Clock drawing and rehabilitation outcome in hip fracture patients

Purpose.?To assess the relationship between the Clock Drawing Test (CDT) and rehabilitation outcome in hip fracture patients within normal range of the Mini Mental State Examination (MMSE).

Methods.?This retrospective study was performed in a post-acute geriatric rehabilitation centre. One hundred and forty-two patients with proximal hip fracture admitted from January 2006 to June 2008 whose MMSE scores was within normal range (>23) were enrolled in the study. The patients were divided into two groups according to CDT performance (impaired versus intact). The differences between the two groups in relation to age, gender, education level, living arrangement, pre fracture functional level, fracture type, and outcome measurements [Functional Independent Measure (FIM), motor FIM, Rate of in-hospital Improvement (RI) in FIM and motor FIM, and Length of Stay (LOS)] were assessed.

Results.?Discharge FIM score and motor FIM scores were significantly lower for the impaired CDT group (89?±?13.7 vs. 94.9?±?11.6, p?=?0.007; 61.6?±?11.1 vs. 65.7?±?9.6, p?=?0.022 respectively); LOS was significantly longer (28.2?±?7.9 vs. 25.3?±?8.5, p?=?0.033) and rates of improvement in FIM and motor FIM were significantly slower (0.62?±?0.35 vs. 0.77?±?0.45, p?=?0.036; 0.61?±?0.34 vs. 0.75?±?0.42, p?=?0.033, respectively). Nevertheless, FIM and motor FIM scores changes were similar in both CDT groups. Following adjustment for age, LOS of patients with impaired CDT was significantly longer (p?=?.027).

Conclusions.?The CDT may assist the multidisciplinary team in identifying hip fracture patients whose MMSE scores are within the normal range, but yet need a longer training period to extract their rehabilitation potential.     

Use of ISTH bleeding assessment tool to predict inherited platelet dysfunction in resource constrained settings

Background: The International Society of Thrombosis &; Hemostasis (ISTH) bleeding assessment tool (ISTH-BAT) is used to record bleeding symptoms in patients with possible bleeding disorders.

Aim: To investigate the utility of the ISTH-BAT in predicting platelet dysfunction in individuals with suspected inherited platelet function disorders.

Method: Individuals with clinical evidence of bleeding and suspected inherited platelet function disorder and healthy volunteers were included in the study. The ISTH-BAT questionnaire was applied prior to light transmission aggregometry (LTA).

Results: A total of 261 participants were included (100 healthy volunteers, and 161 with suspected inherited platelet function disorders). The ISTH-BAT score in participants with suspected inherited platelet function disorders (median 2; interquartile range [IQR] 5–1) was significantly higher than in healthy volunteers (median 0; IQR 2–0). There was also a significant difference between participants with suspected inherited platelet function disorders with a platelet defect detected by LTA (median 4; IQR 8–3) and those with normal platelet function (median 2; IQR 3–1) (p?p?=?p?=?< 0.001]).

Conclusion: The ISTH-BAT is a useful tool for documenting bleeding symptoms and the score obtained is also predictive of the presence of a platelet defect on LTA in patients with suspected inherited platelet dysfunction.     

Topical analgesic added to paraffin enhances paraffin bath treatment of individuals with hand osteoarthritis

Purpose.?To compare treating patients with symptomatic hand osteoarthritis (OA) with paraffin baths only (PO) (100% wax) or paraffin baths 80% wax with 20% topical analgesic (PTA).

Methods.?Subjects met criteria of the American College of Rheumatology for classifying symptomatic hand OA and had a Dreiser's index score >5 points. Current and average pain at rest and with movement was assessed with visual analogue scales. Hand function was assessed by the functional index for hand OA (FIHOA).

Results.?Both groups had a significant reduction in their ‘current’ pain 15?min after the first and twelfth treatments compared to pre-treatment but there was no difference between groups (t?=?0.10, p?>?0.05). The PTA group had greater improvement over the 12 treatment sessions for their pain at rest (t?=?2.92, p?<?0.05) and with movement (t?=?4.73, p?<?0.05) than the PO group. The PTA group also showed greater improvement in their FIHOA following 12 treatments than the PO group (t?=?3.52, p?<?0.05).

