Thromboelastography Parameter and Its Association with Survival of COVID-19 Patients: A Retrospective Cross-Sectional Study

@#Introduction: Coagulopathy associated with Coronavirus disease 2019 (COVID-19) may cause life-threatening complications, especially in severe or critically ill COVID-19 patients. Thromboelastography (TEG) is an effective, dynamic, and reliable test to assess the complete coagulation process. This study aimed to determine the association between selected TEG parameters and survival in COVID-19 patients. Methods: This study was a retrospective observational study using data from medical records of COVID-19 patients who were hospitalized in Dr. Soetomo Hospital, Surabaya, Indonesia. There were 94 COVID-19 patients consisting of 76 survivors and 18 non-survivors. The association between TEG results and certain TEG parameters with survival status was considered significant if the p-value ≤ 0.05. Results: Increased coagulation activity had a significant association with the survival status of COVID-19 patients (p=0.04). There were no significant differences in all TEG parameters between COVID-19 patients who survived and those who did not survive (p > 0.05). Based on the TEG analysis tree, the most TEG results found were secondary fibrinolysis (21.3%) and fibrinolytic shutdown (24.5%). No significant association was found between the coagulability and fibrinolysis abnormality with the survival status in COVID-19 patients (p > 0.05). Conclusion: There was no significant difference in TEG results between COVID-19 survivors and non-survivors. However, based on the TEG result, an increase in coagulation activity is associated with a lower survival rate. Further study with detailed timing of TEG examination, disease severity and comorbidities stratification in COVID-19 patients may be needed.

Effects of Jianpi Huaji Fuzheng Decoction supplemented with conventional chemotherapy on cellular immunity and coagulation-fibrinolysis function in patients with primary hepatic carcinoma of spleen-deficiency syndrome / 国际中医中药杂志

Objective:To explore the effects of Jianpi Huaji Fuzheng Decoction supplemented with conventional chemotherapy on Traditional Chinese Medicine (TCM) syndromes scores, cellular immunity and coagulation-fibrinolysis function in patients with primary hepatic carcinoma of spleen-deficiency syndrome.Methods:Prospective cohort study. A total of 85 patients with primary hepatic carcinoma of spleen-deficiency syndrome who met the inclusion criteria in the hospital between March 2018 and March 2021 were divided into 42 cases in control group and 43 cases in observation group according to the random number table method. The control group was given conventional western medicine chemotherapy, and the observation group was given Jianpi Huaji Fuzheng Decoction on the basis of the control group. Both groups were treated for 3 months. Before and after treatment, the TCM syndromes were scored. The levels of CD4 + and CD8 + were detected by flow cytometry with indirect immunofluorescence, and the ratio of CD4 +/CD8 + was calculated. The plasma prothrombin time (PT), fibrinogen (Fg) and coagulation factor Ⅶ (CFⅦ) were detected by automatic blood coagulation analyzer. The toxic and side effects of chemotherapy during treatment were recorded and the clinical efficacy was evaluated. Results:The total effective rate of syndrome efficacy was 95.35% (41/43) in observation group and 78.57% (33/42) in control group ( χ2=3.92, P=0.047). After treatment, the scores of flank pain, lumps, fatigue and jaundice and total score in observation group were significantly lower than those in the control group ( t=2.60, 2.64, 2.85, 2.91, 3.79, P<0.01). The level of CD4 + [(37.68±3.72)% vs. (35.92±3.61)%, t=2.21] and CD4 +/CD8 + [(1.44±0.22) vs. (1.31±0.23), t=2.66] in observation group were significantly higher than those in the control group ( P<0.05), while the level of CD8 + [(26.20±2.72)% vs. (27.44±2.16)%, t=2.32] was significantly lower than that of the control group ( P<0.05). The levels of Fg [(3.11±0.85) g/L vs. (2.74±0.72) g/L, t=2.16] and CFⅦ [(1.76±0.44) mg/L vs. (1.58±0.37) mg/L, t=2.04] were significantly higher than those in the control group ( P<0.05). PT [(14.65±2.72) s vs. (15.91±3.03) s, t=2.02] was significantly shorter than that of the control group ( P<0.05). During treatment, the incidence rate of toxic and side effects of chemotherapy was 11.63% (5/43) in observation group and that in control group was 30.95% (13/42) ( χ2=4.75, P=0.029). Conclusion:Jianpi Huaji Fuzheng Decoction supplemented with conventional chemotherapy can improve the clinical symptoms, promote the recovery of cellular immune function and coagulation-fibrinolysis function, reduce the incidence rates of toxic and side effects of chemotherapy, and enhance the clinical efficacy of patients with primary hepatic carcinoma.

