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Sami F, Berg S, Manadan AM, Mycyk MB. Acetaminophen overdose: analysis of 2018 US nationwide emergency database. Intern Emerg Med 2024; 19:1727-1732. [PMID: 38446370 DOI: 10.1007/s11739-024-03555-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION Recognized risk factors for acetaminophen overdose include alcohol, opioids, and mood disorders. The aim of this study is to assess additional risk factors for acetaminophen overdose evaluated in the emergency department (ED). METHODS A retrospective study was performed using the 2018 US Nationwide Emergency Department Sample (NEDS). All adult ED visits for acetaminophen overdose were included in the study group and those without it were taken as control. STATA, 16.1 was used to perform multivariable logistic regression analysis and adjusted odds ratios (ORadj) were reported. RESULTS We identified 27,792 ED visits for acetaminophen overdose. Relative to non-acetaminophen ED visits, this group was younger (median age 32 vs 47 years; p < 0.0001), more often female (66.1% vs 57.0%; p < 0.0001), had higher ED charges ($3,506 vs $2,714; p < 0.0001), higher proportion of alcohol-related disorders (15.8% vs 3.5%; p < 0.0001), anxiety disorders (30.2% vs 8.3%; p < 0.0001), cannabis use (8.7% vs 1.4%; p < 0.0001), hematology/oncology diagnoses (13.3% vs 10.9%; p < 0.0001), mood disorders (52.4% vs 7.9%; p < 0.0001), opioid-related disorders (4.1% vs 1.0%; p < 0.0001), and suicide attempt/ideation (12.2% vs 1.1%; p < 0.0001). Multivariable analysis showed alcohol-related disorders (ORadj 2.67), anxiety disorders (ORadj 1.24), cannabis (ORadj 1.63), females (ORadj 1.45), Income Q3 (ORadj 1.09), hematology/oncology diagnoses (ORadj 1.40), mood disorders (ORadj 10.07), opioid-related disorders (ORadj 1.20), and suicide attempt/ideation (ORadj 1.68) were associated with acetaminophen overdose. CONCLUSION In addition to previously recognized risks, our study demonstrated that cannabis use and hematologic/oncologic comorbidities were more common among acetaminophen-overdose ED visits. These new findings are concerning because of rapid legalization of cannabis and the increasing incidence of cancer worldwide. Additional investigation into these risks should be a priority for clinicians, policymakers, and researchers.
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Affiliation(s)
- Faria Sami
- Department of Internal Medicine, Cook County Health, 1950 West Polk Street, Chicago, IL, 60612, USA.
| | - Sarah Berg
- Department of Emergency Medicine, Division of Medical Toxicology, Cook County Health, Chicago, USA
| | | | - Mark B Mycyk
- Department of Emergency Medicine, Cook County Health, Chicago, USA
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2
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Bayram D, Vizdiklar C, Aydin V, Akici N, Atac O, Akici A. Supratherapeutic utilization of paracetamol versus ibuprofen among <12-year-old children in primary care in Istanbul. Fam Pract 2024; 41:270-276. [PMID: 36964758 DOI: 10.1093/fampra/cmad038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Paracetamol and ibuprofen are the most preferred analgesics for pain and fever management in children. Prescribing of these drugs in supratherapeutic doses may predispose to their toxicity. We aimed to compare prescribing patterns and potential overdosing of paracetamol and ibuprofen in primary care for <12-year-old children. METHODS We analysed paracetamol- and ibuprofen-containing prescriptions (PCPs, n = 173,575 and ICPs, n = 145,655) of 1- to 11-year-old children, issued by 3:1 systematically sampled primary care physicians (n = 1,431) in Istanbul during 2016. We compared drug use parameters and prescriptions surpassing daily and single-use dose limits for paracetamol and ibuprofen. RESULTS We identified that 29.9% of PCPs and 20.8% of ICPs were generated for those aged 1-2 years. Concomitant analgesic use was higher in ICPs than in PCPs (15.1% vs. 12.8%). We found that 4.4% of PCPs and 3.1% of ICPs exceeded maximum daily dose limit of paracetamol and ibuprofen, respectively (P < 0.001). This was more common in girls (5.1% and 3.3%, respectively) and at 1 year of age in both groups (9.2% and 8.5%, respectively). Single-use supratherapeutic dosing was encountered in 16.5% of PCPs and 13.2% of ICPs (P < 0.001, pessimistic model) and in 8.6% of PCPs and 10.6% of ICPs (P < 0.001, optimistic model). CONCLUSIONS Paracetamol and ibuprofen were generally used in primary care for similar clinical conditions with subtle differences. However, more pronounced in younger children and girls, potential overdosing seems to be more practiced for paracetamol than ibuprofen both in terms of maximal daily and single-use setting.
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Affiliation(s)
- Dilara Bayram
- Department of Pharmacology, Faculty of Pharmacy, Acibadem Mehmet Ali Aydinlar University, Istanbul, Turkey
| | - Caner Vizdiklar
- Department of Medical Pharmacology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Volkan Aydin
- Department of Medical Pharmacology, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
| | - Narin Akici
- Department of Pediatrics, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Omer Atac
- Department of Public Health, International School of Medicine, Istanbul Medipol University, Istanbul, Turkey
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY, United States
| | - Ahmet Akici
- Department of Medical Pharmacology, School of Medicine, Marmara University, Istanbul, Turkey
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Layman AJ, Alsbrook SM, Koturbash IK, McGill MR. Natural Products That Protect Against Acetaminophen Hepatotoxicity: A Call for Increased Rigor in Preclinical Studies of Dietary Supplements. J Diet Suppl 2024:1-18. [PMID: 38562009 DOI: 10.1080/19390211.2024.2335573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Acetaminophen (APAP) overdose is one of the most common causes of acute liver injury. The current standard-of-care treatment for APAP hepatotoxicity, N-acetyl-l-cysteine, is highly effective when administered early after overdose, but loses efficacy in later-presenting patients. As a result, there is interest in the identification of new treatments for APAP overdose patients. Natural products are a promising source of new treatments because many are purported to have hepatoprotective effects. In fact, a great deal of research has been done to identify natural products that can protect against APAP-induced liver injury. However, serious concerns have been raised about the rigor and human relevance of these studies. Here, we systematically reviewed the APAP-natural product literature from 2013 to 2023 to determine the veracity of these concerns and the scope of the potential problem. The results substantiate the concerns that have been previously raised and point to concrete steps that can be taken to improve APAP-natural product research.
