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Plasma plays a crucial role in maintaining health through regulating coagulation and inflammation. Both are essential to respond to homeostatic threats such as traumatic injury or microbial infection; however, left unchecked, they can themselves cause damage. A well‐functioning plasma regulatory milieu controls the location, intensity, and duration of the response to injury or infection. In contrast, plasma failure can be conceptualized as a state in which these mechanisms are overwhelmed and unable to constrain coagulation and inflammation appropriately. This dysregulated state causes widespread tissue damage and multiple organ dysfunction syndrome. Unlike plasma derangements caused by individual factors, plasma failure is characterized by a heterogeneous set of plasma component deficiencies and excesses. Targeted therapies such as factor replacement or recombinant antibodies are thus inadequate to restore plasma function. Therapeutic plasma exchange offers the unique ability to remove harmful factors and replete exhausted components, thereby reestablishing appropriate regulation of coagulation and inflammation. [ABSTRACT FROM AUTHOR]

The EFFORT Protein trial assessed the effect of high vs usual dosing of protein in adult ICU patients with organ failure. This study provides a probabilistic interpretation and evaluates heterogeneity in treatment effects (HTE). We analysed 60-day all-cause mortality and time to discharge alive from hospital using Bayesian models with weakly informative priors. HTE on mortality was assessed according to disease severity (Sequential Organ Failure Assessment [SOFA] score), acute kidney injury, and serum creatinine values at baseline. The absolute difference in mortality was 2.5% points (95% credible interval –6.9 to 12.4), with a 72% posterior probability of harm associated with high protein treatment. For time to discharge alive from hospital, the hazard ratio was 0.91 (95% credible interval 0.80 to 1.04) with a 92% probability of harm for the high-dose protein group compared with the usual-dose protein group. There were 97% and 95% probabilities of positive interactions between the high protein intervention and serum creatinine and SOFA score at randomisation, respectively. Specifically, there was a potentially relatively higher mortality of high protein doses with higher baseline serum creatinine or SOFA scores. We found moderate to high probabilities of harm with high protein doses compared with usual protein in ICU patients for the primary and secondary outcomes. We found suggestions of heterogeneity in treatment effects with worse outcomes in participants randomised to high protein doses with renal dysfunction or acute kidney injury and greater illness severity at baseline. [ABSTRACT FROM AUTHOR]

Infective endocarditis (IE) caused by MRSA (methicillin-resistant Staphylococcus aureus) is associated with a high mortality rate. This study aimed to elucidate the characteristics of patients with MRSA-IE in Japan and identify the factors associated with prognosis. This retrospective study included patients with a confirmed diagnosis of IE caused by MRSA, between January 2015 and April 2019. A total of 65 patients from 19 centers were included, with a mean age of 67 years and 26 % were female. Fifty percent of the patients with IE were had nosocomial infections and 25 % had prosthetic valve involvement. The most common comorbidities were hemodialysis (20 %) and diabetes (20 %). Congestive heart failure was present in 86 % of patients (NYHA class I, II: 48 %; III, IV: 38 %). The 30-day and in-hospital mortality rates were 29 % and 46 %, respectively. Multi-organ failure was the primary cause of death, accounting for 43 % of all causes of death. Prognostic factors for in-hospital mortality were age, disseminated intravascular coagulation, daptomycin and/or linezolid as initial antibiotic therapy, and surgery. Surgical treatment was associated with a lower mortality rate (odds ratio [OR], 0.026; 95 % confidence interval [CI], 0.002–0.382; p = 0.008 for 30-day mortality and OR, 0.130; 95 % CI; 0.029–0.584; p = 0.008 for in-hospital mortality). Mortality due to MRSA-IE remains high. Surgical treatment is a significant prognostic predictor of MRSA-IE. [ABSTRACT FROM AUTHOR]

Ubah Mumin Ali Osman,1 Selim Turfan,1 Mohamed Farah Yusuf Mohamud1– 4 1Emergency Department, Mogadishu Somali Turkey Training and Research Hospital, Mogadishu, Somalia; 2Somalia Society for Emergency Medicine (SOSEM), Mogadishu, Somalia; 3Tayo Institute for Health, Research, and Development, Mogadishu, Somalia; 4Faculty of Medicine, Mogadishu University, Mogadishu, SomaliaCorrespondence: Mohamed Farah Yusuf Mohamud, Emergency Department, Mogadishu Somali Turkey Training and Research Hospital, Hawa-Abdi Street, Hodan District, Mogadishu, Somalia, Tel +252615591689, Email m.qadar59@gmail.comAbstract: Honeybee bites are a common public health hazard, the incidence of which is gradually increasing. A bee sting incident involving more than fifty stings is categorized as massive envenomation. The clinical manifestations of honey bee stings can range from localized symptoms to severe allergic and systemic reactions.This case study presents a 60-year-old male who experienced multi-organ failure following a severe bee sting incident. According to our research, this is the first documented instance in Somalia of multi-organ failure resulting from a sting by a giant honey bee. The case highlights the potential severity of bee stings, which, while often considered minor, can lead to serious medical complications. Interestingly, despite the patient suffering numerous stings and receiving a substantial amount of venom, an immediate anaphylactic reaction did not occur. Instead, a delayed severe response leading to multi-organ failure emerged within 48 hours of the incident.Keywwords: Honey bee, multi-organ failure, acute kidney injury, acute liver injury, pancreatitis, pulmonary odema

In recent years, humanity has been confronted with a global pandemic due to coronavirus disease 2019 (COVID-19), which has caused an unprecedented health and economic crisis worldwide. Apart from the respiratory symptoms, which are considered the principal manifestations of COVID-19, it has been recognized that COVID-19 constitutes a systemic inflammatory process affecting multiple organ systems. Across the spectrum of organ involvement in COVID-19, acute liver injury (ALI) has been gradually gaining increasing attention by the international scientific community. COVID-19 associated liver impairment can affect a considerable proportion of COVID-19 patients and seems to correlate with the severity of the disease course. Indeed, COVID-19 patients hospitalized in the intensive care unit (ICU) run a greater risk of developing ALI due to the severity of their clinical condition and in the context of multi-organ failure. The putative pathophysiological mechanisms of COVID-19 induced ALI in ICU patients remain poorly understood and appear to be multifactorial in nature. Several theories have been proposed to explain the occurrence of ALI in the ICU setting, such as hypoperfusion and ischemia due to hemodynamic instability, passive liver congestion as a result of congestive heart failure, ischemia-reperfusion injury, hypoxia due to respiratory failure, mechanical ventilation itself, sepsis and septic shock, cytokine storm, endotheliitis with concomitant coagulopathy, drug-induced liver injury, parenteral nutrition and direct cytopathic viral effect. It should be noted that no specific therapy for COVID-19 induced ALI exists. Therefore, the therapeutic approach lies in preventive measures and is exclusively supportive once ALI ensues. The aim of the current review is to scrutinize the existing evidence on COVID-19 associated ALI in ICU patients, explore its clinical implications, shed light on the underlying pathophysiological mechanisms and propose potential therapeutic approaches. Ongoing research on the particular scientific field will further elucidate the pathophysiology behind ALI and address unresolved issues, in the hope of mitigating the tremendous health consequences imposed by COVID-19 on ICU patients.

