Aggressive Supportive Care Research Articles

LDH and NLR, as inflammatory markers, the independent risk factors for COVID-19 complicated with respiratory failure in elderly patients.

Lactate dehydrogenase (LDH) is an enzyme that is responsible for the production of lactic acid, which is a necessary byproduct when the body does not have enough oxygen. LDH levels in the blood can be used as a marker to predict mortality in patients with ARDS, severe COVID-19, and cancer. To analyze the clinical characteristics of COVID-19 in the elderly and the correlation between LDH and respiratory failure in COVID-19 patients, to improve the identification and management of this type of pneumonia by clinicians. This was a single-center retrospective study. We performed routine laboratory tests in 105 COVID-19 patients admitted to the affiliated hospital of Qingdao University (Qingdao, China) from October 1, 2022 to February 1, 2023. The diagnosis of respiratory failure was established based on the results of blood gas analysis upon admission. The median age was 79 years. Among all univariable parameters, LDH, neutrophil to lymphocyte ratio (NLR) and Prothrombin Time (PT) were significantly independent risk factors of RF in elderly COVID-19 patients. LDH (AUC=0.829) also had a maximum specificity (96.5%), with the cutoff value of 280.5. The levels of LDH, NLR, and PT may serve as potential indicators for elderly COVID-19 patients combined with respiratory failure. LDH, NLR and PT assays can be beneficial for patients who need closer respiratory monitoring and more aggressive supportive care to prevent a negative prognosis.

Management of serotonin syndrome (toxicity)

Serotonin syndrome (toxicity), resulting from an excessive accumulation of serotonin in the central nervous system, it can occur due to various factors such as the initiation of medication, overdose or drug interactions. Diagnosing serotonin toxicity presents challenges as there are no definitive criteria. This review delves into the pathophysiology, incidence, clinical assessment and management of serotonin toxicity, stressing the significance of promptly recognizing and managing severe cases. Diagnosis relies primarily relies on clinical assessment due to the absence of specific laboratory tests. The Hunter Serotonin Toxicity criteria are commonly utilized but have only been validated in the overdose setting. Assessing the severity of toxicity is crucial for guiding management decisions. Supportive care, discontinuation of causative agents and symptomatic treatment are prioritized in management. Mild toxicity often requires withdrawal or reduction of the serotonergic agent, while more severe toxicity requires more aggressive resuscitative and supportive care. Severe serotonin toxicity characterized by hyperthermia and rigidity requires aggressive supportive measures, including benzodiazepines, intubation, paralysis and active cooling. Animal studies suggest potential benefits of 5-HT2A receptor antagonists in preventing hyperthermia and fatalities, but only at high doses. Their clinical effectiveness remains uncertain, and evidence is predominately from case series and case reports. Although commonly used, serotonin antagonists like cyproheptadine lack conclusive evidence of efficacy. Other serotonin antagonists such as chlorpromazine and olanzapine have been explored but evidence is limited to case reports. Hence, the cornerstone of treating severe cases does not lie in 'antidote' administration or even diagnosis but in effective early resuscitative and supportive care.

#1304 Clinical characteristics of acute kidney injury caused by Phytolaccaceae ingestion

