Symptomatic Treatment Research Articles

How international guidelines recommend treating children who have severe COVID-19 or risk disease progression.

This study reviewed the current knowledge and guidelines on managing COVID-19 in children and proposed a practical approach to drug treatment. We analysed international guidelines from four prominent scientific bodies on treating COVID-19 in children. These were the UK National Institute for Health and Care Excellence, the American National Institutes of Health, the Infectious Diseases Society of America and the Australian National Clinical Evidence Taskforce COVID-19. Most paediatric patients with COVID-19 only require symptomatic treatment. There was limited evidence on treatment recommendations for children with severe COVID-19 or at risk of disease progression. However, several drugs are available for children and we have summarised the guidelines, in order to provide a concise, practical format for clinicians. All the guidelines agree that nirmatrelvir plus ritonavir or remdesivir can be used as prophylaxis for severe COVID-19 in high-risk patients. Remdesivir can also be used for severe COVID-19 cases. Glucocorticosteroids are recommended, particularly in patients requiring oxygen therapy. Tocilizumab or baricitinib should be reserved for patients with progressive disease and/or signs of systemic inflammation. The guidelines provide useful advice and a degree of consensus on specific drug treatment for children with severe COVID-19 or at risk of progression.

Clinicoepidemiological Profile of Ciguatera Cardiotoxicity: A Systematic Review.

Patients with ciguatera poisoning commonly present with gastrointestinal and neurologic symptoms, but its cardiotoxicity has been largely unrecognized. This systematic review is the first to summarize the evidence regarding clinical characteristics of cardiotoxicity from ciguatera poisoning to provide the illness script and pertinent knowledge for clinicians. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, we searched MEDLINE and EMBASE for all peer-reviewed articles using keywords including "ciguatera" and "cardiotoxicity" from their inception to January 2024. We included 20 articles, including 148 cases, in this systematic review. Among the included cases, the median age was 54 years with male predominance (62.2%). Based on the WHO designation, 68.5% were reported from the Western Pacific Region. Common symptoms included hypotension (75.0%) and bradycardia (67.6%), and chest pain or syncope were less commonly reported (2.7% and 1.4%, respectively). Sinus bradycardia was the most common electrocardiogram abnormality (35.9%), followed by atrioventricular blocks (15.4%). Symptomatic treatments such as atropine, dopamine, and epinephrine were commonly used, and only 4.1% required intensive care unit admission. None expired due to cardiotoxicity from ciguatera. This review summarizes the current evidence and the characteristics of cardiotoxicity from ciguatera. Although ciguatera cardiotoxicity is currently underrecognized, increased awareness of the condition in clinicians is crucial because the clinical outcomes of the patients could be benign as long as it is identified and intervened early.

Long-Term Follow-Up before and during Riluzole Treatment in Six Patients from Two Families with Spinocerebellar Ataxia Type 7.

Currently no curative treatment exists for spinocerebellar ataxias (SCAs). Riluzole repurposing was proposed as a symptomatic treatment in different types of cerebellar ataxia. We report a long-term-follow up under riluzole treatment in SCA type 7. Six patients received Riluzole 50mg twice daily on a compassionate use program for a mean of 4.8 years (range 3.5-9). We measured ataxia onset and progression through the Scale for the Assessment and Rating of Ataxia (SARA), and collected extensive ophthalmological data before and after Riluzole treatment. Electrocardiogram and laboratory profile for drug safety were performed every six months. Riluzole treatment showed no effect on visual function in two patients with an advanced retinal damage. Improvements of visual function occurred in four patients followed by ophthalmologic stability up to 5 years after starting treatment. Two patients had a less steep deterioration of ataxia after treatment compared to pre-treatment, during the first 2,5 years of therapy. One showed soon after therapy an improvement of the SARA score, and then overall stability lasting 3,5 years, followed by ataxia worsening. One visually impaired patient without neurological impairment did not worse until the last visit after 3,5 years of follow-up. The remaining 2 patients showed an improvement of SARA scores soon after therapy, and an overall stability lasting respectively 5 and 3 years. No adverse event was registered during the observation period. This study suggests a possible beneficial action of Riluzole in SCA7 and provides a detailed description of the ophthalmologic profile of these patients.