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Affiliation(s)
- Alexander J Layman
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of AR for Medical Sciences, Little Rock, AR, USA
| | - Scott M Alsbrook
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of AR for Medical Sciences, Little Rock, AR, USA
| | - Igor K Koturbash
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of AR for Medical Sciences, Little Rock, AR, USA
- Center for Dietary Supplements Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mitchell R McGill
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of AR for Medical Sciences, Little Rock, AR, USA
- Center for Dietary Supplements Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Aleid A, ALjayyar MW, Algrafi MB, Kateb HM, Alenazi SF, Almousa M, Mohammed MA, Al-Ghareeb M, Al Mutair A, Almulhim KN. Epidemiology and Management of Poisoning Cases in the Emergency Room: A Cross-Sectional Study in Saudi Arabia. Cureus 2023; 15:e46708. [PMID: 38021713 PMCID: PMC10630713 DOI: 10.7759/cureus.46708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Acute poisoning, arising from exposure to toxic substances, is a critical healthcare challenge. In the United States, it's one of the primary causes of morbidity and mortality. European institutions report that about 1% of all emergency department admissions relate to poisoning, a statistic that becomes alarming given the life-threatening implications. While there's an underreporting of these cases, the actual figure could be much higher. Acute poisoning has resulted in over a million morbidity cases with a 20% mortality rate. Most concerning is the World Health Organization's data indicating that over 90% of accidental poisoning deaths occur in low to middle-income countries. Methods This was a cross-sectional study conducted over a 12-month period in three major hospitals in Saudi Arabia. The study population comprised of 1470 patients who presented to emergency departments with suspected acute poisoning. Medical records were retrospectively reviewed, capturing data on patient demographics, nature and type of poisoning, initial management, and outcomes. Data were analyzed using SPSS software version 28.0 (IBM Corp., Armok, NY). Descriptive statistics were used to summarize the data, while Chi-square tests were employed to determine associations between demographic factors and the nature of poisoning. Furthermore, the Pearson correlation was used to evaluate the link between referrals to specialized centers and patient outcomes. Results Out of the 1470 participants, a significant majority were males, constituting 77.1%. The dominant age group was between 18-24 years, representing 71.4% of the sample. A substantial 88.6% had visited the emergency room due to medical complications stemming from poisoning. When queried about their understanding of acute poisoning, 60.0% were able to correctly define the term. However, a concerning 54.3% reported they had never received any formal training or been part of awareness programs regarding poisoning. There was a marked association (p < 0.001) between demographics and the nature of toxin exposure. Delving deeper into the specifics of poisoning incidents, medications were identified as the primary culprits in 8.6% of the cases, followed by household chemicals at 5.7%. Crucially, a vast majority, 82.9%, were of the opinion that with the right education and precautions in place, the incidence of poisoning cases could be substantially reduced. Conclusion Acute poisoning is a pressing concern in Saudi Arabia, with a significant proportion of the population unaware or inadequately trained to handle such emergencies. This study underscores the importance of awareness campaigns, formal education, and specialized training to prevent and effectively manage poisoning cases in emergency settings. Moreover, the strong association between certain demographics and toxin exposures suggests that targeted interventions might be necessary for specific groups.
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Yang CM, Chien MY, Wang LY, Chuang CH, Chen CH. Goji Ferment Ameliorated Acetaminophen-Induced Liver Injury in vitro and in vivo. Probiotics Antimicrob Proteins 2023; 15:1102-1112. [PMID: 35796949 DOI: 10.1007/s12602-022-09956-y] [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] [Accepted: 05/22/2022] [Indexed: 11/29/2022]
Abstract
This study aimed to investigate the hepatoprotective effects of lyophilized powder of goji ferment (LPGF) against acetaminophen (APAP)-induced hepatic damage in Hep3B cells and in mice. Eleven strains of lactic acid bacteria (LAB) were selected and their hepatoprotection against APAP-induced cellular damage in Hep3B cell line was evaluated. Four strains of LAB, including BCRC11652 (Leuconostoc mesenteroides subsp. mesenteroides), BCRC14619 (Lactobacillus gasseri), KODA-1 (Pediococcus acidilactici), and KODA-2 (Limosilactobacillus fermentum), have hepatoprotective potential against APAP in vitro. Goji significantly stimulated the growth of individual and combined strains of LAB and the optimal fermented condition was the treatment of goji at 10% (w/w) for 24 h. The prepared lyophilized powder of goji ferment (LPGF) containing fifteen combinations of LAB strains was used to explore their hepatoprotection in vitro. LPGF containing all combinations of LAB strains, except for KODA-2, significantly restored APAP-reduced cell viability and improved APAP-increased cellular levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST). In mice model, LPGF containing BCRC11652, BCRC14619, and KODA-2 was chosen to evaluate its hepatoprotection against APAP-induced liver injury. LPGF at diverse doses have a tendency but no significant improvement on APAP-reduced body weight gain and liver weight. LPGF significantly decreased APAP-increased serum ALT and AST levels in a dose-dependent manner. At the end of experiment, LPGF significantly and dose-dependently reversed APAP-reduced activities of GSH and antioxidant enzymes, including glutathione peroxidase, superoxide dismutase, and catalase in hepatic tissue. Overall, LPGF was demonstrated to exhibit hepatoprotection against APAP-induced liver injury in vitro and in vivo.
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Affiliation(s)
- Chih-Min Yang
- Ko Da Pharmaceutical Co. Ltd, Pingzhen Dist, No.20-1, Gongye 3rd Rd, Taoyuan, Taiwan
| | - Mei-Yin Chien
- Ko Da Pharmaceutical Co. Ltd, Pingzhen Dist, No.20-1, Gongye 3rd Rd, Taoyuan, Taiwan
| | - Li-Yu Wang
- Department of Nutrition, Master Program of Biomedical Nutrition, Hungkuang University, No. 1018 Sec. 6 Taiwan Boulevard, Taichung, 43302, Taiwan
- Department of Food Science and Biotechnology, National Chung Hsing University, Taichung, Taiwan
| | - Cheng-Hung Chuang
- Department of Nutrition, Master Program of Biomedical Nutrition, Hungkuang University, No. 1018 Sec. 6 Taiwan Boulevard, Taichung, 43302, Taiwan.
| | - Chao-Hsiang Chen
- Ko Da Pharmaceutical Co. Ltd, Pingzhen Dist, No.20-1, Gongye 3rd Rd, Taoyuan, Taiwan.
- Graduate Institute of Pharmacognosy, Taipei Medical University, Taipei, Taiwan.
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Hwang S, Hicks A, Hoo CZ, Kwon YS, Cho YE, Moore J, Gao B. Novel treatment of acute and acute-on-chronic liver failure: Interleukin-22. Liver Int 2023:10.1111/liv.15619. [PMID: 37208937 PMCID: PMC10657333 DOI: 10.1111/liv.15619] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 05/21/2023]
Abstract
Acute liver failure (ALF) is a life-threatening medical condition, characterized by rapidly progressive hepatic dysfunction, coagulopathy and hepatic encephalopathy in patients without chronic liver disease, while acute-on-chronic liver failure (ACLF) occurs in patients with existing chronic liver disease. ALF and ACLF are often associated with multiple organ failure and a high short-term mortality. In this review, we briefly discuss the causes and pathogenesis of ALF and ACLF, the current options available for the treatment of both deadly maladies and interleukin-22 (IL-22), a novel promising drug that may have great therapeutic potential for ALF and ACLF treatment. IL-22 is a cytokine produced by immune cells but mainly targets epithelial cells including hepatocytes. IL-22 has been shown to protect against organ damage and reduce bacterial infection in many preclinical models and several clinical trials including alcohol-associated hepatitis. The potential application of IL-22 for the treatment of ALF and ACLF is also elaborated.
