Impact of Silymarin Supplements on Liver Enzyme Levels: A Systematic Review

Silymarin, extracted from milk thistle (Silybum marianum), is esteemed for its antioxidative, anti-inflammatory, and antifibrotic properties, notably within liver-related contexts. Nevertheless, a comprehensive grasp of its effects on liver enzymes remains elusive. This systematic review aims to scrutinize the influence of silymarin supplements on liver enzyme levels, elucidating its potential for hepatoprotection. Following PRISMA 2020 guidelines, we systematically reviewed pertinent studies in PubMed/MEDLINE (Medical Literature Analysis and Retrieval System Online). Our inclusion criteria comprised randomized clinical trials (RCTs) published between 1992 and 2023, accessible in English, with a primary focus on liver enzyme levels. Non-original research, ambiguously defined studies, and those lacking essential data were excluded. Of the 1,707 initially identified articles, 29 RCTs met the inclusion criteria, encompassing 3,846 participants with diverse underlying conditions. Silymarin dosages ranged from 140 mg to 420 mg, administered for various durations. Results revealed that 65.5% of the studies reported reduced liver enzyme levels, 20.7% exhibited no significant change, and 13.8% observed elevated liver enzymes. The systematic review implies a potential advantageous influence of silymarin on liver enzyme levels, indicating its hepatoprotective potential. Nevertheless, outcome disparities may stem from comorbidities, suboptimal doses, and underlying diseases. Notably, silymarin's impact on liver enzymes could be context-dependent, with varying responses among different conditions, with the decrease of liver enzyme levels in patients with non-alcoholic fatty liver disease. Silymarin supplements exhibit potential for hepatoprotection by ameliorating liver enzyme levels across diverse conditions. Further research should ascertain optimal dosages and contexts, accounting for individual patient characteristics and underlying diseases.

Exacerbation of Very Late-Onset Darier Disease With COVID-19 Infection: A Case Report

Darier disease is an uncommon hereditary skin disorder characterized by the presence of hyperkeratotic papules and plaques affecting seborrheic areas. The uniqueness of this case lies in the exceptionally late-onset pattern of Darier disease, involving an 82-year-old female patient, and its correlation with COVID-19 infection. The patient had a history of a scaly and itchy rash limited to her arms, initially misdiagnosed as dermatitis, which persisted and worsened over three months. The manifestation of classical features of Darier disease coincided with her recent contraction of COVID-19. This instance emphasizes the varying manifestations of Darier disease that appear very late in life, which could result from new mutations or partial penetrance. Additionally, this case points out the potential worsening of Darier disease when combined with a COVID-19 infection. It highlights the need to be aware of atypical clinical progressions and the potential for increased severity of skin disorders during COVID-19. More studies are essential to grasp the relationship between COVID-19 and inherited skin conditions, aiming to improve patient treatment and care approaches.

Novel Biomarkers and the Multiple-Marker Approach in Early Detection, Prognosis, and Risk Stratification of Cardiac Diseases: A Narrative Review

Cardiac diseases are a primary cause of mortality worldwide, underscoring the importance of early identification and risk stratification to enhance patient outcomes. Biomarkers have become important tools for the risk assessment of cardiovascular disease and monitoring disease progression. This narrative review focuses on the multiple-marker approach, which involves simultaneously evaluating several biomarkers for the early detection and risk stratification of heart diseases. The review covers the clinical applications of novel biomarkers, such as high-sensitivity troponin, galectin-3, source of tumorigenicity 2, B-type natriuretic peptide and N-terminal pro-B-type natriuretic peptide, growth differentiation factor 15, myeloperoxidase, fatty acid-binding protein, C-reactive protein, lipoprotein-associated phospholipase A2, microRNAs, circulating endothelial cells, and ischemia-modified albumin. These biomarkers have demonstrated potential in identifying people who are at high risk for developing heart disease and in providing prognostic data. Given the complexity of cardiac illnesses, the multiple-marker approach to risk assessment is extremely beneficial. Implementing the multiple-marker strategy can improve risk stratification, diagnostic accuracy, and patient care in heart disease patients.

