Unintentional overdose of paracetamol as a problem of modern times - a case report

INTRODUCTION Paracetamol is one of the most widely used analgesics and antipyretics in the world. An overdose of this drug can occur after a single ingestion of a large amount of paracetamol or after repeated ingestion of smaller amounts that eventually exceed the recommended total dose and can result in liver damage.  It is believed that the maximum daily dose of paracetamol for an adult is 4g. MATERIALS AND METHOD Patient information was collected from hospital records available in the clinical toxicology department. In addition, we conducted a literature review on paracetamol using PubMed. CASE REPORT A patient, 16 years old, was admitted from a district hospital to the Clinical Toxicology and Cardiology Department in Lublin for paracetamol intoxication and suspected intoxication with a psychoactive substance. The patient's history revealed that he had taken a total of 20 paracetamol 500mg (10g) tablets in short intervals of 2 h for abdominal pain. The patient was treated with a full dose of antidote (ACC), and the drug infusion was continued at a maintenance dose. Despite the treatment administered, increasing features of liver damage were observed (INR 2.78, AST 6273 U/l, ALT 8854 U/l, bilirubin 3.83 mg/dl).The patient was consulted to qualify for a possible liver transplant. With intensive treatment maintained, a downward trend in liver damage parameters was achieved. The patient was discharged from the Department in good general condition, without complaints. CONCLUSION Due to the increasing number of paracetamol overdoses (intentional or accidental), strategies should be implemented to raise awareness and prevent this-educating patients, encouraging label/leaflet reading, reducing the amount of paracetamol in packages, more visible warnings on packages

The clinical course and risk in patients with pseudo-Mahaim fibers

Background: Pseudo-Mahaim (AP-M) fibers are a rare variant of atrioventricular (AV) accessory pathways. Atriofascicular and atrioventricular accessory connections are characterized by slow conduction and decremental properties. Dual physiological AV node pathways, slow and fast, are observed in a large number of patients with AP-M. Therefore, there is substrate for AV nodal reentrant tachycardia (AVNRT) in addition to antidromic AV reentrant tachycardia (AVRT) with left bundle branch block (LBBB)-like morphology. Other arrhythmia such as atrial fibrillation (AF) or atrial flutter (AFL) and ventricular fibrillation (VF) are also observed. We analysed the occurrence of arrhythmias in a group of patients with AP-M treated in our department. Methods: We evaluated 27 patients (12 women) aged 14-53 years (mean age 25.6 years) with AP-M. The clinical course in these patients, in particular with regard to the occurrence of arrhythmias, was analysed. Patients with dual AV node properties were compared to patients without such findings. Results: We found dual AV node properties in 18 patients (Group 1), while 9 patients had fast pathway only (Group 2). Twenty-six patients presented with AVRT, 2 patients with AVNRT, 3 patients with AF, 1 patient with AT, 2 patients with AFL, and 3 patients with VF. In 2 patients, AP-M were seen in an atypical area. In one patient, the pathway connected the right atrium with the left ventricle (septal region), and in the other patient it connected the left atrium with the left ventricle (left anterior region). Conclusions: The majority of AP-M was right-sided. Two thirds of patients with AP-M had anatomical substrate for AVNRT (fast/slow pathway AV node). VF or asystole occurred in 10% of patients

Reduction of left ventricular mass, left atrial size, and N-terminal pro–B-type natriuretic peptide level following alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy

Background: Alcohol septal ablation (ASA) is an alternative to surgical treatment in patients with hypertrophic obstructive cardiomyopathy (HOCM). Through alcohol-induced necrosis, ASA leads to an increase in left ventricular outflow tract (LVOT) diameter and a decrease in LVOT pressure gradient. Aims: We sought to assess the effect of ASA on left ventricular (LV) wall thickness and mass, left atrial (LA) size, and N-terminal pro–B-type natriuretic peptide (NT-proBNP) level. Methods: The study cohort consisted of 50 patients with HOCM (30 in the ASA group, 20 in the optimal pharmacotherapy group [OPG]). Transthoracic echocardiography (TTE), cardiac magnetic resonance (CMR), and NT-proBNP level analysis were performed at baseline and at six months. Results: All parameters are presented as means. In the ASA group, the maximal LVOT pressure gradient decreased from 122.7 to 54.8 mmHg directly after ASA and to 37.2 mmHg after a further six months (p < 0.0001). The NT-proBNP level decreased from 2174.4 to 1103.4 pg/mL (p < 0.001). On TTE, the interventricular septum (IVS) thickness decreased to from 23.6 to 19.4 mm (p < 0.0001) and the lateral wall (LW) thickness decreased from 15.9 to 14.2 mm (p < 0.007). On CMR, basal IVS thickness decreased from 23.7 to 18.0 mm (p < 0.0001) and the LW thickness decreased from 13.2 to 12.2 mm (p = 0.02). IVS mass reduced from 108.9 to 91.5 g (–16%; p < 0.001). All of the above parameters remained unchanged in the OPG. Conclusions: Successful ASA reduces LV hypertrophy and improves parameters of the LV overload, resulting in LV wall hy­pertrophy regression, and LA size and NT-proBNP level reduction. The above parameters may be as useful in assessing the efficacy of ASA as the LVOT gradient itself