Abstract Background and Aims Phytolaccaceae is a poisonous plant that is associated with cardiac and gastrointestinal toxicity. However, there are limited data about acute kidney injury (AKI) in patients with Phytolaccaceae ingestion. We conducted this study to investigate the clinical characteristics of AKI by Phytolaccaceae overdose. Method From 2010 to 2022, 15 patients with Phytolaccaceae ingestion were enrolled in this study. The incidence, clinical characteristics, and severity of AKI were compared between AKI (N=8) and non-AKI (N=7) groups according to the RIFLE classification. Results Of the 15 patients, 8 patients experienced AKI during hospitalization period. There is no difference in age (54.3 ± 7.2 years vs. 67.1 ± 13.5 years, P=0.057) and comorbidities such as hypertension and diabetes (37.5% vs 28.5%, P=0.563) between two groups. In addition, there is also no difference in total leukocyte count (10.8 × 103/mL vs. 11.4 × 103/mL, P=0.84) and serum albumin level (4.5 ± 2.6 vs 4.3 ± 0.5, P=0.498). Compared to patients without AKI, the estimated glomerular filtration rate was lower in the AKI group (57 ± 12 ml/min/1.73 m2 vs. 77 ± 24 ml/min/1.73 m2, p<0.05) on admission. The AKI group had a significantly longer hospital stay (9.7 ± 6.2 vs 6.1 ± 3.1 days, p<0.001). The overall AKI incidence was 61.5%, of which 46.1% and 15.4% cases were classified as risk and injury, respectively. All patients recovered baseline renal function without renal replacement therapy following antibiotics therapy and supportive care. Conclusion The incidence of AKI in patient with Phytolaccaceae ingestion is 61.5%. Most patients with AKI had a mild type of AKI during admission period. In cases of AKI patients with Phytolaccaceae ingestion, aggressive supportive care including hydration is very important.

Carbon monoxide as a cellular protective agent in a swine model of cardiac arrest protocol.

Out-of-hospital cardiac arrest (OHCA) affects over 360,000 adults in the United States each year with a 50-80% mortality prior to reaching medical care. Despite aggressive supportive care and targeted temperature management (TTM), half of adults do not live to hospital discharge and nearly one-third of survivors have significant neurologic injury. The current treatment approach following cardiac arrest resuscitation consists primarily of supportive care and possible TTM. While these current treatments are commonly used, mortality remains high, and survivors often develop lasting neurologic and cardiac sequela well after resuscitation. Hence, there is a critical need for further therapeutic development of adjunctive therapies. While select therapeutics have been experimentally investigated, one promising agent that has shown benefit is CO. While CO has traditionally been thought of as a cellular poison, there is both experimental and clinical evidence that demonstrate benefit and safety in ischemia with lower doses related to improved cardiac/neurologic outcomes. While CO is well known for its poisonous effects, CO is a generated physiologically in cells through the breakdown of heme oxygenase (HO) enzymes and has potent antioxidant and anti-inflammatory activities. While CO has been studied in myocardial infarction itself, the role of CO in cardiac arrest and post-arrest care as a therapeutic is less defined. Currently, the standard of care for post-arrest patients consists primarily of supportive care and TTM. Despite current standard of care, the neurological prognosis following cardiac arrest and return of spontaneous circulation (ROSC) remains poor with patients often left with severe disability due to brain injury primarily affecting the cortex and hippocampus. Thus, investigations of novel therapies to mitigate post-arrest injury are clearly warranted. The primary objective of this proposed study is to combine our expertise in swine models of CO and cardiac arrest for future investigations on the cellular protective effects of low dose CO. We will combine our innovative multi-modal diagnostic platform to assess cerebral metabolism and changes in mitochondrial function in swine that undergo cardiac arrest with therapeutic application of CO.

Diagnosis of Cystic Fibrosis Beyond Childhood in India

Abstract Cystic fibrosis (CF) is a life-limiting genetic condition with multisystemic manifestations. However, there are vast phenotypic as well as genotypic variations. This contributes to delay in diagnosis, especially in pancreatic-sufficient patients who may not manifest typical symptomatology. The last decade has witnessed significant breakthroughs in CF therapeutics. This in combination with early diagnosis through newborn screening, and aggressive supportive care can offer near-normal life expectancy for a majority of patients with CF (pwCF) worldwide. Even while addressing disparities in CF care around the world, it is crucial to train medical professionals to suspect and diagnose CF in children as well as in adults. Here, we share our experience of pwCF diagnosed beyond 16 years of age with an aim to highlight the clinical presentations in young adults, the need for screening family members of a newly diagnosed pwCF, and the negative effects of late diagnosis of CF.

