Hepatotoxicity of paracetamol and related fatalities

Paracetamol, also known as acetaminophen, is the most commonly used antipyretic and pain reliever and since 1955 it is available over-the-counter as a single formulation or in combination with other substances and, as indicated by the World Health Organization, it can be used in all the three steps of pain intensity. Paracetamol toxicity is one of the most common causes of poisoning worldwide. While paracetamol is described as relatively nontoxic when administered in therapeutic doses, it is known to cause toxicity when taken in a single or repeated high dose, or after chronic ingestion. Repeated supratherapeutic misuse, non-intentional misuse, and intentional ingestion may all result in hepatic toxicity, the main cause of acute liver failure (ALF) in the United States and Europe. Since paracetamol is responsible for nearly half of the cases in the US of acute liver failure and remains the leading cause of liver transplantation, continued awareness promotion, education and research should be constantly undertaken. We herein review the literature on paracetamol toxicity with particular attention to aspects of liver damage and related fatalities.

Drug-induced angioedema: experience of Italian emergency departments

Acute angioedema represents a cause of admission to the emergency department requiring rapid diagnosis and appropriate management to prevent airway obstruction. Several drugs, including angiotensin-converting enzyme inhibitors (ACE-I), nonsteroidal anti-inflammatory drugs (NSAIDs) and oral antidiabetics, have been reported to induce angioedema. The aim of this prospective observational study conducted in a setting of routine emergency care was to evaluate the incidence and extent of drug-induced non-histaminergic angioedema in this specific clinical setting, and to identify the class of drugs possibly associated with angioedema. Patients admitted to seven different emergency departments (EDs) in Rome with the diagnosis of angioedema and urticaria were enrolled during a 6-month period. Of the 120,000 patients admitted at the EDs, 447 (0.37 %) were coded as having angioedema and 655 (0.5 %) as having urticaria. After accurate clinical review, 62 cases were defined as drug-induced, non-histaminergic angioedema. NSAIDs were the most frequent drugs (taken by 22 out of 62 patients) associated with the angioedema attack. Of the remaining patients, 15 received antibiotic treatment and 10 antihypertensive treatment. In addition, we observed in our series some cases of angioedema associated with drugs (such as antiasthmatics, antidiarrheal and antiepileptics) of which there are few descriptions in the literature. The present data, which add much needed information to the existing limited literature on drug-induced angioedema in the clinical emergency department setting, will provide more appropriate diagnosis and management of this potentially life-threatening adverse event.

[Statistical evaluation of potential mistakes and malpractice in a Chest Pain Unit]

AIMS

The Chest Pain Unit (CPU) of Policlinico Umberto I, established in 2008, is charged with the management of patients with non-traumatic chest pain transferred from the Emergency Department and aims at: a) an early recognition of patients at high risk of acute coronary syndrome (ACS), in order to perform a primary PCI within 90 minutes; b) an early diagnosis of patients at low risk of ACS in order to discharge them in a short time, and c) the diagnostic performance of clinical tests in patients at intermediate risk of ACS in order to identify those who require either a new PCI or a coronary artery bypass graft (CABG). The purpose is to avoid malpractice which could even imply the risk of legal conflicts.

MATERIALS AND METHODS

We evaluated the total number of admissions to the Emergency Department of Policlinico Umberto I in the period 2010-2011 and selected the patients with non-traumatic chest pain and acute coronary syndrome. In the Chest Pain Unit, patients with non-traumatic chest pain or ACS were recruited through a) the use of the Chest Pain Score to define the typicality or atypicality of chest pain; b) the stratification of the risk of ACS using the modified Braunwald Score; and c) the stratification of patients at intermediate or high risk of ACS using the GRACE ACS Model in order to perform a PCI.

RESULTS

In the period 2010-2011, 603 patients were admitted to the CPU with non-traumatic chest pain. Of them, 15.75% (95) were diagnosed with atypical chest pain; 27.03% (163) with chronic stable angina pectoris; 9.3% (56) received a diagnosis of chronic heart failure and 47.92% (289) suffered from non ischemic cardiovascular disease. Other 124 subjects were admitted to the CPU with a diagnosis of ACS, but only in 91.93% of the cases such diagnosis was confirmed, whereas for the remaining 8.06% was discarded. On the whole, 54.2% (394) of the 727 patients admitted to the CPU with non-traumatic chest pain and acute coronary syndrome showed a low cardiovascular risk; 30.12% (219) were at intermediate risk and 15.68% (144) at high risk.

DISCUSSION

The aim of the CPU is to accomplish a selection of the subjects at high risk of ACS, to drastically reduce the time of diagnosis and treatment to 24-36 hours and to avoid possible mistakes or adverse events by using both unsophisticated diagnostic tests and a personalized management of diagnosis and treatment.

[An unusual cause of chest pain in]

Myocarditis seems to be mostly caused by a viral infection or more rarely by a pharmacological hypersensitivity or by radiations exposure. Nevertheless, it is not so easy to know the ethiopathogenesis of the myocarditis, because mostly it is impossible to determine the infectious agent that causes the pathology even if it is isolated. The diagnosis could often remain uncertain, so a suspect of myocarditis has to be opportunely confirmed by specific serological and diagnostic investigations, in order to avoid the appearance of a dilated cardiomyopathy which is one of its principal sequences.