Small cell cancer of the esophagus, treatment outcomes of a rare histological type

Purpose: To demonstrate treatment outcomes in two patients with small cell esophageal cancer. Cases reports. Patient M. was assigned to receive polychemotherapy (PC H) composed of etoposide 100 mg/ m2 intravenously on days 1–3 + cisplatin 80 mg/m2 on day 1, every 21 days for 6 cycles and lanreotide 120 mg subcutaneously, every 28 days, followed by chemoradiotherapy (CRT). The patient received 1 cycle of PCT , which was well tolerated. Then, the patient received a cycle of 3D-conformal radiation therapy concurrently with 2 cycles of chemotherapy: etoposide 120 mg/m2 + cisplatin 80 mg/m2. Chemoradiotherapy was well tolerated. Dysphagia regression to grade I was observed. Currently, the patient continues to receive treatment (etoposide 100 mg/ m2 intravenously on days 1–3 + cisplatin 80 mg/m2 on day 1, every 21 days for 6 cycles and lanreotide 120 mg subcutaneously, every 28 days) and tolerates it well. Patient A. was assigned to receive PCT with etoposide 120 mg/m2 + cisplatin 80 mg/m2. After 4 cycles of PCT , the follow-up CT images revealed disease progression (enlarged retroperitoneal lymph nodes). The patient underwent external bean radiation therapy to the primary tumor. Radiotherapy was relatively well tolerated. The patient underwent the course of radiation therapy relatively satisfactorily. Due to the progression of the disease, symptomatic treatment was assigned. The patient died 9 months after diagnosis. Conclusion. Small cell carcinoma of the esophagus is a rare histological type with poor prognosis. Concurrent platinum-based chemoradiotherapy allows achievement of stable disease and disease control.

Biomarkers of Parkinson's disease in perspective of early diagnosis and translation of neurotrophic therapies.

Parkinson's disease (PD) is a common neurodegenerative disorder characterized by progressive loss of dopamine neurons and aberrant deposits of alpha-synuclein (α-syn) in the brain. The symptomatic treatment is started after the onset of motor manifestations in a late stage of the disease. Preclinical studies with neurotrophic factors (NTFs) show promising results of disease-modifying neuroprotective or even neurorestorative effects. Four NTFs have entered phase I-II clinical trials with inconclusive outcomes. This is not surprising because the preclinical evidence is from acute early-stage disease models, but the clinical trials included advanced PD patients. To conclude the value of NTF therapies, clinical studies should be performed in early-stage patients with prodromal symptoms, that is, before motor manifestations. In this review, we summarize currently available diagnostic and prognostic biomarkers that could help identify at-risk patients benefiting from NTF therapies. Focus is on biochemical and imaging biomarkers, but also other modalities are discussed. Neuroimaging is the most important diagnostic tool today, but α-syn imaging is not yet viable. Modern techniques allow measuring various forms of α-syn in cerebrospinal fluid, blood, saliva, and skin. Digital biomarkers and artificial intelligence offer new means for early diagnosis and longitudinal follow-up of degenerative brain diseases.

Simultaneous dual-target magnetic resonance-guided focused ultrasound treatment for patients with tremor-dominant Parkinson’s disease

Introduction. Non-invasive magnetic resonance-guided focused ultrasound (MRgFUS) is a new neurosurgical treatment option for tremor-dominant Parkinson’s disease (TDPD). Outcomes of ablation with dual targeting of two subcortical nuclei to improve functional treatment results are yet to be explored. Aim. This study aimed to evaluate the safety and efficacy of MRgFUS with simultaneous unilateral ablation of two cerebral targets in patients with TDPD. Materials and methods. A total of 82 TDPD patients (20 women, 62 men; median age 65.0 [52.5; 70,0] years) received unilateral MRgFUS, i.e. ventrointermedial (VIM) nucleus thalamotomy and/or pallidothalamotractotomy (PTT). Motor symptoms, including tremor, were assessed using MDS-Unified Parkinson’s Disease Rating Scale Part III (MDS-UPDRS-III). VIM, PTT, and VIM + PTT ablation was received by 34, 12, and 36 patients, respectively. Results. After surgery, MDS-UPDRS-III score improved by 40.1% (30.2; 51.7) without early or late-onset serious complications. Tremor returned in 18 patients (all after VIM thalamotomy); 9 of them successfully underwent re-treatment 9–12 months after the first procedure. Simultaneous dual-target (VIM + PPT) intervention was successfully received by 36 patients without any serious complications. A total of 89.3% and 69.7% of patients remained relapse-free in the dual-target and single-target groups, respectively (p = 0.039). Conclusion. Simultaneous dual-target (VIM and PTT) MRgFUS showed favorable safety and efficacy profiles and can be considered a symptomatic treatment option for TDPD patients.

