The presence of abdominal pain associated with acetaminophen overdose does not predict severity of liver injury.

AIM: Whilst it is known that abdominal pain is a common symptom in patients with acetaminophen overdose, its association with severity of liver injury has not been clearly defined. This study investigates the association between the symptom of abdominal pain on presentation to hospital and the degree of liver injury post-acetaminophen overdose. METHODS: Admissions with acetaminophen poisoning, requiring treatment with acetylcysteine were identified and reviewed from a search of a large Australian tertiary hospital network from February 20th, 2014, to August 30th, 2018. Parameters such as presence of abdominal pain, time post-ingestion and peak ALT were collected. Single acute ingestions, staggered and repeated supratherapeutic ingestions were analysed. RESULTS: 539 cases were identified in the study period, 79% female, with mean age 25 (17-43) years. Patients presenting to the emergency department with abdominal pain post-acetaminophen overdose had a similar risk of developing hepatotoxicity or acute liver injury compared to patients without abdominal pain regardless of time to presentation. Patients presenting <8-h post-overdose with abdominal pain were as likely to develop hepatotoxicity (1/46, 2.2%) compared to those without abdominal pain (1/54 [1.9%]; OR = 1.18 [0.07 to 19.4]). Those presenting >8-h post-overdose with abdominal pain were as likely to develop hepatotoxicity (13/92, 14.1%) compared to those without abdominal pain (4/35 [11.4%]; OR = 1.28 [0.39 to 4.21]). CONCLUSIONS: The presence of abdominal pain after acetaminophen overdose was not predictive of the development of liver injury in patients receiving acetylcysteine treatment. Further prospective studies are required to confirm this finding. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Acute arsenic exposure secondary to deliberate self-poisoning with sheep dip.

A 53-year-old male patient presented to a regional hospital Emergency Department approximately 2 h post an intentional ingestion of Coopers Instant Wetting Powder Sheep Dip (66% arsenic trioxide, 23% sulphur and 0.42% rotenone), mixed in 600 mL water, as a suicide attempt. On arrival to the Emergency Department, the patient had nausea, vomiting and diarrhoea. Seven hours post ingestion, hypotension developed (BP 90/60 mmHg) and intravenous fluids were commenced. He later developed QTc prolongation. He was treated with 2,3-Dimercapto-1-propanesulfonic acid (DMPS) and N-acetylcysteine and improved without development of neurology. Further investigation of NAC efficacy in humans in the setting of acute arsenic poisoning is required and the optimal duration of treatment and dosing needs to be established. This case highlights an uncommon poisoning which presented to the Emergency Department, the acute symptoms of arsenic toxicity and considerations for management.

Trends in calls to a state poisons centre and presentation to emergency departments for intentional antidepressant overdose in Victoria, Australia.

OBJECTIVE: To describe the rates and trends of emergency department presentations and calls to a state poisons centre for antidepressant overdose. METHODS: A retrospective cohort study utilising the Victorian Emergency Minimum Dataset and Victorian Poisons Information Centre call registry between January 2009 and December 2018 was conducted. This captured all presentations to Victorian emergency departments and calls to the Victorian Poisons Information Centre. Any intentional overdose involving an antidepressant was included. Annual rates of emergency department presentations and calls per 100,000 persons and 100,000 prescriptions for antidepressants overall and individual antidepressant classes, in addition to age-group-specific rates, were reported. RESULTS: A total of 3650 presentations to emergency department and 7096 calls to the poisons centre were included. No changes were seen in overall emergency department presentation rates when controlled for population or prescription numbers, but large and significant increases were seen for younger age groups. The 10-14- and 15-19-year age groups had average annual increases of 13.1% (95% CI = [6.5%, 19.7%], p < 0.001) and 7.2% (95% CI = [2.8%, 11.5%], p < 0.001) per 100,000 persons, respectively. Increases were seen in overall annual call rates of 6.7% (95% CI = [5.2%, 8.1%], p < 0.001) per 100,000 persons and 7.5% (95% CI = [4.9%, 10.1%], p < 0.001) per 100,000 prescriptions. CONCLUSION: Overall, emergency department presentation rates remained stable during the study period. Overall poisons centre call rates increased moderately. However, when examining younger persons, large increases were seen in both emergency department presentations and poison centre call rates. These findings highlight the need for future interventions to mitigate against intentional overdose in younger populations.

The CANBACK trial: a randomised, controlled clinical trial of oral cannabidiol for people presenting to the emergency department with acute low back pain.