Fibrinólisis y SARS-CoV-2 / Fibrinolysis and SARS - CoV - 2

La regulación del sistema de la fibrinólisis está mediada por interacciones moleculares específicas entre sus principales componentes y por la síntesis y posterior liberación a partir de las células endoteliales de los activadores e inhibidores del plasminógeno. Por tanto, un incremento de la actividad del sistema de la fibrinólisis favorece la aparición de trastornos hemorrágicos, mientras que el defecto de la actividad fibrinolítica puede predisponer a la trombosis. En los pacientes con SARS-CoV-2 también se han reportado alteraciones en la fibrinólisis. La atenuación del sistema de activación del plasminógeno conduce a un recambio anormal de fibrina en el espacio alveolar con la aparición de trombosis. Se ha informado que los niveles plasmáticos de PAI-1 son un factor de riesgo de mal pronóstico y mortalidad en los pacientes con COVID-19.

The regulation of the fibrinolysis system is mediated by specific molecular interactions between its main components and by the synthesis and subsequent release from endothelial cells of plasminogen activators and inhibitors. Therefore, an increase in the activity of the fibrinolysis system favors the appearance of bleeding disorders, while a defect in fibrinolytic activity may predispose to thrombosis. Alterations in fibrinolysis have also been reported in patients with SARS-CoV-2. Attenuation of the plasminogen activation system leads to abnormal fibrin turnover in the alveolar space with the development of thrombosis. Plasma PAI-1 levels have been reported to be a risk factor for poor prognosis and mortality in patients with Covid-19.

Ensayo controlado y aleatorizado del uso de Heberkinasa® en el derrame pleural paraneumónico en niños / Randomized Controlled Trial of the Use of Heberkinase® in Parapneumonic Pleural Effusion in Children

Introducción: El derrame pleural paraneumónico resulta la complicación más frecuente de la neumonía bacteriana, de manejo complejo y muchas veces quirúrgico. No existen publicaciones en Cuba provenientes de ensayos clínicos controlados y aleatorizados ni del uso de la estreptoquinasa recombinante (Heberkinasa®) en el derrame pleural. Objetivo: Evaluar la eficacia y la seguridad de la Heberkinasa® en el tratamiento del derrame pleural paraneumónico complicado complejo y el empiema en niños. Métodos: Ensayo clínico fase III, abierto, aleatorizado (2:1), en grupos paralelos y controlado. Se concluyó la inclusión prevista de 48 niños (1-18 años de edad), que cumplieron los criterios de selección. Los progenitores otorgaron el consentimiento informado. Los pacientes se distribuyeron en dos grupos: I- experimental: terapia estándar y administración intrapleural diaria de 200 000 UI de Heberkinasa® durante 3-5 días y II-control: tratamiento estándar. Las variables principales: necesidad de cirugía y la estadía hospitalaria. Se evaluaron los eventos adversos. Resultados: Ningún paciente del grupo I-experimental requirió cirugía, a diferencia del grupo II-control en el que 37,5 por ciento necesitó cirugía video-toracoscópica, con diferencia altamente significativa. Se redujo la estadía hospitalaria (en cuatro días), las complicaciones intratorácicas y las infecciones asociadas a la asistencia sanitaria en el grupo que recibió Heberkinasa®. No se presentaron eventos adversos graves atribuibles al producto. Conclusiones: La Heberkinasa® en el derrame pleural paraneumónico complicado complejo y empiema resultó eficaz y segura para la evacuación del foco séptico, con reducción de la necesidad de tratamiento quirúrgico, de la estadía hospitalaria y de las complicaciones, sin eventos adversos relacionados con su administración(AU)