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Affiliation(s)
- Seonghwan Hwang
- College of Pharmacy and Research Institute for Drug Development, Pusan National University, Busan, Republic of Korea
| | - Amy Hicks
- Leeds Liver Unit, St James’s University Hospital, UK
| | - Chai Zhen Hoo
- Leeds Liver Unit, St James’s University Hospital, UK
| | - Yong Seong Kwon
- College of Pharmacy and Research Institute for Drug Development, Pusan National University, Busan, Republic of Korea
| | - Ye Eun Cho
- College of Pharmacy and Research Institute for Drug Development, Pusan National University, Busan, Republic of Korea
| | - Joanna Moore
- Leeds Liver Unit, St James’s University Hospital, UK
| | - Bin Gao
- Laboratory of Liver Diseases, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
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Guo Q, Chen G, Ou H, Jin R, Ni Q, Qin R. Binaprofen induces zebrafish liver injury via the mitochondrial pathway. Mol Med Rep 2022; 26:314. [PMID: 36004474 PMCID: PMC9437965 DOI: 10.3892/mmr.2022.12830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 04/29/2022] [Indexed: 11/06/2022] Open
Abstract
Binaprofen (C18H23NO5) is a drug not commercially available that causes liver injury; however, the underlying mechanism is unknown. The aim of the present study was to determine the mechanism underlying binaprofen‑induced liver injury at the genetic level. Zebrafish were treated with binaprofen. Serum biomarkers [alanine transaminase (ALT), aspartate transaminase (AST) and lactate dehydrogenase (LDH)], malondialdehyde (MDA) and glutathione (GSH) content analysis, liver cell morphology examination, DAPI staining, electron microscopy, microarray analysis and reverse transcription‑quantitative (RT‑q)PCR were performed 12, 24 and 48 h post‑treatment to analyze the mechanism underlying binaprofen‑induced liver injury. Following exposure to binaprofen, zebrafish serum levels of ALT, AST and LDH increased; MDA content of liver tissue increased and GSH content decreased. Liver cells exhibited mild to moderate vacuolization and mitochondria exhibited vacuolization and disrupted cristae. Liver cell apoptosis rate increased. There were 190 common differentially expressed genes at 12, 24 and 48 h. Gene Ontology analysis showed that the function of downregulated genes was primarily associated with 'DNA replication', 'DNA metabolic process', 'cell cycle', 'cell redox homeostasis', 'mitochondrion' and 'lipid transport'. The function of upregulated genes was primarily associated with 'peroxisome proliferator', 'oxidation activity', 'peroxisome' and 'apoptosis'. Pathway analysis showed that downregulated genes were those pertaining to 'cell cycle', 'DNA replication', 'ribosome', 'spliceosome', 'pyrimidine metabolism', 'purine metabolism', upregulated genes were those pertaining to 'PPAR signaling pathway', 'p53 signaling pathway'; RT‑qPCR assay supported the microarray results. The mechanism underlying binaprofen‑induced liver injury was associated with lipid peroxidation and apoptosis. Binaprofen downregulated genes associated with lipid transport and anti‑apoptosis genes, upregulated pro‑apoptosis genes and induces liver cell injury via the mitochondrial signaling pathway.
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Affiliation(s)
- Qiuping Guo
- Drug Non-Clinical Evaluation and Research Center, Guangzhou General Pharmaceutical Research Institute, Haizhu, Guangzhou 510240, P.R. China
| | - Guiying Chen
- Drug Non-Clinical Evaluation and Research Center, Guangzhou General Pharmaceutical Research Institute, Haizhu, Guangzhou 510240, P.R. China
| | - Huiyu Ou
- Drug Non-Clinical Evaluation and Research Center, Guangzhou General Pharmaceutical Research Institute, Haizhu, Guangzhou 510240, P.R. China
| | - Ruomin Jin
- Drug Safety Evaluation Center, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, P.R. China
| | - Qingchun Ni
- Drug Non-Clinical Evaluation and Research Center, Guangzhou General Pharmaceutical Research Institute, Haizhu, Guangzhou 510240, P.R. China
| | - Renan Qin
- Drug Non-Clinical Evaluation and Research Center, Guangzhou General Pharmaceutical Research Institute, Haizhu, Guangzhou 510240, P.R. China
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Progress in the treatment of drug-induced liver injury with natural products. Pharmacol Res 2022; 183:106361. [PMID: 35882295 DOI: 10.1016/j.phrs.2022.106361] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 12/13/2022]
Abstract
There are numerous prescription drugs and non-prescription drugs that cause drug-induced liver injury (DILI), which is the main cause of liver disease in humans around the globe. Its mechanism becomes clearer as the disease is studied further. For an instance, when acetaminophen (APAP) is taken in excess, it produces N-acetyl-p-benzoquinone imine (NAPQI) that binds to biomacromolecules in the liver causing liver injury. Treatment of DILI with traditional Chinese medicine (TCM) has shown to be effective. For example, activation of the Nrf2 signaling pathway as well as regulation of glutathione (GSH) synthesis, coupling, and excretion are the mechanisms by which ginsenoside Rg1 (Rg1) treats APAP-induced acute liver injury. Nevertheless, reducing the toxicity of TCM in treating DILI is still a problem to be overcome at present and in the future. Accumulated evidences show that hydrogel-based nanocomposite may be an excellent carrier for TCM. Therefore, we reviewed TCM with potential anti-DILI, focusing on the signaling pathway of these drugs' anti-DILI effect, as well as the possibility and prospect of treating DILI by TCM based on hydrogel materials in the future. In conclusion, this review provides new insights to further explore TCM in the treatment of DILI.
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Green Tea Polyphenols Protect against Acetaminophen-Induced Liver Injury by Regulating the Drug Metabolizing Enzymes and Transporters. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2020; 2020:2696432. [PMID: 33273950 PMCID: PMC7695491 DOI: 10.1155/2020/2696432] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 09/21/2020] [Accepted: 11/03/2020] [Indexed: 01/15/2023]
Abstract
Green tea polyphenols (GTPs) have been shown to exhibit diverse beneficial effects against a variety of diseases. Acetaminophen (APAP) overdose is one of the most frequent causes of drug-induced liver injury. In the current study, we aimed to investigate the protective effect of GTP on APAP-induced liver injury in mice and the underlying mechanisms involved. Male C57BL/6J mice were treated orally with different doses of GTP (37.5, 75, or 150 mg/kg) 4 h after APAP overdose (400 mg/kg) and continuously given every 8 h until sacrificed at 4, 12, 20, and 48 h after the first treatment of GTP. Survival rate and histological and biochemical assessments were performed to evaluate the APAP-induced liver injury. Protein expression of multiple drug metabolizing enzymes and transporters was measured to demonstrate the possible mechanisms involved. Our results revealed that administration of different doses of GTP significantly alleviated APAP-induced liver injury by improving the survival rate, hepatocellular necrosis, and ALT/AST/GSH levels after APAP overdose (400 mg/kg). The protein expression of APAP-induced drug transporters and metabolizing enzymes was mostly induced by GTP treatment, which was followed by reduction in drug transporters at the later time points. The current study collectively demonstrated that GTP protects against APAP-induced liver injury, possibly through regulating drug metabolizing enzymes and transporters after APAP overdose.
