Is the duration of castration resistance predictive for sequential treatment responses in the metastatic castration-resistant prostate cancer setting?

OBJECTIVE: Prostate cancer is the second leading cause of cancer death in men. Androgen deprivation therapy (ADT) has been the primary therapeutic approach for treatment of prostate cancer. However,nearly all patients develop the castration-resistant disease . We evaluated real-world data with abiraterone and enzalutamide treatment. By this data, we aimed to analyze whether that prior short response to ADT could predict response to subsequent therapy with androgen receptor axis targeted agent (ARATA). MATERIAL AND METHOD: We collected data from two cancer centers, 151 consecutive patients with treated abiraterone or enzalutamide in the first line of metastatic castration resistant prostat cancer (mCRPC) setting were included. The patients who received docetaxel in castration naive setting is also included. Time to castration resistance (TTCR) was defined as the duration from the initial to failure of primary ADT. RESULTS: Patients with treated ARATA were divided into two groups according to the time to castration resistance (TTCR). Patients who became resistant to ADT up to one year had a median PFS of 6.6 months, compared to median PFS of 13.3 months for patients who responded ADT for more than 1 year. (p = 0.002). In the post-docetaxel setting, median PFS is 12.6 months of patients with treated ARATA who had TTCR for more than one year, and median PFS is 6.6 months in those who had TTCR less than one year (p = 0.007).Univariate and multivariate analyses were performed to determine the clinical factors on ARATA outcomes. Eastern Cooperative Oncology Group (ECOG) performance status(PS), median prostate-specific antigen(PSA) and time to CRPC were significantly predicted outcomes of ARATA on multivariate analysis. CONCLUSION: TTCR is also a predictor for PFS of the patients who were treated ARATA both whole cohort and post-docetaxel.

Prognostic factors of ado-trastuzumab emtansine treatment in patients with metastatic HER-2 positive breast cancer.

BACKGROUND: Ado-trastuzumab emtansine is an antibody-drug conjugate that combines the cytotoxic activity of emtansine with human epidermal growth factor receptor 2-targeted antitumor features of trastuzumab. OBJECTIVE: We conducted a study of metastatic breast cancer patients treated with trastuzumab emtansine. By evaluating progression-free survival, overall survival, and response rates, we aimed to find prognostic factors of trastuzumab emtansine treatment. METHODS: Our study is a single-center, retrospective, observational study. We have clinical data from 78 patients treated with trastuzumab emtansine for metastatic breast cancer, from May 2016 through May 2019, at Kartal Dr Lutfi Kirdar Education and Research Hospital, Medical Oncology Department. Our objective is to assess the survival and response rates in trastuzumab emtansine-treated individuals and the factors associated with survival. The factors we analyzed were cancer antigen 15-3 sensitivity, Eastern Cooperative Oncology Group-Performance Status, presence or absence of visceral metastases, presence or absence of cranial metastases, and treatment-associated thrombocytopenia. RESULTS: Among 78 patients, median progression-free survival was 7.8 months, and overall survival was 21.1 months. Twenty of the patients had an objective tumor response. The results showed that trastuzumab emtansine was tolerable with a manageable safety profile and consistent with the results of the previous literature. Mostly seen adverse events were anemia, thrombocytopenia, fatigue, and increased levels of alkaline phosphatase. Patients with Eastern Cooperative Oncology Group-Performance Status = 2 had worse progression-free survival and overall survival compared to ones with Eastern Cooperative Oncology Group-Performance Status < 2; progression-free survival and overall survival are worse in cancer antigen 15-3-sensitive breast cancer patients. According to our findings, treatment-associated thrombocytopenia was a significant prognostic factor for survival. Patients with thrombocytopenia had 12 months progression-free survival, whereas patients without thrombocytopenia had only 4.1 months progression-free survival. In like manner, overall survival was much better in the thrombocytopenia-experienced patients as 29.5 versus 11.8 months. CONCLUSIONS: Trastuzumab emtansine prolongs progression-free survival and overall survival with a manageable safety profile. Thrombocytopenia, Eastern Cooperative Oncology Group-Performance Status, and cancer antigen 15-3 are correlated with progression-free survival and/or overall survival.

Serum Level of Lactate Dehydrogenase is a Useful Clinical Marker to Monitor Progressive Multiple Myeloma Diseases: A Case Report.