OBJECTIVE: To assess the analgesic efficacy and safety of single-dose oral cannabidiol (CBD) as an adjunct to standard care for patients presenting to an emergency department with acute low back pain. DESIGN: Randomised, double blinded, placebo-controlled clinical trial. SETTING: The tertiary emergency department of Austin Hospital, Melbourne. PARTICIPANTS: Patients who presented with acute, non-traumatic low back pain between 21 May 2018 and 13 June 2019. INTERVENTION: One hundred eligible patients were randomised to receiving 400 mg CBD or placebo in addition to standard emergency department analgesic medication. MAIN OUTCOME MEASURES: Pain score two hours after administration of study agent, on a verbal numerical pain scale (range, 0-10). Secondary outcomes were length of stay, need for rescue analgesia, and adverse events. RESULTS: The median age of the 100 participants was 47 years (IQR, 34-60 years); 44 were women. Mean pain scores at two hours were similar for the CBD (6.2 points; 95% CI, 5.5-6.9 points) and placebo groups (5.8 points; 95% CI, 5.1-6.6 points; absolute difference, -0.3 points; 95% CI, -1.3 to 0.6 points). The median length of stay was 9.0 hours (IQR, 7.4-12 hours) for the CBD group and 8.5 hours (IQR, 6.5-21 hours) for the placebo group. Oxycodone use during the four hours preceding and the four hours after receiving CBD or placebo was similar for the two groups, as were reported side effects. CONCLUSION: CBD was not superior to placebo as an adjunct medication for relieving acute non-traumatic low back pain in the emergency department. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12618000487213 (prospective).

The NACSTOP Trial: A Multicenter, Cluster-Controlled Trial of Early Cessation of Acetylcysteine in Acetaminophen Overdose.

Historically, intravenous acetylcysteine has been delivered at a fixed dose and duration of 300 mg/kg over 20 to 21 hours to nearly every patient deemed to be at any risk for hepatotoxicity following acetaminophen overdose. We investigated a 12-hour treatment regimen for selected low-risk patients. This was a multicenter, open-label, cluster-controlled trial at six metropolitan emergency departments. We enrolled subjects following single or staggered acetaminophen overdose with normal serum alanine transaminase (ALT) and creatinine on presentation and at 12 hours, and less than 20 mg/L acetaminophen at 12 hours. Patients were allocated to intervention (250 mg/kg over 12-hour) or control (300 mg/kg over 20-hour) regimens by site. The primary outcome was incidence of "hepatic injury" 20 hours following initiation of acetylcysteine treatment, defined as ALT doubling and peak ALT greater than 100 IU/L, indicating the need for further antidotal treatment. Secondary outcomes included incidence of hepatotoxicity (ALT > 1,000 IU/L), peak international normalized ratio (INR), and adverse drug reactions. Of the 449 acetaminophen overdoses receiving acetylcysteine, 100 were recruited to the study. Time to acetylcysteine (median 7 hours [interquartile ratio 6,12] versus 7 hours [6,10]) and initial acetaminophen (124 mg/L [58,171] versus 146 mg/L [66,204]) were similar between intervention and control groups. There was no difference in ALT (18 IU/L [13,22] versus 16 IU/L [13,21]) or INR (1.2 versus 1.2) 20 hours after starting acetylcysteine between groups. No patients developed hepatic injury or hepatotoxicity in either group (odds ratio 1.0 [95% confidence interval 0.02, 50]). No patients represented with liver injury, none died, and 96 of 96 were well at 14-day telephone follow-up. Conclusion: Discontinuing acetylcysteine based on laboratory testing after 12 hours of treatment is feasible and likely safe in selected patients at very low risk of liver injury from acetaminophen overdose.

Efficacy of fresh frozen plasma transfusion in comparison with conventional regimen in organophosphate poisoning treatment: a meta-analysis study.

