peak potassium concentration 6.5 to <8 mEq/L) or severe (peak potassium concentration ≥ 8mEq/L). RESULTS The National Poison Data System included 1,820 cases, 52.3 percent being adults. Among adult cases, 20% (n = 189) resulted in a moderate effect, major effect or death. Among pediatric cases aged <10 years, all exposures were unintentional. Analysis of 49 case narratives showed a median peak potassium concentration of 7.1 mEq/L (interquartile range 5.4-8.6) and a moderate correlation with the dose ingested (r = 0.66). Severe hyperkalemia was associated with QRS complex widening (P < 0.001), peaked T-waves (P = 0.001), and neurological symptoms (P = 0.04). Whole bowel irrigation was associated with mild hyperkalemia (P = 0.011), and hemodialysis was associated with severe hyperkalemia (P < 0.001). DISCUSSION Analysis of data showed that therapy to promote intracellular shift of potassium is the mainstay of management of oral potassium poisoning, followed by hemodialysis. LIMITATIONS Poison center data are susceptible to reporting bias. National Poison Data System data are affected by completeness and accuracy of reporting from health care providers and the lay public. CONCLUSIONS Single substance, oral potassium poisoning, reported to United States poison centers, is mostly unintentional and rarely results in hyperkalemia.
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Affiliation(s)
- Rita Farah
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA
- Health's Blue Ridge Poison Center, University of Virginia, Charlottesville, VA, USA
| | - Joseph E Carpenter
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
- GA Poison Center, Atlanta, GA, USA
| | - Brent W Morgan
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA
- GA Poison Center, Atlanta, GA, USA
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Li X, Lao R, Lei J, Chen Y, Zhou Q, Wang T, Tong Y. Natural Products for Acetaminophen-Induced Acute Liver Injury: A Review. Molecules 2023; 28:7901. [PMID: 38067630 PMCID: PMC10708418 DOI: 10.3390/molecules28237901] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/07/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023] Open
Abstract
The liver plays a vital role in metabolism, synthesis, and detoxification, but it is susceptible to damage from various factors such as viral infections, drug reactions, excessive alcohol consumption, and autoimmune diseases. This susceptibility is particularly problematic for patients requiring medication, as drug-induced liver injury often leads to underestimation, misdiagnosis, and difficulties in treatment. Acetaminophen (APAP) is a widely used and safe drug in therapeutic doses but can cause liver toxicity when taken in excessive amounts. This study aimed to investigate the hepatotoxicity of APAP and explore potential treatment strategies using a mouse model of APAP-induced liver injury. The study involved the evaluation of various natural products for their therapeutic potential. The findings revealed that natural products demonstrated promising hepatoprotective effects, potentially alleviating liver damage and improving liver function through various mechanisms such as oxidative stress and inflammation, which cause changes in signaling pathways. These results underscore the importance of exploring novel treatment options for drug-induced liver injury, suggesting that further research in this area could lead to the development of effective preventive and therapeutic interventions, ultimately benefiting patients with liver injury caused by medicine.
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Affiliation(s)
- Xiaoyangzi Li
- School of Medicine, Taizhou University, Taizhou 318000, China; (X.L.); (R.L.); (J.L.)
| | - Ruyang Lao
- School of Medicine, Taizhou University, Taizhou 318000, China; (X.L.); (R.L.); (J.L.)
| | - Jiawei Lei
- School of Medicine, Taizhou University, Taizhou 318000, China; (X.L.); (R.L.); (J.L.)
| | - Yuting Chen
- College of Pharmacy, Liaoning University of Traditional Chinese Medicine, Dalian 116000, China;
| | - Qi Zhou
- School of Pharmacy, Taizhou University, Taizhou 318000, China;
| | - Ting Wang
- School of Medicine, Taizhou University, Taizhou 318000, China; (X.L.); (R.L.); (J.L.)
| | - Yingpeng Tong
- School of Pharmacy, Taizhou University, Taizhou 318000, China;
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Factors and Practices Associated with Self-Medicating Children among Mexican Parents. Pharmaceuticals (Basel) 2022; 15:ph15091078. [PMID: 36145300 PMCID: PMC9502490 DOI: 10.3390/ph15091078] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/12/2022] [Accepted: 08/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Pediatric self-medication is based on the subjective interpretation of symptoms in children by the mother or an adult, the decision to self-medicate is made by a third party. The objective of this work is to provide information on the factors and practices associated with the self-medication of children among parents in Mexico. Methods: A cross-sectional and descriptive study was conducted between June 2020 and December 2021 on Mexican parents with children under 12 years of age. Online questionnaires were completed with sections on sociodemographic characteristics, use of medicines or medicinal plants and their treated symptoms, sources of collection, and their recommendation. Results: A total of 9905 online surveys were completed with representation from the 32 states of Mexico, and the prevalence of self-medication was 49.6% (n = 4908). Associated factors were age, having two or more children, children with chronic illnesses, medium educational level, unemployment or employment unrelated to health, medium and high socioeconomic level, and lack of medical security. Respondents self-medicated their children on the recommendation of a family member or friend (55.8%), and own initiative (28%). The most used medication was VapoRub (61.3%), followed by paracetamol (56.9%) and chamomile (33.1%), and the most prevalent symptoms were flu/flow (47.7%) followed by cough (34.2%). The main reasons were perceiving symptoms as not serious (69.9%) and reusing medications (51.9%). Conclusions: There is a high prevalence of self-medication in children in Mexico, mainly associated with children with chronic diseases and families with three or more children.