Initiation of Buprenorphine Treatment of Opioid Use Disorder in Pediatric Emergency Departments.

Pediatric emergency departments (EDs) in the United States are facing a rise in the number of children and adolescents who present with opioid use disorder (OUD), often driven by illicitly manufactured fentanyl. Medication treatment of pediatric OUD in the ED setting is often limited to symptomatic treatment of opioid withdrawal. Pediatric patients are rarely offered medications for OUD, especially in the ED setting. Buprenorphine is a partial opioid agonist that is Food and Drug Administration-approved for the treatment of OUD in patients aged 16 years and older. Adult studies have demonstrated that ED initiation of medication for OUD such as buprenorphine is feasible, safely treats withdrawal symptoms, and can improve patient compliance with outpatient follow-up. However, initiation of buprenorphine in the ED has not been well-studied in the pediatric population. We present 2 cases of adolescent patients, a 16-year-old male and 17-year-old female, who presented to the ED with opioid withdrawal. They were both diagnosed with severe OUD because of their use of counterfeit pills containing fentanyl. Both patients were successfully started on buprenorphine/naloxone in the pediatric ED before transitioning to an outpatient addiction clinic for continued treatment. The case series demonstrates the feasibility of ED-based buprenorphine initiation for adolescents, an important and timely intervention for adolescents with OUD.

Multicenter evaluation of mechanical thrombectomy for distal medium vessel occlusions with National Institute of Health Stroke Scale Scores ≥ 6 and ≤ 6.

While mechanical thrombectomy is considered standard of care for large vessel occlusions, scientific evidence to support treatment for distal and medium vessel occlusions remains scarce. To evaluate feasibility, safety, and outcomes in patients with low National Institute of Health Stroke Scale scores undergoing mechanical thrombectomy for treatment of distal medium vessel occlusions. Retrospective data review and analysis of prospectively maintained databases at 41 academic centers in North America, Asia, and Europe between January 2017 and January 2022. Characteristics and outcomes were compared between groups with low stroke scale score (≤ 6) versus and higher stroke scale scores (> 6). Propensity score matching using the optimal pair matching method and 1:1 ratio was performed. Data were collected on a total of 1068 patients. After propensity score matching, there were a total of 676 patients included in the final analysis, with 338 patients in each group. High successful reperfusion rates were seen in both groups, 90.2% in ≤ 6 and 88.7% in the > 6 stroke scale groups. The frequency of excellent and good functional outcome was seen more common in low versus higher stroke scale score patients (64.5% and 81.1% versus 39.3% and 58.6%, respectively). The 90-day mortality rate observed in the ≤ 6 stroke scale group was 5.3% versus 13.3% in the > 6 stroke scale group. Mechanical thrombectomy in distal and medium vessel occlusions, specifically in patients with low stroke scale scores is feasible, though it may not necessarily improve outcomes over IVT.

The role of nutraceuticals in the management of temporomandibular disorders.

Temporomandibular disorders (TMDs) are usually treated with occlusal appliances and supportive treatments such as physical therapy and drugs. Supplements can be included among potential supportive therapies, with the aim of reducing the use of drugs. To evaluate the efficacy of nutraceuticals' short-term treatment in subjects with temporomandibular disorders. The study started in January 2021 and ended in January 2022. Subjects with temporomandibular disorders and a verbal numeric scale >40 were recruited and randomly assigned to one of the following groups. If waiting to start a therapy, to the nutraceutical group or to the no treatment group, while if already undergoing splint therapy, to nutraceautical+splint group or to splint therapy group. Nutraceutical used was composed by Boswellia Serrata Casperome, Magnesium, Tryptophan and vitamins B2 and D with a posology of one tablet/day before sleep for 40days. Presence of temporomandibular pain, headache, neck pain and sleep/emotional disorders were assessed at T0 and at T1, after 40days. ANOVA was performed to compare treatments with nutraceuticals and theirrespective controls, as for the variables related to painful symptomatology. Chi- Squared was conducted to assess differences in sleep/emotional disorders between groups. The statistical significance was p<0.05. The groups using nutraceuticals showed statistically significant improvements over controls for most of the variables analyzed. The use of nutraceutical seems to be a valuable support for TMD therapy in the short term either alone or combined with occlusal splint therapy.

