Biomedical subjects

Steven M Paul

Publications and source records attributed to Steven M Paul.

At least 37 records · Page 2Linked to original sources

PubMed2005

NF-(kappa)B mediates amyloid beta peptide-stimulated activity of the human apolipoprotein E gene promoter in human astroglial cells.

The apolipoprotein E gene (APOE) plays an important role in the pathogenesis of Alzheimer's disease (AD), and amyloid plaque comprised mostly of the amyloid-beta peptide (A(beta)) is one of the major hallmarks of AD. However, the relationship between these two important molecules is poorly understood. We examined how A(beta) treatment affects APOE expression in cultured cells and tested the role of the transcription factor NF-(kappa)B in APOE gene regulation. To delineate NF-(kappa)B's role, we have characterized a 1098 nucleotide (nt) segment containing the 5'-flanking region of the human APOE gene (-1054/+44, +1 transcription start site). Sequence analysis of this region suggests the presence of two potential NF-(kappa)B elements. To demonstrate promoter activity, the region was cloned upstream of a promoterless luciferase (reporter) gene. This segment was able to drive expression of luciferase in transient transfections of human fetal glial cells. Promoter activity was stimulated twofold by A(beta)(1-40) (25 microM, 24 h) treatment. Pretreatment with double-stranded DNA decoy oligonucleotides against NF-(kappa)B (2 microM) reduced A(beta) stimulation. Deletion and mutagenetic analyses demonstrated that the distal NF-(kappa)B element was functional and showed a strong DNA-protein complex band in gel shift analysis, similar to that from control NF-(kappa)B consensus element. An anti-inflammatory and anti-NF-(kappa)B drug, sodium salicylate, significantly blocked A(beta)-induced APOE promoter function. Our data provide evidence that upregulation of APOE by A(beta) in astroglial cells is mediated by an NF-(kappa)B-element present in the 5'-flanking region of the APOE gene.

Amyloid beta-Peptides↗

PubMed2005

The low density lipoprotein receptor regulates the level of central nervous system human and murine apolipoprotein E but does not modify amyloid plaque pathology in PDAPP mice.

Apolipoprotein E (apoE), a chaperone for the amyloid beta (Abeta) peptide, regulates the deposition and structure of Abeta that deposits in the brain in Alzheimer disease (AD). The primary apoE receptor that regulates levels of apoE in the brain is unknown. We report that the low density lipoprotein receptor (LDLR) regulates the cellular uptake and central nervous system levels of astrocyte-derived apoE. Cells lacking LDLR were unable to appreciably endocytose astrocyte-secreted apoE-containing lipoprotein particles. Moreover, cells overexpressing LDLR showed a dramatic increase in apoE endocytosis and degradation. We also found that LDLR knock-out (Ldlr-/-) mice had a significant, approximately 50% increase in the level of apoE in the cerebrospinal fluid and extracellular pools of the brain. However, when the PDAPP mouse model of AD was bred onto an Ldlr-/- background, we did not observe a significant change in brain Abeta levels either before or after the onset of Abeta deposition. Interestingly, human APOE3 or APOE4 (but not APOE2) knock-in mice bred on an Ldlr-/- background had a 210% and 380% increase, respectively, in the level of apoE in cerebrospinal fluid. These results demonstrate that central nervous system levels of both human and murine apoE are directly regulated by LDLR. Although the increase in murine apoE caused by LDLR deficiency was not sufficient to affect Abeta levels or deposition by 10 months of age in PDAPP mice, it remains a possibility that the increase in human apoE3 and apoE4 levels caused by LDLR deficiency will affect this process and could hold promise for therapeutic targets in AD.

Alzheimer Disease↗

PubMed2005

Effect of docosahexaenoic acid on lipoprotein subclasses in hyperlipidemic children (the EARLY study).

To test the hypothesis that a dietary omega-3 fatty acid, docosahexaenoic acid, improves the lipoprotein subclass profile of children who have hyperlipidemia, we conducted a randomized, double-blind, placebo-controlled study. Children who had hyperlipidemia (n = 20) were stabilized on a low-fat diet for 6 weeks and then randomized to receive 1.2 g/day of docosahexaenoic acid for 6 weeks or placebo. Supplementation with docosahexaenoic acid significantly increased low-density lipoprotein subclass 1 and high-density lipoprotein subclass 2 (large and buoyant; less atherogenic particles) by 91% and 14%, respectively, compared with the placebo phase. Low-density lipoprotein subclass 3 (small and dense; more atherogenic particles) decreased by 48%.