Risk factors of atrial fibrillation recurrence despite successful radiofrequency ablation of accessory pathway: At 11 years of follow-up

Background: Previous reports on patients with radiofrequency catheter ablation (RFCA) of accessorypathway (AP) and atrial fibrillation (AF) include only short follow-up periods. The aim of this studywas to analyze predictors of recurrence of AF in patients after successful RFCA of APs over long termfollow-up periods.Methods: Of the 1,007 patients who underwent non-pharmacological treatment of APs (between theyears 1993–2008), data of 100 consecutive patients were retrospectively analyzed (75 men, mean age43.6 ± 14.7), with the longest period of follow-up (mean 11.3 ± 3.5 years) after successful RFCA ofAP. In Group 1, there were 72 patients (54 men, mean age 40.66 ± 13.85 years) without documentedepisodes of AF after RFCA of AP. Group 2 consisted of 28 patients (21 men, mean age 50.79 ± 14.49years) with AF episodes despite successful elimination of AP.Results: In univariate analysis, patients from Group 1 were significantly younger at the time of ablationthan patients from Group 2 (40.66 ± 13.85 vs. 50.79 ± 14.49 years; p = 0.002), had shorter historyof AF episodes (4.11 ± 4.07 vs. 8.25 ± 7.50 years; p = 0.024) and had less frequently documentedatrial tachycardia (AT) prior to ablation (3.39 vs. 20.00%; p = 0.022). In multivariate analysis, thehistory of AF in years (p = 0.043), was an independent risk factor for AF recurrences.Conclusions: Older patient age, longer history of AF and AT prior to RFCA of APs identified a subgroupof patients who required additional treatment. In the multivariate analysis, the history of AF inyears (p = 0.043) was a risk factor for AF recurrence

Atrial tachycardia ablation in patients with a functional single ventricle after the Fontan surgery