To follow the progression of multiple myeloma (MM) disease, serum lactate dehydrogenase (LDH) levels are as useful markers as beta-2 microglobulin and monoclonal immunoglobulin. With this study, we have presented a case of a patient with a multiple myeloma which was fulminant course, whose LDH levels were normal at the onset of diagnosis increasing as 27 times more than normal as the disease progressed and who showed the development of extramedullary plasmacytomas. The patient, an 80-year-old female, was diagnosed with stage IIIA IgA type multiple myeloma and melphalan-prednisolon (MP) treatment was started. Although the LDH levels were low during the diagnosis and chemotherapy, the LDH levels increased up to 7557 U/L following the progression and occurrence of extramedullary plasmacytomas and the patient died. During the observation of the patient with MM, if the LDH levels are abnormally high, the progression of the disease should be considered after eliminating the other causes. Bone marrow aspiration and biopsy should be examined and the progression or relapse should be shown. On the other hand, the patients with LDH levels are high should be considered to have added plasmacytomas, the whole body should be examined at an early stage before the development of clinical symptoms and early treatment should be started.

Suicide commitment with metformin: our experience with five cases.

Biguanides can function as oral antihyperglycemic drugs. They were used for diabetes mellitus or prediabetes treatment over the last nine decades, but they lost their popularity in 1970s because of phenformin and regained with metformin. For metformin, the most common side effects are diarrhea and dyspepsia, occurring in up to 30% of patients. The most important and serious side effect is lactic acidosis. Phenformin was removed from the markets before 1970, because it caused lactic acidosis in 40-65 patients in 100,000 patient-years. Metformin causes lactate accumulation only in patients who have hepatic failure, renal failure or in patients who attempt suicide with high dosage of drugs. In this report, we present five patients who used high doses of metformin for suicide attempt.

Characteristics and clinical outcome of pT1a-b node-negative breast cancer.

OBJECTIVE: Tumor size, along with other clinicopathological characteristics, has a prognostic role in breast cancer. Recurrence risk tends to rise as tumor size increases. Early T-stage portends a good prognosis. We aimed to investigate the recurrence-free interval rates of T1abN0 group of early breast cancer. METHODS: Patients diagnosed with pT1a and T1b, lymph node metastasis-negative breast cancer were included in the study. Clinicopathologic characteristics including recurrence, distant metastasis, and final status of the patients were obtained retrospectively from the patient files. RESULTS: A total of 84 patients included. Twenty-six patients (31%) had T1a and 58 patients (69%) had T1b tumors. The 5-year distant relapse-free survival (DRFS) rate of T1ab tumors was 95.2%. The DRFS rate of T1a tumors was 96.2%, while the rate of T1b tumors was 94.8% (p=0.555). The 5-year RFS rate of T1ab tumors was 90.5%. The RFS rate of T1a tumors was 84.6%, whereas the rate of T1b tumors was 93.1% (p=0.359). The 5-year DRFS rate of hormone receptor positive group was 97%, Her-2 positive group was 81.8%, and triple negative group was 100% (p=0.041). The 5-year RFS rate of the hormone receptor positive group was 97%, Her-2 positive group was 72.7%, and triple negative group was 57.1% (p=0.001). CONCLUSION: The results of the study provided that both T1a and T1b tumors have a good and similar prognosis.

Initial Ca 125 Value as a Predictive Marker for High-grade Serous Ovarian Cancer.

OBJECTIVE: To determine the relevance between the cut-off level of cancer antigen 125 (CA 125) level and long-term prognosis in high-grade serous ovarian cancer (HGSCs). STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Departments of Oncology, Medeniyet University Goztepe Education and Research Hospital, and Kartal Lutfi Kirdar Education and Research Hospital, Istanbul, Turkey, from January 2017 to June 2019. METHODOLOGY: Medical records of 230 women with HGSC were reviewed randomly from two Oncology Clinics. Descriptive analysis and CA 125 marker levels were evaluated with five years of disease-free survival rate (DFS) and overall survival rate (OS). Patients were divided into groups of high and low initial CA 125 levels (cut-off ≥385U/ml). The ability of initial serum CA 125 levels in predicting the presence of marker-recurrence of ovarian cancer were analysed using ROC (Receiver operating characteristics) curve analysis. RESULTS: Statistically significant predictive value of initial CA 125 level was calculated as 385U/ml (p=0.008). The 5-year DFS of high and low CA 125 levels for all stages in HGSC was statistically significant (p<0.001). The sub-group analysis demonstrated that the significant survival difference was especially in FIGO stage III. Patients with HGSC <385 U/ml had a significantly improved 5-year DFS and OS rates within stage III disease: 5-year DFS (p = 0.008) and 5-year OS (p = 0.004) according to the stratification of CA 125 level. CONCLUSION: Initial CA 125 level appeared to be of beneficial clinical predictive value for HGSC. Key Words: Initial CA 125, Tumor marker, High-grade serous ovarian cancer, Disease-free survival, Overall survival, Predictive value.

