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However, malnutrition and starvation are difficult to assess clinically and in particular protein-calorie malnutrition can co-exist with chronic alcohol use and with inter-current acute or chronic illness, which may independently or in concert increase the risk of paracetamol toxicity and confound the assertion that malnutrition per se increases the risk of paracetamol toxicity [6, 16, 73, 78,79,80,81,82,83]