Adolescent↗

PubMed2005

Human apolipoprotein E4 alters the amyloid-beta 40:42 ratio and promotes the formation of cerebral amyloid angiopathy in an amyloid precursor protein transgenic model.

Alzheimer's disease (AD) is characterized by the aggregation and deposition of the normally soluble amyloid-beta (Abeta) peptide in the extracellular spaces of the brain as parenchymal plaques and in the walls of cerebral vessels as cerebral amyloid angiopathy (CAA). CAA is a common cause of brain hemorrhage and is found in most patients with AD. As in AD, the epsilon4 allele of the apolipoprotein E (apoE) gene (APOE) is a risk factor for CAA. To determine the effect of human apoE on CAA in vivo, we bred human APOE3 and APOE4 "knock-in" mice to a transgenic mouse model (Tg2576) that develops amyloid plaques as well as CAA. The expression of both human apoE isoforms resulted in a delay in Abeta deposition of several months relative to murine apoE. Tg2576 mice expressing the more fibrillogenic murine apoE develop parenchymal amyloid plaques and CAA by 9 months of age. At 15 months of age, the expression of human apoE4 led to substantial CAA with very few parenchymal plaques, whereas the expression of human apoE3 resulted in almost no CAA or parenchymal plaques. Additionally, young apoE4-expressing mice had an elevated ratio of Abeta 40:42 in brain extracellular pools and a lower 40:42 ratio in CSF, suggesting that apoE4 results in altered clearance and transport of Abeta species within different brain compartments. These findings demonstrate that, once Abeta fibrillogenesis occurs, apoE4 favors the formation of CAA over parenchymal plaques and suggest that molecules or treatments that increase the ratio of Abeta 40:42 may favor the formation of CAA versus parenchymal plaques.

Alkenes↗

PubMed2005

Exacerbation of cerebral amyloid angiopathy-associated microhemorrhage in amyloid precursor protein transgenic mice by immunotherapy is dependent on antibody recognition of deposited forms of amyloid beta.

Passive immunization with an antibody directed against the N terminus of amyloid beta (Abeta) has recently been reported to exacerbate cerebral amyloid angiopathy (CAA)-related microhemorrhage in a transgenic animal model. Although the mechanism responsible for the deleterious interaction is unclear, a direct binding event may be required. We characterized the binding properties of several monoclonal anti-Abeta antibodies to deposited Abeta in brain parenchyma and CAA. Biochemical analyses demonstrated that the 3D6 and 10D5, two N-terminally directed antibodies, bound with high affinity to deposited forms of Abeta, whereas 266, a central domain antibody, lacked affinity for deposited Abeta. To determine whether 266 or 3D6 would exacerbate CAA-associated microhemorrhage, we treated aged PDAPP mice with either antibody for 6 weeks. We observed an increase in both the incidence and severity of CAA-associated microhemorrhage when PDAPP transgenic mice were treated with the N-terminally directed 3D6 antibody, whereas mice treated with 266 were unaffected. These results may have important implications for future immune-based therapeutic strategies for Alzheimer's disease.

Aging↗

PubMed2005

Gene delivery of human apolipoprotein E alters brain Abeta burden in a mouse model of Alzheimer's disease.

Apolipoprotein E (apoE) alleles are important genetic risk factors for Alzheimer's disease (AD), with the epsilon4 allele increasing and the epsilon2 allele decreasing risk for developing AD. ApoE has been shown to influence brain amyloid-beta peptide (Abeta) and amyloid burden, both in humans and in transgenic mice. Here we show that direct intracerebral administration of lentiviral vectors expressing the three common human apoE isoforms differentially alters hippocampal Abeta and amyloid burden in the PDAPP mouse model of AD. Expression of apoE4 in the absence of mouse apoE increases hippocampal Abeta(1-42) levels and amyloid burden. By contrast, expression of apoE2, even in the presence of mouse apoE, markedly reduces hippocampal Abeta burden. Our data demonstrate rapid apoE isoform-dependent effects on brain Abeta burden in a mouse model of AD. Gene delivery of apoE2 may prevent or reduce brain Abeta burden and the subsequent development of neuritic plaques.