Conclusion.?Our results indicate that the addition of a topical analgesic to paraffin produced significantly greater pain relief at rest and during movement than paraffin baths alone after 12 treatments. Additionally, the PTA group experienced greater improved hand function.     

Absence of combined effects of anemia and bilateral surgical status on inpatient rehabilitation outcomes following total knee arthroplasty

Purpose.?To examine the effects of anemia on inpatient rehabilitation outcomes following unilateral and bilateral total knee arthroplasty (TKA).

Method.?This was a multicenter, retrospective study from 15 inpatient rehabilitation facilities. Patients (N?=?5421) with very low hematocrit (Hct?<30%), low Hct (30–36% women, 30–41% men), or normal Hct (>36% women, 41% men) were included. Inpatient rehabilitation occurred following TKA. Functional independence measure (FIM) scores, length of stay (LOS), itemized hospital charges, discharge destination were main outcomes.

Results.?LOS was 13% longer and hospital charges were 12.5–18.0% higher in the very low Hct than remaining groups (p?=?0.0001). The FIM score and subscores for walking, stair climbing, bathing, transfers, and dressing changes were comparable for all Hct groups for the overall score. Hct?<30% did not correspond to worse outcomes in patients with bilateral surgeries compared with unilateral surgeries; total FIM scores improved 47–53% across all Hct groups, regardless of bilateral surgical status. Discharge to home ranged 92.6–94.7% across all Hct groups (p?>?0.05).

Conclusions.?Rehabilitation teams can expect comparable functional improvements and discharge to home in anemic and non-anemic patients with either unilateral or bilateral surgeries without hematologic correction in the rehabilitation setting, but might need an additional day to accomplish these outcomes.     

Usefulness of BFB/EMG in facial palsy rehabilitation

Objective.?To analyze and to compare the recovery and the development of synkinesis in patients with idiopathic facial palsy (Bell's palsy) following treatment with two methods of rehabilitation, kinesitherapy (KT) and biofeedback/EMG (BFB/EMG).

Study design.?Retrospective cases?–?series review.

Methods.?Seventy-four patients with Bell’ palsy were clinically evaluated within 1 month from onset of palsy and at 12 months after palsy (House scale and synkinesis evaluation). Electromyography (EMG) and Electroneurography (ENG) were performed about 4 weeks after palsy to better evaluate functional abnormalities due to facial nerve lesion. The patients followed two different protocols for rehabilitation: the first 32 patients were treated with therapeutic exercises performed by therapists (KT group), the latter 42 patients were treated using BFB/EMG methods (BFB group) with inhibition of synkinetic movement as the primary goal.

Results.?KT and BFB patients were evaluated for clinical and neurophysiological characteristics before rehabilitative treatment. BFB patients showed better clinical recovery and minor synkinesis than KT patients.

Conclusions.?BFB/EMG seems to be more useful than KT in Bell's palsy treatment. This could be due to the fact that BFB/EMG gives more accurate information than KT on muscle activation with better modulation in voluntary recruitment of motor unit.     

Effects of thyroid hormone withdrawal on natriuretic peptides during radioactive iodine therapy in female patients with differentiated thyroid cancer

Objective: We aimed to investigate the effects of thyroid hormone withdrawal on N-terminal prohormone forms of atrial natriuretic peptide (NT-proANP) and brain natriuretic peptide (NT-proBNP) during radioiodine therapy in female patients with differentiated thyroid cancer (DTC).

Methods: Serum concentrations of thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), NT-proANP and NT-proBNP were measured in 51 female patients with DTC (48.7?±?4.2 years) at three time-points: day of radioiodine therapy (t1 – under acute hypothyroidism), 5 days after radioiodine (t2 – under acute hypothyroidism) and 3 months after radioiodine (t3 – under TSH suppression). Thirty healthy euthyroid women served as controls (42.8?±?5.6 years).