P-093 The effect of antioxidant supplementation on sperm quality in infertile men: a randomized placebo-controlled clinical trial

Abstract Study question Is sperm quality improved in infertile men after administration for three months of a combination of antioxidants as compared to placebo? Summary answer Administration in infertile men for three months of a combination of antioxidants as compared to placebo does not improve sperm quality. What is known already In infertile men, limited evidence exists to support treatment with a combination of antioxidants for improving sperm quality. A recent Cochrane meta-analysis suggested that treatment of these patients with combinations of antioxidants as compared to placebo or no treatment results in an increase in sperm motility (MD + 12.71 95%CI +11.33 to + 14.08, 7 studies, 684 patients), while no beneficial effect was observed on DNA fragmentation index (DFI) and on the probability of live birth. Nevertheless, combinations of antioxidants are widely used in clinical practice at present. Study design, size, duration This randomized placebo-controlled trial evaluated the effect of a combination of antioxidants on sperm motility (primary outcome). Secondary outcomes were sperm concentration, morphology, DFI and levels of reactive oxygen species (ROS). For this purpose, 79 infertile men, were randomized, using a computer-generated randomization list, between 2019-2022, to receive either a combination of antioxidants (n = 40) or placebo (n = 39) for three months. This was a quadruple-blind trial (participants, clinicians, outcome assessors, data analyst). Participants/materials, setting, methods Sperm variables were evaluated according to WHO criteria, ROS levels by the detection of 8-hydroxy-2-deoxy-guanosine peroxidation product on sperm and DFI by flow cytometry. For all outcomes, the changes between treatment initiation and completion were assessed in both the antioxidant and the placebo groups and compared statistically. Values are expressed as mean (95%CI of the mean) and statistical significance was set at p = 0.05. Main results and the role of chance Nine patients dropped out from the study, since they did not perform the second sperm analysis for personal reasons and thus did not complete the study process. No differences were observed between the antioxidants and the placebo group regarding male age {mean difference (MD) -1.3 years, 95%CI -1.4 to + 4.1}, smoking (antioxidants: 41.6%, 95%CI 25.5 to 59.2 vs placebo: 43.5%, 95%CI 27.8 to 60.3), exercise (antioxidants: 45.4%, 95%CI 28.1 to 63.6 vs placebo: 16.1%, 95%CI 5.4 to 33.7) and primary infertility (antioxidants: 82.3%, 95%CI 65.4 to 93.2 vs placebo: 85.7%, 95%CI 69.7 to 95.1). No statistically significant differences were observed in infertile men who received a combination of antioxidants or placebo, between the changes of pre and post treatment values, regarding sperm motility (-3.5%, 95%CI: -13 to + 5.9, p = 0.742), concentration (-1.9%, 95%CI: -15.7 to + 11.8, p = 0.0.77), morphology (-0.10%, 95%CI: -0.8 to 0.6, p = 0.793), DFI (0.2%, 95%CI: -3.8 to + 4.4, p = 0.891) and levels of ROS (-1.2%, 95%CI: -3.2 to + 0.8, p = 0.231). No side effects were reported in antioxidants combination treated patients for the duration of follow-up. Limitations, reasons for caution The current RCT did not explicitly include men with abnormal DFI, limiting the extrapolation of the results obtained in this group of patients. Moreover, it was not designed to evaluate the probability of pregnancy either spontaneously or after Medically Assisted Reproduction (MAR). Wider implications of the findings The current study does not support the use of antioxidants for enhancing male infertility. Future relevant studies should focus on identifying the optimal population and duration of treatment. Trial registration number NCT04256278

Clinical characteristics analysis of 4 cases with acute flaccid myelitis in children