Background: Facial appearance, whether consciously or subconsciously assessed, may affect clinical assessment and treatment strategies in the Intensive Care Unit (ICU). Nevertheless, the association between objective clinical measurement of facial appearance and multi-organ failure is currently unknown. The objective of this study was to examine whether facial appearance at admission is associated with longitudinal evaluation of multi-organ failure. Methods: This was a sub-study of the Simple Intensive Care Studies-II, a prospective observational cohort study. All adult patients acutely admitted to the ICU between March 26, 2019, and July 10, 2019, were included. Facial appearance was assessed within three hours of ICU admission using predefined pictograms. The SOFA score was serially measured each day for the first seven days after ICU admission. The association between the extent of eye-opening and facial skin colour with longitudinal Sequential Organ Failure Assessment (SOFA) scores was investigated using generalized estimation equations. Results: SOFA scores were measured in 228 patients. Facial appearance scored by the extent of eye-opening was associated with a higher SOFA score at admission and follow-up (unadjusted 0.7 points per step (95%CI 0.5 to 0.9)). There was no association between facial skin colour and a worse SOFA score over time. However, patients with half-open or closed eyes along with flushed skin had a lower SOFA score than patients with a pale or normal facial skin colour (P-interaction < 0.1). Conclusions: The scoring of patients' facial cues, primarily the extent of eye-opening and facial colour, provided valuable insights into the disease state and progression of the disease of critically ill patients. The utilization of advanced monitoring techniques that incorporate facial appearance holds promise for enhancing future intensive care support. [ABSTRACT FROM AUTHOR]

Background: Rickettsioses are infectious diseases which are caused by intracellular bacteria which belong to the family Rickettsiaceae. This zoonosis endemically prefers tropical and subtropical regions of which the Mediterranean is included. Murine typhus is a type of rickettsial disease that commonly presents with undulating fever, headache rash, chills, malaise, and myalgias. It can lead to complications such as multi-organ failure and has a lethality rate of

Abstract Background Thyroid storm can be complicated by liver dysfunction, which may occasionally progress to acute liver failure. We herein report a case of acute liver failure following thyroid storm that was treated with living donor liver transplantation after resuscitation from cardiopulmonary arrest. Case report The patient was a woman in her 40 s who had been diagnosed with an abnormal thyroid function. She suffered from fatigue and vomiting, and was found to have consciousness disorder, a fever, and tachycardia with a neck mass. She was diagnosed with thyroid storm and was referred to our hospital. After arrival, she went into cardiopulmonary arrest and veno-arterial extracorporeal membrane oxygenation was initiated. In addition to treatment for thyroid storm with antithyroid drugs, steroids, and plasma exchange, extracorporeal life support was required for 5 days. However, despite improvements in her thyroid function, her liver function deteriorated. We planned living donor liver transplantation for acute liver failure after ensuring the recovery and control of the thyroid function following total thyroidectomy. The donor was her husband who donated the right lobe of his liver. Although she experienced acute cellular rejection after surgery, and other complications—including intra-abdominal hemorrhaging and ischemic changes in the intestine—her liver function and general condition gradually improved. One year after living donor liver transplantation, the patient was in a good condition with a normal liver function. Conclusions To our knowledge, this is the first report of living donor liver transplantation in a patient with acute liver failure following thyroid storm. Liver transplantation should be recognized as an effective treatment for acute liver failure following thyroid storm.

Background: Delivering higher doses of protein to mechanically ventilated critically ill patients did not improve patient outcomes and may have caused harm. Longitudinal urea measurements could provide additional information about the treatment effect of higher protein doses. We hypothesised that higher urea values over time could explain the potential harmful treatment effects of higher doses of protein. Methods: We conducted a reanalysis of a randomised controlled trial of higher protein doses in critical illness (EFFORT Protein). We applied Bayesian joint models to estimate the strength of association of urea with 30-day survival and understand the treatment effect of higher protein doses. Results: Of the 1301 patients included in EFFORT Protein, 1277 were included in this analysis. There were 344 deaths at 30 days post-randomisation. By day 6, median urea was 2.1 mmol/L higher in the high protein group (95% CI 1.1–3.2), increasing to 3.0 mmol/L (95% CI 1.3–4.7) by day 12. A twofold rise in urea was associated with an increased risk of death at 30 days (hazard ratio 1.34, 95% credible interval 1.21–1.48), following adjustment of baseline characteristics including age, illness severity, renal replacement therapy, and presence of AKI. This association persisted over the duration of 30-day follow-up and in models adjusting for evolution of organ failure over time. Conclusions: The increased risk of death in patients randomised to a higher protein dose in the EFFORT Protein trial was estimated to be mediated by increased urea cycle activity, of which serum urea is a biological signature. Serum urea should be taken into consideration when initiating and continuing protein delivery in critically ill patients. ClinicalTrials.gov Identifier: NCT03160547 (2017-05-17). [ABSTRACT FROM AUTHOR]

Introduction: Increasing numbers of patients with advanced organ disease are being considered for bariatric and metabolic surgery (BMS). There is no prospective study on the safety of BMS in these patients. This study aimed to capture outcomes for patients with advanced cardiac, renal, or liver disease undergoing BMS. Materials and Methods: This was a multinational, prospective cohort study on the safety of elective BMS in adults (=18 years) with advanced disease of the heart, liver, or kidney. Results: Data on 177 patients with advanced diseases of heart, liver, or kidney were submitted by 75 centres in 33 countries. Mean age and BMI was 48.56 ± 11.23 years and 45.55 ± 7.35 kg/m2, respectively. Laparoscopic sleeve gastrectomy was performed in 124 patients (70%). The 30-day morbidity and mortality were 15.9% (n= 28) and 1.1% (n= 2), respectively. Thirty-day morbidity was 16.4%, 11.7%, 20.5%, and 50.0% in patients with advanced heart (n =11/61), liver (n =8/68), kidney (n= 9/44), and multi-organ disease (n =2/4), respectively. Cardiac patients with left ventricular ejection fraction less than or equal to 35% and New York Heart Association classification 3 or 4, liver patients with model for end-stage liver disease score greater than or equal to 12, and patients with advanced renal disease not on dialysis were at increased risk of complications. Comparison with a propensity score-matched cohort found advanced disease of the heart, liver, or kidney to be significantly associated with higher 30-day morbidity. Conclusion: Patients with advanced organ disease are at increased risk of 30-day morbidity following BMS. This prospective study quantifies that risk and identifies patients at the highest risk. [ABSTRACT FROM AUTHOR]