Results: At t1/t2/t3, median NT-proANP was 5.2/1.7/487?pmol/L vs. 297.7?pmol/L in control group (p?p?p?r?=?0.38, p?=?0.005), NT-proANP/NT-proBNP ratios (r?=?0.47, p?=?0.001), heart rate (r?=?0.39, p?=?0.005), and negatively with mean arterial blood pressure (r?=??0.58, p?Conclusions: Our results indicate that NT-proANP reflects more accurately direct thyroid hormone effects than NT-proBNP. Thyroid hormone-dependent hemodynamic effects seem to be overlapped on the direct stimulatory effect of thyroid hormones on NT-proANP secretion by cardiac myocytes.     

Racial disparities in stroke functional outcomes upon discharge from inpatient rehabilitation facilities

Purpose.?Analyse racial disparities in clinical outcomes after stroke in inpatient rehabilitation facilities (IRF).

Methods.?Analyses based on data from a multi-center prospective observational cohort study on inpatient stroke rehabilitation in six IRFs from across the United States. Multivariate models examined racial disparities in functional outcomes upon discharge, taking into account patient characteristics and detailed information on processes of care.

Results.?In the moderate stroke group (N?=?397), functional scores on admission were not significantly different between African-Americans and whites. In the severe stroke group (N?=?335), whites showed significantly lower functional scores at admission [Functional Independence Measurement, (FIM)], mean scores, 44 versus 49 for African-Americans, p?<?0.001). Multivariate analyses predicting discharge motor FIM score found no significant differences between African-American and white stroke patients (p?=?0.2194 and p?=?0.3547 in the moderate and severe stroke group, respectively).

Conclusion.?Controlling for patient characteristics, therapy intensity and processes of care results in non-significant differences between African-Americans and whites in motor FIM scores upon discharge. The absence of significant differences in recovery while patients were on the rehabilitation unit suggests that racial disparities in long-term functional recovery after stroke are likely to have originated before or after the inpatient rehabilitation stay.     

Function and disability in late life: comparison of the Late-Life Function and Disability Instrument to the Short-Form-36 and the London Handicap Scale

Purpose:?We evaluated the Late-Life Function and Disability Instrument's (LLFDI) concurrent validity, comprehensiveness and precision by comparing it with the Short-Form-36 physical functioning (PF-10) and the London Handicap Scale (LHS).

Methods:?We administered the LLFDI, PF-10 and LHS to 75 community-dwelling adults (>?60 years of age). We used Pearson correlation coefficients to examine concurrent validity and Rasch analysis to compare the item hierarchies, content ranges and precision of the PF-10 and LLFDI function domains, and the LHS and the LLFDI disability domains.

Results:?LLFDI Function (lower extremity scales) and PF-10 scores were highly correlated (r?=?0.74???0.86, p?>?0.001); moderate correlations were found between the LHS and the LLFDI Disability limitation (r?=?0.66, p?<?0.0001) and Disability frequency (r?=?0.47, p?<?0.001) scores. The LLFDI had a wider range of content coverage, less ceiling effects and better relative precision across the spectrum of function and disability than the PF-10 and the LHS. The LHS had slightly more content range and precision in the lower end of the disability scale than the LLFDI.

Conclusions:?The LLFDI is a more comprehensive and precise instrument compared to the PF-10 and LHS for assessing function and disability in community-dwelling older adults.     

Effects of low frequency functional electrical stimulation with 15 and 50 Hz on muscle strength in heart failure patients

Purpose.?To compare the acute effects of functional electrical stimulation (FES) with 15 and 50 Hertz (Hz) frequencies on muscle strength in patients with heart failure with healthy individuals.