Successful management of malignant hyperthermia without dantrolene – A case report

Malignant hyperthermia (MH) is a rare inherited genetic disorder implicated in a life-threatening catastrophic event under general anaesthesia. In India, the total number of reported cases are of the magnitude of single digit due to lack of reporting. The mortality of MH is dramatically decreased from 70-80% to less than 5%, due to an introduction of dantrolene sodium for treatment of MH, early detection of MH episode using capnography, and the introduction of diagnostic testing for MH.In India, there is enormous dependence on clinical grading scale rather than halothane caffeine contraction test due to the lack of availability of accredited testing facilities. In addition to this, the drug of choice dantrolene, is not readily available everywhere in India. The scarcity of quintessential monitoring techniques cannot be ignored in peripheral areas. Despite these limitations many reported cases have survived with vigilant monitoring, prompt diagnosis and aggressive supportive care.

Management of Systemic Inflammatory Response Syndrome (SIRS) and Evaluation of Survival Rate in Cats Exposed to Trauma

Background: Systemic inflammatory response syndrome (SIRS) is a complex condition that may be associated with sepsis or may progress with trauma, burns, and major surgery. The aim of this study was to evaluate the systemic inflammatory response syndrome and survival rate in traumatized cats. Methods: The study material consisted of 34(22.66%) cats diagnosed with SIRS among 150 cats who were traumatized by falling from a height. Cats were monitored and vital signs such as pulse, respiration, arterial blood pressure, oxygen saturation and body temperature were recorded. In addition, laboratory whole blood and biochemical tests were performed. In the treatment of cats with SIRS, it was aimed to provide circulatory support and support measures to keep the animal alive. Result: 27(79.41%) cats with SIRS died due to lung failure or multi-organ failure and 7(20.58%) cats survived. The prognosis in SIRS patients with trauma depends on the patient’s response to aggressive treatment and supportive care. SIRS has a high mortality rate. Common causes of death include cardiovascular collapse, multi-organ dysfunction and acute lung injury.

Association of intensifying supportive care with improved survival in patients with gastric cancer with malignant ascites.

294 Background: Gastric cancer patients with malignant ascites often have poor functional status and malnutrition that precludes receipt of systemic therapies. Thus, these patients have a very poor prognosis. Beginning in 2019, our multidisciplinary gastric cancer disease-oriented team implemented a more aggressive supportive care plan for gastric cancer patients with malignant ascites. The initiative included measures such as supplemental enteral nutrition, ascites drainage, and initiation of chemotherapy on an inpatient basis. We compared outcomes for gastric cancer patients who presented with synchronous malignant ascites treated before and after the implementation of the care plan. Methods: We performed a retrospective review of our institutional database to identify patients diagnosed with gastric adenocarcinoma and synchronous malignant ascites between 2010-2022. We compared survival between patients diagnosed from 2010-2018, which will be referred to as the historical control era and patients diagnosed from 2019-2022, which will be called the aggressive supportive care era. Results: 54 patients were included in our analysis; 31 patients were treated in the historical control time frame and 23 patients treated during the aggressive supportive care era. Demographic, clinical, and pathologic characteristics were similar between groups. 3% of historical controls received supplemental tube feeds at diagnosis as compared to 30% of the aggressive supportive care cohort (p=0.008). 3% of historical controls received their first cycle of chemotherapy in the inpatient setting versus 39% of patients treated during the aggressive supportive care era (p=0.001). The median number of chemotherapy cycles received was 5 among historical controls and 9.5 among aggressive supportive care era patients (p = 0.02). There was no difference in the number of days spent as an inpatient between the two groups. The median overall survival for historical control patients was 5.4 months as compared to 10.4 months for patients treated during aggressive supportive care era (p=0.035). Conclusions: Gastric cancer patients with synchronous malignant ascites treated during a timeframe when our multidisciplinary team implemented more aggressive supportive care measures had improved OS as compared to historic controls.Our results suggest that aggressive supportive measures for these patients with highly challenging clinical issues and poor prognosis can prolong survival. Specifically, initiation of chemotherapy in the inpatient setting and supplemental nutrition should be considered for patients at high risk for treatment intolerance.

Intensifying supportive care is associated with improved survival in gastric cancer patients with malignant ascites.