Severe acute pancreatitis (SAP) is a common pathology requiring critical care input. Patients often present with evidence of physiological dysfunction that may require organ support for optimization. Various scoring systems are available which can help in identifying those most at risk of morbidity and mortality. Complications can be significant, and may require surgical intervention for management. As such these patients should be managed with full multidisciplinary input to ensure appropriate targeted treatment. Underlying causes for SAP should be aggressively investigated to reduce the potential for recurrent episodes and where appropriate allow for secondary preventative measures. These patients often require prolonged and recurrent intensive care stays. Of those who are discharged, ongoing issues with chronic pain and nutrition are not uncommon and can lead to significant psycho-social challenges in the community. [ABSTRACT FROM AUTHOR]

Background: Rickettsioses are infectious diseases which are caused by intracellular bacteria which belong to the family Rickettsiaceae. This zoonosis endemically prefers tropical and subtropical regions of which the Mediterranean is included. Murine typhus is a type of rickettsial disease that commonly presents with undulating fever, headache rash, chills, malaise, and myalgias. It can lead to complications such as multi-organ failure and has a lethality rate of <5% in such cases. Case Presentation: A 70-year-old male was hospitalized at the Unit of Infectious Diseases, Mother Teresa Hospital, Tirana, Albania in a comatose condition. He had a seven-day history of fever up to 39-40°C, headache, fatigue, anorexia, vomiting, cough, and myalgia. He was a farmer and had contact with animals. Upon admission, he had scleral hemorrhages, hepatosplenomegaly, jaundice, maculopapular rash over the trunk, abdomen, and palms of his hands as well as severe acidosis, depressed bicarbonate levels, alteration in liver, kidney, and pancreas function tests. He was urgently transferred to the Intensive care unit of the Infectious Diseases Department. He was hemodynamically unstable and was put immediately on vasoactive agents and mechanical ventilation. ELISA Rickettsia typhi IgM resulted positive. Supportive treatment along with antibiotics Levofloxacin and Ceftriaxone was initiated. However, the patient died on the 4th day of hospitalization and the 11th of the disease onset. Conclusion: Murine typhus should be included in the investigation of possible causes when dealing with patients presenting with fever and maculopapular rash complicated by multi-organ failure and coming from a typhus-endemic area, especially in the summer season. [ABSTRACT FROM AUTHOR]

Background: Thyroid storm can be complicated by liver dysfunction, which may occasionally progress to acute liver failure. We herein report a case of acute liver failure following thyroid storm that was treated with living donor liver transplantation after resuscitation from cardiopulmonary arrest. Case report: The patient was a woman in her 40 s who had been diagnosed with an abnormal thyroid function. She suffered from fatigue and vomiting, and was found to have consciousness disorder, a fever, and tachycardia with a neck mass. She was diagnosed with thyroid storm and was referred to our hospital. After arrival, she went into cardiopulmonary arrest and veno-arterial extracorporeal membrane oxygenation was initiated. In addition to treatment for thyroid storm with antithyroid drugs, steroids, and plasma exchange, extracorporeal life support was required for 5 days. However, despite improvements in her thyroid function, her liver function deteriorated. We planned living donor liver transplantation for acute liver failure after ensuring the recovery and control of the thyroid function following total thyroidectomy. The donor was her husband who donated the right lobe of his liver. Although she experienced acute cellular rejection after surgery, and other complications—including intra-abdominal hemorrhaging and ischemic changes in the intestine—her liver function and general condition gradually improved. One year after living donor liver transplantation, the patient was in a good condition with a normal liver function. Conclusions: To our knowledge, this is the first report of living donor liver transplantation in a patient with acute liver failure following thyroid storm. Liver transplantation should be recognized as an effective treatment for acute liver failure following thyroid storm. [ABSTRACT FROM AUTHOR]

End-stage heart failure-related cardiogenic shock (HF-CS) is associated with high risk of short-term mortality, but the causes and mode of death in HF-CS have not been described. This study aimed to (i) describe the causes/modes of death in patients with HF-CS based on the phases-of-care (Rescue-Optimization-Stabilization-Exit therapy), analogous to the phase-of-care mortality analysis, and (ii) assess the impact of the introduction of a standardized team-based care. We included 120 consecutive patients with HF-CS who underwent temporary mechanical circulatory support. The introduction of standardized team-based care reduced mortality at 6 months (36/63 (57%) vs 17/57 (30%), p = 0.003), but did not alter the distribution of phase-of-care mortality. There were fewer deaths following heart transplantation/left ventricular assist device therapy with standardized team-based care (6% vs 28%, p = 0.067) may be clinically relevant.

Abstract Background Leptospirosis is an infectious disease caused by pathogenic Leptospira spp., which could result in severe illnesses. Indirect contact with these pathogens is more common. Individuals could contract this disease through contact with contaminated water or during floods. In this case, we present the details of a 40-year-old male pig farmer who suffered from severe pulmonary hemorrhagic leptospirosis and multiple organ failure. The diagnosis of leptospirosis was confirmed through metagenomics next-generation sequencing (mNGS) while the patient received extracorporeal membrane oxygenation (ECMO) support, and antibiotic treatment was adjusted accordingly. The patient underwent comprehensive treatment and rehabilitation in the intensive care unit. Conclusion This case illustrates the importance of early diagnosis and treatment of leptospirosis. While obtaining the epidemiological history, second-generation metagenomics sequencing was utilized to confirm the etiology. The prompt initiation of ECMO therapy provided a crucial window of opportunity for addressing the underlying cause. This case report offers valuable insights for diagnosing patients with similar symptoms.