Alzheimer Disease↗

PubMed2005

Qualitative research contribution to a randomized clinical trial.

Qualitative research may be combined fruitfully with intervention studies, but few examples provide detailed methodological strategies for doing so. In this article, we describe the qualitative component of a randomized clinical trial (RCT) of the PRO-SELF(c) Pain Control Program, an intervention that provides individualized education, coaching, and support for cancer pain management. We conducted three qualitative analyses of verbatim transcripts of "real-time" audiotaped intervention sessions. As a result, we were better able to ascertain the nature of the individualized coaching component of the intervention, patient and family caregiver use of selected intervention tools, and reasons the intervention did not work for some patients. Study results were used to increase the specificity with which the coaching portion of the intervention is described in the intervention protocol.

Humans↗

PubMed2005

Categorizing the severity of cancer pain: further exploration of the establishment of cutpoints.

Previous work by Serlin and colleagues [Serlin R C, Mendoza T R, Nakamura Y, Edwards K R, Cleeland C S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84] established cutpoints for mild, moderate, and severe cancer pain based on the pain's level of interference with function. Recent work [Jensen M P, Smith D G, Ehde D M, Robinson L R. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22; Zelman D C, Hoffman D L, Seifeldin R, Dukes, E. Development of a metric for a day of manageable pain control: derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35-42]found differences in cutpoints for pain severity for different pain-related conditions. Reasons for these discrepancies may relate to the methods used to determine the cutpoints or to differences based on the type or the cause of the pain. The purposes of this study were to determine the optimal cutpoints for mild, moderate, and severe pain based on patients' ratings of average and worst pain severity, using a larger range of potential cutpoints, and to determine if those cutpoints distinguished among the three pain severity groups on several outcome measures. Results from a homogenous sample of oncology outpatients with pain from bone metastasis confirm a non-linear relationship between cancer pain severity and interference with function and also confirm that the boundary between a mild and a moderate level of cancer pain is at 4 on a 0-10 numeric rating scale. However, this analysis did not confirm the boundary between moderate and severe cancer pain previously described by Serlin and colleagues [Serlin R C, Mendoza T R, Nakamura Y, Edwards K R, Cleeland C S. When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain 1995;61:277-84]. In addition, these results were not consistent with the cutpoints that were found for back pain, phantom limb pain, pain 'in general', or osteoarthritis pain reported by Jensen and colleagues and Zelman and colleagues [Jensen M P, Smith D G, Ehde D M, Robinson L R. Pain site and the effects of amputation pain: further clarification of the meaning of mild, moderate, and severe pain. Pain 2001;91:317-22; Zelman D C, Hoffman D L, Seifeldin R, Dukes, E. Development of a metric for a day of manageable pain control: derivation of pain severity cutpoints for low back pain and osteoarthritis. Pain 2003;106(1/2):35-42]. Possible explanations for these differences are discussed, as well as implications for future research.

Activities of Daily Living↗

PubMed2005

Time-contingent dosing of an opioid analgesic after tonsillectomy does not increase moderate-to-severe side effects in children.

As part of a randomized clinical trial that compared three different analgesic dosing regimens ( Sutters et al., 2004 ), the purpose of this study, in children who underwent tonsillectomy, was to determine whether around-the-clock (ATC) dosing of acetaminophen with codeine, compared with as-needed (PRN) dosing, increased the frequency of moderate-to-severe opioid-related side effects (i.e., daytime sedation, lightheadedness, nightmares, nausea, vomiting, and constipation) in the first 3 days after surgery. Because no differences were found in pain intensity scores and in the amount of analgesic administered between the two ATC groups (i.e., with and without coaching), for these analyses, the two groups were combined ( n = 52) and compared with the PRN group ( n = 28). Each side effect was recoded into a dichotomous response (i.e., 0 = did not have symptoms or had slight symptoms; 1 = symptoms that were moderate, severe, or very severe) to provide an adequate sample size in each cell for the statistical analyses. No differences were found in the frequency of moderate-to-severe side effects between the ATC and PRN groups at any of the postoperative assessments. The number of children who reported moderate-to-severe daytime sedation decreased over time in both the PRN ( p = .02) and ATC groups ( p = .01). Children in the ATC groups reported a statistically significant decrease over time in vomiting ( p = .001) and feeling lightheaded or dizzy ( p = .003), and a significant increase in constipation ( p = .018). Except for daytime sedation, changes, over time, in the frequency of moderate-to-severe side effects were not observed in the PRN group.