Gastric cancer patients with malignant ascites often have poor functional status and malnutrition that preclude receipt of systemic therapies. Thus, these patients have a very poor prognosis. Beginning in 2019, our multidisciplinary gastric cancer disease-oriented team implemented a more aggressive supportive care plan for gastric cancer patients with malignant ascites. The initiative included measures such as supplemental enteral nutrition, ascites drainage, and initiation of chemotherapy on an inpatient basis. We compared outcomes for gastric cancer patients who presented with synchronous malignant ascites treated before and after the implementation of the care plan. We performed a retrospective review of our institutional database to identify patients diagnosed with gastric adenocarcinoma and synchronous malignant ascites between 2010 and 2022. We compared overall survival (OS) between patients diagnosed from 2010 to 2018, which will be referred to as the historical control era and patients diagnosed from 2019 to 2022, which will be called the aggressive supportive care era. Fifty-four patients were included in our analysis; 31 patients were treated in the historical control time frame, and 23 patients were treated during the aggressive supportive care era. Demographic, clinical, and pathologic characteristics were similar between groups. 3% of historical controls received supplemental tube feeds at diagnosis as compared to 30% of the aggressive supportive care cohort (p < 0.01). 3% of historical controls received their first cycle of chemotherapy in the inpatient setting versus 39% of patients treated during the aggressive supportive care era (p < 0.01). The median number of chemotherapy cycles received was 5 among historical controls and 9.5 among aggressive supportive care era patients (p = 0.02). There was no difference in the number of days spent as an inpatient between the two groups. The median OS for historical control patients was 5.4 months as compared with 10.4 months for patients treated during aggressive supportive care era (p = 0.04). Gastric cancer patients with synchronous malignant ascites treated during a timeframe when our multidisciplinary team implemented more aggressive supportive care measures had improved OS as compared with historic controls. Our results suggest that aggressive supportive measures for these patients with highly challenging clinical issues and poor prognosis can prolong survival. Specifically, initiation of chemotherapy in the inpatient setting and supplemental nutrition should be considered for patients at high risk for treatment intolerance.

Unveiling the Digital Landscape of CAR-T Therapies in Multiple Myeloma Using Social Media Insights