Abstract Background Critically ill patients with cirrhosis and ascites are at high risk for intra-abdominal hypertension (IAH) which increases mortality. Clinical guidelines recommend maintaining intra-abdominal pressure (IAP) below 16 mmHg; nonetheless, more than three quarters of critically ill patients with cirrhosis develop IAH during their first week of ICU stay. Standard-of-care intermittent large-volume paracentesis (LVP) relieves abdominal wall tension, reduces IAP, optimizes abdominal perfusion pressure, and is associated with short-term improvement in renal and pulmonary dysfunction. However, there is no evidence of the superiority of different paracentesis strategies in the prevention and treatment of IAH in critically ill patients with cirrhosis. This trial aims to compare the outcomes of continuous passive paracentesis versus LVP in the prevention and treatment of IAH in patients with cirrhosis and ascites. Methods An investigator-initiated, open label, randomized controlled trial, set in a general ICU specialized in liver disease, was initiated in August 2022, with an expected duration of 36 months. Seventy patients with cirrhosis and ascites will be randomly assigned, in a 1:1 ratio, to receive one of two methods of therapeutic paracentesis. A stratified randomization method, with maximum creatinine and IAP values as strata, will homogenize patient baseline characteristics before trial group allocation, within 24 h of admission. In the control group, LVP will be performed intermittently according to clinical practice, with a maximum duration of 8 h, while, in the intervention group, continuous passive paracentesis will drain ascitic fluid for up to 7 days. The primary endpoint is serum creatinine concentration, and secondary endpoints include IAP, measured creatinine clearance, daily urine output, stage 3 acute kidney injury and multiorgan dysfunction assessed at day 7 after enrollment, as well as 28-day mortality rate and renal replacement therapy-free days, and length-of-stay. Prespecified values will be used in case of renal replacement therapy or, beforehand ICU discharge, liver transplant and death. Safety analysis will include paracentesis-related complication rate and harm. Data will be analyzed with an intention-to-treat approach. Discussion This is the first trial to compare the impact of different therapeutic paracentesis strategies on organ dysfunction and outcomes in the prevention and treatment of IAH in critically ill patients with cirrhosis and ascites. Trial registration ClinicalTrials.gov NCT04322201 . Registered on 20 December 2019

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading pathogen responsible for bacteremia and valvular endocarditis. In patients with Coronavirus Disease 2019 (COVID-19), MRSA co-infection represents a challenging scenario, with increased morbidity and mortality.

Background: Leptospirosis is an infectious disease caused by pathogenic Leptospira spp., which could result in severe illnesses. Indirect contact with these pathogens is more common. Individuals could contract this disease through contact with contaminated water or during floods. In this case, we present the details of a 40-year-old male pig farmer who suffered from severe pulmonary hemorrhagic leptospirosis and multiple organ failure. The diagnosis of leptospirosis was confirmed through metagenomics next-generation sequencing (mNGS) while the patient received extracorporeal membrane oxygenation (ECMO) support, and antibiotic treatment was adjusted accordingly. The patient underwent comprehensive treatment and rehabilitation in the intensive care unit. Conclusion: This case illustrates the importance of early diagnosis and treatment of leptospirosis. While obtaining the epidemiological history, second-generation metagenomics sequencing was utilized to confirm the etiology. The prompt initiation of ECMO therapy provided a crucial window of opportunity for addressing the underlying cause. This case report offers valuable insights for diagnosing patients with similar symptoms. [ABSTRACT FROM AUTHOR]

Setting: Paraquat is a highly toxic, herbicide, extensively used in various parts of India. There is no effective treatment for paraquat poison and carries a very high mortality. In India, this compound can be misused for harmful purposes. Objective: A retrospective time-bound descriptive study of paraquat-consumed patients was conducted at Kasturba Hospital, Manipal, from January 1, 2014 to January 31, 2016. Materials and Methods: All the data were analyzed using the SPSS version 16. All the categorical data are expressed in terms of frequency and percentage. Continuous normal variables were expressed in terms of mean ± standard deviation, and skewed variables were expressed in terms of median and quartiles. Chi-square test was used to find the association between the categorical independent variables across the outcome in survivors, nonsurvivors, and those patients who were discharged from the hospital against medical advice. Similarly, Fisher's exact test was performed for those variables, for which 20% of the expected cell count was <5%. Kruskal--Wallis test was used to compare the relationship between the continuous skewed variables across the outcome. Results: A total of 55 paraquat-consumed patients were admitted, out of which 67.27% (n = 37) of patients were men. Only 32.7% (n = 18) of patients were farmers. Oral ulcers were seen in 43.6% (n = 24) of patients. About 65.5% (n = 36) of patients underwent hemoperfusion, 27.3% (n = 15) of patients survived, 47.3% (n = 26) of patients expired, and 25.5% (n = 14) of patients were discharged against medical advice in a critical condition. The presence of respiratory failure, hypotension, need for ventilator supportive therapy, the elevation of levels of blood urea, serum creatinine, and liver enzymes AST and ALT levels were statistically significant in three groups (P < 0.001). Conclusion: Paraquat poisoning is highly fatal. Treatment is expensive and available only in tertiary care hospitals in India. Central and state governments should ensure that it should not be readily accessible to ordinary people and it should be banned progressively. [ABSTRACT FROM AUTHOR]

Abstract Background Drug-induced hypersensitivity syndrome (DIHS), including Stevens-Johnson syndrome (SJS), is a severe rash that often develops 2–6 weeks after the intake of the causative drug; however, its diagnosis is sometimes difficult. This article describes a case in which a patient with DIHS-induced multiple organ failure was successfully treated with blood purification therapy. Case presentation A male patient in his 60s was admitted to our hospital with autoimmune encephalitis. The patient was treated with steroid pulse therapy, acyclovir, levetiracetam, and phenytoin. From the 25th day, he presented with fever (≥ 38 °C) as well as miliary-sized erythema on the extremities and trunk, followed by erosions. DIHS and SJS were suspected; accordingly, levetiracetam, phenytoin, and acyclovir were discontinued. On the 30th day, his condition further deteriorated, and he was admitted to the intensive care unit for ventilatory management. The next day, he developed multi-organ failure and was started on hemodiafiltration (HDF) for acute kidney injury. Although he presented with hepatic dysfunction and the appearance of atypical lymphocytes, he did not meet the diagnostic criteria for DIHS or SJS/toxic epidermal necrolysis. Therefore, he was diagnosed with multi-organ failure caused by severe drug eruption and underwent a 3-day treatment with plasma exchange (PE) in addition to HDF. Accordingly, the patient was diagnosed with atypical DIHS. After being started on blood purification therapy, the skin rash began to disappear; moreover, the organ damage improved, with a gradual increase in urine output. Eventually, the patient was weaned off the ventilator and transferred to the hospital on the 101st day. Conclusions HDF + PE could effectively treat multi-organ failure caused by atypical DIHS, which is difficult to diagnose.

