Paracetamol Overdose Induces Acute Liver Injury accompanied by oxidative stress and inflammation

The concept of paracetamol as a safe drug has become very misleading as this has led to a high rate of paracetamol toxicity. Hepatotoxicity and liver failure have been reported even with doses just more than the maximum therapeutic dose, which was obviously noticed in the (COVID-19) pandemic. Oxidative stress plays an important role in paracetamol hepatotoxicity. The current study investigates the mechanism of action through which paracetamol induces hepatotoxicity and implements an alarming sign for the unsupervised use of paracetamol. Twenty albino rats were equally divided into a normal control group and paracetamol treated group where rats received paracetamol at a dose of 2g/kg b.wt once orally for 24 hours. Oral administration of paracetamol resulted in a significant elevation of liver enzymes in serum such as glutamate pyruvate transaminase and glutamate oxaloacetate transaminase when compared with the results of the control group. In terms of oxidative stress biomarkers, the group that received an overdose of paracetamol showed a significant increase in the tissue level of 4-Hydroxynonenal accompanied by a significant decrease in the activity of the anti-oxidant markers Paraoxonase and Catalase. Histopathological examination revealed focal necrosis in the hepatocytes, Centri-lobular necrobiotic changes, and dilated congested portal vein. Immunohistochemical investigation for the Nuclear factor-kappa B showed strong positive expression in the nuclei of the hepatocytes of rats that received an overdose of paracetamol. Our study suggests that an overdose of paracetamol could attenuate the endogenous antioxidant defense mechanisms and augment the hepatic tissue inflammation;both factors may contribute to the observed increase in apoptosis-related signaling and cell death. ©2023 National Information and Documentation Center (NIDOC).

Use of Rituximab versus Azathioprine Therapy in Neuromyelitis Optica Spectrum Disorder Patients

Background: A severe antibody-mediated inflammatory demyelinating disease of the central nervous system is neuromyelitis optica spectrum disorder (NMOSD). Azathioprine (AZA) and Rituximab (RTX) were used to treat NMO-SD patients though not FDA approved yet. Aim of the study: To compare the effectiveness and safety of rituximab treatment versus azathioprine in treating individuals with NMOSDs. Methods: Seventy four Egyptian individuals with NMOSDs in this retrospective observational study and collecting their medical records from multiple sclerosis (MS) clinics, Neurology Departments, El-Maadi Military Hospital, and Cairo University hospitals. Fourty four patients received either treatment over two year duration, Group 1 (rituximab group) consisted of 19 patients, while group 2 (azathioprine group) consisted of 25 patients. Their full medical history, general and neurological examination, MRI brain and spinal cord results, and laboratory investigation were collected including immune assays and AQP-4 antibody. Results: There was no statistically significant difference between the groups in terms of brain MRI data at the baseline and outcomes. Between the two groups, there were statistically significant differences in last observer spinal MRI (p=0.025), annual relapse rate before treatment with RTX group (P=0.021), EDSS pretreatment (p=0.005), annual relapse rate post-treatment. When it came to the number of relapses after treatment, there was a high statistically significant difference between the two groups (p=0.016), with group 1 (RTX group) having zero relapses. There was a statistically significant decrease comparing EDDS scores pre-and post-treatment regarding the RTX group (p=0.003). Adverse events were Infusion rate reaction (5.3%) and pneumonic COVID (9.5%) of patients. Conclusion: RTX is more helpful and less harmful for NMO-SD patients than AZA.

Reducing futile acute care services (ACS) for terminally ill cancer patients (Dignity Project)