Introduction: Paraneumonic pleural effusion is the most frequent complication of bacterial pneumonia, with complex and often surgical management. There are no publications in Cuba from randomized controlled clinical trials or the use of recombinant streptokinase (Heberkinase®) in pleural effusion. Objective: To evaluate the efficacy and safety of Heberkinase® in the treatment of complex complicated parapneumonic pleural effusion and empyema in children. Methods: Phase III, open-label, randomized (2:1), parallel-group, controlled clinical trial. The planned inclusion of 48 children (1-18 years of age), who met the selection criteria, was completed. Parents gave informed consent. The patients were divided into two groups: I-experimental: standard therapy and daily intrapleural administration of 200,000 IU of Heberkinase® for 3-5 days; and II-control: standard treatment. The main variables: need for surgery and hospital stay. Adverse events were evaluated. Results: No patient in group I-experimental required surgery, unlike group II-control in which 37.5 percent required video-assisted thoracoscopic surgery, with a highly significant difference. Hospital stay (to 4 days), intrathoracic complications and infections associated to healthcare in the group that received Heberkinase® was reduced. No serious adverse events attributable to the product occurred. Conclusions: Heberkinase® in complex complicated parapneumonic pleural effusion and empyema was effective and safe for the draining of the septic focus, with reduction of the need for surgical treatment, hospital stay and complications, with no adverse events related to its administration(AU)

Correlación fisiopatológica, diagnóstica y terapéutica en el derrame pleural paraneumónico / Pathophysiological, diagnostic and therapeutic correlation in parapneumonic pleural effusion

Introducción: La inflamación de la pleura desencadenada por bacterias y mediada por citocinas, aumenta la permeabilidad vascular y produce vasodilatación, lo cual genera desequilibrio entre la producción de líquido pleural y su capacidad de reabsorción por eficientes mecanismos fisiológicos. La condición anterior conduce al desarrollo de derrame pleural paraneumónico. Objetivo: Exponer la importancia de la correlación fisiopatológica y diagnóstica con los pilares fundamentales de actuación terapéutica en el derrame pleural paraneumónico. Métodos: Revisión en PubMed y Google Scholar de artículos publicados hasta abril de 2021 que abordaran el derrame pleural paraneumónico, su fisiopatología, elementos diagnósticos, tanto clínicos como resultados del estudio del líquido pleural, pruebas de imágenes, y estrategias terapéuticas. Análisis y síntesis de la información: El progreso de una infección pulmonar y la producción de una invasión de gérmenes al espacio pleural favorece la activación de mecanismos que conllevan al acúmulo de fluido, depósito de fibrina y formación de septos. Este proceso patológico se traduce en manifestaciones clínicas, cambios en los valores citoquímicos y resultados microbiológicos en el líquido pleural, que acompañados de signos radiológicos y ecográficos en el tórax, guían la aplicación oportuna de los pilares de tratamiento del derrame pleural paraneumónico. Conclusiones: Ante un derrame pleural paraneumónico, con tabiques o partículas en suspensión en la ecografía de tórax, hallazgo de fibrina, líquido turbio o pus en el proceder de colocación del drenaje de tórax, resulta necesario iniciar fibrinólisis intrapleural. Cuando el tratamiento con fibrinolíticos intrapleurales falla, la cirugía video-toracoscópica es el procedimiento quirúrgico de elección(AU)

Introduction: The inflammation of the pleura triggered by bacteria and mediated by cytokines, increases vascular permeability and produces vasodilation, which generates imbalance between the production of pleural fluid and its resorption capacity by efficient physiological mechanisms. The above condition leads to the development of parapneumonic pleural effusion. Objective: To expose the importance of the pathophysiological and diagnostic correlation with the fundamental pillars of therapeutic action in parapneumonic pleural effusion. Methods: Review in PubMed and Google Scholar of articles published until April 2021 that addressed parapneumonic pleural effusion, its pathophysiology, diagnostic elements, both clinical and results of the pleural fluid study, imaging tests, and therapeutic strategies. Analysis and synthesis of information: The progress of a lung infection and the production of an invasion of germs into the pleural space favors the activation of mechanisms that lead to the accumulation of fluid, fibrin deposition and formation of septa. This pathological process results in clinical manifestations, changes in cytochemical values and microbiological results in the pleural fluid, which accompanied by radiological and ultrasound signs in the chest, guide the timely application of the pillars of treatment of parapneumonic pleural effusion. Conclusions: In the event of a parapneumonic pleural effusion, with septums or particles in suspension on chest ultrasound, finding fibrin, turbid fluid or pus in the procedure of placement of the chest drain, it is necessary to initiate intrapleural fibrinolytic. When treatment with intrapleural fibrinolytics fails, video-thoracoscopic surgery is the surgical procedure of choice(AU)