Efficacy of abiraterone acetate in castration-resistant metastatic prostate cancer: A real-world data analysis.

PURPOSE: The aim of this study was to evaluate the efficacy of abiraterone in patients with castration-resistant metastatic prostate cancer. MATERIALS AND METHODS: We retrospectively analyzed 51 patients with mCRPC treated with abiraterone acetate from January 2014 to August 2018. Clinicopathological information, treatment modalities, treatment responses, and survival times were retrospectively reviewed. RESULTS: A total of 51 patients who received abiraterone 1000 mg/day + prednisone 10 mg/day between January 2014 and August 2018 were included in the study. Of these patients, 33 (64.7%) had post-chemotherapy (CT) and 18 (35.3%) had CT-naive abiraterone receipt. Median overall survival (OS) was 17.3 months (range 9.3-33.1). Median OS was found to be 12.7 months (range 9.4-18.3) and 29.4 months (range 9.3-33.0) in the CT-naive and post-CT group, respectively (P = .236). Median radiographic PFS (rPFS) was 10.1 months (range 4.5-18.4). In the CT-naive group, rPFS was 10.1 months (IQR 6.0-14.7) and in the post-CT group, it was 9.7 months (range 4.0-18.4) (P = .808). PSA progression-free survival (PSA-PFS) was 9.1 months (range 4.6-13.1). In the CT-naive group, PSA-PFS was 7.4 months (range 4.6-13.4) and in post-CT, it was 9.1 months (range 4.8-13.1) (P = .843). CONCLUSIONS: These results show that abiraterone acetate is an effective and reliable agent in real-life data.

Role of tumor location on high-grade serous ovarian cancer prognosis.

OBJECTIVES: Ovarian cancer is associated with the highest mortality of gynecologic cancers. Epidemiological and genetic factors of ovarian cancer development are clearly defined but prognostic factors have not been adequately identified. Right and left ovarian cancers seem to act different behaviors at high-grade serous ovarian cancer (HGSOC) prognosis. The aim of this study is to explain this prognostic role of its sidedness. The aim of this study is to explain this prognostic role of its sidedness. MATERIAL AND METHODS: We reviewed 160 consecutive patients with Figo stage 1-3 HGSOCs and undergone surgery at two high-volume hospitals. Prognostic effects of primary tumor location onset were evaluated in terms of 5-year disease free survival and overall survival rate. RESULTS: One hundred-sixty patients with ovarian cancer records were analyzed using the Kaplan-Meier method, that demonstrated a significant difference in the 5-year disease-free survival rates between right and left-sided cancers for all stages (44.6% vs 78.5%, p < 0.001). Also, there was significant difference in the 5-year overall survival rates between the two groups (71.1% vs 91.9%, p = 0.020). CONCLUSIONS: Tumor location within the HGSOC seems to be a compelling prognostic factor ovarian cancer. Further prospective studies are needed in order to support our hypothesis.

Transrectal vacuum treatment for low colorectal anastomotic leaks.

BACKGROUND: Anastomotic leakage after rectal resection is a major complication which increases the rates of morbidity and mortality. A small number of patients with generalised peritonitis need radical surgical treatments. Stable patients with local peritonitis can be treated conservatively. The aim of this study is to evaluate the effects of transrectal vacuum treatment on the healing of low colorectal anastomotic leaks. METHODS: Medical records of fourteen patients managed conservatively with transrectal vacuum treatment for anastomotic leakage after rectal resection between September 2015 and September 2018, were retrospectively reviewed. Anastomotic leakage was documented and evaluated with computerised tomography and rectosigmoidoscopy. RESULTS: 10 of 14 patients had successful closure of the perianastomotic abscess cavity after a mean of 19 days of vacuum treatment. 2 patients in this group had stricture on the anastomotic site as a late complication which was successfully treated with repeated dilatations. 4 of 14 patients had eventually a permanent sigmoid colostomy. CONCLUSION: Our results suggest that transrectal vacuum treatment can be safely used to all stable patients without generalised peritonitis in the management of low colorectal anastomotic leakages. KEY WORDS: Anastomotic leakage, Rectosigmoidoscopy, Vacuum treatment, VAC.