Background: Patients with terminal diseases frequently undergo procedures and interventions that are futile and maybe detrimental to the patients' quality of life. We conducted a quality improvement project aimed to reduce futile acute care services (ACS) for cancer patients treated with a palliative intent. Methods: A multidisciplinary team retrospectively reviewed the records of terminally ill cancer patients who died during in the hospital at our institution, King Abdulaziz Medical City, Riyadh, Saudi Arabia. We included all patients expired between November 2017 to May 2018. The review aimed to assess the magnitude of improper utilization of acute care services (ACS) such as: Critical care response team (CCRT), cardiopulmonary resuscitations (CPR) and admission to intensive care unit (ICU). A root cause analysis and process mapping were conducted to identify reasons for over utilization of these services. Timely documentation of goals of care was identified as a main reason for this problem. Then interventions were implemented to improve the practice. Post intervention data was captured and compared to the baseline data. Results: After delivery of staff education sessions and implementation of mandatory documentation of goals of care in the electronic healthcare record system, the timely documentation of goal of care for patients with palliative intent had significantly increased from 59% of cases in the baseline to 86% for the post intervention phase. As a result, admission to ICU decreased from 32% of cases in the pre intervention phase to 14% in the post intervention phase reducing monthly cost of admission to the ICU by 40% and estimated to be on average of $48,000 USD monthly ($576,000 USD annually). Conclusions: Our interventions resulted in improved documentation of the goal of care leading to decrease in the utilization of acute care services (ACS) including reduction of intensive care unit (ICU) admissions and cost. This outcome is even more relevant nowadays during COVID-19 pandemic and the pressure on critical care resources. Improvement is sustained by integrating the changes in the work process and electronic medical records.

Managing outpatient oncology visits during COVID-19 pandemic: Addressing patients' concerns and precautionary measures

Background: Implementation of precautionary measures in response to COVID-19 pandemic involve patients pre-visit screening of patients to detect any potential risk of infection and proper patient flow to the clinic and adherence to social distancing. Our study evaluates our center experience with the pre-visit screening calls and plans to optimize the process. Methods: As precautionary measure to COVID-19 pandemic, all patients scheduled for oncology outpatient visit were called by a nurse to screen them for any acute respiratory infection (ARI) and triage their visit into physical visit or virtual visit. Patients with high ARI score were directed for proper isolation and COVID-19 testing process and recommended to have virtual clinic visit with their oncologists. Those who have low ARI score and require in person clinic visit receive confirmation of appointment during the call with visit instructions. A tally of all responses and decision were maintained for process monitoring. Results:Between March 23, and June 13, 2020, 1,905 patients had pre-visit screening calls. Nurses could not reach 82 (4%) patients and 23 patients expired per family member report. Out of 1800 patients who responded to call, 1392 (77 %) had confirmed physical appointment, 179 (10%) switched to virtual appointments. Sixteen out of the 19 patients who have high ARI score have swab done. All patients were tracked to assure proper management of their symptoms and continuity of oncological care. A total of 229 (12.7%) patients refused to come due to COVID-19 concerns and all were rescheduled based on primary oncologists decision. A quality improvement project was initiated to understand the concerns of patients who refused to come and address them properly. Conclusions: Pre-visit screening call is a critical intervention, not just in assuring adherence to infection control measures, but in identifying patients concerns and addressing them. There is a need for implementation of updated patient education and awareness approach about the risk of COVID-19 infection and the importance of adherence to their cancer treatment plans.

Implementation of care near home model (CNH) for cancer patients in response to COVID-19 pandemic

Background: Cancer care is heavily centered in health care facilities due to the requirements of providing complex multidisciplinary care with multiple testing and interventions. We describe our experience in implementing a new model of care to minimize cancer patients visit to health care facilities and to reduce the risk of infections and to decrease the pressure on the health care system. Methods: In response to the COVID-19 pandemic, we reengineered the cancer care process to reduce patients visit to the hospital by the implementation of a Care Near Home (CNH) Model, which comprises offour components: Virtual clinic, laboratory testing near home, shipping medications and supplies, and involving local health care facilities. The effectiveness and acceptance of this new model has been assessed by the delivery of timely care successfully and assessing the satisfaction patients and healthcare providers. Results: On March 18, 2020, we launched the virtual clinics followed by different components of the model. The number of virtual clinic visits has increased significantly from 399 visits in March to 1107 in April 2020. More the 90% of physicians and patients who responded to the survey expressed their acceptance and satisfaction with the virtual clinic services. Medications were shipped to total of 603 patients. Of those, 578 (96%) patients received their medications (378 patients outside city, 200 patients inside city of which, 95% received medications within 24 hours). Only 25 (4%) patients did not receive their medications and we arrange for alternative solutions. Laboratories in various regions were set up to perform the tests for our patients and to communicate the results through our electronic healthcare records system. The process of ordering and performing the test were piloted with success and now we are at the scaling up phase. Conclusions: Although the implementation of CNH Model was driven by COVID-19 pandemic, it will be integrated in our work process and utilized as a long term approach to manage many of our patients because it is more convenient to them and more cost effective to the health care system.