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Shah HS, Syamala U, Chaudhari K, Savjani J, Butani S. Process Modelling, Scale-Up and Characterization of Acetaminophen Spray Dried Milk Powder as Novel Pediatric Dosage Form. Pharm Res 2022; 39:2885-2903. [PMID: 35931906 DOI: 10.1007/s11095-022-03354-3] [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: 03/10/2022] [Accepted: 07/31/2022] [Indexed: 10/16/2022]
Abstract
PURPOSE Successful drug therapy in children is contingent upon hassle-free administration of pediatric dosage forms. Pediatric patients suffer from difficulty in swallowing due to weak esophagus muscles in their early age. Considering this challenge liquid formulations are preferred over solid dosage form among pediatric patients to avoid the possibility of choking which can be a serious life-threatening condition in children. The main aim of the present research work was to develop a reconstitutable amorphous acetaminophen spray-dried milk powder (ASDM) as novel pediatric formulation. METHODS ASDM was prepared by spray drying process and the spray drying process was optimized using Box-Behnken design to study the effect of spray drying process parameters at X1 [inlet temperature], X2 [aspiration rate] and X3 [feed rate] to Y1 [% yield], Y2 [angle of repose], Y3 [Hausner's Ratio] and Y4 [Carr's Index] as dependent variables of ASDM. In addition, each batch was characterized for particle size by polarized light microscopy and drug entrapment. RESULTS Predicted parameters from optimized spray drying process model were successfully employed to manufacture a scale up cum validation batch of ASDM, which showed notably improved yield and desirable flow properties. The scale-up validation batch was further characterized using thermal analysis, diffraction studies, spectroscopic analysis, dispersion studies, stability APAP in dispersion formulation and formulation stability studies to confirm the physico-chemical stability of ASDM. CONCLUSIONS Thus, ASDM for oral use can serve as a promising pediatric formulation and the developed prototype formulation can be further extended to future newly discovered drugs with similar characteristics.
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Affiliation(s)
- Harsh S Shah
- J-Star Research Inc., 6 Cedarbrook Drive, Cranbury, NJ, 08512, USA. .,Department of Pharmaceutics, Institute of Pharmacy, Nirma University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, 382481, India.
| | - Urmilasri Syamala
- Division of Pharmaceutical Sciences, Long Island University, 1 University Plaza, Brooklyn, NY, 11201, USA
| | - Khushbu Chaudhari
- Department of Pharmaceutics, Institute of Pharmacy, Nirma University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, 382481, India
| | - Jignasa Savjani
- Department of Pharmaceutics, Institute of Pharmacy, Nirma University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, 382481, India
| | - Shital Butani
- Department of Pharmaceutics, Institute of Pharmacy, Nirma University, Sarkhej-Gandhinagar Highway, Ahmedabad, Gujarat, 382481, India.
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Cendejas-Hernandez J, Sarafian JT, Lawton VG, Palkar A, Anderson LG, Larivière V, Parker W. Paracetamol (acetaminophen) use in infants and children was never shown to be safe for neurodevelopment: a systematic review with citation tracking. Eur J Pediatr 2022; 181:1835-1857. [PMID: 35175416 PMCID: PMC9056471 DOI: 10.1007/s00431-022-04407-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/28/2022] [Accepted: 02/01/2022] [Indexed: 11/26/2022]
Abstract
Although widely believed by pediatricians and parents to be safe for use in infants and children when used as directed, increasing evidence indicates that early life exposure to paracetamol (acetaminophen) may cause long-term neurodevelopmental problems. Furthermore, recent studies in animal models demonstrate that cognitive development is exquisitely sensitive to paracetamol exposure during early development. In this study, evidence for the claim that paracetamol is safe was evaluated using a systematic literature search. Publications on PubMed between 1974 and 2017 that contained the keywords "infant" and either "paracetamol" or "acetaminophen" were considered. Of those initial 3096 papers, 218 were identified that made claims that paracetamol was safe for use with infants or children. From these 218, a total of 103 papers were identified as sources of authority for the safety claim. Conclusion: A total of 52 papers contained actual experiments designed to test safety, and had a median follow-up time of 48 h. None monitored neurodevelopment. Furthermore, no trial considered total exposure to drug since birth, eliminating the possibility that the effects of drug exposure on long-term neurodevelopment could be accurately assessed. On the other hand, abundant and sufficient evidence was found to conclude that paracetamol does not induce acute liver damage in babies or children when used as directed. What is Known: • Paracetamol (acetaminophen) is widely thought by pediatricians and parents to be safe when used as directed in the pediatric population, and is the most widely used drug in that population, with more than 90% of children exposed to the drug in some reports. • Paracetamol is known to cause liver damage in adults under conditions of oxidative stress or when used in excess, but increasing evidence from studies in humans and in laboratory animals indicates that the target organ for paracetamol toxicity during early development is the brain, not the liver. What is New: • This study finds hundreds of published reports in the medical literature asserting that paracetamol is safe when used as directed, providing a foundation for the widespread belief that the drug is safe. • This study shows that paracetamol was proven to be safe by approximately 50 short-term studies demonstrating the drug's safety for the pediatric liver, but the drug was never shown to be safe for neurodevelopment. Paracetamol is widely believed to be safe for infants and children when used as directed, despite mounting evidence in humans and in laboratory animals indicating that the drug is not safe for neurodevelopment. An exhaustive search of published work cited for safe use of paracetamol in the pediatric population revealed 52 experimental studies pointing toward safety, but the median follow-up time was only 48 h, and neurodevelopment was never assessed.