Introduction: The rapid evolution of novel chimeric antigen receptor T-cell (CAR-T) therapies, including Carvykti (ciltacabtagene autoleucel) and Abecma (idecabtagene vicleucel), have revolutionized the treatment landscape for multiple myeloma (MM) patients. These cutting-edge therapies have demonstrated remarkable efficacy in clinical trials, representing a significant advancement in the field. However, their real-world impact on patient and physician experiences, and perceptions remain important topics of ongoing investigation. In recent years, social media platforms have emerged as valuable sources of real-time data and patient perspectives, providing an unprecedented opportunity for researchers to gain insights into physician and patient perceptions around these emerging CAR-T therapies. This study aims to perform a comprehensive digital analysis to measure sentiment expression by different health care stakeholders and to identify health information needs related to MM CAR-T therapies. Methods: This digital analysis utilized publicly available data related to CAR-T therapies approved for the treatment of relapsed or refractory MM from various online sources related to CAR-T therapies. The data was captured using the web indexing tool Talkwalker. The analysis covered the time period from May 21, 2021 to May 21, 2023. Quantitative analysis involved applying filters and Boolean search terms to segment the data and generate figures such as share of voice, language and media type distribution, and treatment and MM mentions over time. Additionally, a qualitative assessment was conducted by reviewing posts related to the key topics of interest. Individuals who self-identify as healthcare professionals (HCPs) based on their bio, social media name, byline in news articles, or other indications were included in stakeholder analysis. Results: Out of the 471.5K MM posts generated over the 2-year study period, 47,909 posts (10%) were about CAR-T therapy, and 13,117 posts specifically commented on either Carvykti (55%) or Abecma (45%). In terms of specialty, hematologists were the primary contributors (47%), followed by oncologists (16%) and pharmacists (6%). CAR-T therapy was most referenced in posts discussing efficacy, safety, duration, and time to cytokine release syndrome (CRS), with a higher number of posts mentioning Carvykti (57%) compared to Abecma (43%). The most prominent key themes of pressing challenges and needs mentioned among CAR-T therapy posts were cost (60.5%), post-CAR-T care (38.6%), access (37.5%), education (6.7%), and quality of life (6.4%). Both Carvykti and Abecma were frequently mentioned alongside access and cost, although access (60%) was more prominent with Carvykti and cost (61%) with Abecma. Among HCPs, the most significant key theme of pressing challenges and needs was post-CAR-T infusion care considerations (58.6%), such as extended hospital stays to manage immune-mediated toxicities such as CRS and neurotoxicity, the risk of cytopenia and infections, and strategies to mitigate these risks. Management strategies mentioned included earlier and more aggressive supportive care, the use of cytokine-targeting therapies such as tocilizumab for any grade CRS, steroids such as dexamethasone for immune effector cell-associated neurotoxicity syndrome, and prophylactic antiseizure medications for all patients regardless of neurotoxicity. In the category of Diversity, Equity, &amp; Inclusion, both Carvykti and Abecma were mentioned similarly on various topics, including access to CAR-T therapies (87% vs. 74%), diversity in clinical trials (19% vs. 17%), geographic location implications (9% vs. 15%), and racial disparities (3% vs. 4%). Conclusions: The study findings highlight the importance of demystifying cost perceptions against the added value to patients, HCPs and payers, and implementing comprehensive post-CAR-T care protocols aligned with the concerns expressed in social media discussions for improvement in CAR-T therapies for multiple myeloma. By leveraging the power of social media data, this study offers valuable real-world insights that can inform clinical decision-making, enhance patient-centered care, and contribute to the development of strategies to overcome challenges associated with CAR-T therapies in multiple myeloma.

Review Article] Review of Streptococcus pyogenes

_Streptococcus pyogenes_, commonly known as group A _Streptococcus_ (GAS), is a bacterium that causes a wide range of clinical diseases. Its ability to cause superficial, invasive, and even life-threatening infections makes it an important pathogen that requires prompt diagnosis and treatment. It is a Gram-positive bacterium. These infections involve the bloodstream and can lead to sepsis, toxic shock syndrome, pneumonia, and necrotizing fasciitis. These infections require immediate medical attention and treatment with high doses of antibiotics and aggressive supportive care. _S. pyogenes_ is a bacterium that causes a wide range of clinical diseases. Its ability to cause superficial, invasive, and even life-threatening infections makes it an important pathogen that requires prompt diagnosis and treatment. With the appropriate use of antibiotics and appropriate infection control measures, the incidence of _S. pyogenes_ infections can be significantly reduced. The main objectives of this review are to know the causes of _Streptococcus pyogenes_.

Review Article] Review of Streptococcus pyogenes

_Streptococcus pyogenes_, commonly known as group A _Streptococcus_ (GAS), is a bacterium that causes a wide range of clinical diseases. Its ability to cause superficial, invasive, and even life-threatening infections makes it an important pathogen that requires prompt diagnosis and treatment. It is a Gram-positive bacterium. These infections involve the bloodstream and can lead to sepsis, toxic shock syndrome, pneumonia, and necrotizing fasciitis. These infections require immediate medical attention and treatment with high doses of antibiotics and aggressive supportive care. _S. pyogenes_ is a bacterium that causes a wide range of clinical diseases. Its ability to cause superficial, invasive, and even life-threatening infections makes it an important pathogen that requires prompt diagnosis and treatment. With the appropriate use of antibiotics and appropriate infection control measures, the incidence of _S. pyogenes_ infections can be significantly reduced. The main objectives of this review are to know the causes of _Streptococcus pyogenes_.