Objective: To summarize the clinical manifestations, diagnosis, treatment and prognosis of acute flaccid myelitis (AFM) in children. Methods: Clinical characteristics of 4 AFM cases from Department of Neurology, Children's Hospital Affiliated to Capital Institute of Pediatrics, from September 2018 to November 2022, were analyzed retrospectively. Results: The age of 4 children with AFM was 7 years, 4 years and 3 months, 7 years and 1 month, 6 years and 5 months, respectively. There were 2 boys and 2 girls. Prodromal infection status showed 3 children of respiratory tract infection and 1 child of digestive tract infection. The main manifestation was asymmetrical limb weakness after infection, and the affected limb range was from monoplegia to quadriplegia. Cranial nerve injury was involved in 1 child, no encephalopathy. Magnetic resonance imaging in the spinal cord of all 4 children showed long T1 and T2 signals, mainly involving gray matter. Cerebrospinal fluid cell-protein separation was observed in 2 children. Pathogen detected in 1 child pharyngeal swab was enterovirus D68. Antibody IgM to adenovirus was positive in the blood of 1 child. Antibody IgG against Echo and Coxsackie B virus were positive in the blood of another child. After glucocorticoid, human immunoglobulin or simple symptomatic treatment and at the same time under later rehabilitation training, muscle strength recovered to different degrees, but there were disabilities left in 3 children. Conclusions: AFM should be considered in children with acute and asymmetrical flaccid paralysis accompanied by abnormal magnetic resonance imaging signal in the central region of spinal cord, especially post-infection. The effective treatment is limited and the prognosis is poor.

Autoimmune encephalitis in Intensive Care Unit: A Review Article

Background: Autoimmune encephalitis (AE) is a group of immunologic diseases affecting the central nervous system (CNS). It is now considered a common cause of encephalitis and often requires intensive care unit (ICU) level care. Aims: This review aims to provide intensivists with a toolkit to better recognize, diagnose, and manage patients with AE in the ICU. Sources: A search of online databases using relevant keywords yielded papers discussing the epidemiology, diagnosis, management, and outcome of AE in the ICU setting. Content: Due to the development of new antibody testing toolkits, the prevalence of AE has been on the rise during the past few decades. Timely recognition and diagnosis of AE in the ICU can significantly improve patient outcomes. Diagnostic criteria help classify patients into possible, probable, or definite AE categories based on clinical and paraclinical findings. Management of AE involves immunomodulatory and immunosuppressive therapies, along with targeting associated neoplastic processes or triggers. First-line treatments include corticosteroids, intravenous immunoglobulin (IVIg), and plasma exchange (PLEX), while second-line therapies may be required for refractory cases. AE can result in seizures, movement disorders, dysautonomia, respiratory failure, altered mental status, and psychosis. These complications require a combination of immunotherapy and symptomatic treatment for effective management. Prognosis varies but timely and appropriate management significantly improves outcomes. Keywords: Autoimmune Encephalitis, ICU, Intensive Care, Diagnosis, Management, Prognosis

Hand osteoarthritis: a fresh look.

Hand osteoarthritis (OA) has been the subject of numerous publications in recent years, particularly in the fields of imaging and therapeutics. The imaging studies revealed a good correlation between the presence of synovitis and/or subchondral edema and arthritic joint pain. Several randomized controlled trials (RCTs) have assessed the efficacy of biologics and conventional DMARDs in patients with symptomatic hand OA. No less than six RCTs have evaluated the symptomatic and, in some cases, structural efficacy of anti-IL-1, anti-TNF or anti-IL-6 drugs. Overall, the results of these trials were disappointing-none of them demonstrated superiority over placebo. There were also two negative trials with hydroxychloroquine. In the end, the only trial that was positive evaluated 10mg oral prednisone versus placebo for 6weeks in patients with flares of hand OA and synovitis visible on ultrasound. While that trial confirms the role of inflammation in hand OA, it should obviously not encourage the long-term use of corticosteroids as a symptomatic treatment.

Malignant hyperthermia in a paediatric patient; managed successfully without dantrolene: a case report

Introduction: Malignant hyperthermia (MH) is a potentially life-threatening pharmacogenetic syndrome triggered by volatile anaesthetics, succinylcholine, and stress such as vigorous exercise. Case presentation: The authors describe a case of an 8-year-old male who presented with classical symptoms of MH after induction of general anaesthesia and symptomatic treatment was done successfully due to the unavailability of Dantrolene. Discussion: Definitive diagnosis of MH can be done based on a contracture test in fresh muscle biopsy in the presence of halothane and caffeine. In the absence of muscle biopsy and genetic testing, diagnosis for MH can be done based on MH scoring. Conclusion: Anesthesiologists should be made aware that proper symptomatic management can also save the life of a patient. Also, strong advocacy should be done to ensure the availability of Dantrolene and further strengthen lab facilities to confirm diagnosis to facilitate diagnosis and management in the future.

