Adult Overdose Research Articles

Applicability of a Chemiluminescence Immunoassay to Screen Postmortem Bile Specimens and Its Agreement with Confirmation Analysis.

Bile has emerged as an alternative matrix for toxicological investigation of drugs in suspected forensic cases of overdose in adults and intoxications in children. Toxicological investigation consists in screening and, subsequently, confirming the result with specific techniques, such as liquid chromatography with tandem mass spectrometry (LC-MS/MS). As there is no screening test on the market to test postmortem bile specimens, the novelty of this study was in investigating the applicability of a chemiluminescence immunoassay, designed for other matrices and available on the market, on bile and validate its use, testing the agreement with LC-MS/MS analysis. Bile specimens were obtained from 25 forensic cases of suspected death from overdose and intoxication. Sample preparation for bile screening consists simply in centrifugation and dilution. Confirmation analysis allows simultaneous identification of 108 drugs and was validated on bile. Kappa analysis assessed a perfect agreement (0.81-1) between the assays for benzodiazepines, methadone, opiates, cocaine, oxycodone, cannabinoids, buprenorphine and pregabalin; a substantial agreement (0.41-0.6) was reported for barbiturates. No agreement was assessed for amphetamines, due to an abundance of putrefactive amines in postmortem specimens. In conclusion, this fast and easy immunoassay could be used for initial screening of bile specimens, identifying presence of drugs, except amphetamines, with reliability.

Older adult drug overdose: an application of latent class analysis to identify prevention opportunities

BackgroundOlder adult overdose death rates have increased significantly in recent years. However, research for prevention of drug overdose death specific to older adults is limited. Our objective is to identify profiles based on missed intervention points (touchpoints) to inform prevention of future older adult unintentional overdose deaths.MethodsWe used latent class analysis methods to identify profiles of decedents aged 55 + years in the Illinois Statewide Unintentional Drug Overdose Reporting System. This system collects data on 92.6% of all unintentional overdose deaths in Illinois and includes data from death certificates, coroner/medical examiner, toxicology, and autopsy reports. Data include decedent demographics, circumstances leading up to and surrounding the fatal overdose and details regarding the overdose. Variables in the latent class analysis model included sex, race, alcohol test result, social isolation, recent emergency department (ED) visit, chronic pain, and pain treatment.ResultsWe identified three distinct decent profiles. Class 1 (13% of decedents) included female decedents who were in pain treatment, had physical health problems, and had greater likelihood of a recent ED visit before their death. Class 2 (35% of decedents) decedents were most likely to be socially connected (live with others, employed, had social or family relationships) but less likely to have recent healthcare visits. Class 3 (52% of decedents) decedents had higher social isolation (lived alone, unemployed, unpartnered), were mostly male, had fewer known physical health conditions, and more alcohol positivity at time of death. White decedents are clustered in class 1 while Black decedents are predominant in classes 2 and 3.ConclusionsThese profiles link to potential touchpoint opportunities for substance use disorder screening harm reduction and treatment. Class 1 members were most likely to be reachable in healthcare settings. However, most decedents were members of Classes 2 and 3 with less engagement in the healthcare system, suggesting a need for screening and intervention in different contexts. For Class 2, intervention touchpoints might include education and screening in work or social settings such as senior centers given the higher degree of social connectivity. For Class 3, the most isolated group, touchpoints may occur in the context of harm reduction outreach and social service delivery.

Management of an unintentional enoxaparin overdose: A case report and literature review.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. The aim of this article is to describe a case in which protamine was used for a low-molecular-weight heparin (LMWH) overdose and present an up-to-date review of the literature on the management of LMWH overdose in adults. An unintentional administration of enoxaparin 900mg occurred in a 73-year-old man with COVID-19-related pulmonary embolism. Management of the overdose included a protamine bolus followed by an infusion. Anti-factor Xa levels and activated partial thromboplastin time were monitored. Anti-factor Xa levels declined in a linear fashion irrespective of protamine administration. No bleeding or further thrombotic complications occurred in the patient. A review of the literature revealed that the optimal strategy to treat an LMWH overdose is unknown, with treatment of overdoses ranging from clinical observation to aggressive protamine dosing in reported cases. Although protamine effectively neutralizes unfractionated heparin, it is unable to completely reverse LMWH activity and has variable effects on laboratory measures of LMWH anticoagulant activity. The current case report provides additional data to previous literature suggesting that protamine may have a limited effect in decreasing anti-factor Xa levels in LMWH overdose. Continued reporting on the management of LMWH overdoses is warranted to clarify the optimal treatment strategy.

