Respiratory exposure to agricultural dust extract promotes increased intestinal Tnfα expression, gut barrier dysfunction, and endotoxemia in mice.

Concentrated animal feeding operations (CAFOs) are responsible for the production of global greenhouse gases and harmful environmental pollutants including hydrogen sulfide, ammonia, and particulate matter. Swine farmers are frequently exposed to organic dust that is proinflammatory in the lung and are thus at greater risk of developing pneumonia, asthma, and other respiratory conditions. In addition to respiratory disease, air pollutants are directly associated with altered gastrointestinal (GI) physiology and the development of GI diseases, thereby highlighting the gut-lung axis in disease progression. Instillation of hog dust extract (HDE) for 3 wk has been reported to promote the development of chronic airway inflammation in mice, however, the impact of HDE exposure on intestinal homeostasis is poorly understood. We report that 3-wk intranasal exposure of HDE is associated with increased intestinal macromolecule permeability and elevated serum endotoxin concentrations in C57BL/6J mice. In vivo studies also indicated mislocalization of the epithelial cell adhesion protein, E-cadherin, in the colon as well as an increase in the proinflammatory cytokine, Tnfα, in the proximal colon. Moreover, mRNA expression of the Paneth cell-associated marker, Lyz1, was increased the proximal colon, whereas the expression of the goblet cell marker, Muc2, was unchanged in the epithelial cells of the ileum, cecum, and distal colon. These results demonstrate that airway exposure to CAFOs dusts promote airway inflammation and modify the gastrointestinal tract to increase intestinal permeability, induce systemic endotoxemia, and promote intestinal inflammation. Therefore, this study identifies complex physiological consequences of chronic exposure to organic dusts derived from CAFOs on the gut-lung axis.NEW & NOTEWORTHY Agricultural workers have a higher prevalence of occupational respiratory symptoms and are at greater risk of developing respiratory diseases. However, gastrointestinal complications have also been reported, yet the intestinal pathophysiology is understudied. This work is novel because it emphasizes the role of an inhaled environmental pollutant on the development of intestinal pathophysiological outcomes. This work will provide foundation for other studies evaluating how agricultural dusts disrupts host physiology and promotes debilitating gastrointestinal and systemic disorders.

Report of consensus panel 2 from the 11th international workshop on Waldenström's macroglobulinemia on the management of relapsed or refractory WM patients.

The consensus panel 2 (CP2) of the 11th International Workshop on Waldenström's macroglobulinemia (IWWM-11) has reviewed and incorporated current data to update the recommendations for treatment approaches in patients with relapsed or refractory WM (RRWM). The key recommendations from IWWM-11 CP2 include: (1) Chemoimmunotherapy (CIT) and/or a covalent Bruton tyrosine kinase (cBTKi) strategies are important options; their use should reflect the prior upfront strategy and are subject to their availability. (2) In selecting treatment, biological age, co-morbidities and fitness are important; nature of relapse, disease phenotype and WM-related complications, patient preferences and hematopoietic reserve are also critical factors while the composition of the BM disease and mutational status (MYD88, CXCR4, TP53) should also be noted. (3) The trigger for initiating treatment in RRWM should utilize knowledge of patients' prior disease characteristics to avoid unnecessary delays. (4) Risk factors for cBTKi related toxicities (cardiovascular dysfunction, bleeding risk and concurrent medication) should be addressed when choosing cBTKi. Mutational status (MYD88, CXCR4) may influence the cBTKi efficacy, and the role of TP53 disruptions requires further study) in the event of cBTKi failure dose intensity could be up titrated subject to toxicities. Options after BTKi failure include CIT with a non-cross-reactive regimen to one previously used CIT, addition of anti-CD20 antibody to BTKi, switching to a newer cBTKi or non-covalent BTKi, proteasome inhibitors, BCL-2 inhibitors, and new anti-CD20 combinations are additional options. Clinical trial participation should be encouraged for all patients with RRWM.

Managing hematological cancer patients during the COVID-19 pandemic: an ESMO-EHA Interdisciplinary Expert Consensus.