Improving Prediction of Early Death in Acute Promyelocytic Leukemia: External Validation Study from Italian Single Center Experience

Background: Despite significant advancements in treatment efficacy of acute promyelocytic leukemia (APL), early death (ED) - mainly related to major hemorrhagic and thrombotic events occurring within 30 days from diagnosis - remains a prominent hurdle to therapeutic success. In this regard, Österroos et al. very recently developed a score which stratifies the risk of ED of patients (pts) with APL in three categories (low [score 0-2], high [score 3-4], very high [score 5-7]) according to age (&amp;lt;50 years, 50-59 years, 60-69 years and ≥70 years), white blood cell count (&amp;lt;3.0x10 9/L, 3.0-5.0x10 9/L and &amp;gt;5.0x10 9/L), and platelet count (≥30x10 9/L and &amp;lt;30x10 9/L), all of which are readily available, real-world variables. However, the presence of specific comorbidities, or diseases characteristics, such as the presence of FLT3-ITD mutation, CD2 expression and bcr3 PML::RARA transcript were not evaluated, even if they could potentially further improve the risk stratification ( Österroos et al. Haematologica 2022;107(7):1528-1537). Aims: The aims of this study were to integrate the score proposed by Österroos et al. and evaluate the role of pts comorbidities and disease biological data in modifying risk stratification. Methods: Data were retrospectively collected from 127 consecutive pts diagnosed at our Center from January 2000 to May 2023. Patients had been treated according to the AIDA protocol (n = 76, 60%) or with the combination of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO) (n = 39, 31%) ( Lo-Coco et al. N Engl J Med 2013;369:111-121); 10 pts received ATRA; only 2 pts did not receive any treatment. Results: Table 1 summarizes the main clinical characteristics of the 127 pts included in this study. Overall, ED rate was 11% (n = 14, 12 died within 7 days from diagnosis); the cause of death was a hemorrhagic event in 11 pts. The score identified low- (n = 79, 64%), high- (n = 39, 31%) and very high-risk (n = 6, 5%) categories; ED rates for each category were 3.8%, 20.5% and 0%, respectively. Despite no ED events were registered in our small very-high risk cohort (n = 6), a third of these pts (n = 2) experienced cerebral hemorrhage at disease onset and eventually survived. We confirmed that the score proposed by Österroos et al. was better at predicting ED risk than the Sanz score, with the Area Under the Receiver Operating Characteristic (AUROC) curve of 0.73 (95% CI 0.60-0.87) vs 0.66 (95% CI 0.51-0.81). The AUROC of the reference study cohort was 0.77 (95% CI 0.72-0.83). The presence of specific biological characteristics of the disease, such as FLT3-ITD mutation, bcr3 PML::RARA transcript or CD2 expression were not associated with an increased risk of ED (Table 2). Similarly, the presence of comorbidities (i.e. cardiovascular diseases, hypertension, chronic kidney disease, diabetes mellitus, dyslipidemia, and smoking) were not associated with an increased risk of ED (data not shown). By univariate analysis the presence of fever at diagnosis and male sex showed a trend toward an increased risk of ED (OR 3.77, 95% CI 0.88-19.26, P = 0.08 and OR 3.13, 95% CI 0.92-14.36, P = 0.09, respectively). Conclusions: Our data support the use of the score developed by Ö sterroos et al. to better predict the risk of ED in APL and to select the pts who may benefit from more aggressive supportive care. The presence of fever at diagnosis and male sex seems to be associated with a further increase in the risk of ED but this association needs to be confirmed in a larger study. The integration of biological characteristics of disease and comorbidities does not improve the risk stratification of ED.