Retraction: Listerial Meningitis and Brain Abscess With Coexisting COVID-19 Infection in a Young, Immunocompetent Male: A Case Report

[This retracts the article DOI: 10.7759/cureus.29455.].

ANCA-Negative EGPA With Pulmonary, Cutaneous, and Neurological Manifestations in a 25-Year-Old Male: A Case Report

Eosinophilic granulomatosis with polyangiitis is a systemic vasculitis characterized by the presence of asthma, hyper-eosinophilia, and necrotizing vasculitis with extravascular eosinophilic granulomas. We report the case of a 25-year-old male who presented to the outpatient department complaining of joint aches and numbness in the hands and legs. Physical examination revealed erythematous blanchable macular rashes on palms and soles. Raynaud's phenomenon was also observed. Lab workup revealed elevated WBC count and peripheral blood eosinophilia. Antibody tests were positive only for anti-nuclear antibodies. A diagnosis of eosinophilic granulomatosis with polyangiitis including peripheral neuropathy, arthralgia, rash, and pulmonary manifestations was established. The patient was started on a therapeutic regimen of corticosteroids and immunosuppressants, which halted the progression of the disease. Peripheral neuropathy and arthralgia also improved.

Listerial Meningitis and Brain Abscess With Coexisting COVID-19 Infection in a Young, Immunocompetent Male: A Case Report

Listeria monocytogenes (LM) is a gram-positive intracellular pathogen that can cause central nervous system infections such as meningitis, meningoencephalitis, rhombencephalitis, or cerebritis. It rarely causes a brain abscess. Listerial meningitis and brain abscess most commonly occur in immunocompromised individuals, neonates, pregnant females, alcoholics, and the elderly. We present a unique case of a young immunocompetent male who presented with listerial meningitis and brain abscess. Coexisting coronavirus disease 2019 (COVID-19) infection was also present. Since LM was not included in the differentials, the standard antibiotic regimen started for the meningitis therapy was ineffective. Remdesivir was administered to treat the coexisting COVID-19 infection. When the lumbar tap polymerase chain reaction pointed out that the causative agent was Listeria, we shifted to ampicillin and gentamicin therapy, to which the patient responded very effectively.LM is an atypical cause of meningitis and brain abscesses. A high index of suspicion is therefore required for early detection and effective treatment of listerial meningitis and brain abscess.

Cardiovascular Collapse Secondary to Beta-Blocker Administration in a Setting of Coexisting Thyroid Storm and Atrial Fibrillation: A Case Report

A thyroid storm is a rare endocrinological emergency caused by severe hyperthyroidism. Reducing circulating levels of free T3 in blood and beta-adrenergic inhibition are the basis of medical treatment for thyroid storms. Propranolol, due to its additional effect of preventing the peripheral conversion of dormant T4 to active form T3, is the chosen drug for blockade in hyperthyroidism and thyroid storm. We describe a rare clinical case of cardiovascular collapse following propranolol administration in a setting of thyroid storm. The patient presented with symptoms of dyspnea and palpitations and had an ejection fraction of 10%. He was started on a calcium channel blocker (diltiazem). Further investigations revealed that the patient also had a thyroid storm and was immediately shifted to methimazole and propranolol. However, following the administration of a beta-blocker, the patient developed circulatory failure as a result of cardiac arrest, necessitating the use of vasopressors and inotropes. This implores the need for further investigations and treatment regimens for cardiovascular conditions, especially atrial fibrillation arising in thyrotoxicosis, as there are no solid treatment guides in the literature to the best of our knowledge.