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Affiliation(s)
- Jasmine Cendejas-Hernandez
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
- WPLab, Inc, 1023 Wells St, Durham, NC 27707 USA
| | - Joshua T. Sarafian
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Victoria G. Lawton
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Antara Palkar
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Lauren G. Anderson
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
| | - Vincent Larivière
- École de Bibliothéconomie Et Des Sciences de L’information, Université de Montréal, Montreal, Canada
| | - William Parker
- Department of Surgery, Duke University School of Medicine, Durham, NC USA
- WPLab, Inc, 1023 Wells St, Durham, NC 27707 USA
- Duke Global Health Institute, Duke University and Duke University Medical Center, Durham, NC 27710 USA
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Offor SJ, Amadi CN, Chijioke-Nwauche I, Manautou JE, Orisakwe OE. Potential deleterious effects of paracetamol dose regime used in Nigeria versus that of the United States of America. Toxicol Rep 2022; 9:1035-1044. [PMID: 36561959 PMCID: PMC9764198 DOI: 10.1016/j.toxrep.2022.04.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 04/21/2022] [Accepted: 04/23/2022] [Indexed: 12/25/2022] Open
Abstract
Paracetamol, also known as acetaminophen (N-acetyl-para-aminophenol, APAP) is the world's most used over-the-counter analgesic-antipyretic drug. Despite its good safety profile, acetaminophen can cause severe hepatotoxicity in overdose, and poisoning from paracetamol has become a major public health concern. Paracetamol is now the major cause of acute liver failure in the United States and Europe. This systematic review aims at examining the likelihood of paracetamol use in Nigeria causing more liver toxicity vis-à-vis the reduced maximum recommended daily adult dose of 3 g for the 500 mg tablet. Online searches were conducted in the databases of PubMed, Google Scholar and MEDLINE for publications using terms like "paracetamol toxicity," "acetaminophen and liver toxicity," "paracetamol and liver diseases in Nigeria," and other variants. Further search of related references in PubMed was carried out, and synthesis of all studies included in this review finalized. There were 94 studies that met the inclusion criteria. Evaluation of hepatic disorder was predicated mostly on a constellation of clinical features and limited clinical laboratory investigations. Determination of blood paracetamol concentration was rarely reported, thus excluding paracetamol poisoning as one of the likely causes of liver disorders in Nigeria. In Nigeria and elsewhere, several factors are known to increase paracetamol's predisposition to liver injury. They include: the over-the-counter status of paracetamol, use of fixed-dose combinations of paracetamol with other drugs, malnutrition, dose miscalculations, and chronic alcohol consumption. The tendency to exceed the new paracetamol maximum daily dose of 3 g in Nigeria may increase its risk for hepatotoxicity than observed in the United States of America known for emphasizing lower dose of the drug. In addition to recommending the new maximal daily paracetamol dose allowance, the historical maximum daily adult dose of 4 g should be de-emphasized in Nigeria.
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Affiliation(s)
- Samuel James Offor
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Uyo, Uyo, Akwa Ibom State, Nigeria
| | - Cecilia Nwadiuto Amadi
- Department of Experimental Pharmacology & Toxicology, Faculty of Pharmacy, University of Port-Harcourt, Port-Harcourt, Rivers State, Nigeria
| | - Ifeyinwa Chijioke-Nwauche
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Port Harcourt, Port Harcourt 5323, Rivers State, Nigeria
| | - Jose E. Manautou
- Department of Pharmaceutical Sciences, University of Connecticut, Storrs, CT 06269, USA
| | - Orish E. Orisakwe
- Department of Experimental Pharmacology & Toxicology, Faculty of Pharmacy, University of Port-Harcourt, Port-Harcourt, Rivers State, Nigeria
- African Centre of Excellence for Public Health and Toxicological Research (ACE-PUTOR), University of Port Harcourt, PMB, 5323 Port Harcourt, Choba, Nigeria
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AlRuwaili N, Zaidan F, AlFattani A, Alenazi S. Urgent need to standardize labelling of acetaminophen-paediatric liquid drug products in Saudi Arabia. Int J Pediatr Adolesc Med 2022; 9:62-65. [PMID: 35573073 PMCID: PMC9072244 DOI: 10.1016/j.ijpam.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 07/12/2021] [Accepted: 09/19/2021] [Indexed: 12/01/2022]
Abstract
In this study, dosing instructions in package inserts of all 12 paediatric liquid acetaminophen products registered in pharmacies in the Kingdom of Saudi Arabia were analysed to determine the potential for administering a supratherapeutic dose of acetaminophen. Doses in millilitres were calculated as mg/kg for four age groups: three months old, one year old, six years old, and twelve years old, and based on the 3rd, 50th, and 75th weight percentiles of each age group. Acetaminophen concentrations in the products varied, and only two products included Arabic language instructions. The dosing instructions in eight products included an age overlap. The most affected age group was the 1-year-old group, with 21 supratherapeutic doses across all 12 products. The least affected age group was the 12-year-old group, with 8 supratherapeutic doses in total. The absence of strict supervision and monitoring of labels of paediatric liquid acetaminophen products increases the risk of liver toxicity in children. Therefore, we call for an immediate standardisation of all dosing instructions regarding the dose per weight and the inclusion of instructions in Arabic.