Clinical profile and outcome of acute febrile encephalopathy in children

Background: This prospective observational study aims at studying clinical profile of patients with acute febrile encephalopathy. Methods: This study was conducted in patients of acute febrile encephalopathy admitted in PICU at tertiary care centre during November 2019 to May 2021 in age group one month to 18 years. 35 patients satisfied the inclusion criteria. Results: 51.4% children belonged to age group less than 60 months and 40% children belonged to age group 61-120 months. Other than fever and altered sensorium (diagnostic criteria), seizures (74.3%), vomiting (60%), headache (22.9%) and refusal to feed (17.1%), were the major complaints. Raised ICT was found in 20 (57.1%). 20 (57.1%) patients had hyponatremia (Na+ &lt;135). MRI brain abnormalities were found in 13 patients with majority finding being edema 8 (61.5%). 15 (62.5 %) patients had CSF cell count between 5-100/µl. 16 (45.7%) children presented with GCS score 10-12. In the present study, most common diagnosis was rickettsia encephalitis in 10 patients (28.6%) followed by Dengue encephalitis 6 (17.1%) and probable Viral encephalitis 6 (17.1%). There was no mortality in the present study. Conclusions: Seizure, headache and vomiting were the other common presenting features in a case of acute febrile encephalopathy. This indicates raised intracranial tension. Rickettsia followed by Dengue and probable Viral encephalitis were the common etiological diagnosis. Many cases are viral in nature and since no particular or highly effective therapy is available, early diagnosis, emergent treatment of raised intracranial pressure and hyponatremia and implementation of aggressive supportive care may reduce mortality and morbidity as in present study.

Summer poisoning hazards

There is a seasonal risk with some poisons and in the summer, when stinging insects and adders are more active, there is a risk of envenomation. Diagnosis of an adder bite may be missed in horses, as the biting event is rarely witnessed. Envenomation may result in local swelling and occasionally, systemic effects. Multiple bee stings are particularly hazardous as this can result in multi-organ involvement, which may be fatal. Grazing on some plants, such as ragwort or bracken, for a prolonged period can also result in poisoning as ragwort contains pyrrolizidine alkaloids which cause liver failure and bracken contains an enzyme that has an anti-thiamine effect, inducing thiamine deficiency. Photosensitisation following exposure to plants containing phototoxins and bright sunlight is also a risk in summer. Treatment of plant poisoning in horses is generally supportive and involves removing the plant, providing good quality food and supportive care. Thiamine supplementation may be required in severe cases of bracken poisoning. Animals should be protected from sunlight following exposure to a phototoxin, with supportive management of skin lesions. Management of adder bite is supportive with administration of adder antivenom. Multiple bee stings require aggressive supportive care.

Hyperfractionated Cyclophosphamide and Dexamethasone Alone or in Combination with Daratumumab and/or Carfilzomib for the Treatment of Relapsed or Refractory Multiple Myeloma: A Single-Center Retrospective Analysis.

Hyperfractionated cyclophosphamide and dexamethasone (HyperCd) alone, or with carfilzomib(K) and/or daratumumab(D), represents a potential treatment option when rapid disease control is needed for patients with aggressive presentations of relapsed/refractory multiple myeloma (RRMM). This is a single-center, retrospective analysis of adult patients with RRMM who received HyperCd with or without K and/or D between May 1, 2016 and August 1, 2019 at the University of Texas MD Anderson Cancer Center. We here report treatment response and safety outcomes. Data from 97 patients, 12 with plasma cell leukemia (PCL), were reviewed in this analysis. Patients had had a median of 5 prior lines of therapy and received a median of 1 consecutive cycle of hyperCd-based therapy. The overall response rate (ORR) of all patients was 71.8% (HyperCd 75%, HyperCdK 64.3%, D-HyperCd 73.3%, and D-HyperCdK 76.9%). Median progression-free survival and overall survival among all patients was 4.3 months (HyperCd 3.1 months, HyperCdK 4.5 months, D-HyperCd 3.3 months, and D-HyperCdK 6 months) and 9.0 months (HyperCd 7.4 months, HyperCdK 9.0 months, D-HyperCd 7.5 months, and D-HyperCdK 15.2 months), respectively. Grade 3/4 hematologic toxicities were common, thrombocytopenia being the most frequent at 76%. Notably, 29-41% of patients per treatment group had existing grade 3/4 cytopenias at initiation of hyperCd-based therapy. HyperCd-based regimens provided rapid disease control among MM patients, even when heavily pre-treated and with few remaining treatment options. Grade 3/4 hematologic toxicities were frequent, but manageable with aggressive supportive care.