Ileocecal Intussusception With Lipoma as a Lead Point Leading to Small Bowel Obstruction in an Elderly Male: A Case Report

Intussusception with a lipoma as a lead point and associated bowel obstruction is very uncommon in adults. The patient presents with abdominal pain and intermittent or sudden intestinal obstruction requiring surgical intervention. We report the case of a 68-year-old male who presented with complaints of severe abdominal pain, nausea, vomiting, and constipation. A CT scan revealed ileocecal intussusception with a lipoma as a lead point. Evidence of small bowel obstruction and ascites was also noted on imaging. The patient underwent an ileocecal resection followed by an ileocolic side-to-side anastomosis. Pathological examination of the specimen revealed two adjacent submucosal lipomas with focal mucosal ischemic hemorrhagic changes of the large distal lipoma. We present this case owing to its rarity and believe that it will serve to broaden the horizon of research regarding intussusceptions secondary to submucosal lipomas.

Early Versus Delayed Treatment for Gartland Type III Supracondylar Humeral Fractures in Children: A Systematic Review and Meta-analysis

PURPOSE

The timing of treatment for Gartland type III supracondylar fractures has been an area of contention as it was previously thought to be a surgical emergency. The aim of this systematic review and meta-analysis is to clarify whether there is a difference in perioperative outcomes between early and delayed treatment for Gartland type III supracondylar humeral fractures in children.

METHODS

Literature search and study selection were performed according to the PRISMA process. The early surgery (ES) and delayed surgery (DS) groups were defined by the authors of each study included, based on the time to surgery. The primary outcome was the risk of conversion to open reduction. The secondary outcome was perioperative complication risks.

RESULTS

A total of 14 studies met the eligibility criteria (n = 1263 patients), of which 665 (52.7%) patients had undergone early surgery, while 598 (47.3%) had delayed surgery. On meta-analysis, there was no significant difference between ES and DS for the outcome of open reduction conversion risk. There was also no significant difference for the secondary outcomes of post-operative compartment syndrome, iatrogenic nerve injury, vascular injury, and surgical site infection.

CONCLUSION

Despite the limitations in the literature, evidence exists to support the notion that a delayed approach to the surgical treatment of Gartland type III supracondylar humeral fractures in children does not result in an increased risk of converting to open reduction and perioperative complications.

Ameliorative effect of metformin on cyclophosphamide-induced memory impairment in mice

OBJECTIVE

Cyclophosphamide (CYP) is a chemotherapeutic agent that is widely used as an adjuvant cancer treatment. Unfortunately, this drug is associated with secondary side effects, including cognitive impairment up to 70% of cancer survivors. The mechanism of this memory impairment is unclear. Thus, to understand the cognitive impairments caused by this chemotherapeutic agent, a clinically relevant dose to cancer treatment was used in mice to establish the chemobrain models, and the spatial memory of these mice was assessed using multiple behavior tests. In addition, metformin (MET) is widely used as an anti-diabetic drug and protects against oxidative stress and hepatotoxicity. Thus, this study tested the protective effects of MET in the chemobrain models.

MATERIALS AND METHODS

Four groups of mice, which weighed about 18-30 g, were collected and divided into 4 groups: control, CYP, MET, and CYP+MET groups. A 100 mg/kg dose of CYP was administered intraperitoneal (on alternate days) for a total of 4 doses. MET was dissolved in the mice's drinking water bottles at a 5 mg/ml concentration from day zero to the end of the treatment period. The mice's memory was tested using hippocampal-dependent tests, including the Y-maze, novel object recognition, and elevated plus maze tests. These tests were performed for three consecutive days after 24 h of the last dose of CYP.

RESULTS

The mice treated with CYP exhibited a decline in memory function in all the behavioral test studies, and this decline was significant in the Y-maze test. However, this decline was rescued by MET administration.

CONCLUSIONS

The clinically relevant model suggests that CYP treatment causes a decline in mice models spatial memory that might be improved by MET administration.