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Affiliation(s)
- Nahar AlRuwaili
- Emergency Department, King Faisal Specialist Hospital & Research Center, AlFaisal University, Saudi Arabia
| | - Faten Zaidan
- General Peadiatric Department, KFSHRC, AlMaarefa University, Saudi Arabia
| | - Areej AlFattani
- Biostatician, King Faisal Specialist Hospital & Research Center, Saudi Arabia
| | - Saud Alenazi
- Pediatric Emergency Medicine, Department of Emergency Medicine, Maternity & Children Hospital, Qassim, Saudi Arabia
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Green C, Krafft H, Guyatt G, Martin D. Symptomatic fever management in children: A systematic review of national and international guidelines. PLoS One 2021; 16:e0245815. [PMID: 34138848 PMCID: PMC8211223 DOI: 10.1371/journal.pone.0245815] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/19/2021] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Divergent attitudes towards fever have led to a high level of inconsistency in approaches to its management. In an attempt to overcome this, clinical practice guidelines (CPGs) for the symptomatic management of fever in children have been produced by several healthcare organizations. To date, a comprehensive assessment of the evidence level of the recommendations made in these CPGs has not been carried out. METHODS Searches were conducted on Pubmed, google scholar, pediatric society websites and guideline databases to locate CPGs from each country (with date coverage from January 1995 to September 2020). Rather than assessing overall guideline quality, the level of evidence for each recommendation was evaluated according to criteria of the Oxford Centre for Evidence-Based Medicine (OCEBM). A GRADE assessment was undertaken to assess the body of evidence related to a single question: the threshold for initiating antipyresis. Methods and results are reported according to the PRISMA statement. RESULTS 74 guidelines were retrieved. Recommendations for antipyretic threshold, type and dose; ambient temperature; dress/covering; activity; fluids; nutrition; proctoclysis; external applications; complementary/herbal recommendations; media; and age-related treatment differences all varied widely. OCEBM evidence levels for most recommendations were low (Level 3-4) or indeterminable. The GRADE assessment revealed a very low level of evidence for a threshold for antipyresis. CONCLUSION There is no recommendation on which all guidelines agree, and many are inconsistent with the evidence-this is true even for recent guidelines. The threshold question is of fundamental importance and has not yet been answered. Guidelines for the most frequent intervention (antipyresis) remain problematic.
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Affiliation(s)
- Cari Green
- Gerhard Kienle Chair, Health Department, University of Witten/Herdecke, Herdecke, Germany
| | - Hanno Krafft
- Gerhard Kienle Chair, Health Department, University of Witten/Herdecke, Herdecke, Germany
| | - Gordon Guyatt
- Departments of Health Research Methods, Evidence and Impact and Medicine at McMaster University, Hamilton, Canada
| | - David Martin
- Gerhard Kienle Chair, Health Department, University of Witten/Herdecke, Herdecke, Germany
- University Children’s Hospital, Tübingen University, Tübingen, Germany
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Evaluating lactate prognostic value in children suspected of acetaminophen-induced liver failure in Liberia. Pediatr Res 2020; 88:605-611. [PMID: 31995809 DOI: 10.1038/s41390-020-0783-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 12/20/2019] [Accepted: 01/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The prognostic significance of hyperlactatemia in young children with liver injury suspected to be attributed to repeated supratherapeutic doses of acetaminophen remain understudied. METHODS We conducted a retrospective medical chart review including children aged <5 years admitted with hepatocellular injury. The study was conducted in Bardnesville Junction Hospital operated by Médecins Sans Frontières in Monrovia, Liberia. RESULTS We analyzed 95 children with liver injury in whom a blood lactate measurement on admission was available. Eighty children (84%) were aged <2 years; 49 children (52%) died during hospitalization. The median acetaminophen concentration on admission was 20 mg/L with 60 (70%) children presenting concentrations exceeding 10 mg/L. Median lactate was significantly higher in children who died (10.7 mmol/L; interquartile range (IQR): 8.5-15.7) than those who survived (6.1 mmol/L; IQR: 4.1-8.5), P value < 0.001). The optimal threshold obtained was 7.2 mmol/L with a sensitivity of 84% and specificity 70% (area under curve = 0.80). The previously established thresholds of 3.5 and 4 mmol/L lactate had very low specificity identifying non-survival in children included in this study. CONCLUSION In this setting, young children with ALF possibly attributed to acetaminophen toxicity were unlikely to survive if the venous blood lactate concentration exceeded 7.2 mmol/L.
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Fey SJ, Korzeniowska B, Wrzesinski K. Response to and recovery from treatment in human liver-mimetic clinostat spheroids: a model for assessing repeated-dose drug toxicity. Toxicol Res (Camb) 2020; 9:379-389. [PMID: 32905230 PMCID: PMC7467243 DOI: 10.1093/toxres/tfaa033] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 01/28/2023] Open
Abstract
Medicines are usually prescribed for repeated use over shorter or longer times. Unfortunately, repeated-dose animal toxicity studies do not correlate well with observations in man. As emphasized by the '3Rs' and the desire to phase-out animal research, in vitro models are needed. One potential approach uses clinostat-cultured 3D HepG2-C3A liver-mimetic spheroids. They take 18 days to recover in vivo physiological functionality and reach a metabolic equilibrium, which is thereafter stable for a year. Acute and chronic repeated-dose studies of six drugs (amiodarone, diclofenac, metformin, phenformin, paracetamol and valproic acid) suggest that spheroids are more predictive of human in vivo toxicity than either 2D-cultured HepG2 cells or primary human hepatocytes. Repeated non-lethal treatment results in a clear response and return to equilibrium. Mitochondrial toxic compounds can be identified using a galactose-based medium. Some drugs induced a protective (or stress) response that intensifies after the second treatment. This 3D spheroid model is inexpensive, highly reproducible and well-suited for the determination of repeated-dose toxicity of compounds (naturally or chemically synthesized).
