Đánh giá hiệu quả lọc máu hấp phụ cytokin trong điều trị bệnh nhân covid-19

TÓM TẮT Đặt vấn đề: Lọc máu hấp phụ được xem là một phương pháp điều trị ở bệnh nhân Covid-19 nặng do có khả năng loại bỏ cytokine viêm. Nghiên cứu này mục đích để đánh giá hiệu quả lọc máu hấp phụ theo phương thức lọc máu ngắt quãng (IHD) ở bệnh nhân Covid-19. Phương pháp nghiên cứu: Nghiên cứu can thiệp, thực hiện trên các bệnh nhân được chẩn đoán viêm phổi do Covid-19 mức độ nặng ở trung tâm hồi sức tích cực bệnh viện dã chiến số 14, thành phố Hồ Chí Minh. Bệnh nhân được điều trị với thuốc kháng virus, kháng sinh, kháng đông và corticoid và liệu pháp oxy và 3 lần lọc máu hấp phụ sử dụng máy lọc máu ngắt quãng. Các chỉ số lâm sàng và xét nghiệm được thu thập và so sánh ở thời điểm trước và sau lọc máu. Kết quả: Có 6 bệnh nhân nam và 4 bệnh nhân nữ ở độ tuổi trung bình 54,60 ± 14,00 điều trị lọc máu hấp phụ, có 7 bệnh nhân cải thiện và cai dần với liệu pháp oxy. Giá trị SpO2 tăng từ 92,00 ± 2,31% đến 94,40 ± 1,71% với p = 0,02. IL - 6 trong máu bệnh nhân giảm từ 110,80 ± 126,84 pg/mL xuống 26,55 ± 26,80 pg/ mL với p = 0,06, CRP giảm từ 139,90 ± 57,41mg/L xuống 56,10 ± 53,10mg/L với p = 0,03. Kết luận: Lọc máu hấp phụ có thể giúp cải thiện SpO2 và hỗ trợ cai liệu pháp oxy ở hầu hết bệnh nhân trong nhóm nghiên cứu. Tuy nhiên, trong tương lai cần có nghiên cứu đa trung tâm, có đối chứng trên nhiều bệnh nhân để có thể đánh giá chắc chắn hiệu quả lọc máu hấp phụ ở bệnh nhân Covid-19. ABSTRACT EFFECTIVENESS OF HEMOPERFUSION IN COID-19 PATIENTS Backgrounds: Extracorporeal blood purification has been proposed as one of the therapeutic approaches in patients with coronavirus infection, because of its beneficial impact on elimination of inflammatory cytokines. This study aims to evaluate the effectiveness of hemoperfusion in coid-19 patients. Methods: This experimental research has been conducted on severe COVID-19 pneumonia patients who admitted in field hospital in Ho Chi Minh city, receiving antiviral, antibacterial drugs, anticoagulant drugs and steroid, and different modalities of respiratory treatments. No randomization and blindness were considered. All of the participants underwent three sessions of resin-directed hemoperfusion using intermittent hemodialysis machine. Results: Six men and four women with a mean age of 54.60 ± 14.00 years has been enrolled in the study, and seven of them have improved after the intervention. Peripheral capillary oxygen saturation (SpO2) changed after cytokine removal therapy. Mean SpO2 before the three session of hemoperfusion was 92.00 ± 2.31% and increased to 94.40 ± 1.71% after them (p = 0.02). Serum IL - 6 showed a reduction from 110.80 ± 126.84 pg/mL to 26.55 ± 26.80 pg/mL p = 0.06; and C-reactive protein decreased from 139.90 ± 57.41mg/L to 56.10 ± 53.10mg/L p = 0.03. Conclusions: Extracorporeal hemoadsorption using intermittent dialyisis machine could improve the general condition in most of recruited patients with severe coronavirus disease, however, large prospective multicenter trials in carefully selected patients are needed to definitely evaluate the efficacy of hemoperfusion in COVID-19 patients. Keywords: Intermittent dialyisis machine, hemoperfusion, COVID-19 pneumonia.