Po uptake in microalgae at different seawater pH: An experimental study simulating ocean acidification

Climate change effects such as ocean acidification (OA) are known to affect the trace metal distribution. This experimental study provides the first data on ²⁰⁹Po uptake rates and ²¹⁰Po concentration in five microalgae species under different pH scenarios. The experiment was conducted in replicates at three pH conditions 8.2, 8.0, and 7.5, representing the current and future climate change scenario as per IPCC RCP8.5. The ²⁰⁹Po uptake in the phytoplankton was highest in Thalassiosira weissflogi, i.e. 83% of the ²⁰⁹Po tracer was taken up at 8.2 pH whereas the lowest uptake was observed in Dunaliella salina equivalent to 20% at 7.5 pH. Similar behavior was observed in ²¹⁰Po concentrations in these microalgae, where ²¹⁰Po ranged between 3.16 ± 0.03 and 11.6 ± 0.04 Bq kg^-1 wet weight (ww), with the highest in the Thalassioria weissflogi at 8.2 pH, and the lowest in Dunaliella salina at 7.5 pH. The difference in ²⁰⁹Po uptake and ²¹⁰Po concentration was statistically significant (p < 0.001) both among species and the pH treatments in the order: Thalassiosira weissflogi > Tetraselmis suecica > Chaetoceros muelleri > Isochrysis galbana > Dunaliella salina and 8.2 > 8.0 > 7.5. A higher concentration of ²⁰⁹Po in seawater was measured at low pH condition in all the experimental tanks. Though the data clearly show the difference in concentration and uptake of polonium at different pH conditions, it is not known if lower pH is affecting the adsorbed or absorbed fraction. A detailed investigation will be required to understand the process as it can have a significant effect on biomagnification and marine food chain transfer under changing climatic scenarios.

Concentration of 210Po and 210Pb in macroalgae from the northern Gulf

This baseline study highlights the 210Po and 210Pb concentration in seven macroalgae species from the northern Gulf that are frequently washed ashore during the bloom season from February to April. The highest concentrations of 210Po and 210Pb were 2.947 ± 0.032 and 1.057 ± 0.145 Bq kg-1 wwt, respectively, in brown algae Sargassum boveanum, and the lowest in green algae Ulva prolifera with 1.533 ± 0.058 and 0.170 ± 0.069 Bq kg-1 wwt, respectively. A 210Po enrichment was observed in both brown and green algae species, with the 210Po/210Pb ratio being >1 for all the samples. The mean concentration of 210Po in all species was an order of magnitude higher than 210Pb, and the difference in mean concentration is statistically significant (p < 0.001). At the same time, the mean concentration of dissolved 210Po and 210Pb in seawater was 0.28 ± 0.01 and 0.52 ± 0.01Bq m-3 with a 210Po/210Pb ratio of 0.54 ± 0.02 indicating that 210Po was absorbed from water and more concentrated by macroalgae. The measured concentration factor (CF) for 210Po in these macroalgae for the northern Gulf varied between 5 × 103-1 × 104, higher than the IAEA recommended value of 1 × 103 which suggests that a revision of that value may be needed. The field derived CFs for 210Pb vary between 3 × 102-1.8 × 103, comparable to the ICRP recommended value of 2 × 103.

210Po concentration in selected diatoms and dinoflagellates in the northern Arabian Gulf

Marine phytoplankton is a primary producer in the ocean that forms the base of the marine food web and supports the pelagic food chain. The two dominant groups of phytoplankton observed in northern Gulf waters are diatoms and dinoflagellates. The diatoms outnumber dinoflagellates in the Gulf waters. This study presents baseline information on the concentration of ²¹⁰Po among selected phytoplankton in the northern Gulf. The concentration among diatoms varies between 6.99 and 11.4 Bq kg^-1 wwt, whereas a higher concentration range of 8.51-15.41 Bq kg^-1 wwt was observed among dinoflagellates. The diatoms analyzed includes Thalassiosira spp. - 10.2-11.4 Bq kg^-1 wwt; Chaetoceros spp. - 6.99-7.14 Bq kg^-1 wwt; Rhizosolenia spp. - 9.12-9.95 Bq kg^-1 wwt. The analyzed dinoflagellate genera include Gymnodinium spp. - 8.51-8.78 Bq kg^-1 wwt; Noctiluca spp. - 15.2-15.4 Bq kg^-1 wwt; and Karenia spp. - 14.1-14.9 Bq kg^-1 wwt. The ²¹⁰Po concentration in seawater shows a seasonal variation, with a higher concentration range of 0.70 and 0.58 mBq L^-1 during summer and autumn, whereas a lower range in concentration of 0.38 and 0.30 mBq L^-1 occurring during winter and spring. The resultant computed concentration factors vary between 2 ∗ 10⁴-5 ∗ 10⁴ demonstrating a significant ²¹⁰Po enrichment in the base of the pelagic food chain.