Abstract Background Cumulative research show association of neutrophils and neutrophil extracellular traps (NETs) with poor outcomes in severe COVID-19. However, to date, there is no curative intent therapy able to block neutrophil/NETs-mediated progression of multi-organ dysfunction. Because of emerging neutrophil heterogeneity, the study of subsets of circulating NET-forming neutrophils [NET + Ns] as mediators of multi-organ failure progression among patients with COVID-19 is critical to identification of therapeutic targets. Methods We conducted a prospective observational study of circulating levels of CD11b + [NET + N] immunotyped for dual endothelin-1/signal peptide receptor (DEspR ±) expression by quantitative immunofluorescence-cytology and causal mediation analysis. In 36 consented adults hospitalized with mod-severe COVID-19, May to September 2020, we measured acute multi-organ failure via SOFA-scores and respiratory failure via SaO2/FiO2 (SF)-ratio at time points t1 (average 5.5 days from ICU/hospital admission) and t2 (the day before ICU-discharge or death), and ICU-free days at day28 (ICUFD). Circulating absolute neutrophil counts (ANC) and [NET + N] subset-specific counts were measured at t1. Spearman correlation and causal mediation analyses were conducted. Results Spearman correlation analyses showed correlations of t1-SOFA with t2-SOFA (rho r S = 0.80) and ICUFD (r S = -0.76); circulating DEspR + [NET + Ns] with t1-SOFA (r S = 0.71), t2-SOFA (r S = 0.62), and ICUFD (r S = -0.63), and ANC with t1-SOFA (r S = 0.71), and t2-SOFA (r S = 0.61). Causal mediation analysis identified DEspR + [NET + Ns] as mediator of 44.1% [95% CI:16.5,110.6] of the causal path between t1-SOFA (exposure) and t2-SOFA (outcome), with 46.9% [15.8,124.6] eliminated when DEspR + [NET + Ns] were theoretically reduced to zero. Concordantly, DEspR + [NET + Ns] mediated 47.1% [22.0,72.3%] of the t1-SOFA to ICUFD causal path, with 51.1% [22.8,80.4%] eliminated if DEspR + [NET + Ns] were reduced to zero. In patients with t1-SOFA > 1, the indirect effect of a hypothetical treatment eliminating DEspR + [NET + Ns] projected a reduction of t2-SOFA by 0.98 [0.29,2.06] points and ICUFD by 3.0 [0.85,7.09] days. In contrast, there was no significant mediation of SF-ratio through DEspR + [NET + Ns], and no significant mediation of SOFA-score through ANC. Conclusions Despite equivalent correlations, DEspR + [NET + Ns], but not ANC, mediated progression of multi-organ failure in acute COVID-19, and its hypothetical reduction is projected to improve ICUFD. These translational findings warrant further studies of DEspR + [NET + Ns] as potential patient-stratifier and actionable therapeutic target for multi-organ failure in COVID-19.

Abstract Background Dettol and sodium hypochlorite have wide use as household disinfectants and cleaners. Intentional and nonintentional ingestion are widespread, mainly causing mild symptoms that require no specific treatment. However, severe complications can occur when large volumes are ingested. Both products affect the same organ systems in the body, which can result in fatalities when ingested together. Case presentation We present the case of a 26-year-old Asian man who died from multiorgan failure after deliberately ingesting a presumed large volume of Dettol and sodium hypochlorite. The case illustrates the severe complications that can occur with mixed ingestion of these commonly used household products. Conclusion Clinicians must be aware of the increased risk of death caused by the combined ingestion of chloroxylenol and sodium hypochlorite.

Background: Critically ill patients with cirrhosis and ascites are at high risk for intra-abdominal hypertension (IAH) which increases mortality. Clinical guidelines recommend maintaining intra-abdominal pressure (IAP) below 16 mmHg; nonetheless, more than three quarters of critically ill patients with cirrhosis develop IAH during their first week of ICU stay. Standard-of-care intermittent large-volume paracentesis (LVP) relieves abdominal wall tension, reduces IAP, optimizes abdominal perfusion pressure, and is associated with short-term improvement in renal and pulmonary dysfunction. However, there is no evidence of the superiority of different paracentesis strategies in the prevention and treatment of IAH in critically ill patients with cirrhosis. This trial aims to compare the outcomes of continuous passive paracentesis versus LVP in the prevention and treatment of IAH in patients with cirrhosis and ascites. Methods: An investigator-initiated, open label, randomized controlled trial, set in a general ICU specialized in liver disease, was initiated in August 2022, with an expected duration of 36 months. Seventy patients with cirrhosis and ascites will be randomly assigned, in a 1:1 ratio, to receive one of two methods of therapeutic paracentesis. A stratified randomization method, with maximum creatinine and IAP values as strata, will homogenize patient baseline characteristics before trial group allocation, within 24 h of admission. In the control group, LVP will be performed intermittently according to clinical practice, with a maximum duration of 8 h, while, in the intervention group, continuous passive paracentesis will drain ascitic fluid for up to 7 days. The primary endpoint is serum creatinine concentration, and secondary endpoints include IAP, measured creatinine clearance, daily urine output, stage 3 acute kidney injury and multiorgan dysfunction assessed at day 7 after enrollment, as well as 28-day mortality rate and renal replacement therapy-free days, and length-of-stay. Prespecified values will be used in case of renal replacement therapy or, beforehand ICU discharge, liver transplant and death. Safety analysis will include paracentesis-related complication rate and harm. Data will be analyzed with an intention-to-treat approach. Discussion: This is the first trial to compare the impact of different therapeutic paracentesis strategies on organ dysfunction and outcomes in the prevention and treatment of IAH in critically ill patients with cirrhosis and ascites. Trial registration: ClinicalTrials.gov NCT04322201. Registered on 20 December 2019 [ABSTRACT FROM AUTHOR]

Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios. [ABSTRACT FROM AUTHOR]

Setting: Paraquat is a highly toxic, herbicide, extensively used in various parts of India. There is no effective treatment for paraquat poison and carries a very high mortality. In India, this compound can be misused for harmful purposes. Objective: A retrospective time-bound descriptive study of paraquat-consumed patients was conducted at Kasturba Hospital, Manipal, from January 1, 2014 to January 31, 2016. Materials and Methods: All the data were analyzed using the SPSS version 16. All the categorical data are expressed in terms of frequency and percentage. Continuous normal variables were expressed in terms of mean ± standard deviation, and skewed variables were expressed in terms of median and quartiles. Chi-square test was used to find the association between the categorical independent variables across the outcome in survivors, nonsurvivors, and those patients who were discharged from the hospital against medical advice. Similarly, Fisher's exact test was performed for those variables, for which 20% of the expected cell count was

Abstract Background Herpes simplex virus (HSV) rarely causes organ-invasive infection. Diagnosis and treatment for such infections are often delayed, and mortality is high. We present the first reported case of disseminated HSV-1 infection in an adult causing liver failure, myocarditis, and encephalitis in a patient who recovered after receiving parenteral acyclovir treatment. Case presentation A 46-year-old female presented with fever, chills, and malaise after 2 weeks of oral corticosteroid treatment for uveitis. She was diagnosed with disseminated HSV-1 infection with multi-organ involvement causing hepatitis, encephalitis, and myocarditis. Diagnosis was made timely using serum polymerase chain reaction (PCR) for HSV DNA and the patient was given intravenous acyclovir treatment promptly, which led to her survival without significant morbidity. Conclusions Clinicians should have a low threshold for suspecting HSV infection and ordering HSV PCR to decrease morbidity and mortality when there is a high clinical suspicion of systemic HSV infection with multi-organ involvement. Serum PCR for HSV DNA is an excellent modality for an initial diagnostic approach. Further research is warranted to elucidate causality between a course of corticosteroid therapy and systemic HSV-1 infection without major immunosuppressive comorbidities or treatments.