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Affiliation(s)
- Stephen J Fey
- CelVivo ApS, Middelfartvej 469, DK-5491 Blommenslyst, Denmark
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Haidar MK, Vogt F, Takahashi K, Henaff F, Umphrey L, Morton N, Bawo L, Kerkula J, Ferner R, Porten K, Baud FJ. Suspected paracetamol overdose in Monrovia, Liberia: a matched case-control study. BMC Pediatr 2020; 20:139. [PMID: 32228536 PMCID: PMC7104478 DOI: 10.1186/s12887-020-2008-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 02/26/2020] [Indexed: 11/10/2022] Open
Abstract
Background A cluster of cases of unexplained multi-organ failure was reported in children at Bardnesville Junction Hospital (BJH), Monrovia, Liberia. Prior to admission, children’s caregivers reported antibiotic, antimalarial, paracetamol, and traditional treatment consumption. Since we could not exclude a toxic aetiology, and paracetamol overdose in particular, we implemented prospective syndromic surveillance to better define the clinical characteristics of these children. To investigate risk factors, we performed a case–control study. Methods The investigation was conducted in BJH between July 2015 and January 2016. In-hospital syndromic surveillance identified children with at least two of the following symptoms: respiratory distress with normal pulse oximetry while breathing ambient air; altered consciousness; hypoglycaemia; jaundice; and hepatomegaly. After refining the case definition to better reflect potential risk factors for hepatic dysfunction, we selected cases identified from syndromic surveillance for a matched case–control study. Cases were matched with in-hospital and community-based controls by age, sex, month of illness/admission, severity (in-hospital), and proximity of residence (community). Results Between July and December 2015, 77 case-patients were captured by syndromic surveillance; 68 (88%) were under three years old and 35 (46%) died during hospitalisation. Of these 77, 30 children met our case definition and were matched with 53 hospital and 48 community controls. Paracetamol was the most frequently reported medication taken by the cases and both control groups. The odds of caregivers reporting supra-therapeutic paracetamol consumption prior to admission was higher in cases compared to controls (OR 6.6, 95% CI 2.1–21.3). Plasma paracetamol concentration on day of admission was available for 19 cases and exceeded 10 μg/mL in 10/13 samples collected on day one of admission, and 4/9 (44%) collected on day two. Conclusions In a context with limited diagnostic capacity, this study highlights the possibility of supratherapeutic doses of paracetamol as a factor in multi-organ failure in a cohort of children admitted to BJH. In this setting, a careful history of pre-admission paracetamol consumption may alert clinicians to the possibility of overdose, even when confirmatory laboratory analysis is unavailable. Further studies may help define additional toxicological characteristics in such contexts to improve diagnoses.
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Affiliation(s)
- Mohamad K Haidar
- Epicentre, 8 Rue Saint Sabin, 75011, Paris, France. .,UMR 8257, Université Paris Descartes, Paris, France.
| | - Florian Vogt
- Epicentre, 8 Rue Saint Sabin, 75011, Paris, France
| | | | - Fanny Henaff
- Médecins sans Frontières - Operational Center Paris, Paris, France
| | - Lisa Umphrey
- Médecins sans Frontières - Operational Center Paris, Paris, France
| | - Nikola Morton
- Médecins sans Frontières - Operational Center Paris, Paris, France
| | - Luke Bawo
- Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Joseph Kerkula
- Ministry of Health and Social Welfare, Monrovia, Liberia
| | - Robin Ferner
- Institute of Clinical Sciences, University of Birmingham, Birmingham, England
| | | | - Frederic J Baud
- Médecins sans Frontières - Operational Center Paris, Paris, France.,Assistance Publique - Hôpitaux de Paris, Paris, France.,University Paris Diderot, Paris, France.,EA7323, Evaluation of prenatal and paediatric therapeutics and pharmacology, Université Paris Descartes, Paris, France
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13
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Bouvet R, Cauchois A, Baert A, Fromenty B, Morel I, Turlin B, Gicquel T. Fatal acetaminophen poisoning with hepatic microvesicular steatosis in a child after repeated administration of therapeutic doses. Forensic Sci Int 2020; 310:110258. [PMID: 32229318 DOI: 10.1016/j.forsciint.2020.110258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/12/2020] [Indexed: 12/21/2022]
Abstract
Acetaminophen is the leading cause of acute liver failure worldwide following massive ingestion. We present here a fatal acute liver failure after repeated administration of four therapeutic doses of acetaminophen at 4-h intervals in a previously healthy 9-year-old female who presented dental pain after a facial trauma during sport practice. A diagnosis of paracetamol-induced hepatitis was deduced from the clinical picture of fulminant hepatitis and tubular necrosis, the encephalopathy with oedema and without signs of trauma. Liver biopsy showed typical acetaminophen-induced necrosis and a microvesicular steatosis in periportal hepatocytes. These injuries might have been favored by pre-existing mitochondrial dysfunction related, for instance, to a deficiency in an enzyme of the mitochondrial β-oxidation pathway, or the respiratory chain. The observation of microvesicular steatosis in the periportal areas suggests an increased vulnerability via pre-existing mitochondrial dysfunction. As the liver status of patients is mostly unknown, the frequency of administration (every six hours) must be respected and the use of pharmaceutical forms allowing to adjust the dose as closely as possible to the child's weight should be promoted.
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Affiliation(s)
- Renaud Bouvet
- Department of Forensic Medicine, Rennes University Hospital, Rennes, France; IDPSP - EA 4640, Rennes University, Rennes, France
| | - Aurélie Cauchois
- Department of Forensic Medicine, Rennes University Hospital, Rennes, France; Department of Pathology, Rennes University Hospital, Rennes, France
| | - Alain Baert
- Department of Forensic Medicine, Rennes University Hospital, Rennes, France
| | - Bernard Fromenty
- Univ Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, Rennes, France
| | - Isabelle Morel
- Univ Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, Rennes, France; Department of Forensic Toxicology, Rennes University Hospital, Rennes, France
| | - Bruno Turlin
- Univ Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, Rennes, France; Department of Pathology, Rennes University Hospital, Rennes, France
| | - Thomas Gicquel
- Univ Rennes, Inra, Inserm, Institut NUMECAN - UMR_A 1341, UMR_S 1241, Rennes, France; Department of Forensic Toxicology, Rennes University Hospital, Rennes, France.