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Serdenes R, Graham J. Evaluating the Psychiatric Benefits of Formulating Acetaminophen With N-Acetylcysteine. Front Psychiatry 2020; 11:564268. [PMID: 33192684 PMCID: PMC7649790 DOI: 10.3389/fpsyt.2020.564268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 09/15/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ryan Serdenes
- PGY2 Psychiatry Resident, Temple University Health System, Philadelphia, PA, United States
| | - James Graham
- Department of Psychiatry, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, United States
- Medical Director-Crisis Response Center, Temple University Health System, Philadelphia, PA, United States
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Kuan KK, Lim HC, Goh G, Arciaga GS, Goh PL, Mong R, Chow WL, Tan HH. Cost Savings and Efficacy in Management of Paracetamol Poisoning in a 23-hours Emergency Department Observation Unit: A Comparison to Inpatient Care. Cureus 2019; 11:e6294. [PMID: 31819842 PMCID: PMC6894894 DOI: 10.7759/cureus.6294] [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] [Indexed: 11/10/2022] Open
Abstract
Introduction Emergency department observation units (EDOU) have been shown to be effective in decreasing hospitalization rates and length of stay (LOS) for various conditions. However, cost savings and efficacy in the management of poisoning in EDOU have not been widely studied. The objective of our study is to compare the costs and effectiveness of managing paracetamol poisoned patients in the EDOU with those treated in the inpatient wards. Methods We conducted a historical controlled observational study comparing paracetamol-poisoned patients (who received at least 21 hours of IV N-acetylcysteine [NAC]) admitted to the EDOU during 2013-2014 with similar patients admitted to inpatient ward during 2011, 2013-2014. Results We found 136 patients admitted to the inpatient ward and 95 to our EDOU due to paracetamol poisoning but only 78 and 39 patients respectively fulfilled the inclusion criteria. Between the EDOU and inpatient ward groups, we found similar demographics, poisoning presentation, treatment, and adverse event profiles. There were no fatalities and only two patients (one from each group) developed hepatotoxicity. The "medical" length of stay was 31.9 hours shorter in the EDOU group compared to the inpatient ward group (23.3 versus 55.2 hours). EDOU patients have statistically significant savings (comparing bill size) of S$784 per patient. Conclusions Admission to the EDOU resulted in significant cost savings and 58% decreased LOS when compared to inpatient wards. The EDOU is a cost-effective and safe alternative for the management of selected paracetamol poisonings requiring NAC. Further studies would be needed to verify these results.
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Affiliation(s)
- Kelvin K Kuan
- Accident and Emergency, Changi General Hospital / Singhealth, Singapore, SGP
| | - Hoon Chin Lim
- Accident and Emergency, Changi General Hospital / Singhealth, Singapore, SGP
| | - Geraldine Goh
- Health Sciences Research, Changi General Hospital / Singhealth, Singapore, SGP
| | - Gabriel S Arciaga
- Accident and Emergency, Changi General Hospital / Singhealth, Singapore, SGP
| | - Pak Liang Goh
- Accident and Emergency, Changi General Hospital / Singhealth, Singapore, SGP
| | - Rupeng Mong
- Accident and Emergency, Changi General Hospital / Singhealth, Singapore, SGP
| | - Wai Leng Chow
- Health Sciences Research, Changi General Hospital / Singhealth, Singapore, SGP
| | - Hock Heng Tan
- Accident and Emergency, Changi General Hospital / Singhealth, Singapore, SGP
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Seo M, Kim H, Lee JH, Park JW. Pelargonidin ameliorates acetaminophen-induced hepatotoxicity in mice by inhibiting the ROS-induced inflammatory apoptotic response. Biochimie 2019; 168:10-16. [PMID: 31669604 DOI: 10.1016/j.biochi.2019.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/22/2019] [Indexed: 12/11/2022]
Abstract
The common analgesic acetaminophen (N-acetyl-p-aminophenol, APAP) is non-toxic to the liver at therapeutic doses. However, an overdose of APAP can lead to APAP-induced liver failure, which has emerged as a serious issue in the US and Europe. Pelargonidin is an anthocyanidin found in pomegranates, plums, and various berries. Pelargonidin has strong antioxidant effects, directly scavenging superoxide radicals and inhibiting H₂O₂-induced lipid peroxidation. Focusing on these effects, we studied the preventative effect of pelargonidin on APAP-induced hepatotoxicity and its underlying mechanisms in vivo. We observed that pelargonidin mitigates serum alanine aminotransferase and aspartate aminotransferase activity, which are strongly associated with APAP-induced hepatotoxicity. We also found that pelargonidin reduced APAP-induced hepatic necrosis by removing excessive ROS. Hepatic necrosis stimulates the release of molecular pathogens that induce inflammation, which increases cell stress and can lead to apoptosis. Therefore, pelargonidin was able to reduce levels of necrosis, inflammation, and hepatocyte apoptosis. These results indicate that the administration of pelargonidin protects against APAP-induced hepatotoxicity and that it could be a novel protective strategy against APAP-induced liver failure.
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Affiliation(s)
- Minseok Seo
- School of Life Sciences, BK21 Plus KNU Creative BioResearch Group, College of Natural Sciences, Kyungpook National University, Taegu, Republic of Korea
| | - Hyunjin Kim
- School of Life Sciences, BK21 Plus KNU Creative BioResearch Group, College of Natural Sciences, Kyungpook National University, Taegu, Republic of Korea
| | - Jin Hyup Lee
- Department of Food and Biotechnology, Korea University, Sejong, Republic of Korea
| | - Jeen-Woo Park
- School of Life Sciences, BK21 Plus KNU Creative BioResearch Group, College of Natural Sciences, Kyungpook National University, Taegu, Republic of Korea.