Xylazine Complicating Opioid Ingestions in Young Children.

The authors of this report present 3 cases of synthetic opioid intoxication complicated by the concomitant presence of the additive xylazine, a nonopioid sedative analgesic and muscle relaxant used in veterinary medicine that potentiates respiratory depression associated with the opioid toxidrome. Three exposed children presented with severe signs and symptoms, 2 of whom experienced cardiac arrest, a need for continuous naloxone infusion or multiple naloxone doses, or mechanical ventilation to treat respiratory failure after their exposures. Additives were detected in urine studies only through the performance of specialized toxicology testing. Detection of xylazine among adult overdose deaths has recently increased sharply, particularly across the northeastern United States. Adulteration by xylazine is an emerging public health threat nationally. Our report reveals that pediatricians should be aware of sentinel drug trends among adults, including the emerging types of illicit, synthetic, or counterfeit formulations of recreational substances, because children may be harmed because of accidental or intentional exposure. Children exposed to dangerous substances also need child protection services that may entail safe relocation outside of the home and the referral of affected caregivers to necessary substance use treatment services. Given epidemic drug use among adults, pediatricians should be competent to recognize common toxidromes and be aware that signs and symptoms may be potentiated by synergistic novel additives or polysubstance exposures. Importantly, standard urine drug screens may not detect synthetic opioid derivatives or contributing additives, so that diagnosis will require specialized toxicology testing.

759: CHARACTERIZATION OF CONTINUOUS-INFUSION NALOXONE DOSING IN OPIOID OVERDOSE

Introduction: Naloxone is a competitive antagonist that is used to reverse the effects of opioid overdose. Due to its short half-life continuous infusions have been indicated in overdose patients. Current recommendations endorse starting naloxone infusions at two-thirds the initial effective dose, however, case reports describe doses ranging from 0.1 mg to 4 mg/hr. The purpose of this medication utilization review is to characterize the utilization and initial dosing of continuous infusion naloxone in adult overdose patients who presented to the emergency department (ED) at a single academic medical center. Methods: This study retrospectively evaluated a cohort of patients 18 years and older who presented to the ED at Virginia Commonwealth University Health and received continuous infusion naloxone for opioid overdose between January 1, 2006, and December 31, 2021. Patients were excluded if the naloxone infusion was not administered, if it was ordered for indications other than opioid overdose, or if the patient required naloxone for iatrogenic overdose. Results: Out of 3056 patient encounters where naloxone was given, only 66 patients were started on a naloxone infusion. On average patients were 46 years old, 65% male, and 73% African American. Heroin was the primary suspected overdose agent in 35% of patients and was unknown in 46% of patients. Seventy-four percent of patients received intravenous naloxone by EMS and 97% received additional naloxone boluses in the ED before starting a continuous infusion. Patients received a median of 3 mg of naloxone as boluses before starting continuous infusion naloxone. Fifty percent of patients were started on naloxone infusions < 2 mg/hr, 39% were started on the institution default of 2 mg/hr, and 11% were started >2 mg/hr with a median infusion rate of 1.5 mg/hr and duration of 7.8 hours. Fifty-four percent of patients who were started on an initial rate of 2 mg/h had an infusion dose decrease before discontinuation, while 31% required a dose increase. Conclusions: Given the current opioid epidemic, the optimal dosing of continuous infusion naloxone is unknown. It is unclear whether the recommendation of two-thirds of initial effective dose is still applicable. Currently, empiric dosing is variable and provider dependent.