Background: Drug-induced hypersensitivity syndrome (DIHS), including Stevens-Johnson syndrome (SJS), is a severe rash that often develops 2–6 weeks after the intake of the causative drug; however, its diagnosis is sometimes difficult. This article describes a case in which a patient with DIHS-induced multiple organ failure was successfully treated with blood purification therapy. Case presentation: A male patient in his 60s was admitted to our hospital with autoimmune encephalitis. The patient was treated with steroid pulse therapy, acyclovir, levetiracetam, and phenytoin. From the 25th day, he presented with fever (≥ 38 °C) as well as miliary-sized erythema on the extremities and trunk, followed by erosions. DIHS and SJS were suspected; accordingly, levetiracetam, phenytoin, and acyclovir were discontinued. On the 30th day, his condition further deteriorated, and he was admitted to the intensive care unit for ventilatory management. The next day, he developed multi-organ failure and was started on hemodiafiltration (HDF) for acute kidney injury. Although he presented with hepatic dysfunction and the appearance of atypical lymphocytes, he did not meet the diagnostic criteria for DIHS or SJS/toxic epidermal necrolysis. Therefore, he was diagnosed with multi-organ failure caused by severe drug eruption and underwent a 3-day treatment with plasma exchange (PE) in addition to HDF. Accordingly, the patient was diagnosed with atypical DIHS. After being started on blood purification therapy, the skin rash began to disappear; moreover, the organ damage improved, with a gradual increase in urine output. Eventually, the patient was weaned off the ventilator and transferred to the hospital on the 101st day. Conclusions: HDF + PE could effectively treat multi-organ failure caused by atypical DIHS, which is difficult to diagnose. [ABSTRACT FROM AUTHOR]

Background: Dettol and sodium hypochlorite have wide use as household disinfectants and cleaners. Intentional and nonintentional ingestion are widespread, mainly causing mild symptoms that require no specific treatment. However, severe complications can occur when large volumes are ingested. Both products affect the same organ systems in the body, which can result in fatalities when ingested together. Case presentation: We present the case of a 26-year-old Asian man who died from multiorgan failure after deliberately ingesting a presumed large volume of Dettol and sodium hypochlorite. The case illustrates the severe complications that can occur with mixed ingestion of these commonly used household products. Conclusion: Clinicians must be aware of the increased risk of death caused by the combined ingestion of chloroxylenol and sodium hypochlorite. [ABSTRACT FROM AUTHOR]

Copyright of Summa, Animali da Compagnia is the property of Point Veterinaire Italie s.r.l. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

COVID-19 disease caused by the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), started in December 2019 in Wuhan, China, and quickly became the global pandemic. The high spread rate, relatively high mortality rate, and the lack of specific medicine have led researchers and clinicians worldwide to find new treatment strategies. Unfortunately, evidence shows that the virus-specific receptor Angiotensin-Converting Enzyme 2 (ACE-2) is present on the surface of most cells in the body, leading to immune system dysfunction and multi-organ failure in critically ill patients. In this context, the use of Mesenchymal Stem Cells (MSCs) and their secret has opened new therapeutic horizons for patients due to the lack of ACE2 receptor expression. MSCs exert their beneficial therapeutic actions, particularly anti-inflammatory and immunomodulatory properties, mainly through paracrine effects which are mediated by exosomes. Exosomes are bilayer nanovesicles that carry a unique cargo of proteins, lipids and functional nucleic acids based on their cell origin. This review article aims to investigate the possible role of exosomes and the underlying mechanism involved in treating COVID-19 disease based on recent findings.

Alpha lipoic acid (ALA) is an anti-oxidant found in many over-the-counter supplements and is used in treatments for diabetes, hypertension, and obesity. Although it is a safe oral molecule, there have been eight cases of ALA toxicity reported. Three reported cases were among adult patients and five were among pediatric patients. A 14-year-old girl died after ingestion of 6 g of ALA leading to multi-organ failure. A 42-year-old woman presented to the emergency department 4 h after an intentional overdose of 10 tablets of ALA 600 mg each (6 g, 92.3 mg/kg). She developed refractory seizures, metabolic acidosis, thrombocytopenia, rhabdomyolysis, depressed cardiac contractility, kidney injury, and supraventricular tachycardia. Her condition deteriorated and she developed multi-organ failure. The patient was started on dual pressors, anti-epileptic medications, high-dose insulin and euglycemia protocol, and methylene blue (1 mg/kg). Despite aggressive resuscitation, she required intubation and died. This was the ninth case and the first reported adult mortality from ALA toxicity with multi-organ failure. Our case shared some similar findings with previously reported cases, including refractory seizures, metabolic acidosis, thrombocytopenia, and rhabdomyolysis. Refractory supraventricular tachycardia and severe agitation have not been reported with ALA toxicity previously. The range of toxicity of ALA is not well established. A reported dose of 6 g caused death in a pediatric patient as well as our patient, but others survived doses of 6 g and 18 g. Toxicologists and emergency physicians should be prepared for clinical deterioration and consider aggressive resuscitation in severe ALA toxicity. [ABSTRACT FROM AUTHOR]

Sepsis leads to multi-organ failure due to aggressive systemic inflammation, which is one of the main causes of death clinically. This study aimed to evaluate whether ginseng sprout extracts (GSE) can rescue sepsis and explore its underlying mechanisms. C57BL/6J male mice (n = 15/group) were pre-administered with GSE (25, 50, and 100 mg/kg, p.o) for 5 days, and a single injection of lipopolysaccharide (LPS, 30 mg/kg, i.p) was administered to construct a sepsis model. Additionally, RAW264.7 cells were treated with LPS with/without GSE/its main components (Rd and Re) to explain the mechanisms corresponding to the animal-derived effects. LPS injection led to the death of all mice within 38 h, while GSE pretreatment delayed the time to death. GSE pretreatment also notably ameliorated LPS-induced systemic inflammation such as histological destruction in both the lung and liver, along with reductions in inflammatory cytokines, such as TNF-α, IL-6, and IL-1β, in both tissues and serum. Additionally, GSE markedly diminished the drastic secretion of nitric oxide (NO) by suppressing the expression levels of inducible nitric oxide synthase (iNOS) and cyclooxygenase 2 (COX2) in both tissues. Similar changes in TNF-α, IL-1β, NO, iNOS, and COX2 were observed in LPS-stimulated RAW264.7 cells, and protein expression data and nuclear translocation assays suggested GSE could modulate LPS-binding protein (LBP), Toll-like receptor 4 (TLR4), and NF-κB. Ginsenoside Rd could be a major active component in GSE that produces the anti-sepsis effects. Our data support that ginseng sprouts could be used as an herbal resource to reduce the risk of sepsis. The corresponding mechanisms may involve TLR4/NF-κB signaling and a potentially active component. [ABSTRACT FROM AUTHOR]