Methods.?Twenty-two 61.6?±?1.0 y-old male volunteers were studied: 10 patients with heart failure (functional class II-III) and 12 healthy controls. The isometric muscle peak torque (IMPT) of the quadriceps femoral muscle was measured through a Biodex dynamometer in maximum voluntary contraction (MVC), and under FES of 50?Hz and 15?Hz, which was applied with a 0.4?ms pulse width, 10-s contraction time, 50- s resting time and maximum tolerable intensity.

Results.?The IMPT differed in MVC, 50?Hz and 15?Hz FES both in patients (201.9?±?14, 55.6?±?13 and 42.1?±?12 Newton-metre, respectively; p?<?0.001) and in controls (179.3?±?9, 62.4?±?8 and 52.3?±?7 Newton-metre, respectively; p?<?0.001). There were no differences between the groups. In patients and controls, respectively, the 50?Hz FES corresponded to 27% versus 35% and the 15?Hz to 21% versus 29% of the IMPT generated at the MVC (p?<?0.001).

Discussion.?This result can be attributed to the fact that muscle strength is proportional to the stimulation frequency and to the number of recruited motor units. Thus, the higher the frequency, the greater the motor recruiting, producing increased muscle strength.

Conclusion.?The IMPT generated by acute 50?Hz application of FES is higher than the one generated by 15?Hz, but it is lower than MVC in controls and patients with heart failure.     

Relationship between quality of life and functional status of young adults and adults with cerebral palsy

Purpose.?The aim of this study was investigate the relation between health related quality of life (HRQoL) and functional status in young adult or adult cerebral palsied individuals.

Methods.?The study included 45 cerebral palsied subjects who were divided into two groups as young adults (n?=?21, group 1) and adults (n?=?24, group 2), over the age 15 years. Gross Motor Function Classification System (GMFCS), Functional Independence Measurement (FIM), Physical Mobility Scale (PMS), Nottingham Health Profile (NHP), Visual Analogue Scale (VAS) were used as outcome measures.

Results.?In group 1, GMFCS and PMS scores were significantly correlated with total the total score of FIM (p?<?0.05). Although total FIM, PMS, LS and GMFCS scores were not correlated with the total NHP score (p?>?0.05), pain subscale of NHP was significantly correlated with self care and mobility subscales of FIM (p?<?0.05). Also, self care, mobility, locomotion subscales and total score of FIM were highly correlated with the physical activity subscale of NHP (p?<?0.05). In group 2, our findings were also similar to those of young adults when the relations between total NHP score and total FIM, PMS, LS and GMFCS were investigated (p?>?0.05) and also some subscales of FIM and NHP presented high correlations in between. In addition, there were significant differences between the groups in GMFCS, LS and locomotion and self care subscales of FIM (p?<?0.05).

Conclusion.?Although HRQoL in young cerebral palsied individuals seems to be more effected by parameters related to physical condition, in cerebral palsied adults psychological and emotional aspects may be more important indicators related to HRQoL. For that reasons, more population specific measures have to be developed for in-depth analysis of these factors.     

Management of severe pain after dermal contact with caterpillars (erucism): a prospective case series

Context: Erucism, envenomation caused by dermal contact with larval forms of moths, may result in intense local pain, mainly after contact with puss caterpillars (family Megalopygidae).

Objective: To evaluate the response to different treatments for controlling severe pain in a case series of erucism in Campinas, southeastern Brazil.

Patients and methods: Prospective cohort study. A Numeric Pain Rating Scale (NPRS 0–10) was used to assess pain intensity in the Emergency Department (ED). Pain was considered as severe upon ED admission (T0) when the NPRS was ≥8. Inclusion criteria: age ≥8 years old, severe pain at T0, with continuous assessment of pain intensity in all patients using the NPRS during the ED stay (T5, T15, T30, T60?min and at discharge).