Mucormycosis as a complication of COVID-19 coronavirus infection: eye symptoms

COVID-19 causes an immunosuppressive condition and increases the risk of secondary infections, including fungal diseases such as mucormycosis (MM), so doctors should be aware of the possibility of MM development in COVID-19 patients. Since no specific complaints or clinical symptoms exist and the disease is rare, especially in developed countries with a moderate climate, it is often impossible to diagnose MM at the initial examination. Therefore, the detection of the pathogen (mycelium zygomycetes) plays a key role in the diagnosis. Over 70 % of MM patients experience eye damages. According to the literature, the most common manifestations thereof are blepharoptosis, ophthalmoplegia, exophthalmos, injection and conjunctival chemosis. Quite often, the patients have eye pains, orbital cellulitis or phlegmon of the orbit, accompanied by a decrease in vision. For the effective treatment of this severe infectious COVID-19 complication, which takes the form of deep and aggressive mycosis, an interdisciplinary approach is necessary. The complex treatment should make use of antimycotic agents and symptomatic therapy, and, essentially, surgical rehabilitation of infection foci by removing the affected necrotic tissues. The prognosis is always very serious.

Neonatal Enteroviral Meningoencephalitis: Clinical and Paraclinical Characteristics of a Nosocomial Outbreak in Colombia

Enteroviruses (EVs) are a common cause of infection in neonates, they spread from person to person by a variety of routes and can cause severe symptoms and complications, including meningoencephalitis, myocarditis, and hepatic failure. We report the clinical and paraclinical characteristics of six patients diagnosed in a hospital cluster with late-onset sepsis, mostly preterm newborns. The most common symptoms were the same as a sepsis-like syndrome, the predominant sign of presentation was fever. The most frequent laboratory finding was elevated C-reactive protein, and later positive cerebrospinal fluid multiplex for EVs. Support treatment was given. A benign course was observed. Seizures were the only complication, with a normal electroencephalography at 6-month follow-up. In-hospital cases would benefit from a high clinician suspicion and early detection for achieving immediate isolation and containment measures to limit the spread to sick and vulnerable newborns, avoiding clusters.

Is conventional radiofrequency ablation of the superolateral branch, one of the three genicular nerves targeted as standard, necessary or not? A non-inferiority randomized controlled trial.

Radiofrequency ablation is an effective treatment modality in the symptomatic treatment of knee osteoarthritis. Our aim was to compare the efficacy of radiofrequency ablation of the superomedial and inferomedial genicular nerves (2 branches) with the superolateral, superomedial, and inferomedial genicular nerves (3 branches) and to show whether the 2-branch procedure is inferior to the 3-branch procedure. This study is a prospective, randomized, single-blind clinical study. Eligible participants were randomized into 2 groups: group A, which applied the procedure to the superomedial and inferomedial genicular nerves, and group B, which applied it to the superomedial, superolateral and inferomedial genicular nerves. Pain was evaluated with the numerical rating scale, quality of life with the Short Form-36 (SF-36), and disability with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index before, and at 1 and 3 months after the procedure. A total of 41 patients were included. There were no differences between the groups except for the SF-36 physical health sub-score at baseline. A significant improvement was seen in the numeric rating scale (NRS) score, SF-36 sub-scores, WOMAC Index total, as well as pain and physical function scores in both groups, though no significant difference was detected between the groups during follow-up. Although we were unable to establish the noninferiority of conventional radiofrequency ablation (CRFA) applied to 2 branches to CRFA applied to 3 branches, in this trial, significant and similar improvement was observed in NRS, WOMAC total, pain, and physical function and SF-36 scores in both groups.

Persistent hypoglycemia in patients with liver cancer.