BACKGROUND: The COVID-19 pandemic has created enormous challenges for the clinical management of patients with hematological malignancies (HMs), raising questions about the optimal care of this patient group. METHODS: This consensus manuscript aims at discussing clinical evidence and providing expert advice on statements related to the management of HMs in the COVID-19 pandemic. For this purpose, an international consortium was established including a steering committee, which prepared six working packages addressing significant clinical questions from the COVID-19 diagnosis, treatment, and mitigation strategies to specific HMs management in the pandemic. During a virtual consensus meeting, including global experts and lead by the European Society for Medical Oncology and the European Hematology Association, statements were discussed and voted upon. When a consensus could not be reached, the panel revised statements to develop consensual clinical guidance. RESULTS AND CONCLUSION: The expert panel agreed on 33 statements, reflecting a consensus, which will guide clinical decision making for patients with hematological neoplasms during the COVID-19 pandemic.

Induction of distinct neuroinflammatory markers and gut dysbiosis by differential pyridostigmine bromide dosing in a chronic mouse model of GWI showing persistent exercise fatigue and cognitive impairment.

AIMS: To characterize neuroinflammatory and gut dysbiosis signatures that accompany exaggerated exercise fatigue and cognitive/mood deficits in a mouse model of Gulf War Illness (GWI). METHODS: Adult male C57Bl/6N mice were exposed for 28 d (5 d/wk) to pyridostigmine bromide (P.O.) at 6.5 mg/kg/d, b.i.d. (GW1) or 8.7 mg/kg/d, q.d. (GW2); topical permethrin (1.3 mg/kg), topical N,N-diethyl-meta-toluamide (33%) and restraint stress (5 min). Animals were phenotypically evaluated as described in an accompanying article [124] and sacrificed at 6.6 months post-treatment (PT) to allow measurement of brain neuroinflammation/neuropathic pain gene expression, hippocampal glial fibrillary acidic protein, brain Interleukin-6, gut dysbiosis and serum endotoxin. KEY FINDINGS: Compared to GW1, GW2 showed a more intense neuroinflammatory transcriptional signature relative to sham stress controls. Interleukin-6 was elevated in GW2 and astrogliosis in hippocampal CA1 was seen in both GW groups. Beta-diversity PCoA using weighted Unifrac revealed that gut microbial communities changed after exposure to GW2 at PT188. Both GW1 and GW2 displayed systemic endotoxemia, suggesting a gut-brain mechanism underlies the neuropathological signatures. Using germ-free mice, probiotic supplementation with Lactobacillus reuteri produced less gut permeability than microbiota transplantation using GW2 feces. SIGNIFICANCE: Our findings demonstrate that GW agents dose-dependently induce differential neuropathology and gut dysbiosis associated with cognitive, exercise fatigue and mood GWI phenotypes. Establishment of a comprehensive animal model that recapitulates multiple GWI symptom domains and neuroinflammation has significant implications for uncovering pathophysiology, improving diagnosis and treatment for GWI.

JAK-STAT Pathway Regulation of Intestinal Permeability: Pathogenic Roles and Therapeutic Opportunities in Inflammatory Bowel Disease.

The epithelial barrier forms the interface between luminal microbes and the host immune system and is the first site of exposure to many of the environmental factors that trigger disease activity in chronic inflammatory bowel disease (IBD). Disruption of the epithelial barrier, in the form of increased intestinal permeability, is a feature of IBD and other inflammatory diseases, including celiac disease and type 1 diabetes. Variants in genes that regulate or belong to the JAK-STAT signaling pathway are associated with IBD risk. Inhibitors of the JAK-STAT pathway are now effective therapeutic options in IBD. This review will discuss emerging evidence that JAK inhibitors can be used to improve defects in intestinal permeability and how this plays a key role in resolving intestinal inflammation.

Every breath you take: Impacts of environmental dust exposure on intestinal barrier function-from the gut-lung axis to COVID-19.

As countries continue to industrialize, major cities experience diminished air quality, whereas rural populations also experience poor air quality from sources such as agricultural operations. These exposures to environmental pollution from both rural and populated/industrialized sources have adverse effects on human health. Although respiratory diseases (e.g., asthma and chronic obstructive pulmonary disease) are the most commonly reported following long-term exposure to particulate matter and hazardous chemicals, gastrointestinal complications have also been associated with the increased risk of lung disease from inhalation of polluted air. The interconnectedness of these organ systems has offered valuable insights into the roles of the immune system and the micro/mycobiota as mediators of communication between the lung and the gut during disease states. A topical example of this relationship is provided by reports of multiple gastrointestinal symptoms in patients with coronavirus disease 2019 (COVID-19), whereas the rapid transmission and increased risk of COVID-19 has been linked to poor air quality and high levels of particulate matter. In this review, we focus on the mechanistic effects of environmental pollution on disease progression with special emphasis on the gut-lung axis.