Acetaminophen↗

PubMed2005

Minocycline blocks bilirubin neurotoxicity and prevents hyperbilirubinemia-induced cerebellar hypoplasia in the Gunn rat.

Encephalopathy induced by hyperbilirubinemia in infants has been described in the medical literature for over a century but neither the cellular nor molecular mechanisms underlying bilirubin neurotoxicity are well understood. In this study, we have demonstrated that minocycline potently protects primary cultured rat cerebellar granule neurons against bilirubin neurotoxicity (IC50 approximately 2 microm) and almost completely blocks cerebellar hypoplasia and the profound loss of Purkinje and granule neurons observed in homozygous Gunn rats, a genetic model of hyperbilirubinemia-induced neurotoxicity. Minocycline-treated newborn Gunn rats had nearly equivalent numbers of viable Purkinje and granule neurons in the cerebellum as did control animals. Moreover, minocycline inhibits the bilirubin-induced phosphorylation of p38 mitogen-activated protein kinase both in vivo as well as in vitro. Taken together our data demonstrate that minocycline is able to greatly reduce bilirubin-induced neurotoxicity and suggest that minocycline's neuroprotective effects may be due in part to an inhibition of p38 mitogen-activated protein kinase activity. Our findings may lead to novel approaches for treating bilirubin-induced encephalopathy.

Animals↗

PubMed2005

Anti-Abeta antibody treatment promotes the rapid recovery of amyloid-associated neuritic dystrophy in PDAPP transgenic mice.

Neuritic plaques are a defining feature of Alzheimer disease (AD) pathology. These structures are composed of extracellular accumulations of amyloid-beta peptide (Abeta) and other plaque-associated proteins, surrounded by large, swollen axons and dendrites (dystrophic neurites) and activated glia. Dystrophic neurites are thought to disrupt neuronal function, but whether this damage is static, dynamic, or reversible is unknown. To address this, we monitored neuritic plaques in the brains of living PDAPP;Thy-1:YFP transgenic mice, a model that develops AD-like pathology and also stably expresses yellow fluorescent protein (YFP) in a subset of neurons in the brain. Using multiphoton microscopy, we observed and monitored amyloid through cranial windows in PDAPP;Thy-1:YFP double-transgenic mice using the in vivo amyloid-imaging fluorophore methoxy-X04, and individual YFP-labeled dystrophic neurites by their inherent fluorescence. In vivo studies using this system suggest that amyloid-associated dystrophic neurites are relatively stable structures in PDAPP;Thy-1:YFP transgenic mice over several days. However, a significant reduction in the number and size of dystrophic neurites was seen 3 days after Abeta deposits were cleared by anti-Abeta antibody treatment. This analysis suggests that ongoing axonal and dendritic damage is secondary to Abeta and is, in part, rapidly reversible.

Alzheimer Disease↗

PubMed2004

Use of multimetric statistical analysis to characterize and discriminate between the performance of four Alzheimer's transgenic mouse lines differing in Abeta deposition.