Underdosed Direct Oral Anticoagulants in Atrial Fibrillation Patients Reduce Stroke Severity and Improve Outcome

<b><i>Background and Purpose:</i></b> Anticoagulant drugs, including vitamin K antagonist (VKA) and direct oral anticoagulants (DOACs), can reduce stroke severity and are associated with good functional outcomes. Some patients are prescribed lower-than-recommended doses of DOACs; whether these have similar effects has not been clarified. <b><i>Methods:</i></b> We retrospectively evaluated 1,139 consecutive ischemic stroke and transient ischemic attack patients with atrial fibrillation. Patients were divided into 5 groups according to their preceding anticoagulant drug therapies: no anticoagulant therapy (AC_n), undercontrolling VKA doses (VKA_uc), recommended, controlling VKA doses (VKA_rec), prescribed underdoses of DOAC (DOAC_ud), and recommended doses of DOAC (DOAC_rec). We investigated the associations between these anticoagulant drug therapies and patients’ initial stroke severity and 3-month outcomes. <b><i>Results:</i></b> Median National Institutes of Health Stroke Scale scores at admission were as follows: AC_n: 16, VKA_uc: 15, VKA_rec: 9, DOAC_ud: 5, and DOAC_rec: 7. When the AC_n group was used as a reference, regression analysis showed that VKA_rec (odds ratio [OR] 1.49, 95% confidence interval [CI] 1.01–2.21), DOAC_ud (OR 2.84, 95% CI: 1.47–5.66), and DOAC_rec (OR 1.83, 95% CI: 1.23–2.74) were associated with milder stroke severity, while VKA_uc was not. Median 3-month modified Rankin Scale scores were 2 in the DOAC_ud and DOAC_rec groups and 4 in all other groups. After adjusting for confounding factors, DOAC_ud (OR 3.14, 95% CI: 1.50–6.57) and DOAC_rec (OR 1.67, 95% CI: 1.05–2.64) were associated with good 3-month outcomes while VKA_uc and VKA_rec were not. <b><i>Conclusions:</i></b> In patients with atrial fibrillation, recommended doses and underdoses of DOACs reduced stroke severity on admission and were associated with good 3-month outcomes.

Investigation of Education Requirements of Individuals Using Warfarin and Achievement of Target INR Value

Thromboembolic diseases are important causes of morbidity and mortality. Oral anticoagulants for preventing or treating thromboembolic diseases reduce blood clotting and prevent fibrin deposition, thrombus development, and growth. This study aimed to investigate the educational needs and the rate of reaching the target INR level of individuals using warfarin for heart diseases. The population of this cross-sectional study was attempted to reach the entire population by not choosing a sample due to heart diseases between August –September 2019 in the cardiology outpatient clinic of a public hospital operating in Istanbul. However, due to the voluntary basis and incorrect registration of the questionnaires, 157 participants formed the sample. Data were analyzed using the SPSS 25.0 program. 75.1% of the individuals stated that they were informed about the use of warfarin, and 66.8% of those who received the information stated that they received the information from their physician. In addition, 75.7% stated that they took warfarin regularly, 81.7% had regular INR control, 52.1% knew the target INR value, 68.9% knew the complications. It was found to be 47.6. A statistically significant difference was found between individuals who reached the target INR level and those who did not, according to their information acquisition status (p <0.05). The low rate of individuals reaching the target INR level draws attention. For this reason, it is thought that the knowledge level of patients who are starting treatment with warfarin should be increased, and new generation oral anticoagulant drugs can be used as an anticoagulant treatment instead of warfarin in patients whose target INR cannot be achieved despite sufficient training.

Prevention of thrombosis in patients with gastrointestinal bleedings, anticoagulant therapy: literature review

Background. Analysis of the causes of unfavorable outcomes in gastrointestinal bleedings shows that one of the directions in improving the results of treatment of such patients is not only improving the methods of non-operative (endoscopic + drug) hemostasis, but also predicting the risk of recurrent bleeding, prevention and treatment of thromboembolic complications. Objective: to study the risks of thromboembolic complications in patients with gastrointestinal bleedings and the prospects for anticoagulant therapy. Materials and methods. The review analyzes the results of clinical studies investigating the risks of thromboembolic complications, clarification of risk groups, volumes and methods of prevention; identifies the most promising effective and safe methods. The critical analysis was carried out based on the study and systematization of scientific researches presented on specialized medical sites. Results. The basis for a reasonable determination of the risk of thrombotic complications in patients with gastrointestinal bleedings is an objective assessment of the balance between the mechanisms of bleeding and thrombosis. Prevention of thromboembolic complications in patients with gastrointestinal bleedings is carried out taking into account individual characteristics. The therapy should consider risk factors both for the development of rebleeding and thromboembolic complications. Thromboelastography is a modern and adequate method for monitoring blood homeostasis at all stages of treatment. Conclusions. A multidisciplinary approach with the participation of surgeons and anesthesiologists is required to make a decision on the prescription, scope and methods of therapy. Such a decision must be justified, taking into account many factors. It is important to consider the mechanisms of action of hemostatic and anticoagulant drugs. Consideration and systematization of all these data does not exclude, but, on the contrary, provides an individual approach to each patient, the determination of an individual strategy with an optimal ratio of the risks of developing rebleeding and prevention of thromboembolic complications.