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14
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Mehrotra S. Postoperative anaesthetic concerns in children: Postoperative pain, emergence delirium and postoperative nausea and vomiting. Indian J Anaesth 2019; 63:763-770. [PMID: 31571690 PMCID: PMC6761783 DOI: 10.4103/ija.ija_391_19] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The incidence of anaesthetic complications in children is much more than in adults and sometimes with a severe outcome. Patients under one year of age, those with co-morbidities and posted for emergency surgery are at increased risk for morbidities. Sources of information on the risk involved come from institutional audit, closed claim analysis, and large-scale studies of cardiac arrest. A strategy for preventing postoperative nausea and vomiting (PONV), emergence delirium (ED) and postoperative pain should be a part of every anaesthetic plan. A planned multimodal approach should be opted consisting of nonpharmacologic and pharmacologic prophylaxis along with interventions to reduce the baseline risks. The literature in this subject is reviewed extensively to give comprehensive information to postgraduate students about the current understanding of postoperative anaesthetic concerns. Relevant articles from Pub med, review articles, meta-analysis, and editorials were the primary source of information for this article.
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Affiliation(s)
- Shikha Mehrotra
- Department of Anaesthesiology, Gandhi Medical College, Bhopal, Madhya Pradesh, India
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15
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Luo S, Ran M, Luo Q, Shu M, Guo Q, Zhu Y, Xie X, Zhang C, Wan C. Alternating Acetaminophen and Ibuprofen versus Monotherapies in Improvements of Distress and Reducing Refractory Fever in Febrile Children: A Randomized Controlled Trial. Paediatr Drugs 2017; 19:479-486. [PMID: 28523589 DOI: 10.1007/s40272-017-0237-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND No evidence can be found in the medical literature about the efficacy of alternating acetaminophen and ibuprofen treatment in children with refractory fever. OBJECTIVE Our objective was to assess the effect of alternating acetaminophen and ibuprofen therapy on distress and refractory fever compared with acetaminophen or ibuprofen as monotherapy in febrile children. METHODS A total of 474 febrile children with axillary temperature ≥38.5 °C and fever history ≤3 days in a tertiary hospital were randomly assigned to receive either (1) alternating acetaminophen and ibuprofen (acetaminophen 10 mg/kg per dose with shortest interval of 4 h and ibuprofen 10 mg/kg per dose with shortest interval of 6 h and the shortest interval between acetaminophen and ibuprofen ≥2 h; n = 158), (2) acetaminophen monotherapy (10 mg/kg per dose with shortest interval of 4 h; n = 158), or (3) ibuprofen monotherapy (10 mg/kg per dose with shortest interval of 6 h; n = 158). The mean Non-Communicating Children's Pain Checklist (NCCPC) score was measured every 4 h, and axillary temperatures were measured every 2 h. RESULTS In total, 471 children were included in an intention-to-treat analysis. No significant clinical or statistical difference was found in mean NCCPC score or temperature during the 24-h treatment period in all febrile children across the three groups. Although the proportion of children with refractory fever for 4 h and 6 h was significantly lower in the alternating group than in the monotherapy groups (4 h: 11.54% vs. 26.58% vs. 21.66%, respectively [p = 0.003]; 6 h: 3.85% vs. 10.13% vs. 17.83%, respectively [p < 0.001]), the mean NCCPC score of children with refractory fever for 4 or 6 h was not lower than those in either of the monotherapy groups. The number of patients who developed persistent high body temperature was consistent across all study groups. CONCLUSIONS Alternating acetaminophen and ibuprofen can reduce the proportion of children with refractory fever, but if one cycle of alternating therapy cannot reduce febrile distress as defined by NCCPC score, two or more cycles of alternating therapy may have minimal to no clinical efficacy in some cases. The trial was registered with the Chinese Clinical Trial Registry as ChiCTR-TRC-13003440 and the WHO Registry Network as U1111-1146-6714.
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Affiliation(s)
- Shuanghong Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 17 Section Three, Ren Min Nan Lu Avenue, Chengdu, 610041, Sichuan, China
| | - Mengdong Ran
- Department of Epidemiology and Health Statistics, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China
| | - Qiuhong Luo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 17 Section Three, Ren Min Nan Lu Avenue, Chengdu, 610041, Sichuan, China
| | - Min Shu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 17 Section Three, Ren Min Nan Lu Avenue, Chengdu, 610041, Sichuan, China
| | - Qin Guo
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 17 Section Three, Ren Min Nan Lu Avenue, Chengdu, 610041, Sichuan, China
| | - Yu Zhu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 17 Section Three, Ren Min Nan Lu Avenue, Chengdu, 610041, Sichuan, China
| | - Xiaoping Xie
- Department of Pediatrics, Dujiangyan Medical Center, Chengdu, Sichuan, China
| | - Chongfan Zhang
- Department of Clinical Epidemiology, Children's Hospital of Fudan University, Shanghai, China
| | - Chaomin Wan
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 17 Section Three, Ren Min Nan Lu Avenue, Chengdu, 610041, Sichuan, China.