Outcomes of involuntary hospital admission. Satisfaction with treatment and the effect of involuntary admissions on patients

Introduction

Involuntary hospitalization in those presumed to be mentally ill has been a common practice. Although some patients are hospitalized for aggression, two-thirds of the patients are hospitalized because of the threat they pose to themselves. Although these patients require risk assessment and evaluation for possible presence of mental illness, the question is how much these patients will benefit from involuntary admission and what the long-term outcome would be.

Method

All patients admitted involuntary to the psychiatric ward in Kingston, Canada, and psychiatrists involved in their care were interviewed to see whether they think the involuntary admission was helpful. All patients were asked to fill-out MacArthur AES to assess their satisfaction with hospitalization.

Results

Although psychiatrists frequently reported that the admission was justified, only 29 out of 81 patients reported being explained to why they had been admitted involuntarily. Also, there was a significant difference in AES scores between those who were and were not given an explanation for admission. In addition, psychiatrists more often reported that the involuntary admission worsened the therapeutic relationship which was significantly associated with involuntary admission that was not explained to patients.

Discussion

The results of our study shows that patients admitted involuntarily often feel disappointed with staff and mental health system. It could lead to feeling of hopelessness, frustration and low self-esteem. If explained, some patients who present with risk to self might accept voluntary admissions, that will improve therapeutic alliance with psychiatrists and increase satisfaction from hospitalization. Result of this study could improve the decision making process for involuntary admissions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Autoimmune haemolytic anaemia due to Omeprazole

A 72-year-old lady who was prescribed Omeprazole for gastroesophageal reflux developed an allergic reaction within two days, which manifested initially as a generalised rash and marked eosinophilia. This was followed by a fall in haemoglobin without any obvious bleeding. Investigations pointed to drug related intravascular haemolysis as the cause. She made an uneventful recovery after omitting Omeprazole and treatment with steroids. Omeprazole should be considered amongst other recognised causes of drug-induced haemolysis

The dual-wave bolus feature in continuous subcutaneous insulin infusion pumps controls prolonged post-prandial hyperglycaemia better than standard bolus in Type 1 diabetes

The dual-wave bolus delivers a combination of an immediate normal pre-meal insulin bolus (approximately 3 min) followed by an extended (or square-wave) bolus that is evenly delivered over several hr as programmed by the patient. The purpose of this study was to compare post-prandial glycaemic excursions following a high-fat meal after administration of insulin by normal vs dual-wave bolus. During this prospective, cross-over, repeated measures study, subjects with diabetes and treated with insulin pump therapy were evaluated using the continuous glucose monitoring system (CGMS) following three combinations of meal and bolus type. A control meal or a high-fat meal was given in place of the evening meal on three separate occasions and comparisons were made between: a) the control meal with normal insulin bolus delivery, b) the high-fat meal with normal insulin bolus delivery, and c) the high-fat meal with dual-wave insulin bolus delivery. Although mean baseline CGMS values were similar in each of the three combinations of meal and bolus type (p=0.54) and in the three hr immediately following the meal (p=0.64, p=0.83, p=1.0), when compared to the control meal/normal bolus and high-fat meal/dual-wave bolus combinations, CGMS profiles disclosed significantly elevated post-prandial glucose in hr 5 through 14 (p<0.05) following the high-fat/normal bolus combination. Prolonged post-prandial glycaemic excursions are identified using the CGMS. Treating post-prandial hyperglycaemia with dual-wave insulin delivery may help manage chronic hyperglycaemia in patients with diabetes.