Valor prognóstico do escore SYNTAX residual nos desfechos clínicos intra- hospitalares e de acompanhamento em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST submetidos à estratégia farmacoinvasiva / Prognostic value of residual SYNTAX score on in-hospital and follow-up clinical outcomes in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive strategy

Introdução: A doença arterial coronariana multiarterial é um desafio na prática clínica. Uma abordagem individualizada deve considerar não apenas as características do paciente, mas também um enfoque multidisciplinar, com o Heart Team. Diversos escores angiográficos foram propostos com o objetivo de quantificar o risco associado à doença arterial coronariana multiarterial. O escore SYNTAX residual foi proposto como um método para caracterizar e quantificar a doença coronariana residual, de forma sistemática, após intervenção coronária percutânea. Existem poucos dados na literatura que correlacionam o escore SYNTAX residual em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST submetidos a uma estratégia farmacoinvasiva. O objetivo deste estudo foi avaliar o escore SYNTAX e o escore SYNTAX residual como preditores de desfechos intra-hospitalares e de médio prazo (180 a 380 dias), em pacientes com doença coronária multiarterial no contexto de infarto do miocárdio com supradesnivelamento do segmento ST, após terapia fibrinolítica bem-sucedida. Métodos: Em um estudo transversal, analítico e prospectivo, avaliamos o escore SYNTAX residual como preditor de desfechos intra-hospitalares e de médio prazo (6 meses a 1 ano), em pacientes com doença arterial coronariana multiarterial, no contexto de infarto do miocárdio com supradesnivelamento do segmento ST após estratégia farmacoinvasiva. Resultados: Entre agosto de 2019 e dezembro de 2020, foram analisados 108 pacientes com infarto do miocárdio com supradesnivelamento do segmento ST após fibrinólise, com critérios de reperfusão. O escore SYNTAX médio foi 13,98 (±4,87) e o escore SYNTAX residual médio foi 7,56 (±4,47). O escore SYNTAX residual elevado foi associado à nefropatia induzida por contraste e evento cardíaco adverso maior. Também foi um preditor independente de evento cardíaco adverso maior, com risco aumentado 9,69 vezes (p=0,0274). Conclusão: O escore SYNTAX residual elevado confere pior prognóstico em pacientes com infarto do miocárdio com elevação do segmento ST após estratégia farmacoinvasiva.

Background: Multivessel coronary artery disease is a challenge in clinical practice. An individualized approach should consider not only the patient characteristics, but also a multidisciplinary approach, together with the Heart Team. Multiple angiographic scores have been proposed with the aim of quantifying the risk associated with multivessel coronary artery disease. Residual SYNTAX score has been proposed as a method to systematically characterize and quantify residual coronary disease after percutaneous coronary intervention. There are few data in the literature correlating the residual SYNTAX score in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive strategy. The objective of this study was to evaluate the SYNTAX score and residual SYNTAX score as predictors of in-hospital and medium-term outcomes (180 to 380 days) in patients with multivessel coronary artery disease in the setting of ST-segment elevation myocardial infarction, after successful fibrinolytic therapy. Methods: In a cross-sectional, analytical, and prospective study, we evaluated residual SYNTAX score as predictor of in-hospital and medium-term outcomes (6 months to 1 year), in patients with multivessel coronary artery disease, in the setting of ST-segment elevation myocardial infarction after pharmacoinvasive strategy. Results: Between August 2019 and December 2020, 108 patients with ST-segment elevation myocardial infarction after fibrinolysis, with reperfusion criteria, were analyzed. The mean SYNTAX score was 13.98 (±4.87) and the mean residual SYNTAX score was 7.56 (±4.47). High residual SYNTAX score was associated with contrast-induced nephropathy and major adverse cardiac event. It was also an independent predictor of major adverse cardiac event with a 9.69-fold increased risk (p=0.0274). Conclusion: High residual SYNTAX score confers worse prognosis in patients with ST-segment elevation myocardial infarction after pharmacoinvasive strategy.