Results: Fifty-five patients fulfilled the inclusion criteria and were divided into three groups according to the initial treatment at T0: local anesthesia alone with 2% lidocaine (group 1, n?=?15), local anesthesia and analgesics (group 2, n?=?26) and analgesics without local anesthesia (group 3, n?=?14). Most patients were admitted within 2?h after dermal contact with the stinging bristles of caterpillars (median =90?min, IQR: 40–125?min). In 22 cases (40%), the caterpillar was brought for identification (Podalia spp., n?=?18; Megalopyge spp., n?=?4). There was a significant decrease in pain from T5 onwards with all of the treatments. When the short-term response (T5 and T15) was considered, analgesia was more effective in groups 1 and 2 compared to group 3 (p?n?=?25/55), mainly in group 1 (n?=?11/15). The median length of stay in the ED was 120?min (IQR: 80–173?min).

Conclusions: The association of local anesthesia with analgesics was apparently a good combination for the rapid management of severe pain in the ED.     

Evaluation of Clostridium difficile Infection with PET/CT Imaging in a Mouse Model

Purpose

Existing clinical or microbiological scores are not sensitive enough to obtain prompt identification of patients at risk of complicated Clostridium difficile infection (CDI). Our aim was to use a CDI animal model to evaluate 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography ([¹⁸F]FDG-PET) as a marker of severe course of infection.

Procedures

CDI was induced with cefoperazone for 10 days followed by clindamycin 1 day before C. difficile inoculation. Mice were divided into wild type (n?=?6), antibiotic without infection (AC n?=?4), h001-infected (n?=?5, ribotype 001), and h027-infected (n?=?5, ribotype 027). Two days after inoculation, [¹⁸F]FDG-PET was acquired. Weight, general animal condition, and survival were monitored daily for 9 days.

Results

h001 group showed symptoms for 4 days with 0 % mortality and a similar colon uptake than control animals (h001 0.52?±?0.20, WT 0.42?±?0.07, and AC 0.36?±?0.06). The h027 group showed symptoms up to 7 days, with 66.7 % of mortality 4 days after infection, and significantly higher colon uptake (0.93?±?0.38, p?<?0.05). Clinical score was associated to colon and cecum uptake (rho?=?0.78, p?=?0.0001) (rho?=?0.73, p?=?0.0003).

Conclusion

High toxin producer ribotype 027 induced more severe CDI infections, correlating with higher colon and cecum [¹⁸F]FDG uptake. Colon uptake may purportedly serve as early predictor of CDI severity.

     

Comparison of overground and treadmill propulsion patterns of manual wheelchair users with tetraplegia

Purpose.?The purpose of this investigation was to compare overground and treadmill propulsion patterns in persons with tetraplegia.

Methods.?In this case series study, we recruited eight adult subjects with tetraplegia (5 men and 3 women, aged 32.5?±?9.5). All subjects used manual wheelchairs. We used a video motion capture system to record movements as the subject manually wheeled overground and on a treadmill. We classified propulsion patterns into one of four patterns and measured five different geometric variables of each pattern. We compared them statistically using ANOVA.

Results.?There were significant differences in max height/max length×100 (H/L%) between propulsion over ground (mean 20%?±?15.3/Lhand, mean 21.3%?±?16.5/Rhand) versus propulsion on treadmill surfaces (roller: mean 30.9%?±?11.2/Lhand, mean 33.5%?±?12.8/Rhand; belted: mean 27.7%?±?8.7/Lhand, mean 34.9%?±?14.2/Rhand) and between the left and right hand.

Conclusion.?Results indicated area and H/L% were different among the three surface types and between right and left sides. Caution must be used in extrapolating treadmill results to propulsion over ground or in assuming bilateral symmetry.     

Investigating the internal validity of the Trunk Impairment Scale (TIS) using Rasch analysis: the TIS 2.0

Purpose.?To examine the internal validity of the static sitting balance, dynamic sitting balance, and coordination subscales of the Trunk Impairment Scale (TIS), a reliable and valid scale measuring trunk performance and sitting balance in people after stroke.

Method.?A total of 162 people after stroke were included in the study. Participants were recruited from an acute unit and in- and out- patient rehabilitation setting. To examine internal validity of the subscales of the TIS, we conducted a Rasch analysis by means of the Partial Credit Model. For each subscale, we examined whether the distribution of scores fitted the theoretical Rasch model.

