Supra-Therapeutic Oral Paracetamol Overdose in Adults: An Update for the Dental Team.

Paracetamol (acetaminophen) is a commonly used analgesic; its 'over the counter' availability, low cost and popularity amongst patients often make it the first choice for dental pain. It is in this that its potential toxicity, made more complicated by the ever extending range of paracetamol-containing products, make the understanding of this medication key to the safe management of patients presenting to surgery with dental pain. Clinical relevance: The purpose of this article is to supply dental practitioners with the knowledge to manage patients who present having taken an oral supra-therapeutic paracetamol overdose. Consideration is given to those patients who can be treated safely in primary care and to those who require transfer to Accident and Emergency (A&E).

Poor nutritional status correlates with mortality and worse postoperative outcomes in patients with femoral neck fractures.

AIMS: Patients who sustain neck of femur fractures are at high risk of malnutrition. Our intention was to assess to what extent malnutrition was associated with worse patient outcomes. METHODS: A total of 1,199 patients with femoral neck fractures presented to a large UK teaching hospital over a three-year period. All patients had nutritional assessments performed using the Malnutrition Universal Screening Tool (MUST). Malnutrition risk was compared to mortality, length of hospital stay, and discharge destination using logistic regression. Adjustments were made for covariates to identify whether malnutrition risk independently affected these outcomes. RESULTS: Inpatient mortality was 5.2% (35/678) in the group at low risk of malnutrition, 11.3% (46/408) in the medium-risk group, and 17.7% (20/113) in the high-risk group. Multivariate analysis showed each categorical increase in malnutrition risk independently predicted inpatient mortality with an odds ratio (OR) of 1.59 (95% confidence interval (CI) 1.14 to 2.21; p = 0.006). An increased mortality rate persisted at 120 days post-injury (OR 1.64, 95% CI 1.20 to 2.22; p = 0.002). There was a stepwise increase in the proportion of patients discharged to a residence offering a greater level of supported living. Multivariate analysis produced an OR of 1.34 (95% CI 1.03 to 1.75; p = 0.030) for each category of MUST score. Median length of hospital stay increased with a worse MUST score: 13.9 days (interquartile range (IQR) 8.2 to 23.8) in the low-risk group; 16.6 days (IQR 9.0 to 31.5) in the medium-risk group; and 22.8 days (IQR 10.1 to 41.1) in the high-risk group. Adjustment for covariates revealed a partial correlation coefficient of 0.072 (p = 0.008). CONCLUSION: A higher risk of malnutrition independently predicted increased mortality, length of hospital stay, and discharge to a residence offering greater supported living after femoral neck fracture. Cite this article: Bone Joint J 2021;103-B(1):164-169.

Dapagliflozin (SGLT2-i) induced euglycaemic diabetic ketoacidosis.

Sodium glucose co-transporter-2 inhibitors (SGLT2-i) have become a popular therapeutic strategy in the management of hyperglycaemia in type 2 diabetes mellitus. The primary site of action of SGLT2-i is at the proximal renal convoluted tubule. They work by blocking SGLT2 receptors, sodium-dependent glucose co-transport molecules, which in turn prevents glucose reabsorption, facilitating glucosuria, improving glycaemic control as well as a moderate degree of weight loss. We report the case of a 51-year-old woman admitted to the acute medical unit with abdominal pain and vomiting, who was diagnosed with euglycaemic diabetic ketoacidosis secondary to recent initiation of an SGLT2-i medication (dapagliflozin). Clinicians should be aware of this rare side effect of SGLT2-i, to circumvent delays in patient management.

Linezolid-induced pancytopenia.

Linezolid is a bacteriostatic antibiotic of the Oxazolidinone class; it works by inhibiting the initiation of protein synthesis on bacterial ribosomes. Due to its excellent bioavailability after oral dosing, it has become an important tool in combating multi-drug-resistant bacteria including glycopeptide-resistant enterococci and methicillin-resistant Staphylococcus aureus Side effects are multiple and potentially serious. We report the case of an 87-year-old man who developed pancytopenia secondary to a 6-week course of linezolid. Withdrawal of the antibiotic was decided as the treatment and resolution of the pancytopenia was evident within 2 weeks. Clinicians should be aware of this side effect of linezolid therapy and that weekly full blood count monitoring is paramount.

Staged extubation to manage the airway after operations on the head and neck.

Management of the airway after operations on the head and neck is potentially problematic. We describe leaving a guidewire in the trachea after successful extubation in two patients, to make reintubation easier if the airway was later compromised.

Immunohistochemical localization of WT1 in epithelial salivary tumors.

The subcellular localization of WT1 is controversial and has received little attention in the epithelial tumors of salivary glands. Paraffin-embedded, surgical specimens from 80 salivary tumors were investigated by immunohistochemistry using a monoclonal, anti-WT1 antibody (6F-H2, Dako). Immunostaining was seen in 14/14 pleomorphic adenomas (PAs), 6/6 myoepitheliomas, 4/4 basal cell adenomas, 4/4 canalicular adenomas, 0/7 Warthin tumors, 0/1 oncocytoma, 1/6 acinic cell carcinomas (Cas), 0/11 mucoepidemoid Cas, 1/11 adenoid cystic Cas, 11/12 polymorphous low-grade adenocarcinomas (PLGAs), 1/2 Ca ex PA, 0/1 salivary duct Ca and 0/1 clear cell adenocarcinoma. Stained-cell subpopulations up to 90% were not uncommon in the benign tumors. Up to 80% of cells in PLGA could be stained. Staining was weak to intense and confined to the cytoplasm of preferentially non-luminal or adjacent to stroma cells. One adenoid cystic Ca showed nuclear staining. The results suggest that WT1 is often highly expressed in benign non-oncocytic salivary tumors whereas the malignant tumors show decreased expression, the exception being PLGA. The expression is usually cytoplasmic and associated with non-luminal cells. PLGA immunoreactivities could be useful in histological differential diagnosis.