Wstęp: Częstoskurcze przedsionkowe (AT) są jedną z wiodących przyczyn chorobowości i śmiertelności u pacjentów po operacji Fontana, a skuteczność terapii lekami antyarytmicznymi w tej grupie chorych jest z reguły ograniczona. Cel: Celem pracy była ocena wyników bezpośrednich i odległych ablacji AT u pacjentów po operacji Fontana oraz ocena charakterystyki klinicznej, elektrofizjologicznej i elektroanatomicznej arytmii. Metody: Retrospektywną analizą objęto dane 8 pacjentów (5 mężczyzn, 3 kobiety) po operacji Fontana kierowanych na ablację w latach 2002–2013 z powodu AT. Istotność kliniczną i nasilenie arytmii przed i po ablacji oceniono za pomocą zmodyfikowanego wskaźnika arytmicznego. Jest on sumą czterech składowych wartościujących, takich jak: 1) maksymalny czas trwania arytmii, 2) objawy związane z arytmią, 3) metody przerywania arytmii, 4) terapia antyarytmiczna konieczna do zapobiegania napadom. Wskaźnik ten przyjmuje wartości od 0 (bez istotnej arytmii) do 12 punktów (ciężka arytmia). U wszystkich pacjentów zabiegi ablacji wykonywano z zastosowaniem systemu CARTO, co pozwoliło na półilościową ocenę wielkości obszarów niskoamplitudowych (< 0,5 mV) i blizn w obrębie przedsionka. Wyniki: U 7 chorych obecne było połączenie prawy przedsionek–tętnica płucna, a u 1 chorego — tunel zewnątrzsercowy. Średni wiek pacjentów w trakcie wykonania operacji Fontana wynosił 9,4 ± 3,1 roku, a w trakcie wykonywania pierwszej ablacji — 26,2 ± 4,6 roku. W badanej grupie wykonano łącznie 18 ablacji bez istotnych powikłań, 1–4 ablacje/chorego; mediana 2,5. U pacjentów, u których przeprowadzono więcej niż 1 ablację, odstęp czasu między pierwszym a ostatnim zabiegiem wynosił średnio 34,8 miesiąca (zakres 1–64 miesiące). W trakcie zabiegów u poszczególnych pacjentów obserwowano od 1 do ponad 4 różnych morfologii częstoskurczów (mediana 2,5). Średni cykl AT wynosił 334 ± 95 ms. U 6 pacjentów obszary istotnego uszkodzenia z amplitudą < 0,5 mV zajmowały 25–50% powierzchni prawego przedsionka, a u dwóch kolejnych osób, odpowiednio, 10–25% i < 10% jego powierzchni. Siedem ablacji było w pełni skuteczne (usunięto wszystkie AT — kliniczne i wywołane stymulacją), kolejne 7 ablacji było częściowo skuteczne (nie usunięto wszystkich arytmii, ale usunięto kliniczny AT), a 4 ablacje były nieskuteczne (nie usunięto klinicznego AT). Średnie czasy zabiegu, skopii rentgenowskiej i dostarczania energii o częstotliwości radiowej wynosiły odpowiednio: 176 ± 54,6; 13,7 ± 5,7 i 21,7 ± 11,9 minut. W obserwacji odległej, średnio 58,6 ± 46 (zakres 11–127) miesięcy po ostatniej ablacji, u 4 pacjentów nie stwierdzono arytmii. Mediana wskaźnika arytmicznego przed pierwszą ablacją wynosiła 8 punktów, a po ostatniej ablacji — 4,5 punktu (p < 0.05). Wnioski: Ablacja AT u pacjentów po operacji Fontana jest zabiegiem bezpiecznym, ale jej skuteczność bezpośrednia i odległa jest ograniczona. Wynika to z rozległego i złożonego substratu oraz trudnych warunków anatomicznych. Uzyskanie dobrych efektów może wymagać wykonania więcej niż jednej ablacji. Opanowanie arytmii przyczynia się do poprawy stanu klinicznego pacjentów.Background: Atrial tachyarrhythmias are a leading source of morbidity and mortality after Fontan-type procedures and antiarrhythmic drug therapy is often ineffective in these patients. Aim: To evaluate short- and long-term outcomes of radiofrequency current ablation for atrial tachycardia (AT) in patients after the Fontan procedure, and to report clinical, electrophysiological and electroanatomical characteristics of these arrhythmias. Methods: We retrospectively analysed data obtained in 8 patients (5 males, 3 females) after the Fontan procedure who underwent ablation for AT between 2002 and 2013. In order to compare the clinical impact of arrhythmia before and after ablation, we used the modified arrhythmia score, ranging from 0 (no arrhythmia activity) to 12 (very severe arrhythmia). In all patients, electroanatomical mapping using the CARTO system was performed, allowing semiquantification of low-voltage (< 0.5 mV) areas and scars. Results: Seven patients had an atriopulmonary connection and 1 patient had an extracardiac conduit. The mean patient age was 9.4 ± 3.1 years at the time of the Fontan procedure and 26.2 ± 4.6 years at the time of the first ablation. A total of 18 ablations were performed with no complications, 1 to 4 (median 2.5) procedures per patient. In patients who had more than 1 ablation, the mean time from the first to the last procedure was 34.8 months (range 1–64 months). In individual patients, 1 to 4 (median 2.5) different ATs were observed, with the mean tachycardia cycle length of 334 ± 95 ms. In 6 patients, low-voltage area (< 0.5 mV) comprised 25–50% of the right atrium, and in two others it comprised 10–25% and < 10% of the right atrium, respectively. Seven procedures were fully successful (ablation of all ATs), 7 were partially successful (ablation of only some AT, including clinical arrhythmia, but not of all ATs) and 4 were unsuccessful (failed ablation of clinical AT). The mean procedural, fluoroscopy and ablation times were 176 ± 54.6, 13.7 ± 5.7 and 21.7 ± 11.9 min, respectively. Freedom from arrhythmia during the mean follow-up of 58.6 ± 46 months (range 11–127 months) since the last procedure was obtained in 4 patients. The median arrhythmia score after the last ablation was significantly reduced compared to baseline (4.5 vs. 8; p < 0.05). Conclusions: Catheter ablation of AT in patients after the Fontan procedure is safe but its acute and long-term efficacy is limited. Due to complex and extensive substrate, along with complex anatomy, recurrences are frequent and patients may require repeat ablation procedures. Suppression of arrhythmia is associated with an improved clinical status of the patients

Management of hypertension in pregnancy — prevention, diagnosis, treatment and long-term prognosis. A position statement of the Polish Society of Hypertension, Polish Cardiac Society and Polish Society of Gynaecologists and Obstetricians

ADDITIONAL INFORMATION This article has been co‑published in Kardiologia Polska (doi:10.33963/KP.14904), Arterial Hypertension (doi:10.5603/AH.a2019.0011), and Ginekologia Polska (doi:10.5603/GP.2019.0074). The articles in Kardiologia Polska, Arterial Hypertension, and Ginekologia Polska are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Any citation can be used when citing this article