Hypoglycemia is one of the paraneoplastic syndrome manifestations that arise from primary and secondary liver cancer. Hypoglycemia usually presents in the late stage of the disease and indicates a poor prognosis. This case series displays the characteristics profile of patients with primary and secondary liver cancer who are presented with hypoglycemia in a tertiary referral hospital in Indonesia. The study included 41 liver cancer patients who were presented with hypoglycemia. Hepatocellular carcinoma was diagnosed in 51.2% of patients, metastatic liver disease in 14.6% of patients, and undiagnosed liver cancer in 34.1% of patients. The mean age was 47.7 years with male predominance (65.9%). Jaundice was found in 58.5% and hepatomegaly in 70.7% of patients. The mean (± S.D.) initial blood glucose was 42.15 ± 17.11 mg/dL and the Child-Pugh score was 9.93 ± 2.11. Based on imaging, tumor diameter was 12.6 ± 6.9 cm, multiple (61%), and involving both lobes (61%). Treatments for hypoglycemia included oral/enteral feeding, intravenous dextrose, and steroids. No treatment was given for the cancer because all patients were in an advanced stage. The treatment resulted in 41.5% blood glucose being controlled, 56.1% refractory, and 2.4% persistent. Mortality was 70.7% and in average occurred 5.76 ± 4.99 days after hypoglycemia. The mainstay of treatment in these cases is treating the tumor with cytoreduction. However, it was difficult to do cytoreduction because the tumor was already in an advanced stage. Beneficial supportive treatments for maintaining normal blood glucose are frequent meals, dextrose infusion, steroids, and glucagon. Hypoglycemia in liver cancer occurs due to the failure of the liver to fulfill body glucose demand because the liver parenchyma has been largely replaced by the tumor, in addition to the high production of insulin growth factor (IGF). Hypoglycemia is often caused by islet cell and non-islet cell tumors, with a higher occurrence in non-islet cell tumors due to paraneoplastic syndrome and the high metabolic requirements of the tumor. The mainstay of NICTH treatment is treating the tumor with cytoreduction. However, in an advanced stage, cytoreduction therapy is often challenging to conduct. Beneficial supportive treatments for controlling blood glucose are frequent meals, dextrose infusion, and the injection of steroids and glucagon. Steroids play a beneficial role in the treatment of persistent hypoglycemia in hepatocellular carcinoma by stimulating gluconeogenesis and increasing lipolysis. Steroids also have roles in the inhibition of peripheral glucose intake, suppression of big IGF-2 production, and modulation of the GH-IGF axis.

Perioperative albumin among adults undergoing Thoracic Surgery in the United States: utilization, associations with clinical outcomes, and contribution to hospital costs

Objectives: To estimate the use of albumin among adults undergoing thoracic surgery in the United States, compare baseline characteristics, clinical and cost outcomes of recipients versus non-recipients, and determine albumin's contribution to total hospital costs. Design: Retrospective cohort study. Setting: Nationwide sample of US hospitals. Participants: Adults undergoing open and minimally invasive thoracic surgery between 2011 and 2017. Interventions: Albumin on the day of surgery (identified using itemized hospital billing logs). Measurements and Main Results: Albumin was used in 170 of 342 US hospitals, among 13% and 7% of 14672 and 22532 patients who respectively underwent open and minimally invasive thoracic surgery (median volume 500cc). Baseline comorbidities and organ supportive treatments were several-fold more prevalent among recipients (particularly vasopressors, mechanical ventilation, red cell transfusions). In standardized mortality ratio propensity score weighted analysis, albumin use was not associated with in-hospital mortality (adjusted RR 1.17 [0.72, 1.92] and 1.51 [0.97, 2.34], with open and minimally procedures), but was associated with morbidity and higher costs, more so with minimally invasive than open surgery. Total costs among recipients were higher by $4,744 [$3,591, $5,897] and $5,088 [$4,075, $6,100] for open and minimally invasive procedures respectively. Albumin accounted for 2.6% of this difference (median $124 [$83-$189] per patient). Conclusions: Albumin use varies widely across hospitals, and 9% of patients receive it (median 500cc). Use was not associated with in-hospital mortality and was associated with more morbidity and cost. The cost of albumin accounted for a trivial portion of hospital costs. Clinical trials must examine effects of albumin on complications and costs after thoracic surgery.

Insuficiencia hepática aguda por adenovirus tratada con inmunoglobulina intravenosa

Background: Acute liver failure in pediatric age is a serious multisystem disease, characterized by a failure of the synthesis and detoxification function of the liver. Among the etiologies, viral infection should be investigated. Treatment is supportive and some cases require liver transplantation. Case report: A 2-year-old girl was admitted for acute liver failure. The PCR viral panel was positive for Adenovirus 41 and IgG antibodies to SARS-CoV-2 were also found. Supportive treatment was started without improvement, so intravenous immunoglobulin was administered, with resolution of the liver failure. Conclusion: Immunoglobulin has immunomodulatory mechanisms in children with severe acute hepatitis of infectious etiology, so in some cases, its administration can be considered as adjuvant therapy. Keywords: Acute liver failure, Hepatitis, Adenovirus, Immunoglobulin.