OBJECTIVE: To evaluating the efficacy of fresh frozen plasma (FFP) in comparison with conventional regimen in the treatment of organophosphate (OP) poisoning. METHODS: PubMed, ScopeMed, Cochrane, Scopus, and Google Scholar databases were searched. The search strategy used the following key words "organophosphate" and "poisoning or toxicity", "(atropine and oxime)", "fresh frozen plasma", "clinical trial", "outcome". The treatment with atropine or/and oxime was considered conventional therapy. The length of hospitalization, the length of ICU admission, need for mechanical ventilation and its duration, clinical recovery point, choline esterase level, mortality rate, and intermediate syndrome (IMS) occurrence were the key outcomes of interest. Databases were searched during the period of 2003-2019. Five studies were included in the analysis. RESULTS: Pooling of data showed that the relative risk (RR) of mortality in OP poisoning for five included trials comparing FFP-treated group with conventional regimen therapy was [0.563 (95% CI (0.252, 1.255)]. The summary of RR for IMS in two studies was [RR: 1.34, 95% CI (0.655, 2.742)]. In addition, there was a non-significant mean difference (MD) in hospital stay [MD: -0.106, 95% CI (-0.434, 0.223)] in three included trials. A significant MD was observed in the length of ICU admission in two trials between FFP-treated group compared to the conventional treatment group [MD: -2.672, 95% CI (-4.189, -1.154)], but after random effects meta-analysis, the changes were not significant [MD: -2.015, 95% CI (-6.308, 2.277)]. The summary of fixed-effect meta-analysis for choline esterase level in three trails was [MD: -0.117, 95% CI (-0.468, 0.234)]. The RR of ventilation requirement for two included trials in the FFP-treated group comparing to the conventional regimen therapy was [0.84, 95% CI (0.691, 1.022)] while for ventilation duration in two studies was [MD: -0.183, 95% CI (-0.567, 0.201)]. CONCLUSION: The addition of FFP to conventional therapy did not improve the outcomes of mortality, IMS, hospital length of stay, cholinesterase levels, need or duration of mechanical ventilation, and only the length of ICU stay could affect in the treated group.

Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand.

INTRODUCTION: Paracetamol is a common agent taken in deliberate self-poisoning and in accidental overdose in adults and children. Paracetamol poisoning is the commonest cause of severe acute liver injury. Since the publication of the previous guidelines in 2015, several studies have changed practice. A working group of experts in the area, with representation from all Poisons Information Centres of Australia and New Zealand, were brought together to produce an updated evidence-based guidance. MAIN RECOMMENDATIONS (UNCHANGED FROM PREVIOUS GUIDELINES): The optimal management of most patients with paracetamol overdose is usually straightforward. Patients who present early should be given activated charcoal. Patients at risk of hepatotoxicity should receive intravenous acetylcysteine. The paracetamol nomogram is used to assess the need for treatment in acute immediate release paracetamol ingestions with a known time of ingestion. Cases that require different management include modified release paracetamol overdoses, large or massive overdoses, accidental liquid ingestion in children, and repeated supratherapeutic ingestions. MAJOR CHANGES IN MANAGEMENT IN THE GUIDELINES: The new guidelines recommend a two-bag acetylcysteine infusion regimen (200 mg/kg over 4 h, then 100 mg/kg over 16 h). This has similar efficacy but significantly reduced adverse reactions compared with the previous three-bag regimen. Massive paracetamol overdoses that result in high paracetamol concentrations more than double the nomogram line should be managed with an increased dose of acetylcysteine. All potentially toxic modified release paracetamol ingestions (≥ 10 g or ≥ 200 mg/kg, whichever is less) should receive a full course of acetylcysteine. Patients ingesting ≥ 30 g or ≥ 500 mg/kg should receive increased doses of acetylcysteine.

Pharmacokinetic modelling of modified acetylcysteine infusion regimens used in the treatment of paracetamol poisoning.

PURPOSE: Paracetamol overdose is common and is treated with acetylcysteine to prevent the development of hepatotoxicity. N-acetyl-p-benzoquinone imine (NAPQI) is the toxic metabolite of paracetamol overdose. We aimed to assess the expected acetylcysteine concentration time profiles following delivery of modified acetylcysteine regimens proposed for those at high and low risk of hepatotoxicity. In addition, we will determine acetylcysteine concentrations post-cessation of abbreviated infusions. METHOD: We performed pharmacokinetic simulations using Berkeley Madonna (version 8.3.23.0) comparing the time course of acetylcysteine concentration during and after the cessation of an abbreviated 12-h regimen (250 mg/kg) using a two-bag infusion and compared this to the standard 21-h three-bag (300 mg/kg) regimen. We also simulated extended duration acetylcysteine regimens and other increased dosing strategies that have been recommended in specific paracetamol poisoning scenarios. RESULTS: A more sustained serum concentration is achieved when the acetylcysteine loading dose is delivered over 4 h using the two-bag compared to the 1-h loading dose of the three-bag regimen. When administering an abbreviated 12-h acetylcysteine regimen, circulating acetylcysteine is detectable for 8 h after cessation of the infusion. This may provide a continued hepatoprotective effect if NAPQI is still being generated after the infusion is ceased. CONCLUSION: This pharmacokinetic simulation study is an important step in determining plasma acetylcysteine concentrations that are likely to be achieved using various modified treatment regimens. Importantly, for patients at low risk of liver injury after acute overdose, acetylcysteine is likely to be detectable many hours post-cessation of a 12-h regimen. This should provide a safety factor against development of hepatotoxicity for any ongoing paracetamol metabolism after cessation of the acetylcysteine infusion.