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Zhang YV, Fan SL, Kellogg MD. Effect of hemolysis, icterus, and lipemia on three acetaminophen assays: Potential medical consequences of false positive results. Clin Chim Acta 2018; 487:287-292. [DOI: 10.1016/j.cca.2018.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/09/2018] [Accepted: 10/10/2018] [Indexed: 12/28/2022]
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14
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Chan BY, Tsang HM, Ng CWY, Ling WHW, Leung DCW, Lee HHC, Mak CM. Performance evaluation of five commercial assays for detection of acetaminophen. J Clin Lab Anal 2018; 33:e22683. [PMID: 30288787 DOI: 10.1002/jcla.22683] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 08/17/2018] [Accepted: 09/03/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND To evaluate the analytical performance of five commercial acetaminophen assays and select the best method for routine use. METHODS Imprecision, accuracy, linearity, and interferences of three enzymatic assays (Beckman Coulter AU Paracetamol, Abbott MULTIGENT Acetaminophen, and Sekisui Acetaminophen L3K) and two immunoassay-based assays (Beckman Coulter SYNCHRON ACTM (Acetaminophen) Reagent and Siemens SYVA Emit-tox Acetaminophen) were evaluated on a Beckman Coulter AU680 chemistry analyzer. Hook effect for immunoassay-based assays and recovery in ultrafiltrate for enzymatic methods were studied. RESULTS Within-run and between-run imprecision of the enzymatic assays ranged 0.26%-0.82% and 0.53%-2.86%, respectively, while that for the immunoassay-based methods ranged 0.96%-6.34% and 1.50%-11.33%, respectively. All assays except the SYNCHRON assay fell within the program analytical performance specifications (±20 µmol/L or 10%) for external quality assurance (EQA) samples, with the highest positive bias (31.7%) observed in the SYNCHRON assay. Icteric interference was demonstrated most significantly in the Abbott assay (up to 88 μmol/L positive bias in blank serum). The lipemic interference on the SYNCHRON was significant (up to 110% positive bias at level of 100 μmol/L). The immunoassay-based methods were less susceptible to hemolytic interference, while the Abbott and AU assays were more susceptible to N-acetylcysteine interference. Both immunoassay-based methods showed no hook effect up to 18 000 μmol/L. Ultrafiltration recoveries for enzymatic methods were satisfactory, ranging from 80.0% ± 5.1% to 89.5% ± 3.0%. CONCLUSIONS Proportional bias was observed in the SYNCHRON assay, while the Siemens and Sekisui assays were minimally affected by bilirubin interferences.
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Affiliation(s)
- Bao-Yum Chan
- Department of Pathology, Clinical Laboratory, North Lantau Hospital, Lantau, Hong Kong
| | - Hing-Man Tsang
- Department of Pathology, Clinical Laboratory, North Lantau Hospital, Lantau, Hong Kong
| | - Candy Wai-Yan Ng
- Department of Pathology, Chemical Pathology Laboratory, Princess Margaret Hospital, Kowloon, Hong Kong
| | - William Hin-Wing Ling
- Department of Pathology, Clinical Laboratory, North Lantau Hospital, Lantau, Hong Kong
| | - Daniel Cheuk-Wa Leung
- Department of Pathology, Chemical Pathology Laboratory, Princess Margaret Hospital, Kowloon, Hong Kong
| | - Hencher Han-Chih Lee
- Department of Pathology, Chemical Pathology Laboratory, Princess Margaret Hospital, Kowloon, Hong Kong
| | - Chloe Miu Mak
- Department of Pathology, Chemical Pathology Laboratory, Princess Margaret Hospital, Kowloon, Hong Kong
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15
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Chao X, Wang H, Jaeschke H, Ding WX. Role and mechanisms of autophagy in acetaminophen-induced liver injury. Liver Int 2018; 38:1363-1374. [PMID: 29682868 PMCID: PMC6105454 DOI: 10.1111/liv.13866] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 04/14/2018] [Indexed: 02/06/2023]
Abstract
Acetaminophen (APAP) overdose is the most frequent cause of acute liver failure in the USA and many other countries. Although the metabolism and pathogenesis of APAP has been extensively investigated for decades, the mechanisms by which APAP induces liver injury are incompletely known, which hampers the development of effective therapeutic approaches to tackle this important clinical problem. Autophagy is a highly conserved intracellular degradation pathway, which aims at recycling cellular components and damaged organelles in response to adverse environmental conditions and stresses as a survival mechanism. There is accumulating evidence indicating that autophagy is activated in response to APAP overdose in specific liver zone areas, and pharmacological activation of autophagy protects against APAP-induced liver injury. Increasing evidence also suggests that hepatic autophagy is impaired in nonalcoholic fatty livers (NAFLD), and NAFLD patients are more susceptible to APAP-induced liver injury. Here, we summarized the current progress on the role and mechanisms of autophagy in protecting against APAP-induced liver injury.
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Affiliation(s)
- Xiaojuan Chao
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Hua Wang
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA.,Department of Toxicology, School of Public Health, Anhui Medical University, Hefei, China
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Wen-Xing Ding
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
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16
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Rubin JB, Hameed B, Gottfried M, Lee WM, Sarkar M. Acetaminophen-induced Acute Liver Failure Is More Common and More Severe in Women. Clin Gastroenterol Hepatol 2018; 16:936-946. [PMID: 29199145 PMCID: PMC5962381 DOI: 10.1016/j.cgh.2017.11.042] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 11/19/2017] [Accepted: 11/21/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Acetaminophen overdose is the leading cause of acute liver injury (ALI) and acute liver failure (ALF) in the developed world. Sex differences in acetaminophen-induced hepatotoxicity have not been described. METHODS We collected data from the Acute Liver Failure Study Group cohort, a national registry of 32 academic medical centers in North America of adults with ALI or ALF, including 1162 patients with acetaminophen-induced ALI (n = 250) or acetaminophen-induced ALF (n = 912) from January 2000 through September 2016. We analyzed data on patient presentation, disease course, demographics, medical and psychiatric history, medication use, substance use, and details of acetaminophen ingestion. Sex differences in continuous and categorical variables were evaluated by Wilcoxon rank-sum and χ2 analysis or the Fisher exact test. Our primary aim was to evaluate sex differences in the presentation and clinical course of acetaminophen-induced acute liver injury or liver failure, and our secondary goal was to compare overall and transplant-free survival between sexes. RESULTS Most patients with acetaminophen-induced ALI (68%) or ALF (76%) were women. Higher proportions of women than men had psychiatric disease (60% of women vs 48% of men, P < .01) and had co-ingestion with sedating agents (70% of women vs 52% of men, P < .01)-more than half of which were opioids. Higher proportions of women had severe hepatic encephalopathy (HE) (68% of women vs 58% of men), and required intubation (67% of women vs 59% of men, P values <.03). Higher proportions of women used vasopressors (26% of women vs 19% of men, P = .04) or mannitol (13% of women vs 6% of men, P < .01); proportions of male vs female patients with transplant-free survival were similar (68%). On adjusted analysis, women had higher risk of severe HE (adjusted odds ratio [AOR], 1.66; 95% CI, 1.17-2.35). We found a significant interaction between sex and co-ingestion of sedating agents (P < .01); co-ingestion increased odds of severe HE in women 2-fold (AOR, 1.86; 95% CI, 1.28-2.69; P < .01) but not in men (AOR; 0.62; 95% CI, 0.34-1.13; P = .12). CONCLUSIONS In an analysis of the Acute Liver Failure Study Group cohort, we found acetaminophen-induced ALI and ALF to be more common among women. Women have greater critical care needs than men, and increased risk for severe HE, which could be due in part to increased use of sedatives. Future studies should investigate sex differences in acetaminophen metabolism and hepatotoxicity, particularly among users of opioids.
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Affiliation(s)
- Jessica B Rubin
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Bilal Hameed
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Michelle Gottfried
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Monika Sarkar
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California, San Francisco, San Francisco, California.