Results.?The first item of the static sitting balance subscale had to be removed since it had a large ceiling effect. The remaining static sitting balance subscale did not fit the Rasch model (Chi-square?=?7.03, p?<?0.0001 with Bonferroni adjusted p-level?=?0.01). Both the dynamic sitting balance (Chi-square?=?42.65, p?=?0.0052 with Bonferroni adjusted p-level?=?0.005) and coordination subscales (Chi-square?=?7.87, p?=?0.4461 with Bonferroni adjusted p-level?=?0.01) fitted the Rasch model.

Conclusions. Internal validity of the dynamic sitting balance and coordination subscales was confirmed. Based on our results, we present the TIS, version 2.0 (TIS 2.0).     

A cross-sectional observational study comparing foot and ankle characteristics in people with stroke and healthy controls

Purpose: The purpose of this study was to explore and compare foot and ankle characteristics in people with stroke and healthy controls; and between stroke fallers and non-fallers.

Methods: Participants were recruited from community groups and completed standardized tests assessing sensation, foot posture, foot function, ankle dorsiflexion and first metatarsal phalangeal joint range of motion (1st MPJ ROM), hallux valgus presence and severity.

Results: Twenty-three stroke participants (mean age 75.09?±?7.57 years; 12 fallers) and 16 controls (mean age 73.44?±?8.35 years) took part. Within the stroke group, reduced 1st MPJ sensation (p?=?0.016) and 1st MPJ ROM (p?=?0.025) were observed in the affected foot in comparison to the non-affected foot; no other differences were apparent. Pooled data (for both feet) was used to explore between stroke/control (n?=?78 feet) and stroke faller/non-faller (n?=?46 feet) group differences. In comparison to the control group, stroke participants exhibited reduced sensation of the 1st MPJ (p?=?0.020), higher Foot Posture Index scores (indicating greater foot pronation, p?=?0.008) and reduced foot function (p?=?0.003). Stroke fallers exhibited significantly greater foot pronation in comparison to non-fallers (p?=?0.027).

Conclusions: Results indicated differences in foot and ankle characteristics post stroke in comparison to healthy controls. These changes may negatively impact functional ability and the ability to preserve balance. Further research is warranted to explore the influence of foot problems on balance ability and falls in people with stroke.

• Implications for Rehabilitation

• Foot problems are common post stroke.

• As foot problems have been linked to increased fall risk among the general population we recommend that it would be beneficial to include foot and ankle assessments or a referral to a podiatrist for people with stroke who report foot problems.

• Further research is needed to explore if we can improve functional performance post stroke and reduce fall risk if treatment or prevention of foot problems can be included in stroke rehabilitation.

     

Ability to manage everyday technology: a comparison of persons with dementia or mild cognitive impairment and older adults without cognitive impairment

Purpose.?The ability to manage technology is important for performance and participation in everyday activities. This study compares the management of technology in everyday activities among people with mild-stage dementia or mild cognitive impairment (MCI) with older adults without known cognitive impairment (OA).

Method.?Persons with mild-stage dementia (n?=?38), MCI (n?=?33) and OA (n?=?45) were observed and interviewed when managing their everyday technology at home by using the Management of Everyday Technology Assessment (META). A computer application of a Rasch measurement model was used to generate measures of participants' ability to manage technology. These measures were compared groupwise with ANCOVA.

Results.?The management of everyday technology was significantly more challenging for the samples with mild-stage Alzheimer's disease (AD) or MCI compared to the OA sample (AD – OA, p?<0.001; d?=?1.87, MCI – OA, p?<0.001; d?=?0.66). The sample with MCI demonstrated a significantly higher ability to manage technology than the sample with mild-stage AD (AD – MCI, p?<0.001; d?=?1.23). However, there were overlaps between the groups and decreased ability appeared in all groups.

Conclusions.?Persons with cognitive impairment are likely to have decreased ability to manage everyday technology. Since their decreased ability can have disabling consequences, ability to manage technology is important to consider when assessing ability to perform everyday activities.     

