Cytotoxic Chemotherapy as an Alternative for Systemic Treatment of Advanced Hepatocellular Carcinoma in Developing Countries.

Systemic therapy options nowadays for advanced hepatocellular carcinoma (HCC) are either immunotherapy with immune checkpoint inhibitors or targeted therapy. As the incidence of liver cancer is much higher in developing countries, these new medications are not readily accessible for most of the patients. Cytotoxic chemotherapy agents are more available and affordable in developing countries. We are trying to explore the effectiveness of the newer cytotoxic agents in the systematic treatment for advanced HCC. This is a systematic review of all randomized controlled trials since 1997 that utilized systemic cytotoxic chemotherapy agents in the systemic treatment for advanced HCC using Scopus, PubMed, and Cochrane library up to February 2020. Six randomized trials were found. Different drugs and dosages were used, so it was statistically inappropriate to conduct a meta-analysis. No Phase III trial showed statistically significant overall survival (OS) benefit for cytotoxic chemotherapy, except subgroup analysis of Chinese patients in one study who had leucovorin, fluorouracil, and oxaliplatin (FOLFOX) regimen. There was no significant progression-free survival (PFS) or response rate in the Phase II trials. There are not enough data to infer the actual benefits of systemic cytotoxic chemotherapy in advanced HCC. However, oxaliplatin-based regimens may give feasible results. Health systems with limited access to targeted therapy and immunotherapy agents may use oxaliplatin-based regimens in clinical trials for advanced HCC. These results should be confirmed in multiple future randomized clinical trials.

Levamisole-Adulterated Cocaine-Induced Skin Lesions: A Case Report and Literature Review.

Levamisole is used as an agent to increase the total weight of street cocaine. We report the case of a 28-year-old female who presented with multiple painful, ulcerating lesions. She tested positive for cocaine and levamisole. Her skin lesions improved with abstinence from cocaine. Patients with levamisole-induced toxicity most often present with skin manifestations or joint pain. Leukopenia, neutropenia, and agranulocytosis are common lab abnormalities seen in these patients. Complete resolution of the skin lesions are observed approximatelythree weeks after abstinence. Patients known to use street drugs, who present with unexplained skin rash, neutropenia, and multiple immunological abnormalities, should be tested for both cocaine and levamisole. Urine toxicology screen is positive for cocaine approximately 72 hours after ingestion. Levamisole requires specialized testing that is not readily available commercially andis positive forless than 48 hours after exposure.

Penicillin Encephalopathy: An Unlikely Adversary in the Treatment of Neurosyphilis--Case Report and Review of the Literature.

UNLABELLED: Penicillin encephalopathy is a rare, potentially reversible phenomenon of drug-induced neurotoxicity. CASE: A 65-year-old female with a history of HIV was admitted with a three-day history of worsening headache, confusion, and lethargy. On examination she was awake but confused. Cerebrospinal fluid (CSF) and serum venereal disease research laboratory (VDRL) test returned positive and the patient was started on intravenous penicillin G with probenecid. On the second day of therapy, she developed myoclonic jerking, consistent with penicillin neurotoxicity. Repeat labs also showed new onset renal failure. Penicillin and probenecid therapy were stopped with a resolution of symptoms. Subsequently, therapy without probenecid was reinstituted uneventfully. DISCUSSION: Herein, we describe a female who developed penicillin neurotoxicity after initiation of intravenous penicillin therapy with probenecid for neurosyphilis. It is important that penicillin-induced toxicity be considered if characteristic myoclonic movements accompany encephalopathy. The presence of coexistent renal compromise should heighten the vigilance of clinicians.

A Case of Mysterious Impacted Duodenal Foreign Body Presenting with Halitosis.

The majority of gastrointestinal (GI) foreign bodies (FBs) discovered in adults are the result of intentional ingestion, most of which are found in patients with a preexisting psychiatric illness, with substance abuse disorders, or in people seeking secondary gain. No similar case of internal injuries following unintentional ingestion of a barbecue grill cleaning brush bristle has been reported. A 58-year-old Caucasian male with no significant history presented with complaint of halitosis, not improving after oral care and dental hygiene measures. He denied any other symptoms. After ruling out oral causes of halitosis, an esophagogastroduodenoscopy was performed, which revealed a black wire-shaped metallic FB embedded in the duodenum. The FB was identified as a silver metallic flexible wire resembling the bristle of a barbecue grill cleaning brush. The halitosis resolved completely within 3 weeks of the removal of the FB. To the best of our knowledge, this is the first case of duodenal impaction of a barbecue grill cleaning brush bristle atypically presenting with halitosis. Physicians' awareness of this potential injury from grill cleaning brush bristles would lead to a quick diagnosis after a focused history. Also avid grillers must be made aware of this potential hazard and should be encouraged to carefully examine the barbecue grill surface for any remnant bristle of the grill cleaning brush. Appropriate history taking, considering GI causes as potentially inducing halitosis, and an awareness of this entity among providers are important to facilitate prompt diagnoses and prevent major adverse outcomes.