[High digoxin serum levels in an elderly patient for the endogenous digoxin-like immunoreactive substances. A case report]

Digoxin is typically prescribed in the treatment of heart failure. Its limited therapeutic range requires systematic monitoring of plasmatic concentration through immunoreactive tests. Laboratory results, however, can be altered by the presence of digoxin-like immunoreactive factors (DLIF) which are released in all clinical conditions involving volemic expansion.

CASE REPORT

An 86-year-old woman arrived in emergency with severe dyspnoea, atrial flutter and a medical history of ischemic cardiopathy. The patient was treated with ACE inhibitor, furosemide, spironolactone and digoxin. The first lab test for digoxin showed levels of digoxin of 7.05 ng/ml. Although the patient did not show any clinical evidence of digital intoxication nor was she treated with drugs which might interfere with digoxin kinetics and even if she had markers of renal function within clinical limits, digoxin was suspended and a treatment was initiated with 0.9% NaCl solution and furosemide. The second lab test showed levels of digoxin of 8.38 ng/ml. A possible interference of DLIF with immunoreactive tests was therefore assumed.

MATERIALS AND METHODS

The patient's serum was ultrafiltered and centrifugated to remove possible DLIF; subsequently, the measurement of digoxin levels was repeated. As a result, the digoxin level decreased to 0.25 ng/ml.

CONCLUSIONS

DLIF increase in several diseases, including heart failure, end-stage renal disease, pre-eclampsy and acromegaly. High digoxin levels in a patient who does not show any symptoms of digital intoxication should lead to suspect the presence of these factors and to preventively determine DLIF in serum so as not to incur the risk of suspending an important treatment like digoxin in heart failure.

[The syncope in Emergency Department: usual management vs guidelines]

INTRODUCTION

The syncope is a common cause of admission to Emergency Departments, representing around 1-3% of all admissions to the service. However, elderly age and important comorbidities often hinder a definite etiologic diagnosis, with increasing requests for diagnostic tests and longer periods of hospitalization.

MATERIALS AND METHODS

We analyzed the management of 1,204 patients admitted to our Emergency Department for transient loss of consciousness in the period between 1 June 2009 and 1 June 2010, evaluating the following parameters: average age, gender, triage color code at admittance, performed diagnostic tests, diagnosis at discharge from ED and destination ward. We also studied a subgroup of 93 patients admitted to emergency medicine units evaluating their OESIL score at admittance, comorbidities, performed diagnostic tests and diagnosis at discharge from the ward.

RESULTS

In the Emergency Department, 45% of patients were discharged with a diagnosis of syncope of unknown origin; in 21% of patients syncope was excluded; 19% of patients received a diagnosis of cardiogenic syncope; 11% were diagnosed with a presyncope; 3% with orthostatic hypotension and 1% with vasovagal syncope. In emergency medicine units, 51% of patients were discharged with a diagnosis of cardiogenic syncope, 11% were diagnosed with vasovagal syncope, 11% with presyncope, 11% with TIA, 8% with loss of consciousness non-syncope and 8% with syncope of unknown origin.

CONCLUSIONS

Management of patients with syncope, elderly people with important comorbidities in particular, is still a serious problem for the emergency physician. The creation of specialized units for the management of syncope, the so-called syncope units, through the implementation of a shared diagnostic and therapeutic protocol, aims at reducing inappropriate hospitalization and average length of stay.

[The use of cardiac markers bed test in acute coronary syndrome in emergency department]

AIMS

The evaluation of the patient with chest pain in the emergency department is one of the most common situations that the doctor has to face. The diagnostic procedure supposes an observation period of at least 6-12 hours, a well organized medical facilities and the identification of all SCA cases to reduce inappropriate admission.

MATERIALS AND METHODS

In our study we have estimated the utility of the marker assay that is associated to the use of risk scores (TIMI and GRACE risk score) to obtain indication about the most appropriate assistance level. In particular, we used the assay of necrosis markers to highlight the damage along with the assay of natriuretic peptides for their role in the diagnosis and in the monitoring of the patients with cardiac damage.

RESULTS

Also PCR has an important role such as marker of plaque stability and of inflammation. These markers associated to the necrosis markers could give important clinical information of independent nature.

DISCUSSION

The sensibility of laboratory markers, without important necrosis, is low and it is not possible to exclude in a few time a SCA There is now an alternative strategy: a precocious risk stratification. Using clinical criteria it is possible to do a first evaluation of the probability of SCA and the complications.

