Resectable single hepatic epithelioid hemangioendothelioma in the left lobe of the liver: a case report

Hepatic epithelioid hemangioendothelioma (HEHE) is an extremely rare malignancy of vascular origin. When most patients with HEHE are diagnosed, they have a diffuse nodular phenotype, which is usually unresectable. A single nodular phenotype is found in only a small proportion (13%) of patients, and most are reported to be located in the right lobe of the liver. Although the prognosis of HEHE is considered more favorable than that of other hepatic malignant tumors, the 5-year survival rate is reported to be 64% after treatment. Herein, we present an unusual case of resectable HEHE of a single nodular type in the left lobe of the liver. The patient survived 15 years without recurrence after the multimodal treatment of radical resection and postoperative chemotherapy with thalidomide. The aim of the present study is to emphasize that multimodal treatment of radical resection followed by chemotherapy with thalidomide may achieve a relatively good survival outcome in patients with resectable HEHE of a single nodular type.

AN OBSERVATIONAL STUDY OF 11 CASES OF CARTAP POISONING - A RARE POISONING

Objective: Cartap hydrochloride poisoning is an uncommon poisoning encountered in India. The aim of this study was to assess the characteristics, severity, management, and outcome of patients with Cartap poisoning, treated with N-acetylcysteine (NAC) in intensive care unit (ICU) of a tertiary referral hospital.Methods: This is a retrospective study where 11 cases of Cartap poisoning admitted to hospital ICU between 2011 and 2016 were identified from the case records. The demographic data, mode of ingestion, time to treat, ingested dose and severity of poisoning, presenting features, duration of mechanical ventilation (MV), dose of NAC used, complications, and outcome were noted.Results: Patients were scored as moderate or severe cases of poisoning. Severe cases consumed >10 g, underwent gastric lavage > 4 hrs, and took Cartap concomitantly with alcohol or in empty stomach. Duration of MV varied from 68-94 hrs in severe cases and 12-48 hrs in moderate cases. Average dose of NAC in severe case was 11.19 g and moderate case was 8.89 g. The most common presenting symptoms were vomiting, altered sensorium, and breathlessness. Severe cases had more complications, and the most common complication was hypotension followed by seizures. Survival was 100%.Conclusion: 50% of Cartap poisoning cases had good survival outcome. Severity of poisoning depends on amount of Cartap ingested, time taken for gastric lavage, and concomitant administration of alcohol. Duration of MV and dose of NAC and complications encountered correlates with the severity of poisoning.

Abstract 3: Defining the Association of Do-Not-Attempt-Resuscitate Orders with Patients’ Likelihood of Survival after In-Hospital Cardiac Arrest

Background: The long-term prognosis after In-Hospital Cardiac Arrest (IHCA) is variable, but often triggers discussions about further resuscitative efforts. Whether Do-Not-Attempt-Resuscitation (DNAR) orders after IHCA are aligned with patients’ likelihood of meaningful neurological survival is unknown. Methods: Using the Get With the Guidelines-Resuscitation registry, we identified 42,537 patients between 1/2000 and 9/2012 who achieved return of spontaneous circulation (ROSC) after IHCA. Each patient’s likelihood of meaningful survival without severe neurological disability (Cerebral Performance Category score ≤2) was calculated using the previously validated CASPRI prediction model. We examined the proportion of patients made DNAR within each CASPRI score decile to determine whether end-of-life decision-making was correlated with predicted likelihood of favorable neurological survival. Results: Overall, 26,198 patients (61.6%) were made DNAR after ROSC. These patients were older (68.7 ± 15.9 vs. 63.1 ± 17.1) and had higher rates of multiple comorbidities (all P <0.05). Among those with the best prognostic CASPRI scores (Decile 1), 34.6% were made DNAR after ROSC, as compared with 74.2% among those with the worst prognosis (Decile 10; P for trend <0.001). (Figure 1) Only 567 (2.2%) patients made DNAR survived to discharge without severe neurological disability. This rate was consistently low even in the CASPRI deciles with a high predicted likelihood of a good survival outcome (e.g., 6.4% in Decile 1). In contrast, 40.4% of patients not made DNAR survived without severe neurological disability, with a substantially higher rate in the lower CASPRI deciles (e.g., 74.7% in Decile 1). Conclusion: Among patients successfully resuscitated from IHCA, we found reassuring evidence that the decision to adopt DNAR status was generally aligned with a patient’s predicted likelihood of meaningful neurological survival. However, discordance between predicted and actual rates of this outcome among DNAR patients with the highest likelihood of survival suggest either competing, unmeasured interests or the need to inform physicians and patients about prognosis when discussing goals of care. Whether the use of the CASPRI score can further assist in these discussions requires prospective testing.