Background: Sepsis is a complex, life-threatening, heterogeneous infectious disease associated with increased rates of morbidity and mortality. Early assessment of the prognosis of sepsis is key to achieving a favorable outcome for the disease. This study aimed to identify the prognostic value of PCT for sepsis patients. Materials and Methods: We conducted a prospective analytical study involving 100 adult patients with sepsis who were admitted to the Medicine dept and intensive care unit from 2019 to 2020.At least one blood test for PCT level was performed for all patients within the first 24 hours of suspecting an infection. Results: Our study found that a maximum number of patients (43.0%) were between 51-60 years age group, mean age of the patient was 49.35 ± 11.7 years. Out of 100 cases, 65% were male and 35% were female. The male and female ratio was 1.85:1. In this study serum, procalcitonin levels 0.5-2.0 ng/were detected in 15.0% of patients with mean±SD 1.3±0.8. Serum procalcitonin levels 2.1-10.0 ng/mL were detected in 29.0% of patients with mean±SD 5.9±2.5 and >10.0 ng/mL was detected in 56 patients. Based on the receiver-operator characteristic (ROC) curves, procalcitonin had the area under curve 0.923, with 89.4% sensitivity and 87.5% specificity. In our study, procalcitonin showed the best predictive value for the short-term outcome of sepsis with a cut-off value of 14.8 ng/mL (AUC 0.923). Study shows that 76.0% of the patients recovered completely, but 24.0% of patients expired during the hospital stay. Conclusion: There was a statistically significant correlation in serum procalcitonin with the outcome of sepsis (p < 0.001). So the effectiveness of serum procalcitonin has proven significant in the prediction of mortality in sepsis patients. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has driven an upheaval of new research, providing key insights into the pathogenesis of this disease. Lymphocytopenia, hyper-inflammation and cardiac involvement are prominent features of the disease and have prognostic value. However, the mechanistic links among these phenomena are not well understood. Likewise, some COVID-19 patients exhibit multi-organ failure with diseases affecting the cardiac system, appearing to be an emerging feature of the COVID-19 pandemic. Neutrophil extracellular traps (NETs) have been frequently correlated with larger infarct sizes and can predict major adverse cardiac events. However, the exact mechanism behind this remains unknown. Although the excessive NET formation can drive inflammation, particularly endothelial and promote thrombosis, it is essential to normal immunity. In this paper, we postulate the role of NETs in cardiac disease by providing an overview of the relationship between NET and inflammasome activities in lung and liver diseases, speculating a link between these entities in cardiac diseases as well. Future research is required to specify the role of NETs in COVID-19, since this carries potential therapeutic significance, as inhibition of NETosis could alleviate symptoms of this disease. Knowledge gained from this could serve to inform the assessment and therapeutics of other hyper inflammatory diseases affecting the heart and vasculature alike.

Background: Herpes simplex virus (HSV) rarely causes organ-invasive infection. Diagnosis and treatment for such infections are often delayed, and mortality is high. We present the first reported case of disseminated HSV-1 infection in an adult causing liver failure, myocarditis, and encephalitis in a patient who recovered after receiving parenteral acyclovir treatment.Case Presentation: A 46-year-old female presented with fever, chills, and malaise after 2 weeks of oral corticosteroid treatment for uveitis. She was diagnosed with disseminated HSV-1 infection with multi-organ involvement causing hepatitis, encephalitis, and myocarditis. Diagnosis was made timely using serum polymerase chain reaction (PCR) for HSV DNA and the patient was given intravenous acyclovir treatment promptly, which led to her survival without significant morbidity.Conclusions: Clinicians should have a low threshold for suspecting HSV infection and ordering HSV PCR to decrease morbidity and mortality when there is a high clinical suspicion of systemic HSV infection with multi-organ involvement. Serum PCR for HSV DNA is an excellent modality for an initial diagnostic approach. Further research is warranted to elucidate causality between a course of corticosteroid therapy and systemic HSV-1 infection without major immunosuppressive comorbidities or treatments. [ABSTRACT FROM AUTHOR]

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Inhalant misuse is a growing concern among Americans. According to recent reports by the National Institutes of Health and the Substance Abuse and Mental Health Services Administration, the prevalence of teenage inhalant misuse is increasing. Of the many household items that are "huffed", refrigerant-based propellant cleaners or air dusters, are one of the most misused. Although commonly referred to as "compressed air", refrigerant-based propellant cleaners contain harmful fluorinated hydrocarbons, such as 1,1-difluoroethane, that have significant toxic effects when inhaled. While the central nervous system is primarily affected, there are case reports of cardiovascular, renal, hepatic, and musculoskeletal injury secondary to 1,1-difluoroethane toxicity. However, there are few cases that have presented 1,1-difluoroethane toxicity leading to multi-organ system failure in adults with a long history of inhalant misuse. We present a unique case of multi-system organ failure secondary to 1,1-difluoroethane toxicity in a middle-aged female that was "huffing" a refrigerant-based propellant aerosol duster for more than three months. This case stresses the importance of obtaining a detailed social history to identify inhalant misuse in patients that present with acute illness of unknown etiology. This case also highlights the importance of early communication with toxicology professionals for treatment and supportive care recommendations in patients presenting the life-threatening 1,1-difluoroethane toxicity. Furthermore, this case demonstrates that 1,1-difluoroethane toxicity in the setting of "huffing" air duster has the potential to cause multi-organ system failure. [ABSTRACT FROM AUTHOR]

Antimicrobial therapy is often a life-saving medical intervention for inpatients and outpatients. Almost all medical disciplines are involved in this therapeutic procedure. Knowledge of adverse drug reactions (ADRs) and drug-drug interactions (DDIs) is important to avoid drug-related harm. Within the broad spectrum of antibiotic and antifungal therapy, most typical ADRs are known to physicians. The aim of this study was to evaluate relevant pharmacological aspects with which we are not so familiar and to provide further practical guidance. Individual pharmacotherapy management (IPM) as a synopsis of internal medicine and clinical pharmacology based on the entirety of the digital patient information with reference to drug information, guidelines, and literature research has been continuously performed for over 8 years in interdisciplinary intensive care and trauma and transplant patients. Findings from over 52,000 detailed medication analyses highlight critical ADRs and DDIs, especially in these vulnerable patients with polypharmacy. We present the most relevant ADRs and DDIs in antibiotic and antifungal pharmacology, which are less frequently considered in relation to neurologic, hemostaseologic, hematologic, endocrinologic, and cardiac complexities. Constant awareness and preventive strategies help avoid life-threatening manifestations of these inherent risks and ensure patient and drug safety in antimicrobial therapy. [ABSTRACT FROM AUTHOR]