A Retrospective Comparative Study of Serbian Underground Coalmining Injuries

Background@#During 2011, a study was undertaken to assess safety conditions in Serbian underground coalmines by analysis of injury data. The study covered all Serbian coalmines, identified week spots from the aspect of safety, and recommended possible courses of action. Since then, Serbia has made changes to safety and health legislation; all coalmines introduced new preventive measures, adopted international standards, and made procedures for risk management. After 10 years a new study has been performed to analyze the impact of these changes. @*Materials and methods@#In this study, the injuries that have occurred in the Serbian underground coal mines over the last 20 years were analyzed. Statistical data analysis was performed by IBM SPSS Statistics v23. The injuries that occurred in the last ten years were compared with the results of the previous study (2000–2009). The average values of injury rates for both periods were compared for each of the categories (severity, age, body part, qualification), and the results were presented as absolute difference or percentile difference. @*Results@#The results showed reduction in the number of injuries in the category of 20–30 years old workers, where the new training procedures for workers, which were set by mandatory legal regulations, certainly contributed. They also showed an increase in the number of injuries in the category of old workers, which indicates that the law did not have a positive effect on this category. @*Conclusion@#The total number of injuries is still high; therefore, it is necessary to introduce mechanization and automation in mines and have a better policy for older workers who retire later nowadays.

Prevalence of entanglements of seabirds in marine debris in the central Portuguese coast.

Plastic pollution and the subsequent entanglement of marine animals is a global and increasing problem. In this study we present an analysis of the seabirds recorded as entangled by a rehabilitation centre and an associated marine animal stranding network, along the central coast of Portugal, between 2008 and 2018. Results show a high annual rate of entangled seabirds (average 6.9%) compared to other studies and fisheries related materials are a relevant cause of seabird entanglement (82%) compared to other debris. When comparing age classes, juveniles were more vulnerable to entanglement than other age classes in the species studied. Regarding the rehabilitation of entangled seabirds, the release rate was higher in non-fishing material entanglement cases. In conclusion, this study highlights the impact of fisheries related material on marine fauna and the need for reinforcement of the existing legislation for protecting seabirds and the implementation of mitigation measures associated with fishing activities.

Probiotic Supplementation Has a Limited Effect on Circulating Immune and Inflammatory Markers in Healthy Adults: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: A main mechanism of action proposed for oral probiotic supplementation is immunomodulation, which is expected to impart health benefits in the host by influencing circulating immune and inflammatory factors. To date, the effectiveness of probiotic supplementation for immunomodulation in healthy adults without disease has not been evaluated in a systematic review. OBJECTIVE: The objective of this systematic review was to evaluate the effect of probiotic supplementation on circulating immune and inflammatory markers of healthy adults compared to placebo. METHODS: PubMed, SCOPUS, ISI Web of Science, ProQuest, and Cochrane databases were searched for English articles up to May 15, 2019. Additional papers were identified by checking references of relevant papers. Only randomized controlled trials studying the administration of probiotic supplements compared to placebo on immune and inflammatory markers in healthy adults (aged 18 to 65 years), without acute or chronic disease, and in generally good health were examined. Independent extraction of articles was conducted by two authors using predefined search terms and restrictions/filters. The methodologic quality of each study was appraised using the Academy of Nutrition and Dietetics Evidence Analysis Library Quality Rating Worksheet and the body of evidence was assessed using the Academy of Nutrition and Dietetics Grade Definitions and Conclusion Grading Table. RESULTS: Eighteen articles, including 819 subjects, met eligibility criteria and were included in the present systematic review. Five articles were rated neutral in quality and 13 were rated high in quality. Eight articles reported a significant effect on immune and/or inflammatory parameters including increases in natural killer cells, lymphocytes, and monocytes, and decreases in proinflammatory cytokine concentrations. CONCLUSIONS: Based on the 18 articles extracted in this systemic review, probiotic supplementation was concluded to have a limited effect on immune and inflammatory markers in healthy adults. Overall, the evidence was heterogenous, precluding a meta-analysis, and difficult to aggregate and conclude on effect size. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO ref CRD42018110856.

A comparison of the nutritional physiology and gut microbiome of urban and rural house sparrows (Passer domesticus).