Giant benign tumor of the sacrum - A case report

Introduction: A benign sacral tumor is a rare disease, especially with a giant tumor. We will present the clinical examination, imaging diagnosing images, and our experience in this case. Case presentation: We report a 25-year-old female with a massive sacral tumor, which had been developing for ten years. Clinical examination showed a 210 × 150 × 210mm mass originating from S2 into the sacrum with organ displacement. The biopsy confirmed that was a benign tumor. The surgery was performed with the anterior and posterior approach to remove the tumor and preserve sacroiliac joints. After 18 months, her recovery was smooth. However, she still presented irreversible damages to the bladder and rectal sphincter functions. Conclusion: En block resection of the giant benign sacral tumor with the anterior and posterior approaches is only administrated for a massive and complicated mass, which can only be performed in hospitals with advanced operating departments, anesthesiology, and aggressive supportive care.

Cardiac arrest and severe encephalopathy following e-cigarette nicotine intoxication: a case report

Traditionally, most cases of nicotine poisoning have been due to ingestion of nicotine pesticides. However, the increasing use of electronic cigarettes (e-cigarettes) has resulted in both intentional and unintentional exposure to concentrated liquid nicotine or “eliquid” leading to an increase in nicotine poisoning cases. However, fatalities following the ingestion of the e-liquid are extremely rare. We report a rare case of cardiac arrest and severe encephalopathy following the intentional ingestion of e-liquid. We present the case of a 20-year-old woman who intentionally ingested liquid nicotine intended for e-cigarette use. She was found in asystole and experienced a return of spontaneous circulation (ROSC) after undergoing approximately 46 mins of cardiopulmonary resuscitation. Her plasma nicotine levels were &gt;500 ng/ml. Despite aggressive supportive care, she was found to have encephalopathy consistent with severe anoxic brain injury on magnetic resonance imaging. In recent times, there have been some reports of deaths following liquid nicotine ingestion. Our case illustrates the potential for fatal nicotine toxicity from ingestion of e-cigarettes.

The outbreak of Ebola virus disease in 2022: A spotlight on a re-emerging global health menace.

Ebola virus disease (EVD) is a rare but highly contagious and lethal disease that occurs predominantly in African countries, with a case-fatality rate of 30-90%. The causative viral pathogens of EVD are within the genus Ebolavirus in the family Filoviridae. The primary route of human-to-human transmission is through direct contact with blood, bodily fluids and secretions from infected individuals. Direct contact with virally contaminated objects and sexual transmission have also been reported. Management of EVD is aggressive supportive care with possibly new therapeutic options. On 20 September 2022, an EVD outbreak was declared in Uganda, caused by Sudan ebolavirus. As of 7 November 2022, a total of 136 confirmed cases, 53 confirmed deaths have been reported, including 18 cases with seven deaths among healthcare workers. In the Democratic Republic of Congo (DRC), an EVD outbreak was also declared on 22 August 2022 (which ended on 27 September 2022); with only one case, a middle-aged woman. At the time when most countries in the world have been occupied with the coronavirus disease 2019 (COVID-19) pandemic and the recent human monkeypox outbreak, these two outbreaks of EVD have the potential to significantly add to the burden on global health. Authorities need to augment their multi-faceted response, including stringent contact tracing and border control, to avoid the catastrophe of the 2014-2016 EVD epidemic.

Multisystem Inflammatory Syndrome in Adults (MIS-A) Associated With COVID-19: A Presentation of Mixed Shock

Multisystem inflammatory syndrome in adults (MIS-A) is an uncommon hyperinflammatory complication of COVID-19 that carries significant morbidity. MIS-A cases have been published, but details regarding effective treatment strategies are limited. Here, we describe a 33-year-old woman with no medical history who developed mixed distributive and cardiogenic shock from MIS-A 5 weeks after COVID-19 infection. She received anakinra, intravenous immunoglobulin, steroids, and aggressive supportive care including mechanical ventilation, inotropic and vasopressor support, and diuresis. This patient case highlights the importance of early consideration and recognition of MIS-A and treatment of mixed shock in MIS-A.