Alexithymia in respiratory rehabilitation

Purpose.?To date, there are no studies that have investigated the role of alexithymia in respiratory rehabilitation. We aimed to observe the prevalence of alexithymia in patients attending respiratory rehabilitation and to verify the presence of a difference between alexithymics and non-alexithymics responsiveness to the respiratory rehabilitation standard protocol.

Methods.?A prospective cohort study evaluating the influence of alexithymia on functional recovery of in-patients afferent to the Respiratory Rehabilitation Unit of IRCCS San Raffaele Pisana. Sixty patients were consecutively enrolled into the study and evaluated for alexithymia, anxiety and depression. Functional recovery was assessed with the six-minute walking test (6MWT). Prior and post-completion of this test dyspnoea, oxygen saturation and cardiac frequency were recorded.

Results.?Alexithymia was not found to be significantly affecting the functional recovery of participants in respiratory rehabilitation. The distance walked at the 6MWT (6MWD) increased in both alexithymics and non-alexithymics (p_alexithymics?=?0.014; p_{non-alexithymics}?<?0.0001). Dyspnoea strongly improved among non-alexithymics, although a signal for improvement was also found in alexithymics (p_alexithymics?=?0.046; p_{non-alexithymics}?=?0.0001).

Conclusions.?These findings suggest that alexithymia did not have a significant impact on functional recovery of patients in respiratory rehabilitation.     

Massive paracetamol overdose: an observational study of the effect of activated charcoal and increased acetylcysteine dose (ATOM-2)

Context: Paracetamol is commonly taken in overdose, with increasing concerns that those taking “massive” overdoses have higher rates of hepatotoxicity and may require higher doses of acetylcysteine. The objective was to describe the clinical characteristics and outcomes of “massive” (≥?40?g) paracetamol overdoses.

Methods: Patients were identified through the Australian Paracetamol Project, a prospective observational study through Poisons Information Centres in NSW and Queensland, over 3 and 1.5 years, respectively, and retrospectively from three clinical toxicology unit databases (over 2.5 to 20 years). Included were immediate-release paracetamol overdoses ≥?40?g ingested over ≤?8?h. Outcomes measured included paracetamol ratio[defined as the ratio of the first paracetamol concentration taken 4–16?h post-ingestion to the standard (150?mg/L at 4?h) nomogram line at that time] and hepatotoxicity (ALT >1000?U/L).

Results: Two hundred paracetamol overdoses were analysed, reported median dose ingested was 50?g (interquartile range (IQR): 45–60?g) and median paracetamol ratio 1.9 (IQR: 1.4–2.9, n?=?173). One hundred and ninety-three received acetylcysteine at median time of 6.3?h (IQR: 4–9.3?h) post-ingestion. Twenty-eight (14%) developed hepatotoxicity, including six treated within 8?h of ingestion. Activated charcoal was administered to 49(25%), at median of 2?h post-ingestion (IQR:1.5-5?h). Those receiving activated charcoal (within 4?h of ingestion), had significantly lower paracetamol ratio versus those who did not: 1.4 (n?=?33, IQR: 1.1–1.6) versus 2.2 (n?=?140, IQR: 1.5–3.0) (p?Seventy-nine had a paracetamol ratio ≥2, 43 received an increased dose of acetylcysteine in the first 21?h; most commonly a double dose in the last bag (100 to 200?mg/kg/16?h). Those receiving increased acetylcysteine had a significant decrease risk of hepatotoxicity [OR:0.27 (95% CI: 0.08–0.94)]. The OR remained similar after adjustment for time to acetylcysteine and paracetamol ratio.

Conclusion: Massive paracetamol overdose can result in hepatotoxicity despite early treatment. Paracetamol concentrations were markedly reduced in those receiving activated charcoal within 4?h. In those with high paracetamol concentrations, treatment with increased acetylcysteine dose within 21?h was associated with a significant reduction in hepatotoxicity.