Urbanization influences food quality and availability for many wild species, but our knowledge of the consequences urbanization has on the nutritional physiology of these animals is currently limited. To fill this gap, we captured House Sparrows (Passer domesticus) from rural and urban environments and hypothesized that increased access to human refuse in urban areas may significantly alter the gut microbiome and nutritional physiology of Sparrows. While there were no significant differences in circulating triglycerides or free glycerol concentrations between populations, urban birds had significantly greater blood glucose concentrations, which suggests greater circulating glucagon concentrations, accessibility to carbohydrates, and/or higher rates of gluconeogenesis in an urban setting. Rural birds had significantly more plasma uric acid, suggesting that they may metabolize more proteins or experience lower inflammation than urban birds. Rural birds also had significantly higher liver free glycerol concentrations, indicating that they metabolize more fat than urban birds. There were no significant differences in the relative abundance of gut microbial taxa at the phyla level between the two populations, but linear discriminant analysis effect size (LEfSe) showed that urban House Sparrows were more enriched with class- and order-level microbes from the phylum Proteobacteria, which are implicated in several mammalian intestinal and extra-intestinal diseases. These findings demonstrate that urbanization significantly alters the nutritional physiology and the composition of the gut microbiome of House Sparrows.

A novel organic mineral complex prevented high fat diet-induced hyperglycemia, endotoxemia, liver injury and endothelial dysfunction in young male Sprague-Dawley rats.

The prevalence of metabolic syndrome (MetSyn) has risen 35% since 2012 and over two-thirds of Americans exhibit features characterizing this condition (obesity, dyslipidemia, hyperglycemia, insulin resistance and/or endothelial dysfunction). The aim of this study was to evaluate the effects of a novel dietary supplemental organic mineral complex (OMC) on these risk factors in a rodent model of MetSyn. Six-week old male Sprague-Dawley rats were fed either standard chow or a high-fat diet (HFD) composed of 60% kcal from fat for 10 weeks. Rats were also treated with OMC in their drinking water at either 0 mg/mL (control), 0.6 mg/mL, or 3.0 mg/mL. The HFD-treated rats exhibited significantly increased body mass (p<0.05), epididymal fat pad mass (p<0.001), waist circumference (p = 0.010), in addition to elevations in plasma endotoxins (p<0.001), ALT activity (p<0.001), fasting serum glucose (p = 0.025) and insulin concentrations (p = 0.009). OMC did not affect body weight or adiposity induced by the HFD. At the higher dose OMC significantly blunted HFD-induced hyperglycemia (p = 0.021), whereas both low and high doses of OMC prevented HFD-induced endotoxemia (p = 0.002 and <0.001, respectively) and hepatocyte injury (ALT activity, p<0.01). Despite evidence of oxidative stress (elevated urinary H2O2 p = 0.032) in HFD-fed rats, OMC exhibited no demonstrable antioxidative effect. Consistent with prior studies, mesenteric arteries from HFD rats had more uncoupled eNOS (p = 0.006) and iNOS protein expression (p = 0.027) in addition to impaired endothelium-dependent vasodilation that was abrogated by the high dose of OMC (p<0.05). This effect of OMC may be attributed to the high nitrate content of the supplement. These findings suggest that the OMC supplement, particularly at the higher dose, ameliorated several risk factors associated with MetSyn via a non-antioxidant-dependent mechanism.

A Dual Phosphodiesterase Inhibitor, Zardaverine (Type 3/4), Enhances Motility of Frozen-thawed Boar Sperm.

BACKGROUND: Cryopreserved semen is useful for animal breeding via artificial insemination (AI); however, the use of frozen-thawed boar sperm is limited due to cryodamage. OBJECTIVE: The goal of this study was to improve post-thaw motility of boar semen by supplementing the thawing medium with a phosphodiesterase inhibitor, Zardaverine. MATERIALS AND METHODS: Thawed boar semen samples were treated with different concentrations of Zardaverine (0, 20, 50, 75, 100 µM) and the motility was evaluated using a computer-assisted sperm analyser. Toxic effects (sperm viability, DNA integrity, mitochondrial activity) were examined by eosin-nigrosin staining, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay and MitoTracker. RESULTS: Sperm motility values included curvilinear velocity, rectilinear speed, average value, linearity index, straightness index, and progressive motility. The kinetic values were significantly higher with the 50 uM Zardaverine supplementation compared to non-treated control. Furthermore, there were no toxic effects of the Zardaverine treatment. CONCLUSION: The dual phosphodiesterase inhibitor (type 3/4) Zardaverine significantly enhanced the motility of thawed spermatozoa without adverse effects.