Behavioral assessment of genetically-manipulated mouse lines for Alzheimer's disease has become an important index for determining the efficacy of therapeutic interventions and examining disease pathogenesis. However, the potential for higher level statistical analyses to assist in these goals remains largely unexplored. The present study thus involved multimetric statistical analyses of behavioral and beta-amyloid (Abeta) deposition measures from four PDAPP-derived transgenic mouse lines that differ in extent of Abeta deposition. For all four lines, multiple behavioral measures obtained from a comprehensive task battery administered at 15-16 months of age were collectively examined by correlation, factor, and discriminant function analyses. In addition, both compact and total beta-amyloid (Abeta) histologic measures were determined from the same animals. Widespread intra- and inter-task correlations were evident, with impairment in all three water tasks (Morris maze, platform recognition, and radial arm water maze) correlating extensively with Abeta deposition in hippocampus and cerebral cortex. By elucidating the underlying relationships among measures, factor analysis revealed a single primary factor (Factor 1) that loaded most cognitive measures, particularly those for working memory and recognition. Abeta deposition measures loaded exclusively on this primary factor. In individual animals, only factor scores derived from this primary factor were correlated with Abeta deposition. Both of these findings again underscore the association between cognitive impairment and Abeta deposition. Finally, discriminant function analysis (step-wise forward method) was able to distinguish between all four AD transgenic lines based on behavioral performance alone, as well as when Abeta deposition measures were included. Our results demonstrate the utility of higher level, multimetric analysis of behavioral measures from AD transgenic mice. Analyses such as these will be very beneficial for the functional evaluation of therapeutic interventions against AD and for finding behavioral measures that can serve as predictors of pathology.

Alzheimer Disease↗

PubMed2004

Apolipoprotein E promotes astrocyte colocalization and degradation of deposited amyloid-beta peptides.

We have previously shown that apolipoprotein E (Apoe) promotes the formation of amyloid in brain and that astrocyte-specific expression of APOE markedly affects the deposition of amyloid-beta peptides (Abeta) in a mouse model of Alzheimer disease. Given the capacity of astrocytes to degrade Abeta, we investigated the potential role of Apoe in this astrocyte-mediated degradation. In contrast to cultured adult wild-type mouse astrocytes, adult Apoe(-/-) astrocytes do not degrade Abeta present in Abeta plaque-bearing brain sections in vitro. Coincubation with antibodies to either Apoe or Abeta, or with RAP, an antagonist of the low-density lipoprotein receptor family, effectively blocks Abeta degradation by astrocytes. Phase-contrast and confocal microscopy show that Apoe(-/-) astrocytes do not respond to or internalize Abeta deposits to the same extent as do wild-type astrocytes. Thus, Apoe seems to be important in the degradation and clearance of deposited Abeta species by astrocytes, a process that may be impaired in Alzheimer disease.

Amyloid beta-Peptides↗

PubMed2004

Randomized clinical trial of the effectiveness of a self-care intervention to improve cancer pain management.

PURPOSE: This randomized clinical trial tested the effectiveness of the PRO-SELF Pain Control Program compared with standard care in decreasing pain intensity scores, increasing appropriate analgesic prescriptions, and increasing analgesic intake in oncology outpatients with pain from bone metastasis. PATIENTS AND METHODS: Patients were randomly assigned to the PRO-SELF intervention (n = 93) or standard care (n = 81). Patients in the standard care arm were seen by a research nurse three times and were called three times by phone between the home visits. PRO-SELF group patients were seen by specially trained intervention nurses and received a psychoeducational intervention, were taught how to use a pillbox, and were given written instructions on how to communicate with their physician about unrelieved pain and the need for changes in their analgesic prescriptions. Patients were coached during two follow-up home visits and three phone calls on how to improve their cancer pain management. RESULTS: Pain intensity scores decreased significantly from baseline (all P <.0001) in the PRO-SELF group (ie, least pain, 28.4%; average pain, 32.5%; and worst pain, 27.0%) compared with the standard care group (ie, least increased by 14.6%, average increased by 1.9%, and worst decreased by 1.2%). The percentage of patients in the PRO-SELF group with the most appropriate type of analgesic prescription increased significantly from 28.3% to 37.0% (P =.008) compared with a change from 29.6% to 32.5% in the standard care group. CONCLUSION: The use of a psychoeducational intervention that incorporates nurse coaching within the framework of self-care can improve the management of cancer pain.

Aged↗

PubMed2004

ApoE and clusterin cooperatively suppress Abeta levels and deposition: evidence that ApoE regulates extracellular Abeta metabolism in vivo.