Evaluation of Critical Factors of Postoperative Arrhythmia and Preventive Measures of Deep Venous Thrombosis

The study focused on the risk factors of postoperative arrhythmia and lung infection and the preventive effects of targeted low-molecular-weight heparin (LMWH) on the occurrence of deep venous thrombosis (DVT) in patients with esophageal/cardia cancer. In this article, 82 patients who were pathologically diagnosed with esophageal/cardia cancer and underwent surgical treatment were selected as the research subjects. According to the different preoperative treatment methods, the patients were divided into the control group (without anticoagulant drugs before the operation, 44 cases) and the anticoagulation group (anticoagulant drugs were administered before the operation, 38 cases), and they were compared for basic clinical indicators and disease history. Logistic regression analysis was performed to analyze the risk factors of adverse events, and the Wells and Autar scale scores were calculated. Different groups were compared for the operation time, blood loss, and postoperative drainage volume during the operation. D-dimer was detected on the first 1, 3, 5, and 7 days after the operation, and the lower extremity venous color Doppler ultrasound was performed on the 1st and 7th days after the operation. The results showed that age ≥65 years, abnormal preoperative ECG, preoperative coronary heart disease (CHD), preoperative chronic obstructive pulmonary disease (COPD), operative time ≥4 h, and preoperative blood sodium <4.04.0 mmol/L were all risk factors for postoperative arrhythmia. Age, preoperative diabetes mellitus, preoperative COPD, length of hospital stay, and FEV1 were all risk factors for postoperative lung infections. In the control group and anticoagulation group, 11 cases (13.41%) and 5 cases (16.10%) had lower extremity DVT, respectively. The incidence of lower extremity DVT was lower in the anticoagulation group than in the control group P < 0.01 . It suggested that age, preoperative disease history, hospital stay, and operation time were risk factors for postoperative adverse events in patients with esophageal/cardia cancer. The targeted anticoagulant LMWH has a significant preventive effect on the occurrence of lower extremity DVT in patients with esophageal/cardia cancer, providing an effective reference for the prognosis and prevention of esophageal/cardia cancer.

Combined antiplatelet therapy reduces the pro-inflammatory properties of activated platelets

The cause of atherothrombosis is rupture or erosion of atherosclerotic lesions, leading to an increased risk on myocardial infarction or stroke. Here, platelet activation plays a major role, leading to the release of bioactive molecules, e.g. chemokines and coagulation factors, and to platelet clot formation. Several antiplatelet therapies have been developed for secondary prevention of cardiovascular events, in which anticoagulant drugs are often combined. Besides playing a role in haemostasis, platelets are also involved in inflammation. However, it is unclear whether current antiplatelet therapies also affect platelet immune functions. In this study, the possible anti-inflammatory effects of antiplatelet medications on chemokine release were investigated using ELISA and on the chemotaxis of THP-1 cells towards platelet releasates. The cause of atherothrombosis is rupture or erosion of atherosclerotic lesions, leading to an increased risk on myocardial infarction or stroke. Here, platelet activation plays a major role, leading to the release of bioactive molecules, e.g. chemokines and coagulation factors, and to platelet clot formation. Several antiplatelet therapies have been developed for secondary prevention of cardiovascular events, in which anticoagulant drugs are often combined. Besides playing a role in haemostasis, platelets are also involved in inflammation. However, it is unclear whether current antiplatelet therapies also affect platelet immune functions. In this study, the possible anti-inflammatory effects of antiplatelet medications on chemokine release were investigated using ELISA and on the chemotaxis of THP-1 cells towards platelet releasates. We found that antiplatelet medication acetylsalicylic acid (ASA) led to reduced chemokine (C-C motif) ligand 5 (CCL5) and chemokine (C-X-C motif) ligand 4 (CXCL4) release from platelets, while leukocyte chemotaxis was not affected. Depending on the agonist, αIIbβ3- and P2Y12-inhibitors also affected CCL5 or CXCL4 release. The combination of ASA with a P2Y12 inhibitor or a phosphodiesterase inhibitor did not lead to an additive reduction on CCL5 or CXCL4 release. Interestingly, these combinations did reduce leukocyte chemotaxis. This study provides evidence that combined therapy of ASA and a P2Y12 or PDE3 inhibitor can decrease the inflammatory leukocyte recruiting potential of the releasate of activated platelets.