Tratamento de feridas excisionais de coelhos com extrato de barbatimão associado a células mononucleares autólogas da medula óssea / Treatment of excisional wound in rabbits with barbatiman extracts associated with autologous bone marrow mononuclear cells

Objetivou-se com este estudo avaliar o processo de cicatrização de feridas de coelhos tratadas com extrato de barbatimão (S. adstringens) associado a células mononucleares autólogas da medula óssea (CMMO). Utilizaram-se 20 coelhos, distribuídos em quatro grupos: B, extrato de barbatimão; CB, CMMO com extrato de barbatimão; CS, CMMO com solução fisiológica; S, solução fisiológica. Foi avaliada a presença de crosta, hiperemia, secreção, hemorragia, reepitelização, área da ferida e tempo de cicatrização. No terceiro, sétimo, 14º e 21º dias pós-operatório, realizou-se a biópsia das feridas e avaliaram-se os indicadores dos processos de inflamação e de reparo, com destaque para o colágeno, na coloração picrosírius, bem como de proliferação celular, na coloração AgNOR. Houve maior deposição de fibras colágenas nos grupos B e CB (P=0,00003) e formação de crostas mais espessas no sétimo dia, com fibras colágenas mais organizadas no 21º dia. Conclui-se que o barbatimão estimula a produção de fibras colágenas e promove a formação de crostas mais espessas sobre a ferida na fase inicial da cicatrização e, na fase de remodelação, favorece a orientação das fibras colágenas. Além disso, a associação desse fitoterápico com CMMO não estimula a cicatrização de feridas.(AU)

This study aimed to evaluate the healing process of wounds of rabbits in response to treatment with barbatiman extract (S. adstringens) associated with autologous mononuclear bone marrow cells (BM-MNC). We used 20 rabbits, divided into four groups: B, 10% barbatiman extract with 9.48% of total tannins; CB, BM-MNC with barbatiman extract; CS, BM-MNC with NaCl 0.9% solution; S, NaCl 0.9% solution. Clinical evaluation was performed by observing the presence of crust, redness, discharge, bleeding, re-epithelialization, the wound area and healing time in days. In the third, seventh, 14th and 21st postoperative days wounds were biopsied for microscopic evaluation of inflammation and repair process indicators, especially collagen, in picrosirius staining, and cell proliferation, in AgNOR staining. There was a greater deposition of collagen fibers in groups B and CB (p=0.00003) on the seventh day and formation of thicker crusts, and more organized collagen fibers on the 21st day in these groups. In conclusion, in the initial phase of healing, barbatiman extract stimulates the production of collagen fibers and promotes the formation of more exuberant crusts on the wounds and remodeling phase favors the orientation of collagen fibers, but when combined with BMMC does not stimulate wound healing in rabbits.(AU)

The endocannabinoid system expression in the female reproductive tract is modulated by estrogen.

The endocannabinoid system (ECS) is involved in several physiological events that resulted in a growing interest in its modulation. Moreover, the uterine levels of anandamide (AEA), the major endocannabinoid, must be tightly regulated to create proper embryo implantation conditions. However, there are no evidences about the regulation of AEA in uterus by estrogen. Thus, the aim of this study is to elucidate whether estradiol benzoate (EB) and tamoxifen (TAM) administration to ovariectomized (OVX) rats can induce changes in the expression of cannabinoid receptors and AEA-metabolic enzymes in uterus by evaluating gene transcription and protein levels by qPCR, Western blot and immunohistochemistry. Moreover, the plasmatic and uterine levels of AEA and of prostaglandin E2 (PGE2) and prostaglandin F2α (PGF2α), the major cyclooxygenase-2 (COX-2) products, were determined by UPLC-MS/MS. The immunohistochemistry showed that cannabinoid receptors, as well as AEA-metabolic enzymes are mainly located in the epithelial cells of both lumen and glands and, to a lesser extent, in the muscle cells. Moreover, EB administration to OVX rats significantly increased CB1, CB2, NAPE-PLD, FAAH and COX-2 expression and transcription. These effects were absent in TAM and TAM+EB treatments showing that this response is estrogen receptor dependent. Additionally, although uterine levels of AEA remained unchanged in EB or TAM treated animals, they showed a rise with EB treatment in plasma. The latter also produced a decrease in uterine PGE2 levels. In summary, these data collectively indicate that the expression of ECS components, as well as, the AEA and PGE2 levels in rat uterus is modulated by EB. Thus, estradiol may have a direct regulatory role in the modulation of ECS in female reproductive tissues.