Apolipoprotein E (apoE) and clusterin can influence structure, toxicity, and accumulation of the amyloid-beta (Abeta) peptide in brain. Both molecules may also be involved in Abeta metabolism prior to its deposition. To assess this possibility, we compared PDAPP transgenic mice that develop age-dependent Abeta accumulation in the absence of apoE or clusterin as well as in the absence of both proteins. apoE(-/-) and clusterin(-/-) mice accumulated similar Abeta levels but much less fibrillar Abeta. In contrast, apoE(-/-)/clusterin(-/-) mice had both earlier onset and markedly increased Abeta and amyloid deposition. Both apoE(-/-) and apoE(-/-)/clusterin(-/-) mice had elevated CSF and brain interstitial fluid Abeta, as well as significant differences in the elimination half-life of interstitial fluid Abeta measured by in vivo microdialysis. These findings demonstrate additive effects of apoE and clusterin on influencing Abeta deposition and that apoE plays an important role in regulating extracellular CNS Abeta metabolism independent of Abeta synthesis.

Amyloid beta-Peptides↗

PubMed2004

Increased soluble amyloid-beta peptide and memory deficits in amyloid model mice overexpressing the low-density lipoprotein receptor-related protein.

Amyloid-beta peptide (Abeta) is central to the pathogenesis of Alzheimer's disease, and the low-density lipoprotein receptor-related protein (LRP) has been shown to alter Abeta metabolism in vitro. Here, we show that overexpression of a functional LRP minireceptor in the brain of PDAPP mice results in age-dependent increase of soluble brain Abeta, with no changes in Abeta plaque burden. Importantly, soluble brain Abeta was found to be primarily in the form of monomers/dimers and to be highly correlated with deficits in spatial learning and memory. These results provide in vivo evidence that LRP may contribute to memory deficits typical of Alzheimer's disease by modulating the pool of small soluble forms of Abeta.

Amyloid beta-Peptides↗

PubMed2004

Cognitive impairment in PDAPP mice depends on ApoE and ACT-catalyzed amyloid formation.

Biochemical and genetic studies indicate that the inflammatory proteins, apolipoprotein E (ApoE) and alpha(1)-antichymotrypsin (ACT) are important in the pathogenesis of Alzheimer's disease (AD). Using several lines of multiply transgenic/knockout mice we show here that murine ApoE and human ACT separately and synergistically facilitate both diffuse A beta immunoreactive and fibrillar amyloid deposition and thus also promote cognitive impairment in aged PDAPP(V717F) mice. The degree of cognitive impairment is highly correlated with the ApoE- and ACT-dependent hippocampal amyloid burden, with PDAPP mice lacking ApoE and ACT having little amyloid and little learning disability. A analysis of young mice before the onset of amyloid formation shows that steady-state levels of monomeric A beta peptide are unchanged by ApoE or ACT. These data suggest that the process or product of amyloid formation is more critical than monomeric A beta for the neurological decline in AD, and that the risk factors ApoE and ACT participate primarily in disease processes downstream of APP processing.

Aging↗

PubMed2004

A randomized clinical trial of the effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in children following tonsillectomy.

The purpose of this study was to determine whether around-the-clock (i.e. ATC) dosing of acetaminophen with codeine, with or without nurse coaching, compared to standard care with as needed (i.e. PRN) dosing: reduced children's reports of pain intensity with and without swallowing; increased pain relief, and increased analgesic consumption. Eighty children, 6-15 years, undergoing tonsillectomy were randomized to one of three treatment groups to receive acetaminophen with codeine (120 mg/12 mg/5 ml) for 3 days after surgery: PRN group (N = 28)-every 4 h PRN, with standard postoperative instructions, without nurse coaching; ATC group (N = 26)-every 4 h ATC, with standard postoperative instructions, without nurse coaching; and ATC+coaching group (N = 26)-every 4 h ATC, with standard postoperative instructions and nurse coaching. In all three groups, significant decreases were found over time in pain intensity scores at rest (P < 0.001) and with swallowing (P < 0.001). However, mean pain scores at rest and with swallowing were >3/10 until the fourth evening after tonsillectomy. Children in both ATC dosing groups received significantly greater amounts of acetaminophen and codeine than children in the PRN group (P < 0.003). No significant differences were found in the amount of analgesic administered between the ATC dosing groups with and without nurse coaching. No significant differences were found in the amount of nausea and vomiting among the three groups. Scheduled dosing of acetaminophen with codeine did not provide adequate pain relief for children following tonsillectomy. Nurse coaching does not increase parent's adherence with an ATC dosing schedule.

Acetaminophen↗