Clinical toxicology of propranolol and metoprolol overdose in adults

Clinical toxicology of propranolol and metoprolol overdose in adults

Trends in opioid overdose fatalities in Cuyahoga County, Ohio: Multi-drug mixtures, the African-American community and carfentanil

BackgroundOhio's age-adjusted opioid overdose fatality rate is double the national average. In an ever-evolving epidemic, it is crucial to monitor trends to inform public health interventions. MethodsA retrospective study was conducted using the Medical Examiner's decedent case files for all accidental opioid-related adult overdose deaths in Cuyahoga County (Cleveland), Ohio in 2017. Characterization of trends was based on autopsy/toxicology and first responder reports, medical records and death scene investigations. ResultsOf 543 accidental opioid-related adult overdose fatalities, 64.1% died from 3+ drugs. The most common cause of death (COD) drugs included fentanyl (63.4%), heroin (44.4%), cocaine (37.0%) and carfentanil (35.0%). There were four times as many African American decedents as two years prior. Three or more COD drugs was >50% more common in those with fentanyl (Prevalence Ratio (PR) = 1.56[1.34–1.70]; p<.001) or carfentanil (PR = 1.51[1.33–1.70]; p<.001) as a COD drug, more common with a history of prescription drug abuse (PR = 1.16[1.02–1.33]; p=.025), but less common in divorced/widowed decedents (PR = 0.83[0.71–0.97]; p=.022). Carfentanil was nearly 4 times as prevalent in those with previous illicit drug use (PR = 3.88[1.09–13.70]; p=.025), and less common in those with previous medical history (PR = 0.72[0.55–0.94]; p=.016) or age 50+ (PR = 0.72[0.53–0.97]; p=.031). ConclusionsAccidental opioid-related overdose fatalities in Cuyahoga County adults were dominated by 3+ COD drugs, with cocaine/fentanyl mixtures driving sharp increases in African American fatalities. Carfentanil was more prevalent in people fitting the profile of recreational drug use. This data can inform harm reduction interventions.

Risk Factors for Hepatotoxicity Due to Paracetamol Overdose in Adults.

Background and Objectives: Over-the-counter availability and a good safety profile make paracetamol one of the most common analgesics in developed countries but also the leading cause of liver failure due to overdose. The objectives of the study were to identify modifiable risk factors for severe hepatotoxicity following paracetamol overdose in adults. Materials and Methods: A retrospective cohort study involved the consecutive adult patients hospitalized in a toxicological center over a period of seven years due to paracetamol overdose. Complete medical datasets of laboratory and anamnestic variables were analyzed and validated by means of logistic regression model. Results: A total of 185 patients entered the study, including 25 individuals who developed severe hepatotoxicity (plasma aminotransferases levels above 1000 UI/L) and 31 individuals with mild to moderate liver injury (plasma aminotransferases levels above upper normal range, but below 1000 UI/L). In the univariable analysis, significant hepatotoxicity risk factors were male gender, alcohol abuse, an ingested paracetamol dose, and a timespan from ingestion to hospital admission. The later one was the only significant risk factor in the multivariable model (adjusted odds ratio 1.08; 95% CI: 1.03–1.12). Conclusions: A delay in hospital admission, resulting in a delayed administration of disease-specific treatment outweighs any other known risk factors of paracetamol-induced hepatotoxicity.

Prevalence of symptoms in patients poisoned with iron in Ahvaz Razi Hospital in 2014-2017

Background: Iron is an important element for normal cell metabolism, but in excess amounts is quite cytotoxic, and even deadly. Iron poisoning is a calamity repeated many times in the world. The clinical signs of the patients include gastrointestinal symptoms, a short period of relative stability, Cardiogenic shock, liver failure, and scarring of the gastrointestinal tract. Iron tablets are specifically tempting to children because they are similar to candy. Iron overdose in adults is usually to attempt suicide. Methods: The present study is a descriptive-analytic study based on hospital information, that was conducted among the patients affected with iron poisoning admitted to Razi hospital (a referral medical setting for poisoning treatment in southwest Iran) during 2014-2017. Patient information has been extracted and inserted in the inquiry form and data were analyzed by SPSS software. Results: In this study, 52 patients (94.2% female) were studied. 5 (9.6%) of women were pregnant. The majority of them (69.2%) were between 15-25 years of age. Nausea and vomiting (50%) are two of the most common side effects. 5 patients (9.6%) received deferoxamine. All Patients who received deferoxamine, symptoms had less than 6 hours of onset. Most patients were hospitalized between 6-24 hours. 25% of patients took vitamins simultaneously with iron. The Serum level of iron in 3 patients (5.8%) was above 300 µg/dL. Based on this research, mortality was reported in one patient. Conclusion: In this study, the prevalence of iron poisoning was examined based on demographic and clinical characteristics. Considering the most prevalent iron poisoning in the young age group (96.2% suicides), more research in the psychological and social problems is critical for preventative behaviors.