Comparison Of Drugs in Patients Using New Generation Anticoagulants

Aim: New generation anticoagulants rapidly find a wider area of use in the clinic due to the use problems of other oral anticoagulants. Anticoagulants such as Dabigatran, Rivaroxaban, and Apixaban with safer treatment intervals have been accepted in clinical practice guidelines and have taken their place as preferred drugs. In this study, we aimed to retrospectively examine the effects of three new-generation anticoagulant drugs on a group of patients. Material and Methods: In this retrospectively planned study, patients diagnosed with atrial fibrillation (n = 522) were divided into three groups according to the drugs used for treatment (Dabigatran, Rivaroxaban, and Apixaban). Routine blood values of the patients in each group were retrospectively scanned according to age, gender, time of drug initiation and presence of chronic disease. Results: According to the results obtained, it was found that the mean HCT, BUN, AST, ALT, MPV, Iron, and Ferritin were higher in patients using Apixaban than those using Dabigatran and Rivaroxaban drugs, but the age, average values of Hgb1 Hgb2, Hgb1, PLT, CrCl, Gfr and INR of the patients using Apixaban lower than those using Dabigatran and Rivaroxaban. The highest rate (22.5%) was found in the group of patients taking apixaban (n=93) when people taking the drugs were examined in terms of mortality. Conclusion: It has been observed that Rivaroxaban can be used more safely in patients with a history of acute cancer and thrombosis, patients with recurrent venous thromboembolism, and patients with high frailty, three drugs should be preferred instead of oral anticoagulants.

Long term dual antiplatelet therapy after myocardial infarction: retrospective analysis in an outpatient population

Long term treatment with ticagrelor 60 mg and low-dose aspirin are indicated after acute coronary syndrome (ACS). We retrospectively reviewed aggregate data of 187 patients (155 M and 38 F) (mean age 63.8±9 years) in follow up after ACS with at least one high risk condition (Multivessel disease, diabetes, GFR<60 mL/min, history of prior myocardial infarction, age >65 years) treated with ticagrelor 60 mg twice daily (after 90 mg twice daily for 12 months). The results were compared with findings (characteristics of the patients at baseline, outcomes, bleeding) of PEGASUS-TIMI 54 trial and Eu Label. The highrisk groups were represented as follows: multivessel disease 105 pts (82%), diabetes 63 pts (33%), GFR< 60 mL/min 27 pts (14%), history of prior MI 33 pts (17%), >65 year aged 85 pts (45%). Treatment was withdrawn in 7 patients: 3 cases showed atrial fibrillation and were placed on oral anticoagulant drugs, one developed intracranial bleeding, in three patients a temporary withdrawal was due to surgery (1 colon polyposis and 2 cases of bladder papilloma). Chest pain without myocardial infarction occurred in 16 patients (revascularization was required in 9 patients). Dyspnea was present in 15 patients, but was not a cause for discontinuation of therapy. Long term treatment with ticagrelor 60 mg twice daily plus aspirin 100 mg/day showed a favourable benefit/risk profile after ACS. In this study all patients had been given ticagrelor 90 mg twice daily for 12 months and the 60 mg twice daily dosage was started immediately thereafter, unlike PEGASUS-TIMI 54 trial in which it was prescribed within a period ranging from 1 day to 1 year after discontinuation of the 90 mg dose. This makes our results more consistent with current clinical practice. However, a careful outpatient follow-up and constant counseling are mandatory to check out compliance to therapy and adverse side effects.

Incidentally discovered Kawasaki disease in an adult man

Kawasaki disease (KD) is a systemic vasculitis of unknown cause which usually diagnosed in small children. However, KD can be present as coronary disease in adults even with no history of the disease in childhood. Here, we describe a case of KD in a 42-year-old male patient presented with severe retrosternal chest pain radiating to the left arm and provisionally diagnosed as acute coronary disease. Coronary artery ectasia and multiple aneurysms have been confirmed by coronary angiography that led to the diagnosis of KD. The patient was treated with Aspirin 81 mg orally once daily, Apixapan 5 mg orally twice daily, Rosuvastatin 40 mg orally once daily, Bisoprolol 5 mg orally once daily, and omeprazole 20 mg orally once daily. The patient was improved and discharged with anticoagulant drugs for life. Physicians should be aware that KD can be present as coronary disease in adults even with no history of the disease in childhood and has a limited treatment options due to unfavorable coronary anatomy. doi: https://doi.org/10.12669/pjms.37.7.4199 How to cite this:Haider KH, Alshoabi SA, Qurashi AA, Hamid AM. Incidentally discovered Kawasaki disease in an adult man. Pak J Med Sci. 2021;37(7):---------. doi: https://doi.org/10.12669/pjms.37.7.4199 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.