Accidente lonómico leve atribuido a la oruga de la especie Lonomia obliqua en el departamento de Santander, Colombia, 2021

Las orugas del género Lonomia, del orden Lepidoptera y familia Saturnidae, son de interés médico en Sudamérica por ser causantes del lonomismo, tipo de envenenamiento que aumenta cada vez más en Colombia, con tasas de mortalidad de 2,5 %. La severidad es variable y los casos no son de notificación obligatoria, lo que lleva a un subregistro de estos eventos. Se presenta el caso de una mujer adulta joven, quien acude a urgencias por la picadura de 20 orugas Lonomia en la palma de la mano izquierda; presentó signos locales inflamatorios, dolor y limitación de la movilidad de la mano. Se hospitalizó por tres días, se clasificó como leve y se trató con analgesia y antihistamínico endovenoso, lo que logró favorable evolución. El envenenamiento por oruga Lonomia es una urgencia que puede ser mortal, por tanto, es importante que se conozcan estos eventos en la literatura para su adecuado abordaje.

Caterpillars of the genus Lonomia, of the order Lepidoptera, family Saturnidae are of medical interest in South America for being the cause of lonomism, poisoning that is increasing more and more in Colombia, with mortality rates of 2.5%, the severity is variable and they are not mandatory notification, which leads to an underreporting of these events. We present the case of a young adult woman, who went to the emergency room due to the bite of 20 Lonomia caterpillars in the palm of her left hand, generating local inflammatory signs, pain and limitation of hand mobility. She was hospitalized for 3 days, classified as mild and treated with analgesia and intravenous antihistamine; which achieved favorable evolution. Therefore, it was concluded that Lonomia caterpillar poisoning is an emergency, which can be fatal. It is important that these events are known in the literature for their proper approach.

A study to compare fibrinolytic therapy versus primary percutaneous coronary intervention in ST-segment elevation myocardial infarction in a tertiary care hospital

Background: ST-segment elevation myocardial infarction (STEMI) is the most dramatic manifestation of coronary artery disease, acute STEMI is a clinical syndrome defined by characteristic symptoms of myocardial ischemia in association with persistent electrocardiographic ST elevation and subsequent release of biomarkers of myocardial necrosis. Reperfusion with thrombolysis or PCI (percutaneous coronary intervention) is the current standard of care for STEMI. Aims and Objectives: The aim of the study was to compare the effectiveness of fibrinolytic therapy and primary PCI which are the available reperfusion strategies for STEMI. Materials and Methods: This prospective and observational study was conducted at a tertiary care hospital in Bangalore. Patients presenting with STEMI to emergency department were treated with either fibrinolysis or PCI as per protocol. Patients in each arm were followed up to know the differences in outcome at discharge and 30-day follow-up. Results: Patients admitted with STEMI had overall in hospital mortality of 17 (7.1%) patients, of which 9 (7.6%) patients were from fibrinolysis group and 8 (6.6%) patients from PCI group with no statistically significant difference (P = 0.760). There was significant incidence (P = 0.001) of reinfarct in fibrinolysis group (9.3%) when compared to PCI group (0%). Conclusion: There was no statistically significant mortality difference at discharge and at 30 day between fibrinolysis and primary PCI in patients with STEMI in our study, this may be attributed to use of rescue PCI in failed fibrinolysis patients and early tricuspid valve repair in many patients after fibrinolysis.

Extensive atherosclerosis associated with mobile thrombus in the left carotid bulb in an elderly

A case of extensive atherosclerosis in an 88-year-old, chronic heavy smoker, associated with mobile thrombus in the left carotid bulb is presented. This patient also suffered from chronic obstructive pulmonary disease (COPD) and hypertension. He was fully worked up and confirmed as a case of the mobile thrombus attached to the plaque in the left carotid bulb by echocardiography and carotid Doppler. Thrombolysis of a large, mobile clot poses a theoretical risk of stroke worsening from incomplete fibrinolysis. He was prescribed anticoagulants and has been doing fine till the last follow-up. The importance of preventing premature atherosclerosis in the next generations is also discussed. We report this case to create awareness about this preventable malady and treatment options.

A Case Report of Successful Fibrinolysis in a Multiple Coronary Ectasia ST-segment Elevation Myocardial Infarction Validated by Coronary Angiography

Coronary artery ectasia (CAE) often presents in the form of an acute coronary syndrome (ACS) caused by slow blood flow leading to thrombus formation in ectatic coronary arteries. The usual approach is thrombectomy with intracoronary thrombolysis but often does not guarantee immediate blood flow. A 45-year-old male presented with anginal chest pain and was diagnosed with ST-segment elevation myocardial infarction (STEMI), managed Immediately with tissue plasminogen activator(t-PA) followed later with coronary angiography revealing diffused Multiple coronary ectasia MCEA with no identified culprit lesions afterward. The patient was followed up periodically, with favorable outcomes on daily aspirin, direct oral anticoagulant (DOAC), and guideline-directed medical therapy (GDMT) for coronary artery disease (CAD) and reduced ejection fraction heart failure (HF-rEF). This case management strategy was dictated by available resources at the time of presentation; however, it signifies the importance and favorable outcome of thrombolysis in CEA/STEMI patients. Future large-scale studies are required toward defining the duration as well as the choice of long-term anticoagulation.