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17
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Castro E, Dent D. A comparison of transdermal over-the-counter lidocaine 3.6% menthol 1.25%, Rx lidocaine 5% and placebo for back pain and arthritis. Pain Manag 2017; 7:489-498. [DOI: 10.2217/pmt-2017-0029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Transdermal lidocaine therapy has become a gold standard as part of a treatment regimen for patients who suffer from localized pain. We compared transdermal patches: over-the-counter (OTC) lidocaine 3.6% combined with menthol 1.25%, prescription lidocaine 5% (Rx) and placebo. Methods: In a double-blind, placebo-controlled trial, 87 patients were randomized to: OTC, Rx or placebo. Results: OTC met primary end points of noninferiority compared with Rx for efficacy, side effects and quality of life. Versus placebo, OTC proved superiority for efficacy, general activity and normal work. Side effects were similar. Conclusion: It is theorized that menthol's ability to increase skin permeability facilitated more efficient drug delivery to the site of pain causing higher than expected efficacy. Decreased cost and resource utilization could benefit patients and payers.
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Affiliation(s)
- Eric Castro
- Department of Medicine, Advocate Good Sheppard Hospital, Barrington, IL 60010, USA
| | - David Dent
- Department of Medicine, University of Southern California, Los Angeles, CA 90033, USA
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18
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Stumpf JL, Liao AC, Nguyen S, Skyles AJ, Alaniz C. Knowledge of appropriate acetaminophen use: A survey of college-age women. J Am Pharm Assoc (2003) 2017; 58:51-55. [PMID: 29079404 DOI: 10.1016/j.japh.2017.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 07/07/2017] [Accepted: 09/20/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To evaluate college-age women's knowledge of appropriate doses and potential toxicities of acetaminophen, competency in interpreting Drug Facts label dosing information, and ability to recognize products containing acetaminophen. METHODS In this cross-sectional prospective study, a 20-item written survey was provided to female college students at a University of Michigan fundraising event in March 2015. RESULTS A total of 203 female college students, 18-24 years of age, participated in the study. Pain was experienced on a daily or weekly basis by 22% of the subjects over the previous 6 months, and 83% reported taking acetaminophen. The maximum 3-gram daily dose of extra-strength acetaminophen was correctly identified by 64 participants; an additional 51 subjects indicated the generally accepted 4 grams daily as the maximum dose. When provided with the Tylenol Drug Facts label, 68.5% correctly identified the maximum amount of regular-strength acetaminophen recommended for a healthy adult. Hepatotoxicity was associated with high acetaminophen doses by 63.6% of participants, significantly more than those who selected distracter responses (P < 0.001). Knowledge of liver damage as a potential toxicity was correlated with age 20 years and older (P < 0.001) but was independent from race and ethnicity and level of alcohol consumption. Although more than one-half of the subjects (58.6%) recognized that Tylenol contained acetaminophen, fewer than one-fourth correctly identified other acetaminophen-containing products. CONCLUSION Despite ongoing educational campaigns, a large proportion of the college-age women who participated in our study did not know and could not interpret the maximum recommended daily dose from Drug Facts labeling, did not know that liver damage was a potential toxicity of acetaminophen, and could not recognize acetaminophen-containing products. These data suggest a continued role for pharmacists in educational efforts targeted to college-age women.
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Stuntz M, Busko K, Irshad S, Paige T, Razhkova V, Coan T. Nationwide trends of clinical characteristics and economic burden of emergency department visits due to acute ischemic stroke. Open Access Emerg Med 2017; 9:89-96. [PMID: 29033616 PMCID: PMC5614785 DOI: 10.2147/oaem.s146654] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We aimed to provide estimates of the volume and associated charges of acute ischemic stroke (AIS) visits in the US, as well as to assess predictors of patient disposition following an emergency department (ED) visit for AIS. Our study was conducted using the 2010–2013 data from the Nationwide Emergency Department Sample. We identified adult visits with AIS as the primary diagnosis. A generalized linear model was used to calculate mean charges per visit after adjusting for covariates. Multinomial logistic regression was used to assess predictors of patient disposition following an ED visit for AIS. The national incidence did not appreciably change over time, increasing from 26.4 to 27.0 visits per 10,000 adults. Adjusted mean charges per event were highest in the West, increasing from $3,761 in 2010 to $4,575 in 2013. Multinomial logistic regression showed that older age was associated with increased likelihood of both hospital admission and mortality in the ED, while male sex was associated with lower odds of mortality in the ED. Despite improvements in primary and secondary prevention of cardiovascular disease, AIS remains a significant burden on the health care system with a high volume of ED visits and increasing charges for care.
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Affiliation(s)
| | | | | | | | | | - Tim Coan
- Deerfield Institute, New York, NY, USA
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20
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Parry MJ, Isoniemi H, Koivusalo AM, Hoppu K. Increased acetaminophen related calls to Finnish PIC better reflect acetaminophen sales than serious poisonings. Clin Toxicol (Phila) 2017; 56:209-215. [PMID: 28812385 DOI: 10.1080/15563650.2017.1359619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE Acetaminophen (APAP) or paracetamol is a commonly encountered medicine in poisonings. We studied the changes in APAP related calls to the Finnish poison information centre (FPIC), and serious intoxications, involving hepatotoxicity or death in 2001-2014. These data were compared with paracetamol sales in Finland. METHODS This is a retrospective analysis of the FPIC database calls, national cause of death registry, registries of liver transplantations and molecular adsorbent recycling system (MARS)-treated patients from Helsinki University Hospital together with the National Institute of Health and Welfare registry of patients hospitalized. Data on APAP sales were obtained from the Finnish Medicines Agency. RESULTS Between 2001 and 2014, the number of calls/year related to human APAP exposures to the FPIC increased from 227 to 1058. No change in the age distribution of enquiries was seen. Most calls involved minors: 58% (range 52-64%) for children under 6 years old, and 9% (range 6-14%) for children of 6-15 years. In Finland, APAP related fatalities have gradually increased from an average of 7/year (range 4-10) in 2000-2005 to an average of 11/year (range 6-17) in 2010-2013, whereas the number of liver transplantations remained low, average 0.6/year (range 0-2). For patients in need of MARS-treatment, a slight decrease was seen. Total APAP sales increased from 5.6 (47% prescription, 53% OTC) to 29.7 (81% prescription, 19% OTC). DDD/1000 inhabitants/day from 2001 to 2014 is recorded. Best linear relationship (R2 = 0.97; p < .001) was observed between total FPIC calls and total sales of APAP in 2001-2014. Fatalities show a weaker relationship with sales (R2 = 0.317; p = .045). CONCLUSIONS During the study period, we see an increase in FPIC exposure calls accompanied by an increase in APAP sales. Changes in the chosen indicators for serious poisonings show only a weak association. Despite an evident trend between sales and fatalities, the correlation with fatality remains weak due to the small number of fatalities.