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Calvo PL, Tandoi F, Haak TB, Brunati A, Pinon M, Olio DD, Romagnoli R, Spada M. NBAS mutations cause acute liver failure: when acetaminophen is not a culprit. Ital J Pediatr 2017; 43:88. [PMID: 28946922 PMCID: PMC5613325 DOI: 10.1186/s13052-017-0406-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/13/2017] [Indexed: 01/25/2023] Open
Abstract
Background Pediatric acute-liver-failure due to acetaminophen (APAP) administration at therapeutic dosage is rare, while viral infections and metabolic defects are the prevalent causes. Yet, as acetaminophen is routinely used in febrile illnesses, it may be mistakenly held responsible for the acute liver damage. Case presentation An 11 month old boy had been on acetaminophen for 10 days (total dose 720 mg = 72 mg/kg) when he developed acute-liver-failure with encephalopathy. As he rapidly improved on N-acetylcysteine (NAC) infusion, it was concluded that chronic acetaminophen administration in an infant had lead to acute-liver-failure even at therapeutic doses, that N-acetylcysteine infusion had been life-saving and should be immediately started in similar circumstances. The child, however, had two further episodes of acute liver damage over a 34-month period, without having been given acetaminophen, as the parents carefully avoided using it. His clinical, laboratory and radiological findings between the acute episodes were unremarkable. His features and skeletal surveys were not suggestive of a syndromic condition. He then went on to suffer another episode of acute-liver-failure with multi-organ failure, necessitating an urgent liver transplant. All efforts to come to a diagnosis for the causes of his recurrent episodes of liver failure had been unsuccessful, until a biallelic mutation in the NBAS gene was reported to be associated with recurrent acute-liver-failure in children. The boy’s DNA analysis revealed compound heterozygous pathogenic mutations in the NBAS gene. Liver failure episodes in these patients are triggered and worsened by fever, most likely due to thermal susceptibility of hepatocytes, hence APAP, rather than being a culprit, is part of the supportive treatment. Conclusions We suggest that, in acute-liver-failure with a history of acetaminophen exposure at therapeutic dosage, clinicians should not be contented with administering NAC, but should consider an alternative etiology, above all if the episodes are recurrent, and actively start supportive and antipyretic treatment while seeking the advice of a specialist unit.
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Affiliation(s)
- Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia 94, 10126, Torino, Italy.
| | - Francesco Tandoi
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Tobias B Haak
- Institute of Human Genetics, Technische Universität München, 81675, Munich, Germany.,Institute of Human Genetics, Helmholtz Zentrum München, 85764, Neuherberg, Germany
| | - Andrea Brunati
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia 94, 10126, Torino, Italy
| | - Dominic Dell Olio
- Regional Transplant Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Renato Romagnoli
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Marco Spada
- Department of Pediatrics, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
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17
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Serum Acetaminophen Protein Adduct Concentrations in Pediatric Emergency Department Patients. J Pediatr Gastroenterol Nutr 2017; 64:533-535. [PMID: 27846064 DOI: 10.1097/mpg.0000000000001459] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Acetaminophen toxicity is a common cause of pediatric liver failure. The diagnosis may be limited by the short window of detection of acetaminophen in serum. Recently acetaminophen protein adducts (APAP-CYS) have been used as a biomarker with a longer duration of detection. The objective of this study was to describe the serum concentrations of APAP-CYS in pediatric patients with and without reported therapeutic acetaminophen exposure. METHODS A cross-sectional study of children age 1 to <12 years presenting to a pediatric emergency department. Subjects were stratified by recent acetaminophen use and had serum APAP-CYS measured using LC/MS. RESULTS One hundred patients were enrolled. All of the patients whose caregivers denied acetaminophen exposure had nondetectable APAP-CYS. Fifty-two percent of subjects who were reported to have taken acetaminophen in the preceding 2 weeks had detectable serum APAP-CYS. The APAP-CYS concentrations were positively correlated with higher overall dose and more recent ingestion. CONCLUSIONS APAP-CYS is detectable in the majority of children taking acetaminophen and not detected in the majority of children who are not exposed to acetaminophen.
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18
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Rodríguez MC, Villamor P, Castillo T. Assessment and management of pain in pediatric otolaryngology. Int J Pediatr Otorhinolaryngol 2016; 90:138-149. [PMID: 27729121 DOI: 10.1016/j.ijporl.2016.09.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 09/10/2016] [Accepted: 09/13/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Pain is a disease by itself and it's a public health concern of major implication in children, not just because of the emotional component of the child and his family, but also due to the potential morbidity and mortality involving it. A proper assessment of pain it's a challenge in the pediatric population, due to their lack of understanding and verbalization of hurt. Additionally, a satisfactory treatment of pediatric pain can be arduous due to a lack of clinical knowledge, insufficient pediatric research, and the fear to opioid side effects and addiction. OBJECTIVES The aim of this review is to address the current definitions of pain, its physiological mechanisms and the consequences of its inadequate management, as well as, to guide the clinicians in the assessment and management of pain in the pediatric population at otolaryngology services. METHODOLOGY Narrative review by selective MeSH search terms: Children, Pediatrics, Otolaryngology, Pain measurement, Pain Management, Analgesics and Analgesia, from databases: MEDLINE/PubMed, Cochrane, ISI, Current Contents, Scielo and LILACS, between January 2000 and May 2016. RESULTS 129 articles were reviewed according to the requirements of the objectives. Pain measurement is a challenge in children as there are no physical signs that constitute an absolute or specific indicator of pain, and its diagnosis must rely on physiological, behavioral and self-report methods. Regarding treatment, a suitable alternative are the non-pharmacological cognitive/behavioral therapies helped by pharmacological therapies tailored to the severity of pain and the child's age. We provide evidence-based recommendations on pain treatment, including non-opioid analgesics, opioid analgesics and adjuvant medicines to improve the management of pain in children in otolaryngology services. CONCLUSIONS We present a global review about assessment and management of pain in pediatric otolaryngology, which leads to future specific reviews on each topic. Research gaps on pain assessment and pharmacological interventions in neonates, infants and children are very wide and it should be promoted ethical and safe research on pain control in this population.