Post-Bariatric Body Contouring.

BACKGROUND: The "epidemic" of obesity has recently been accompanied by a new "epidemic" of massive weight loss. The demand for post-bariatric contouring is rising and, as such, it is extremely important for plastic surgeons to be well versed in the treatment of these patients. Unfortunately, the problem is not solely surgical. OBJECTIVES: The aim of this article is to understand the nutritional and psychological complications that can occur in patients following massive weight loss, to understand the anatomic deformities in massive weight loss as a means to correct those deformities surgically, and to understand the complications from post-bariatric contouring procedures in an effort to avoid them. METHODS: This article discusses the nutritional and psychological considerations in the massive weight loss patient, anatomical considerations in this patient group, and the surgical techniques designed to address these anatomic concerns. Important pertinent studies are reviewed and discussed. RESULTS: Anatomical changes are encountered in each region of the body: there are surgical options available to correct them, although potential complications are associated with these surgical procedures. These surgical options are reviewed as well as the risk and benefits associated with them. CONCLUSIONS: There are many problems that need to be addressed in the massive weight loss patient prior to embarking on surgical treatment. Additionally, surgery on massive weight loss patients has unique considerations that distinguish these operations from those performed on the non-bariatric population.

Has the rescheduling of modified-release paracetamol in Australia affected the frequency of overdoses?

OBJECTIVES: In June 2020, modified-release paracetamol (paracetamol-MR) preparations were up-scheduled from schedule-2 (available in pharmacy) to schedule-3 (available by request to a pharmacist only). The present study aims to ascertain whether up-scheduling affected the frequency of paracetamol-MR overdoses. METHODS: This is a retrospective cohort study of two data sets from 1 June 2017 to 31 May 2022. Monash Health data were extracted using the diagnosis of paracetamol overdose coding and electronic medical records data. Calls regarding paracetamol-MR overdoses to Victorian Poisons Information Centre (VPIC) were extracted from the Poisons centre call database. We used a quasi-experimental research design with interrupted time series analysis to evaluate the immediate impact and change in trend of poisoning-related calls and ED presentations before and after June 2020. The change in proportion of paracetamol-MR cases in both databases was analysed using the Χ2 test. RESULTS: The proportion of paracetamol-MR cases in both data sets did not change. From Monash Health, there was no level change in monthly paracetamol-MR overdose-related presentations following re-scheduling (rate ratio [RR] = 1.08, 95% confidence interval [CI] = 0.57-2.01). There was no change in monthly paracetamol-MR overdose-related calls to VPIC following re-scheduling (RR = 1.05, 95% CI = 0.96-1.14). CONCLUSION: The proportion of paracetamol-MR overdoses did not decrease after the up-scheduling to S3. Similarly, the frequency of overdoses by month remained similar. Further limitations on access to paracetamol products may need to be considered.

Making the most of what we have: What does the future hold for Emergency Department data?

Over 10 million ED visits occur each year across Australia and Aotearoa New Zealand. Outside basic administrative data focused on time-based targets, there is minimal information about clinical performance, quality of care, patient outcomes, or equity in emergency care. The lack of a timely, accurate or clinically useful data collection represents a missed opportunity to improve the care we deliver each day. The present paper outlines a proposal for a National Acute Care Secure Health Data Environment, including design, possible applications, and the steps taken to date by the Australasian College for Emergency Medicine ED Epidemiology Network in collaboration with the College of Emergency Nursing Australasia. Optimal use of the existing information collected routinely during clinical care of emergency patients has the potential to enable data-driven quality improvement and research, leading to better care and better outcomes for millions of patients and families each year.

Follow-up of Methanol-related Visual Defects in a Cohort Study: Initial Severity Predicts Long-term Outcome.