[Management model of chest pain in Medical Emergency Room and Chest Pain Unit of Policlinico Umberto I of Rome]

In Italy one of the most common cause of access to the Emergency Departments is not traumatic chest pain, representing from the 6% to 10% of all the diagnoses. Admissions to the Emergency Department (DEA) of Policlinico Umberto I of Rome for non-traumatic chest pain, occurred between 2000 and 2008, were analyzed in this study. Out of 26,8910 admissions to the medical emergency room (PS), 21,088 (7.84%) were due to non-traumatic or precordial chest pain. Of these, 2881 (14%) patients had a diagnosis of myocardial infarction STEMI, NSTEMI and IA and 18,207 (86%) had a diagnosis of atypical chest pain, representing respectively 1.07% and 6.77% of all admissions to PS. About 27.62% of patients with atypical chest pain were discharged from the PS, 33.27% were hospitalized, 36.73% refused hospitalization, 1.68% were transferred elsewhere, and 0.7% did not uptake the visit. 85% of patients with myocardial infarction STEMI, NSTEMI and IA were hospitalized, 3.75% refused hospitalization, 8.82% were transferred elsewhere, and 1.71% died in the PS. Hospitalizations resulted often in unjustified and protracted length of hospital stays for clinical investigations, with negative repercussions for patients and costs. In the last years, the number of inappropriate hospitalizations progressively increased, partly as consequence of recourse to the court aiming at defining legal responsibility of the health board.Since avoiding inappropriate hospital admissions is an essential requirement for containing healthcare costs and improving the health service, Chest Pain Unit has been established. Its responsibility is to recognize and promptly treat patients with chest pain and acute coronary syndrome. As well, it is responsible to quickly discharge patients with chest pain at low and intermediate risk of acute coronary insufficiency, after careful clinical assessment lasting 24-36 hours.

[The role of D-dimer in aortic dissection]

OBJECTIVES

The aim of this retrospective study is to indicate the correlation between the grade of the extent of the aortic pathology, the presence of complications, the evolution of the pathology value of the D-dimer in all the patients with aortic dissection in order to know a prognostic role a short-long time of this test.

MATERIALS AND METHODS

Only in 40 patients were possible to determine the value of D-dimer priol of these patients were not received invasive cares. The patients are divided into 4 classes in accordance with the extent of the aortic pathology valued TAC images and after we have taken in observation the presence of clinical complications shown and the positive history for chronic aortic dissection.

RESULTS

The elevation of D-dimer is strictly associated with the extent of the aortic dissection. The value of D-dimer is more elevated during the progress of the pathology and in the presence of clinical complications than during chronic aortic dissection.

CONCLUSIONS

The D-dimer is considered a diagnostic marker by the clinicians during the acute setting of the aortic dissection. A lot of points of view should be valued and cleared, its possible to attribute a prognostic role at the D-dimer during the acute aortic dissection.

[Therapy optimization of heart failure through the evaluation of the plasma concentration variation of B-type natriuretic peptide]

AIM

Our research was based over the critical evaluation of the plasmatic concentration variation of B-type Natriuretic Peptide in emergency in patients with heart failure during therapy with diuretics, anti-aldosterone, ACE-inhibitors, beta-blockers and nitroderivates.

MATERIALS AND METHOD

We selected 108 patients: 30 control subjects (average 58.40 +/- SD13.32 for 20 M, and 65 +/- SD 14.74 for 10 W), and 78 subjects (average 75.90 +/- SD 9.60 for 41 M, and 77.89 +/- SD 8.62 for 37 W) arrived to the emergency and reception department for dyspnea and/or precordialgia and/or palpitations with heart failure diagnosis according to NYHA Classification. The variation of BNP concentration was evaluated in these subjects at the admission, after 1 week, and 1 month from the beginning of the therapy.

RESULTS

Patients with heart failure had a BNP concentration high during all measurements. The values were high during admission, but after 1 week and after 1 month, they reduced reaching the balance.

CONCLUSIONS

BNP evaluation is a good indicator for the diagnosis of heart failure and for improving the therapy. The main limit of BNP diagnostic role is the need of knowing in advance the specific values for each patient.

[Praecox feeling in medicine]

In this work the idea of praecox gefüll or praecox feeling is resumed by H. C. Rumke in 1941 and by Minkowski in 1968 for patient with schizophrenia. The diagnosis is not done only by patient's examination and by symptoms, but also by diligent examination which the psychiatry does about himself. To perceive one and to diagnose by praecox feeling is a personal ability, but it is a training with ourselves: to be sensible of the "effect" of disease in us. The praecox feeling, attributed in psychiatry, may be expanded in other medical areas. Case report gives evidence about this.

[Drug-induced toxic hepatitis]

The case is described of a woman with drug hepatotoxicity, who was a psychiatric patient. The case is reported because the diagnosis occurred by a "praecoxfeeling", in fact physician's intuition is a personal structure which is born from same external incitements instead of other. The diagnosis was confirmed by clinical tests and by subsequent clinical research.

[Monitored and random arterial blood pressure as prediction of biological risk. Comparison with domiciliary self-measurement]

The approach to the hypertensive patient is still a subject of debate. The use of new measurement methods permits us to obtain more exact blood pressure values which represent an index of cardiovascular condition. We also demonstrated that non-invasive monitoring and self-measurement at home consent better management of hypertension.