Acute Pancreatitis Caused By Mushroom Poisoning: A Report of Two Cases.

Of the more than 5000 species of mushrooms known, 100 types are toxic and approximately 10% of these toxic types can cause fatal toxicity. A type of mushroom called Amanita phalloides is responsible for 95% of toxic mushroom poisonings. In this article, we report 2 cases of mushroom poisonings caused by Lactarius volemus, known as Tirmit by the local people. The patient and his wife were admitted to the emergency room with abdominal pain, nausea, and vomiting 20 hours after consuming Lactarius volemus, an edible type of mushroom. The patients reported that they had been collecting this mushroom from the mountains and eating them for several years but had never developed any clinicopathology to date. Further examination of the patients revealed a very rare case of acute pancreatitis due to mushroom intoxication. The male patient was admitted to the intensive care unit while his wife was followed in the internal medicine service, because of her relative mild clinical symptoms. Both patients recovered without sequelae and were discharged. In this article, we aimed to emphasize that gastrointestinal symptoms are often observed in mushroom intoxications and can be confused with acute pancreatitis, thus leading to misdiagnosis of patients. Early diagnosis and appropriate treatment can improve patients' prognosis and prevent the development of complications.

Are the blood groups of women with preeclampsia a risk factor for the development of hypertension postpartum?

INTRODUCTION: Preeclampsia (PE) is a pregnancy-related disorder characterized by hypertension (HT) and proteinuria noticeable after 20 weeks of gestation. PE is now considered as a cardiovascular disease risk factor and a number of studies have shown that experiencing PE increases the prevalence of various cardiovascular risk factors, such as metabolic syndrome and HT. In this study, we aimed to investigate any possible relationship between the ABO/Rh blood group system and PE in Turkey. In the second part of the study, we examined the relationship between the ABO blood group system and development of HT after PE. PATIENTS AND METHODS: A total of 250 patients with PE from Kayseri Training and Research Hospital between 2002 and 2012 were included in the study. Patients were classified according to blood groups (A, B, AB, and O) and Rh status (+/-). RESULTS: There was a significant difference between the patients with PE and the control group in terms of distribution of ABO blood groups and the percentage of group AB was found to be higher in patients with PE compared to the control group (P=0.029). The risk of developing PE was significantly higher in group AB than other blood groups (P=0.006). The risk of developing HT after PE was significantly higher in group O than other blood groups (P=0.004). DISCUSSION: In this study, we found that the patients with blood group AB have a higher risk for PE. The patients with PE of blood group O are at high risk of developing HT, and Rh factor was identified as another risk at this point and these patients should be closely followed postpartum.

The role of blood groups in the development of diabetes mellitus after gestational diabetes mellitus.