Objective: Methanol poisoning can occur either intentionally through the consumption of methanol-containing products or accidentally through ingestion, resulting in visual impairment. We assessed the long-term visual sequelae in patients with methanol poisoning. Methods: This prospective cohort study was conducted at referral centers, Khorshid and Alzahra University Hospitals, affiliated with Isfahan University of Medical Sciences, Isfahan, Iran. The study included patients hospitalized for methanol poisoning from June 22, 2018, to June 21, 2020, with follow-up extended until June 2021. Toxico-clinical and ophthalmologic examination data were collected from patients upon hospital admission, discharge, and during follow-up. Findings: Thirty-nine patients were assessed in this study. The majority of them (94.9%) were male, with an average age of 34 years. Patients who presented with reduced visual acuity (VA) upon admission subsequently showed abnormalities (in acuity and visual fields) during follow-up (n = 13). Among the patients who displayed visual field defects on admission, bilateral optic disc atrophy was observed in follow-up (n = 13). Conversely, patients who reported blurred vision, with or without photophobia upon admission, had normal results in their follow-up eye examinations. Among the 36 patients who underwent dialysis, 14 (38.9%) exhibited visual impairment during follow-up examinations. Additionally, 38 patients received sodium bicarbonate, and 14 of them (36.85%) also presented ocular abnormalities. Conclusion: Patients who demonstrated VA deficits upon admission are more likely to experience long-term VA and visual field defects, as well as optic disc atrophy. Patients who solely complained of blurred vision, with or without photophobia, during admission were less likely to develop long-term visual defects.

Missed childhood-onset carpal tunnel syndrome diagnosed as chronic pain: case report.

We report the case of a 15-year-old girl with a red, swollen, and painful right hand. She first developed symptoms when she was 7 years old. Numerous physicians evaluated her at various institutions but were able to classify her only with chronic pain syndrome. She continued with regular occupational therapy and had to use special aids to compensate throughout school. After 8 years of treatment with no improvement, she presented to our office, where we diagnosed carpal tunnel syndrome. Intraoperative findings revealed a large proximal muscle belly of the index lumbrical, a thickened transverse carpal ligament, and marked compression of the median nerve. Two weeks after the surgery, her symptoms cleared; at 5 months, she remained symptom free.

International efforts in plastic surgery: the Hartford Hospital, Connecticut Children's Medical Center and University of Connecticut experience in Ecuador.

UNLABELLED: Plastic and reconstructive surgery provide a necessary and essential service to public health efforts in resource-poor regions around the world. Disease processes amenable to plastic surgical treatment significantly contribute to worldwide disability, and it is the poor and underserved who are disproportionately affected. METHODS: We conducted a week-long plastic and reconstructive surgical trip to Latacunga, Ecuador to provide reconstructive surgical services for the underserved in this region. RESULTS: Over the course of a week, 97 patients received surgery. Most patients were young (mean age = 21.8 years) and 50.5% were female. Burns and burn scar contractures were the most common diagnoses requiring surgery(21.6%), but cleft lip and palate deformities, scars, nevi, and congenital ear deformities comprised a significant proportion of the case load as well (17.5%, 11.3%, 12.4%, and 10.3%, respectively). There was one postoperative complication requiring reoperation. CONCLUSION: This short-term surgical trip successfully delivered essential reconstructive surgical care to an underserved population in rural Ecuador. Although this is most certainly only a fraction of the true surgical disease burden within this population, our experience provides a testament to the need for essential reconstructive surgical services in developing nations around the world.

Metal fume fever - a case review of calls made to the Victorian Poisons Information Centre.

OBJECTIVE: To determine the epidemiology of metal fume fever over an extended period in Victoria, Australia. METHODS: A retrospective case review of all metal fume fever related calls to the Victorian Poisons Information Centre. Specific defined criteria were used to identify cases of metal fume fever and a set of data points extracted for each. RESULTS: Eighty-four (99%) of the cases involved adults. Fifty-three percent of exposures occurred in the workplace. The most frequent day of symptom manifestation was Monday (24%). All of the calls concerned people involved in welding metal with subsequent inhalation of fumes. DISCUSSION: Calls were most common at the beginning of the week, reflecting the previously described phenomena of increased symptoms occurring after a period on nonexposure (loss of tolerance). Workplace safety and education is key to prevention of metal fume fever. Medical profession education may help prevent occurrences of metal fume fever at home, at school and in the workplace.