Background: Multiple organ failure is a common complication in patients undergoing ECLS significantly affecting patient outcomes. Gaining knowledge about the mechanisms of onset, clinical course, risk factors, and potential therapeutic targets is highly desirable. Methods: Data of 354 patients undergoing ECLS with one‐, two, three‐, and four organ failures were retrospectively analyzed. Incidence of multiple organ dysfunction (MODS), its impact on survival, risk factors for its occurrence, and the impact of proinflammatory mediators on the occurrence of MODS in patients undergoing ECLS were investigated. Results: The median follow‐up was 66 (IQR 6; 820) days. 245 (69.2%) patients could be weaned from ECLS, 30‐day survival and 1‐year survival were 194 (54.1%) and 157 (44.4%), respectively. The duration of mechanical support was 4 (IQR 2; 7) days in the median. Increasing severity of MODS resulted in significant prolongation of mechanical circulatory support and worsening of the outcome. Liver dysfunction had the strongest impact on patient mortality (OR = 2.5) and survival time (19 vs 367 days). The serum concentration of analyzed interleukins rose significantly with each, additional organ affected by dysfunction (p < 0.001). All analyzed proinflammatory cytokines showed significant predictivity relative to the occurrence of MODS with interleukin 8 serum level prior to ECLS showing the strongest predictive potential for the occurrence of MODS (AUC 0.78). Conclusion: MODS represents a frequent complication in patients undergoing ECLS with a significant impact on survival. Proinflammatory cytokines show prognostic capacity regarding the occurrence and severity of multi‐organ dysfunction. [ABSTRACT FROM AUTHOR]

Vector-Borne disease represent a significant global public health issue, with tsutsugamushi disease (TD) being a notable zoonotic disease transmitted through the bites of chigger larvae. TD is associated with a broad spectrum of complications and is characterized by high rates of morbidity and mortality. Diagnostic, therapeutic, and care standards for TD differ across regions worldwide, and there is a dearth of documented care cases. This case report details a critical TD presentation involving infectious shock and multiple organ failure. After nine days of intensive treatment and nursing intervention, which included correction of hypoxemia, anti-infection measures, antispasmodic and asthmatic management, and stabilization of the internal environment, the patient's condition was effectively managed., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

3, 4-methylenedioxyamphetamine (MDMA) has gained significance over the years, especially at rave festivals, as a recreational drug for its noted effects in mood enhancement and autonomic stimulation. While these effects have been noted, severe adverse outcomes, and even death, following the ingestion of MDMA have been recorded. We present a 35-year-old male who ingested the drug at the Electric Daisy Carnival (EDC), the largest electronic dance music festival in North America as of 2024 [1]. Every year, many young adults are brought to local hospitals from the festival for drug overdoses, hyperthermia, and dehydration. At the festival, the patient was witnessed to have a seizure, presented with altered mental status and deemed hyperthermic at 109 degrees Fahrenheit. For these reasons, he was rapidly intubated and submerged in an ice bath at the festival's medical tent. At the county hospital, the patient was diagnosed with multiorgan failure, cerebrovascular ischemia, and coagulopathy. He received life-saving treatment such as continuous renal replacement therapy as well as intubation for acute hypoxemic respiratory failure. MRI of the brain showed central- embolic infarcts and the patient was closely monitored in the intensive care unit (ICU) for eight days. After twenty days of inpatient treatment, the patient was discharged. He was discharged with his mental status at baseline and without gross neurologic deficits. A permacath was placed for hemodialysis to be continued outpatient. This case report highlights the importance of prompt medical management which can be crucial for patient survival following a life-threatening overdose with MDMA. It also exemplifies the need for increasing social awareness regarding the severe and detrimental outcomes an MDMA overdose can cause as this drug continues to be widely used in the setting of rave and music festivals., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Authors.)

Major thermal injury induces a complex pathophysiological state characterized by burn shock and hypercatabolism. Steroids are used to modulate these post-injury responses. However, the effects of steroids on acute post-burn outcomes remain unclear. In this study of 52 thermally injured adult patients (median total burn surface area 42%, 33 males and 19 females), the effects of corticosteroid and oxandrolone on mortality, multi-organ failure (MOF), and sepsis were assessed individually. Clinical data were collected at days 1, 3, 7, and 14 post-injury. Twenty-two (42%) and 34 (65%) burns patients received corticosteroids and oxandrolone within the same cohort, respectively. Following separate analysis for each steroid, corticosteroid use was associated with increased odds of in-hospital mortality (OR 3.25, 95% CI: 1.32–8•00), MOF (OR 2.36, 95% CI: 1.00–1.55), and sepsis (OR 5.95, 95% CI: 2.53–14.00). Days alive (HR 0.32, 95% CI: 0.18–0.60) and sepsis-free days (HR 0.54, 95% CI: 0.37–0.80) were lower among corticosteroid-treated patients. Oxandrolone use was associated with reduced odds of 28-day mortality (OR 0.11, 95% CI: 0.04–0.30), in-hospital mortality (OR 0.19, 95% CI: 0.08–0.43), and sepsis (OR 0.24, 95% CI: 0.08–0.69). Days alive, at 28 days (HR 6.42, 95% CI: 2.77–14.9) and in-hospital (HR 3.30, 95% CI: 1.93–5.63), were higher among the oxandrolone-treated group. However, oxandrolone was associated with increased MOF odds (OR 7.90, 95% CI: 2.89–21.60) and reduced MOF-free days (HR 0.23, 95% CI: 0.11–0.50). Steroid therapies following major thermal injury may significantly affect patient prognosis. Oxandrolone was associated with better outcomes except for MOF. Adverse effects of corticosteroids and oxandrolone should be considered when managing burn patients. [ABSTRACT FROM AUTHOR]

Some coronavirus disease-2019 (COVID-19) patients exhibit multi-organ failure, which often includes the liver. Indeed, liver disease appears to be an emerging feature of COVID-19 infections. However, the exact mechanism behind this remains unknown. Neutrophil extracellular traps (NETs) have increasingly been attributed as major contributors to various liver pathologies, including sepsis, ischemic-reperfusion (I/R) injury, and portal hypertension in the setting of chronic liver disease. Although vital in normal immunity, excessive NET formation can drive inflammation, particularly of the endothelium. Collectively, we propose that NETs observed to be elevated in severe COVID-19 infection play principal roles in liver injury in addition to acute lung injury. Herein, we discuss the potential mechanisms underlying COVID-induced liver injury including cytopathic effects from direct liver infection, systemic inflammatory response syndrome, and hypoxic injury, encompassing I/R injury and coagulopathy. Further research is required to further elucidate the role of NETs in COVID. This holds potential therapeutic significance, as inhibition of NETosis could alleviate the symptoms of acute respiratory distress syndrome and liver injury, as well as other organs. [ABSTRACT FROM AUTHOR]