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

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. 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. The new guidelines recommend a two-bag acetylcysteine infusion regimen (200mg/kg over 4h, then 100mg/kg over 16h). 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 (≥10g or ≥200mg/kg, whichever is less) should receive a full course of acetylcysteine. Patients ingesting ≥30g or ≥500mg/kg should receive increased doses of acetylcysteine.

Comparing the predictive capability of self-report and medically-verified non-fatal overdose in adults released from prison: A prospective data linkage study

BackgroundSelf-reported non-fatal overdose (NFOD) is a predictor of future overdose and is often used to target overdose prevention for people released from prison. However, the level of agreement between self-reported and medically-verified NFOD history remains unknown. This study aimed to determine the agreement between, and predictive value of, self-reported and medically-verified history of NFOD in people recently released from prison. MethodsPre-release baseline survey data from 1307 adults in prison surveyed from 2008 to 2010 in Queensland, Australia were linked to ambulance, emergency department, and hospital records. We compared the agreement of self-reported NFOD history in the baseline survey and medically-verified NFOD ascertained through linked medical data. Unadjusted and adjusted regression models were used to determine the association between self-reported and medically verified NFOD history and medically-verified NFOD after release from prison. Results224 (19 %) participants self-reported NFOD history only, 75 (5 %) had medically-verified NFOD history only, and 56 (4 %) both self-reported and had medically-verified NFOD history. Compared to those with no NFOD history, those who self-reported and had a medical history of NFOD (adjusted hazard ratio (AHR) 6.1, 95 %CI 3.1–11.9), those with a medical history only (AHR 3.4, 95 %CI 1.7–7.0), and those who self-reported only (AHR 1.8, 95 %CI 1.0–3.5) were at increased risk of medically-verified NFOD after release from prison. ConclusionsRelying on self-report of NFOD is likely to miss people at increased risk of future NFOD, many of whom could be identified through medical records. Wherever possible, data related to NFOD should be triangulated from multiple sources.

Observation unit management of low-risk emergency department patients with acute drug overdose

Introduction: Observation units (OU) are being increasingly used within the Emergency Department (ED) to optimize care and reduce costs, but their use for management of overdose patients is unclear. The present study examined demographics, disposition and outcomes for ED overdose patients managed in an OU.Methods: This was a secondary analysis of a prospective consecutive cohort of adult overdose patients managed in an OU in a single ED from March 2015 to September 2018. The primary composite study outcome was occurrence of any advanced airway intervention, adverse cardiovascular events (ACVE), or mortality. Secondary outcomes were disposition and return visits.Results: Of 946 patients screened, 648 were included in the cohort. Of 132 patients requiring additional medical management after the ED visit, 25 (18.9%) were managed in the OU; 88% of OU patients were discharged home, no patients required airway management, one patient experienced an ACVE requiring admission, and there were no deaths. Three OU patients (12%) had 30-day return visits.Conclusion: In this study, almost one-fifth of patients requiring additional medical management after the ED visit qualified for a low-risk drug overdose OU pathway. Overdoses from a variety of substances were safely managed with acceptably low adverse event rates.

Getting the Message: The Declining Trend in Opioid Prescribing for Minor Orthopaedic Injuries in Children and Adolescents Over the Past 14 Years

Purpose: Opioid addiction has become an American crisis. More than 4,200 teens and young adults (aged 15-24) died from drug related overdoses in 2015; more than half were attributable to prescription opioids. The impact on the health care system is enormous: for every young adult overdose death, there are 119 emergency room visits and 22 treatment admissions. Many opioid addictions begin with a medical prescription for injury or pain. Prevention efforts are now focusing on avoiding the first exposure, particularly in common, minor injuries, when opioids are not needed. In …

Association Between Parental Medical Claims for Opioid Prescriptions and Risk of Suicide Attempt by Their Children