INTRODUCTION: Gestational diabetes mellitus (GDM) is a common condition that is defined as glucose intolerance of varying degree with onset or first recognition during pregnancy and it affects approximately 5% of all pregnancies all over the world. GDM is not only associated with adverse pregnancy outcomes such as macrosomia, dystocia, birth trauma, and metabolic complications in newborns, but it is also a strong predictor of transitioning to overt DM postpartum. The association of ABO blood groups with DM has been observed before in several epidemiological and genetic studies and resulted with inconsistent findings, but still there are not enough studies in the literature about the association of ABO blood groups with GDM. In this study, we aimed at investigating any possible relationship between the ABO blood group system and GDM and also the transitioning of GDM to overt DM postpartum, in Turkey. PATIENTS AND METHODS: A total of 233 patients with GDM from Kayseri Training and Research Hospital between 2002 and 2012 were included in the study. The cases that have serologically determined blood groups and Rh factor in the hospital records were included in the study, and the patients with unknown blood groups were excluded. Patients were classified according to blood groups (A, B, AB, and O) and Rh status (+/-). GDM was diagnosed based on the glucose cut-points of the International Association of the Diabetes and Pregnancy Society Groups. The distributions of blood groups of the patients with GDM were compared with the distribution of blood groups of 17,314 healthy donors who were admitted to the Turkish Red Crescent Blood Service in our city in 2012. RESULTS: There was a significant difference between the patients with GDM and control group in terms of distribution of ABO blood groups. Blood group AB was found to be higher in the patients with GDM compared to the control group (P=0.029). When the patients were compared according to the development of DM, the ratio of group O was higher than others, while the ratio of group B was lower in the group developing DM (P=0.001). There was a significant difference between the groups - GDM patients with or without DM - in terms of distribution of ABO blood groups with Rh factor and the ratio of developing DM is found to be higher in patients with +Rh factor among all the blood groups except for group B (P=0.008). CONCLUSION: In this study, we found a higher risk of GDM for the patients with blood group AB, which means that we have to be more careful on the follow-up of pregnant women with blood group AB. The patients with GDM of blood group O are under a higher risk of developing DM and also +Rh factor must be considered as another risk factor, so these patients should be closely followed postpartum by the oral glucose tolerance tests. To our knowledge, this is the first analysis that investigates the association between the ABO blood groups and transitioning to DM after GDM.

Hepatitis B and C seroprevalence in solid tumors - necessity for screening during chemotherapy.

BACKGROUND: Hepatitis B and C are the leading causes of liver diseases worldwide. For hematological and solid malignancy patients undergoing chemotherapy, increases in HBV DNA and HCV RNA levels can be detected which may result in reactivation and hepatitis-related morbidity and mortality. The aim of this study was to determine the seroprevalence of Hbs ag and Anti HCV positivity in patients with solid malignancies undergoing chemotherapy and consequences during follow-up. MATERIALS AND METHODS: The files of 914 patients with solid malignancies whose hepatitis markers were determined serologically at diagnosis were reviewed retrospectively. All underwent adjuvant/palliative chemotherapy. For the cases with HBV and/or HCV positivity, HBV DNA and HCV RNA levels, liver function tests at diagnosis and during follow-up and the treatment modalities that were chosen were determined. RESULTS: Of 914 cases, Hbs Ag, anti Hbs and anti HCV positivity were detected in 40 (4.4%), 336 (36.8%) and 26 (2.8%) of the cases respectively. All of the Hbs ag positive patients received prophylactic lamuvidine before the start of chemotherapy. In the Hbs ag and anti HCV positive cases, liver failure was not detected during chemotherapy and a delay in chemotherapy courses because of hepatitis was not encountered. CONCLUSIONS: Just as with hematological malignancies, screening for HBV and HCV should also be considered for patients with solid tumors undergoing chemotherapy. Prophylactic antiviral therapy for HBV reduces both the reactivation rates and HBV related mortality and morbidity. The clinical impact of HCV infection on patients undergoing chemotherapy is still not well characterized.

Is hypertriglyceridemia a prognostic factor in sepsis?

INTRODUCTION: Sepsis and septic shock are important causes of mortality in intensive care unit patients, hence early diagnosis and therapy are important in management of their treatment. The available information on sepsis patients is not enough to recommend or to discard the routine evaluation of triglyceride (TG) levels at the onset of sepsis. The aim of this study was to investigate the association of hypertriglyceridemia and clinical outcome (or mortality) in patients with severe sepsis. MATERIALS AND METHODS: Between January 1 and December 31, 2011, a total of 84 patients with sepsis from the intensive internal care unit at the Kayseri Training and Research Hospital, Kayseri, Turkey, were investigated retrospectively. Sepsis was defined according to the American College of Chest Physicians/Society of Critical Care Medicine/European Society of Intensive Care Medicine consensus conference definitions. For each patient, survival was recorded at the end of the last day of hospitalization as dead or alive. The TG values were taken retrospectively from the records, which were performed routinely for each patient with sepsis at the time of diagnosis. TG >150 mg/dL was considered as hypertriglyceridemia. RESULTS: The percentages of male and female patients were 44% and 56%, respectively. The mean age of patients was 71.49±11.071 years. The percentage of patients with TG values more than 150 mg/dL was 81% (25/31) in the non-survivor group and 19% (6/31) in the survivor group. There was a significant difference regarding TG values between groups (P=0.039). DISCUSSION: It was observed in this study that patients in the intensive care unit with sepsis had high TG levels. We also observed that the TG level >150 mg/dL at 0 hour (onset of sepsis) was a significant predictive marker of sepsis mortality rate. The contribution of hypertriglyceridemia to mortality might be modest compared to increase in severity of illness, but, nevertheless, these simple measurements represent a potential therapeutic target in sepsis.