Effects of gonadal steroids and of estrogen receptor agonists on the expression of estrogen receptor alpha in the medial preoptic nucleus of female rats.

The medial preoptic nucleus (MPN) is a sexually dimorphic cell group of the medial preoptic area that plays a central role in the integration of olfactory and hormonal stimuli that modulate sexually differentiated behaviors. The influence of sex steroids in these behaviors is mediated through activation of estrogen receptors (ERs), which are highly expressed in this nucleus. Little is known about the effects of progesterone (P) or the selective activation of each ER subtype on the expression of estrogen receptor alpha (ERα) in the MPN of female rats. We have addressed this subject in the current investigation by estimating, using stereological tools, the total number of MPN neurons that express ERα in rats at each phase of the estrous cycle and in ovariectomized rats treated with estradiol benzoate (EB), P or the ERα- and estrogen receptor beta (ERß)-specific agonists. Results show that the total number of ERα-immunoreactive neurons does not change over the estrous cycle, except at proestrus when the number is reduced. A similar effect was observed after the administration of EB, but not of P. Results also show that the estradiol-induced down-regulation of the ERα is mediated by activation of both ER subtypes, and that ERß activation leads to a reduction in the total number of ERα-immunoreactive neurons that is twice that resulting from ERα activation. Present data suggest that ERα activation triggers a sort of negative feedback mechanism in MPN neurons that reduces its own expression, which might be of importance for the regulation of estradiol-dependent physiological and behavioral responses.

Detection of Toxoplasma gondii in the milk of naturally infected goats in the Northeast of Brazil.

The aim of the present study was to detect the genomic DNA of Toxoplasma gondii in milk samples from naturally infected goats in the state of Pernambuco, (Brazil). In total, 248 blood serum samples were collected and processed from lactating goats and then submitted to a search for antibodies to T. gondii through the indirect immunofluorescence reaction. Samples with a score of 64 or more were considered positive. In total, 248 milk samples were collected and processed from the same group of goats in order to study the DNA of T. gondii using the polymerase chain reaction (PCR) technique. In the serum samples, 56/248 (22.58%) of the animals were positive, whereas the DNA of the parasite was detected in 15/248 (6.05%) of the milk samples. Five of these 15 samples were animals who were also positive in the serology. This study reports the first occurrence of the elimination of T. gondii from the milk of naturally infected goats in the north-east of Brazil. It is suggested that the consumption of in natura goat milk may constitute a potential risk to the health of milk consumers in this region.

Severe methemoglobinemia due to ingestion of toxicants.

BACKGROUND: Toxin-induced methemoglobinemia is seen in poisoning with oxidizing agents. We report the clinical features and outcome of patients admitted with severe methemoglobinemia due to intentional ingestion of toxicants. METHODS: In this observational case series, patients admitted with toxin-induced methemoglobinemia between September 2011 and January 2014 were identified from the institutional poisoning database. Clinical profile and outcome of patients with methemoglobin concentration greater than or equal to 49% is reported. RESULTS: Of the 824 patients admitted with poisoning, 5 patients with methemoglobin concentration greater than or equal to 49% were included. The implicated compounds were nitrobenzene, benzoylphenylurea, flubendamide and Rishab(TM). One patient refused to name the compound. All patients were managed in the intensive care unit. Altered sensorium [Glasgow coma scale (GCS) < 10] was common (80%); 2 patients presented with a GCS greater than 4. All patients manifested cyanosis, low oxygen saturation and chocolate-brown-colored blood despite supplemental oxygen therapy. The median methemoglobin concentration was 64.7% (range 49.8-91.6%); 2 patients had methemoglobin concentration greater than 70%. One patient needed inotropes. Four patients required mechanical ventilation for 4-14 days. All patients were treated with methylene blue; 4 received more than one dose. Three patients also received intravenous ascorbic acid 500 mg, once daily, for 3 days. Following treatment, there was evidence of haemolysis in all patients; 2 required blood transfusion. All patients survived. CONCLUSION: Patients with severe toxin-induced methemoglobinemia present with altered sensorium and cyanosis and may require ventilatory support and inotropes. Though methemoglobin concentrations greater than 70% are considered fatal, aggressive management with methylene blue and supportive therapy can lead to survival.