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Affiliation(s)
- Maria Claudia Rodríguez
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
| | - Perla Villamor
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia.
| | - Tatiana Castillo
- Department of Otolaryngology, Hospital Infantil de San José, Fundación Universitaria de Ciencias de la Salud, Bogotá, Colombia
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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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Mund ME, Quarcoo D, Gyo C, Brüggmann D, Groneberg DA. Paracetamol as a toxic substance for children: aspects of legislation in selected countries. J Occup Med Toxicol 2015; 10:43. [PMID: 26664414 PMCID: PMC4674926 DOI: 10.1186/s12995-015-0084-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/22/2015] [Indexed: 12/21/2022] Open
Abstract
Paracetamol is used widely in pediatrics because it has a high drug safety when used in therapeutic dosages. In case of overdose the majority of paracetamol is metabolized to N-acetyl-p-benzoquinone imine (NAPQI), which is responsible for the severe toxic effects. The covalent connection between NAPQI and hepatic proteins leads to hepatocellular damage and possibly to severe liver failure. The antidote for paracetamol is N-acetylcysteine (NAC). It is a precursor of glutathione and aids to fill glutathione stores. The Rumack-Matthew nomogram should be used to decide on antidote treatment. Pediatric drug metabolism differs from adult metabolism. Children have a larger liver size compared to their body weight than adults, resulting in a higher metabolism rate. Young children seem to be less sensitive to acute intoxication than adults. One hypothesis to explain the lower rate refers to the larger liver size. The acute toxic dosage for children is more than 200 mg/kg body weight. There seems to be a global increase in accidental pediatric paracetamol overdose. Governmental websites of various European Union (EU) countries were searched for legal information on paracetamol availability in pharmacies and non-pharmacy stores. Various EU countries permit prescription-free sales of paracetamol in pharmacies and non-pharmacy stores. In Sweden paracetamol 500 mg may be sold in both pharmacies and non-pharmacies in a maximum pack size of 20 units. In the United Kingdom (UK) paracetamol 500 mg is listed in the general sales list with a maximum pack size of 30 effervescent tablets or 16 tablets. In Ireland paracetamol 500 mg may be sold in a maximum pack size of 12 units in a non-pharmacy. In the Netherlands paracetamol 500 mg is legal to be sold in a maximum pack size of 50 units in a drug store and with a maximum of 20 units in any other non-pharmacy. Several countries in the European Union are permitted to offer paracetamol prescription-free in pharmacies and non-pharmacy stores without legal guidance on the storage position within the store. Further research is needed to investigate whether paracetamol is located directly accessible to young children within the stores in EU countries which permit prescription-free sales of paracetamol.
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Affiliation(s)
- Menen E Mund
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany
| | - David Quarcoo
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany
| | - Christoph Gyo
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany
| | - Dörthe Brüggmann
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany ; Department of Obstetrics and Gynecology, Keck School of Medicine of USC, Los Angeles, California USA
| | - David A Groneberg
- Departments of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe University, Frankfurt am Main, Theodor-Stern-Kai 7, Frankfurt, 60590 Germany
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21
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Zurlinden TJ, Heard K, Reisfeld B. A novel approach for estimating ingested dose associated with paracetamol overdose. Br J Clin Pharmacol 2015; 81:634-45. [PMID: 26441245 DOI: 10.1111/bcp.12796] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/04/2015] [Accepted: 10/01/2015] [Indexed: 11/28/2022] Open
Abstract
AIM In cases of paracetamol (acetaminophen, APAP) overdose, an accurate estimate of tissue-specific paracetamol pharmacokinetics (PK) and ingested dose can offer health care providers important information for the individualized treatment and follow-up of affected patients. Here a novel methodology is presented to make such estimates using a standard serum paracetamol measurement and a computational framework. METHODS The core component of the computational framework was a physiologically-based pharmacokinetic (PBPK) model developed and evaluated using an extensive set of human PK data. Bayesian inference was used for parameter and dose estimation, allowing the incorporation of inter-study variability, and facilitating the calculation of uncertainty in model outputs. RESULTS Simulations of paracetamol time course concentrations in the blood were in close agreement with experimental data under a wide range of dosing conditions. Also, predictions of administered dose showed good agreement with a large collection of clinical and emergency setting PK data over a broad dose range. In addition to dose estimation, the platform was applied for the determination of optimal blood sampling times for dose reconstruction and quantitation of the potential role of paracetamol conjugate measurement on dose estimation. CONCLUSIONS Current therapies for paracetamol overdose rely on a generic methodology involving the use of a clinical nomogram. By using the computational framework developed in this study, serum sample data, and the individual patient's anthropometric and physiological information, personalized serum and liver pharmacokinetic profiles and dose estimate could be generated to help inform an individualized overdose treatment and follow-up plan.
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Affiliation(s)
- Todd J Zurlinden
- Department of Chemical and Biological Engineering, Colorado State University, Fort Collins, Colorado, 80523-1370
| | - Kennon Heard
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Avenue Campus Box B-215, Aurora, CO, 80045.,Rocky Mountain Poison and Drug Center, Denver, CO, 80204
| | - Brad Reisfeld
- Department of Chemical and Biological Engineering, Colorado State University, Fort Collins, Colorado, 80523-1370.,School of Biomedical Engineering, Colorado State University, Fort Collins, Colorado, 80523-1376, USA
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