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Affiliation(s)
- Mikko J Parry
- a Poison Information Centre, Helsinki University Hospital , Helsinki , Finland
| | - Helena Isoniemi
- b Department of Transplantation and Liver Surgery , Abdominal Center, Helsinki University Hospital , Helsinki , Finland
| | - Anna-Maria Koivusalo
- c Department of Anaesthesiology and Intensive Care , Helsinki University Hospital , Helsinki , Finland
| | - Kalle Hoppu
- a Poison Information Centre, Helsinki University Hospital , Helsinki , Finland
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21
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Wiffen PJ, Derry S, Moore RA, McNicol ED, Bell RF, Carr DB, McIntyre M, Wee B. Oral paracetamol (acetaminophen) for cancer pain. Cochrane Database Syst Rev 2017; 7:CD012637. [PMID: 28700092 PMCID: PMC6369932 DOI: 10.1002/14651858.cd012637.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Pain is a common symptom with cancer, and 30% to 50% of all people with cancer will experience moderate to severe pain that can have a major negative impact on their quality of life. Non-opioid drugs are commonly used to treat mild to moderate cancer pain, and are recommended for this purpose in the WHO cancer pain treatment ladder, either alone or in combination with opioids.A previous Cochrane review that examined the evidence for nonsteroidal anti-inflammatory drugs (NSAIDs) or paracetamol, alone or combined with opioids, for cancer pain was withdrawn in 2015 because it was out of date; the date of the last search was 2005. This review, and another on NSAIDs, updates the evidence. OBJECTIVES To assess the efficacy of oral paracetamol (acetaminophen) for cancer pain in adults and children, and the adverse events reported during its use in clinical trials. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase from inception to March 2017, together with reference lists of retrieved papers and reviews, and two online study registries. SELECTION CRITERIA We included randomised, double-blind, studies of five days' duration or longer, comparing paracetamol alone with placebo, or paracetamol in combination with an opioid compared with the same dose of the opioid alone, for cancer pain of any intensity. Single-blind and open studies were also eligible for inclusion. The minimum study size was 25 participants per treatment arm at the initial randomisation. DATA COLLECTION AND ANALYSIS Two review authors independently searched for studies, extracted efficacy and adverse event data, and examined issues of study quality and potential bias. We did not carry out any pooled analyses. We assessed the quality of the evidence using GRADE and created a 'Summary of findings' table. MAIN RESULTS Three studies in adults satisfied the inclusion criteria, lasting up to one week; 122 participants were randomised initially, and 95 completed treatment. We found no studies in children. One study was parallel-group, and two had a cross-over design. All used paracetamol as an add-on to established treatment with strong opioids (median daily morphine equivalent doses of 60 mg, 70 mg, and 225 mg, with some participants taking several hundred mg of oral morphine equivalents daily). Other non-paracetamol medication included non-steroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants, or neuroleptics. All studies were at high risk of bias for incomplete outcome data and small size; none was unequivocally at low risk of bias.None of the studies reported any of our primary outcomes: participants with pain reduction of at least 50%, and at least 30%, from baseline; participants with pain no worse than mild at the end of the treatment period; participants with Patient Global Impression of Change (PGIC) of much improved or very much improved (or equivalent wording). What pain reports there were indicated no difference between paracetamol and placebo when added to another treatment. There was no convincing evidence of paracetamol being different from placebo with regards to quality of life, use of rescue medication, or participant satisfaction or preference. Measures of harm (serious adverse events, other adverse events, and withdrawal due to lack of efficacy) were inconsistently reported and provided no clear evidence of difference.Our GRADE assessment of evidence quality was very low for all outcomes, because studies were at high risk of bias from several sources. AUTHORS' CONCLUSIONS There is no high-quality evidence to support or refute the use of paracetamol alone or in combination with opioids for the first two steps of the three-step WHO cancer pain ladder. It is not clear whether any additional analgesic benefit of paracetamol could be detected in the available studies, in view of the doses of opioids used.
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Key Words
- adult
- humans
- acetaminophen
- acetaminophen/administration & dosage
- administration, oral
- analgesics, non‐narcotic
- analgesics, non‐narcotic/administration & dosage
- analgesics, opioid
- analgesics, opioid/administration & dosage
- anti‐inflammatory agents, non‐steroidal
- anti‐inflammatory agents, non‐steroidal/administration & dosage
- antidepressive agents, tricyclic
- antidepressive agents, tricyclic/administration & dosage
- antipsychotic agents
- antipsychotic agents/administration & dosage
- cancer pain
- cancer pain/drug therapy
- drug therapy, combination
- patient preference
- quality of life
- randomized controlled trials as topic
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Affiliation(s)
| | | | | | - Ewan D McNicol
- Tufts Medical CenterDepartment of Anesthesiology and Perioperative MedicineBostonMAUSA
| | - Rae Frances Bell
- Haukeland University HospitalRegional Centre of Excellence in Palliative CareBergenNorway
| | - Daniel B Carr
- Tufts University School of MedicinePain Research, Education and Policy (PREP) Program, Department of Public Health and Community MedicineBostonMassachusettsUSA
| | | | - Bee Wee
- Churchill HospitalNuffield Department of Medicine and Sir Michael Sobell HouseOld RoadHeadingtonOxfordUKOX3 7LJ
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22
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Kim SJ, Kim KM, Yang JH, Cho SS, Kim JY, Park SJ, Lee SK, Ku SK, Cho IJ, Ki SH. Sestrin2 protects against acetaminophen-induced liver injury. Chem Biol Interact 2017; 269:50-58. [DOI: 10.1016/j.cbi.2017.02.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 12/29/2016] [Accepted: 02/03/2017] [Indexed: 12/22/2022]
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23
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Levine M, Stellpflug S, Pizon AF, Traub S, Vohra R, Wiegand T, Traub N, Tashman D, Desai S, Chang J, Nathwani D, Thomas S. Estimating the impact of adopting the revised United Kingdom acetaminophen treatment nomogram in the U.S. population. Clin Toxicol (Phila) 2017; 55:569-572. [DOI: 10.1080/15563650.2017.1291945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, Division of Medical Toxicology, University of Southern California, Los Angeles, CA, USA
| | - Sam Stellpflug
- Department of Emergency Medicine, Division of Medical Toxicology, Regions Healthcare, St. Paul, MN, USA
| | - Anthony F. Pizon
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen Traub
- Department of Emergency Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | - Rais Vohra
- Department of Emergency Medicine, UCSF Fresno Medical Center and the California Poison Control System, Fresno, CA, USA
| | - Timothy Wiegand
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Nicole Traub
- Department of Medicine, Division of Gastroenterology, Mayo Clinic, Scottsdale, AZ, USA
| | - David Tashman
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shoma Desai
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jamie Chang
- Department of Emergency Medicine, UCSF Fresno Medical Center, Fresno, CA, USA
| | - Dhruv Nathwani
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Stephen Thomas
- Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Emergency Department, Weill Cornell Medical College in Qatar, Doha, Qatar
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24
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Alverson B. Seriously. Clowns. Hosp Pediatr 2017; 7:57-58. [PMID: 27908975 DOI: 10.1542/hpeds.2016-0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Brian Alverson
- Department of Pediatrics, Rhode Island Hospital, Providence, Rhode Island
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25
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Vliegenthart A, Kimmitt RA, Seymour JH, Homer NZ, Clarke JI, Eddleston M, Gray A, Wood DM, Dargan PI, Cooper JG, Antoine DJ, Webb DJ, Lewis SC, Bateman DN, Dear JW. Circulating acetaminophen metabolites are toxicokinetic biomarkers of acute liver injury. Clin Pharmacol Ther 2016; 101:531-540. [PMID: 27770431 PMCID: PMC6099202 DOI: 10.1002/cpt.541] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/15/2016] [Accepted: 10/17/2016] [Indexed: 02/07/2023]
Abstract
Acetaminophen (paracetamol-APAP) is the most common cause of drug-induced liver injury in the Western world. Reactive metabolite production by cytochrome P450 enzymes (CYP-metabolites) causes hepatotoxicity. We explored the toxicokinetics of human circulating APAP metabolites following overdose. Plasma from patients treated with acetylcysteine (NAC) for a single APAP overdose was analyzed from discovery (n = 116) and validation (n = 150) patient cohorts. In the discovery cohort, patients who developed acute liver injury (ALI) had higher CYP-metabolites than those without ALI. Receiver operator curve (ROC) analysis demonstrated that at hospital presentation CYP-metabolites were more sensitive/specific for ALI than alanine aminotransferase (ALT) activity and APAP concentration (optimal CYP-metabolite receiver operating characteristic area under the curve (ROC-AUC): 0.91 (95% confidence interval (CI) 0.83-0.98); ALT ROC-AUC: 0.67 (0.50-0.84); APAP ROC-AUC: 0.50 (0.33-0.67)). This enhanced sensitivity/specificity was replicated in the validation cohort. Circulating CYP-metabolites stratify patients by risk of liver injury prior to starting NAC. With development, APAP metabolites have potential utility in stratified trials and for refinement of clinical decision-making.