The rate of youth suicide has increased over the past 15 years in the United States as has the rate of death due to opioid overdose in adults of parental age. To explore the possible connection between parental use of prescription opioids and the increasing rate of youth suicide. A pharmacoepidemiologic study was conducted from January 1, 2010, to December 31, 2016, linking medical claims for parental opioid prescriptions with medical claims for suicide attempts by their children. The study used MarketScan medical claims data covering more than 150 million privately insured people in the United States. The study included 121 306 propensity score-matched 30- to 50-year-old parents who used opioids and parents who did not use opioids and their 10- to 19-year-old children (148 395 children of parents who did not use opioids and 184 142 children of parents who used opioids). Propensity score matching was used to identify relevant control families based on demographic features and concomitant use of psychotropic medication. Opioid use in a parent was defined as having prescription fills covering more than 365 days of an opioid between 2010 and 2016. Suicide attempt rate in the children of parents who used opioids and those who did not use opioids. A total of 148 395 children (75 575 sons and 72 820 daughters; mean [SD] age, 11.5 [1.6] years at the start of follow-up) had parents who did not use opioids and 184 142 children (94 502 sons and 89 640 daughters; mean [SD] age, 11.8 [1.8] years at the start of follow-up) with parents who did use opioids. There were 100 899 children aged 10 to 14 years and 47 496 children aged 15 to 19 years with parents who did not use opioids and 96 975 children aged 10 to 14 years and 87 163 children aged 15 to 19 years with parents who did use opioids. Of the children with parents who did not use opioids, 212 (0.14%) attempted suicide; of the children with parents who did use opioids, 678 (0.37%) attempted suicide. Parental use of opioids was associated with a doubling of the risk of a suicide attempt by their offspring (odds ratio [OR], 1.99; 95% CI, 1.71-2.33). The association remained significant after adjusting for child age and sex (OR, 1.85; 95% CI, 1.58-2.17), addition of child and parental depression and diagnoses of substance use disorder (OR, 1.46; 95% CI, 1.24-1.72), and addition of parental history of suicide attempt (OR, 1.45; 95% CI, 1.23-1.71). Geographical variation in opioid use did not change the association (OR, 2.00; 95% CI, 1.71-2.34). Children of parents who use prescription opioids are at increased risk for suicide attempts, which could be a contributing factor to the time trend in adolescent suicidality. The care of families with a parent who uses opioids should include mental health screening of their children.

Clinical toxicology of beta-blocker overdose in adults.

Beta-blocker overdose is potentially harmful due to the strong blood pressure-lowering and heart rate-lowering effects. However, conflicting data exist as to their differential toxicity, single-substance exposures and the effect of co-exposure with additional antihypertensive medication. For this, a 10-year retrospective, explorative analysis of the Mainz Poison Center/Germany database with regard to circumstances of beta-blocker exposure, doses, symptoms and treatment was carried out. Analyses were restricted to adult patients with single-substance exposures and co-exposures with one additional antihypertensive substance. Written follow-up information was obtained in half the cases. A total of 2967 cases were analysed, of which 697 were single-substance exposures. Metoprolol was most frequently reported followed by bisoprolol, atenolol, propranolol and sotalol. Metoprolol showed a linear dose-symptom relationship, whereas propranolol and sotalol seemed to have a threshold dose beyond which symptoms aggravated. Symptoms did not differ substantially, except for more seizures being reported with propranolol, and more CNS depression/vomiting with sotalol. Activated charcoal was used in 38%, gastric lavage in 11%, temporary pacemaker in 3%, glucagon in 1%, intubation for respiratory insufficiency and cardiopulmonary resuscitation in 1% and 0.5%. All patients recovered. In 174 co-exposure cases, the distribution of poisoning severity and rate of worsening of symptoms was comparable with single-substance exposures except one patient deceased after bisoprolol and verapamil co-exposure. In adults with beta-blocker overdose, no significant differences in poisoning severity among beta-blockers were detected, and no fatalities were observed with single-substance exposures. Co-exposures with other antihypertensives, sedatives or alcohol should be carefully attended to as fatalities might occur.

Naloxone nasal spray (Nyxoid®) in opioid overdose: a profile of its use in the EU

Naloxone is an opioid antagonist that reverses opioid-induced respiratory depression. Concentrated naloxone 1.8 mg nasal spray (Nyxoid®) is approved for the emergency treatment of opioid overdose in adults and adolescents aged ≥ 14 years in non-medical and healthcare settings. It is well tolerated, but may lead to opioid withdrawal syndrome in opioid-dependent individuals. Naloxone nasal spray is rapidly absorbed and, relative to reference intramuscular naloxone 0.4 mg, achieves generally similar early exposure, but better maintenance of plasma levels, during the intermediate period (15–120 min).