Lithium intoxication and nephrogenic diabetes insipidus: a case report and review of literature.

Lithium is one of the drugs used widely in the treatment of mood disorders. However, it has a very narrow therapeutic index and side effects can be seen in many organ systems, one of which affects the kidneys. We can see varying degrees of renal damage associated with acute or chronic lithium use. Lithium intoxication is diagnosed by a rise in the serum lithium concentration, but it must be remembered that serum levels and clinical findings do not always overlap. Treatment of lithium intoxication varies according to the clinical findings. There are various ways of treating lithium intoxication, but there is no specific antidote. The purpose of treatment is to remove the toxin from the body. Here we report a patient who was treated for lithium intoxication and developed diabetes insipidus during follow-up, and discuss the relevant literature.

Acute liver failure caused by mushroom poisoning: a case report and review of the literature.

It is estimated that there are over 5,000 species of mushrooms worldwide. Some of them are edible and some are poisonous due to containing significant toxins. In more than 95% of mushroom toxicity cases, poisoning occurs as a result of misidentification of the mushroom by an amateur mushroom hunter. The severity of mushroom poisoning may vary, depending on the geographic location where the mushroom is grown, growth conditions, the amount of toxin delivered, and the genetic characteristics of the mushroom. Amanita phalloides is the most common and fatal cause of mushroom poisoning. This mushroom contains amanitins, which are powerful hepatotoxins that inhibit RNA polymerase II in liver. Mushroom poisoning is a relatively rare cause of acute liver failure. A 63-year-old male patient was admitted to the emergency room with weakness, nausea, vomiting, and diarrhea. He reported ingesting several wild mushrooms about 36 hours earlier. In this article we report a case of lethal Amanita phalloides intoxication from stored mushrooms.

A case of bismuth intoxication with irreversible renal damage.

Bismuth is a chemical element symbolized as Bi and is a trivalent poor metal, which chemically resembles arsenic and antimony. Colloidal bismuth subcitrate (CBS) and bismuth subsalicylate are the bismuth salts widely used in the treatment of peptic ulcers, functional dyspepsia, and chronic gastritis. Intoxications with CBS are rare. In a few case reports, acute renal failure was described, but the literature review revealed no chronic renal failure related to CBS intoxication. In this case report we present a 21-year old female with chronic renal failure after a one year follow-up of CBS intoxication.

Colchicine intoxication: a report of two suicide cases.

Colchicine, an old and well-known drug, is an alkaloid extracted from Colchicum autumnale and related species. Colchicine inhibits the deposition of uric acid crystals and is an inhibitor of mitosis. Nausea, vomiting, abdominal pain, and diarrhea, with a massive loss of fluid and electrolytes are the first clinical symptoms of colchicine poisoning. Stomach lavage and rapid gastric decontamination with activated charcoal are crucial. An acute dose of about 0.8 mg/kg of colchicine is presumed to be fatal. We report the clinical outcomes of two different cases of colchicine intoxication for attempted suicide. The dose required for morbidity or mortality varies significantly. The dose of 1 mg/kg in the first case was directly related with mortality, while the dose of 0.2 mg/kg in the second was related with survival. The other difference between the patients was the time of arrival to hospital after ingestion. This period was 4 hours for case 1 and only 1, hour for case 2. The initiation of treatment later than 2 hours after ingestion of colchicine may significantly impair treatment because the absorption time for colchicine after oral administration is about 30-120 minutes. The rising lactate level and high anion gap metabolic acidosis in our patient (case 1) were attributed to lactic acidosis, so hemodialysis was performed, and the duration of hemodialysis was prolonged. Lactic acidosis in the first case was one of the reasons for mortality. The most important parameters which define the chance of survival are the dose of ingested drugs and the arrival time to hospital after ingestion. The patients must be monitored closely for lactic acidosis and the decision to start hemodialysis must be made promptly for patients who develop lactic acidosis.