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Affiliation(s)
- Adb Vliegenthart
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - R A Kimmitt
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - J H Seymour
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - N Z Homer
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - J I Clarke
- MRC Centre for Drug Safety Science, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - M Eddleston
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - A Gray
- Emergency Medicine Research Group, Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - D M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - P I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,King's College London, London, UK
| | - J G Cooper
- Emergency Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - D J Antoine
- MRC Centre for Drug Safety Science, Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - D J Webb
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - S C Lewis
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - D N Bateman
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, UK
| | - J W Dear
- Pharmacology, Toxicology and Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, UK
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36th International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) 24-27 May, 2016, Madrid, Spain. Clin Toxicol (Phila) 2016; 54:344-519. [DOI: 10.3109/15563650.2016.1165952] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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McGill MR, Kennon-McGill S, Durham D, Jaeschke H. Hearing, reactive metabolite formation, and oxidative stress in cochleae after a single acute overdose of acetaminophen: an in vivo study. Toxicol Mech Methods 2016; 26:104-11. [PMID: 26982240 DOI: 10.3109/15376516.2015.1122136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
CONTEXT Although the liver is the primary target organ in acetaminophen (APAP) toxicity, other organs are affected. Previous data suggested that chronic APAP abuse can be ototoxic and the mechanism involves APAP-induced oxidative stress and reactive metabolite (N-acetyl-p-benzoquinone imine, NAPQI)-induced endoplasmic reticulum stress. However, the effect of a single acute overdose on hearing has not been tested. OBJECTIVES To determine if a single acute APAP overdose causes hearing damage, and to explore possible mechanisms of APAP ototoxicity. MATERIALS AND METHODS Male C57BL/6 J mice were treated with a single human-relevant overdose of APAP (300 mg APAP per kg bodyweight). Blood, liver and cochleae were harvested at 0, 2, 6 and 24 h post-APAP. In some mice, auditory brainstem responses (ABRs) to a range of frequencies were measured at 24 h. The furosemide plus kanamycin (FS/K) model of drug ototoxicity was used as a positive control for hearing loss. NAPQI formation after APAP was assessed by measuring glutathione depletion and covalent protein binding, and oxidative stress was assessed by measuring glutathione disulfide. RESULTS There was no evidence of reactive metabolite formation or hearing loss after a single overdose of APAP at a clinically relevant dose. However, there was a transient increase in oxidative stress. DISCUSSION Although a single acute overdose was not ototoxic, there was evidence of oxidative stress which may support a role for oxidative stress in hearing loss due to chronic APAP abuse. CONCLUSION A single human-relevant acute overdose of APAP causes transient oxidative stress in cochleae but not hearing loss.
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Affiliation(s)
| | - Stefanie Kennon-McGill
- b Department of Otolaryngology - Head and Neck Surgery , University of Kansas Medical Center , Kansas City , KS , USA
| | - Dianne Durham
- b Department of Otolaryngology - Head and Neck Surgery , University of Kansas Medical Center , Kansas City , KS , USA
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Alanazi MQ, Al-Jeriasy MI, Al-Assiri MH, Afesh LY, Alhammad F, Salam M. Hospital Performance Indicators and Their Associated Factors in Acute Child Poisoning at a Single Poison Center, Central Saudi Arabia. Medicine (Baltimore) 2015; 94:e2339. [PMID: 26717371 PMCID: PMC5291612 DOI: 10.1097/md.0000000000002339] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Admission rate and length of stay (LOS) are two hospital performance indicators that affect the quality of care, patients' satisfaction, bed turnover, and health cost expenditures. The aim of the study was to identify factors associated with higher admission rates and extended average LOS among acutely poisoned children at a single poison center, central Saudi Arabia.This is a cross-sectional, poison and medical chart review between 2009 and 2011. Exposures were child characteristics, that is, gender, age, body mass index (BMI), health history, and Canadian 5-level triage scale. Poison incident characteristics were, that is, type, exposure route, amount, form, home remedy, and arrival time to center. Admission status and LOS were obtained from records. Chronic poisoning, plant allergies, and venomous bites were excluded. Bivariate and regression analyses were applied. Significance at P < 0.05.Of the 315 eligible cases, (72%) were toddlers with equal gender distribution, (58%) had normal BMI, and (77%) were previously healthy. Poison substances were pharmaceutical drugs (63%) versus chemical products (37%). Main exposure route was oral (98%). Home remedy was observed in (21.9%), which were fluids, solutes, and/or gag-induced vomiting. Almost (52%) arrived to center >1 h. Triage levels: non-urgent cases (58%), less urgent (11%), urgent (18%), emergency (12%), resuscitative (1%). Admission rate was (20.6%) whereas av. LOS was 13 ± 22 h. After adjusting and controlling for confounders, older children (adj.OR = 1.19) and more critical triage levels (adj.OR = 1.35) were significantly associated with higher admission rates compared to younger children and less critical triage levels (adj.P = 0.006) and (adj.P = 0.042) respectively. Home remedy prior arrival was significantly associated with higher av. LOS (Beta = 9.48, t = 2.99), compared to those who directly visited the center, adj.P = 0.003.Hospital administrators are cautioned that acutely poisoned children who received home remedies prior arrival are more likely to endure an extended LOS. This non-conventional practice is not recommended.
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Affiliation(s)
- Menyfah Q Alanazi
- From the Drug Policy and Economics Center (MQA); King Abdullah International Medical Research Center (KAIMRC) (MJ, MHA, LYA, MS); Pharmaceutical Care and King Saud bin Abdulaziz University for Health Sciences (KSAU-HS) (MJ); and Pediatrics Emergency Department (FA); King Abdulaziz Medical City, Riyadh, Saudi Arabia
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