Hepatotoxicity induced by acute and chronic paracetamol overdose in adults. Where do we stand?

Paracetamol (Acetaminophen) poisoning data can reveal the potential deficiencies of paracetamol poisoning management guidelines. We conducted a retrospective cohort study of patients >18years who were attended in the emergency department (ED) of a Spanish tertiary hospital, from 2005 to 2010 for suspected paracetamol overdose and who had measurable paracetamol concentrations. 208 patients suspected of paracetamol poisoning were identified. The annual incidence in the ED increased from 2.0 (95%-CI: 0.2–7.2) cases per 10,000 patients in 2005 to 3.4 (95%-CI: 1.1–8.8) in 2010. Only 7 of 98 patients (7.14%) with acute poisoning at toxic doses showed hepatotoxicity signs, 4 (57.1%) of whom presented acute liver failure (ALF) criteria, while 8 of 10 patients (80%) with chronic paracetamol poisoning at toxic doses presented hepatotoxicity and 3 (37.5%) with ALF criteria. The time required to find medical care was 9.0h for acute poisoning and 49.6h for chronic poisoning (p<0.001). We conclude that the incidence of suspected cases of paracetamol poisoning at our hospital is increasing. The majority of toxicity cases, including ALF, associated with the ingestion of paracetamol were due to chronic poisoning. This finding constitutes an important warning regarding paracetamol chronic poisoning, and clinicians should have a higher index of clinical suspicion for this entity.

Acetylcysteine and Acetaminophen Overdose: The Many Shades of Gray.

Acetylcysteine and Acetaminophen Overdose: The Many Shades of Gray.

Predicting acute acetaminophen hepatotoxicity with acetaminophen-aminotransferase multiplication product and the Psi parameter

Context. Prediction of potential hepatotoxicity is important for individualizing therapy with N-acetylcysteine (NAC) in patients with acute acetaminophen overdose. Acetaminophen-aminotransferase multiplication product (APAP × AT) and the Psi Parameter (Psi) have been reported to be the predictors of acetaminophen hepatotoxicity. Objective. To determine the validity of APAP × AT and Psi in predicting hepatotoxicity secondary to acute acetaminophen overdose. Materials and methods. We retrospectively reviewed acute acetaminophen overdose cases who were treated with NAC at Siriraj Hospital, Thailand during January 2004–June 2012. The patients’ ages were 12 years or more. Initial acetaminophen concentration (mg/L) and aminotransferase (IU/L) were multiplied to obtain APAP × AT. Psi were derived from initial acetaminophen concentrations (mg/L) and lag time (hours) to NAC therapy. The cut-off values for APAP × AT and Psi were 1500 mg∙IU/L2 and 5 mM∙h, respectively. Hepatotoxicity (defined as aspartate or alanine aminotransferase (ALT) greater than 1000 IU/L) was the outcome of interest. Results. A total of 255 patients were included, 32 of whom developed hepatotoxicity. APAP × AT had sensitivity, specificity, and negative likelihood ratio of 90.6%, 62.8%, and 0.2, respectively. The sensitivity of Psi, specificity, and negative likelihood ratio were 96.9%, 91.5%, and 0.0, respectively. The areas under the curve of the receiver operating characteristic (ROC) curve for APAP × AT and Psi were 0.82 and 0.96, respectively, with a statistically significant difference between the two methods (p = 0.002). APAP × AT showed higher specificity (92.5%) in patients who presented 8–24 h after the overdose. Discussion and conclusion. Psi and APAP × AT are valid clinical tools in predicting hepatotoxicity secondary to acute acetaminophen overdose in adults. APAP × AT is useful in predicting a low likelihood of hepatotoxicity after standard NAC therapy among late-presenting patients.

Iron and acetaminophen a fatal combination?

Intentional iron overdose in adults is uncommon. Clinical consequences are variable and depend on the quantity of iron ingested and the delay to treatment. Severe iron overdose can lead to multi-organ failure and acute hepatic necrosis. Here, we report three cases of polypharmacy overdose including iron resulting in acute liver failure. Despite maximum supportive care including liver transplantation in two cases, all patients died. Iron poisoning may have an additive toxic effect in drug-induced acute liver failure and worsen outcome.