Coagulation and fibrinolysis parameters and mortality in patients with ischemic stroke: a 10-year follow-up study / 国际脑血管病杂志

Objective:To investigate the long-term death of patients with ischemic stroke and its influencing factors.Methods:Based on the data of patients with ischemic stroke in the multi-center oral fibrinogen-lowering drug secondary prevention database, the follow-up patient information and the cause of death were registered through the epidemiological investigation method, and then compared with the baseline data of patients in the original database.Results:A total of 278 patients completed the follow-up, and 166 were in lumbrokinase group and 112 were in control group. There were 124 deaths (44.6%) within 10 years, of which 92 (74.2%) were vascular deaths. In the lumbrokinase group, 74 patients (44.6%) died of all causes and 55 (33.1%) died of vascular diseases; in the control group, 50 (44.6%) died of all causes and 37 (33.0%) died of vascular diseases. Cox proportional risk model analysis showed that lumbrokinase treatment had no significant effect on the 10-year survival rate of patients with ischemic stroke. The analysis of death influencing factors showed that the baseline international normalized ratio (INR) was significantly associated with the 10-year non-vascular death risk of patients (hazard ratio [ HR] 1.98, 95% confidence interval [ CI] 1.21-3.25; P=0.006). The greater the decrease of tissue plasminogen activator (tPA) within half a year, the lower the 10-year all-cause mortality risk ( HR 0.94, 95% CI 0.90-0.99; P=0.011); the greater the decrease in INR within one year , the lower the 10-year vascular death risk ( HR 0.41, 95% CI 0.17-0.96; P=0.040); the greater the decrease of D-dimer within one year , the higher the risk of the 10-year vascular death ( HR 1.37, 95% CI 1.02-1.83; P=0.034). The greater the decrease of INR in patients with ischemic stroke within one year, the higher the 10-year non-vascular death risk ( HR 2.15, 95% CI 1.29-3.59; P=0.004). Conclusions:The 10-year mortality rate of patients with ischemic stroke is higher, and about 3/4 are vascular deaths. The fibrinogen-lowering treatment in the acute stage has no significant effect on the 10-year all-cause mortality of patients with ischemic stroke. The greater the decrease of tPA in half a year, the lower the all-cause mortality; the greater the decrease of D-dimer level at baseline and within 1 year, the higher the 10-year vascular death; the greater the decrease of INR at baseline and within 1 year, the higher the 10-year non-vascular death risk.

Evaluating the effect of antidiabetic treatment on haemostatic and fibrinolytic parameters among type 2 diabetics in Ilorin, Nigeria

Background:Type 2 Diabetes Mellitus is a disease of epidemic proportions and many patients are at a great risk of premature mortality and complication of atherothrombotic disorders affecting coronary, cerebral and peripheral arterial trees. Increased Plasminogen Activator Inhibitor Type 1 inhibits fibrinolysis and predicts cardiovascular risk in those living with Type 2 Diabetes. This study aimed to determine the effect of antidiabetic treatment on haemostatic and fibrinolytic parameters among Type 2 Diabetic subjects in Ilorin.Methods:This was a comparative cross-sectional study involving 78 Type 2 diabetic patients, (39 treatment naïve, 39 treatment experienced). Full blood count was performed using Sysmex XP300 while Prothrombin time was determined using one stage test of Owren. Activated partial thromboplastin time was determined by method of Proctor and Rapaport. Fibrinogen and Plasminogen Activator Inhibitor type-1 were assayed using AssayMax Human Fibrinogen ELISAand AssayMax Human PAI-1 ELISAkit. Data Analysis was done using SPSS version 25.0.Results:Mean PAI-1 levels were significantly higher in treatment naïve diabetics when compared to treatment experienced diabetics (2.44 ±2.57 vs 2.51±1.47 ng/ml p=0.002) as were fibrinogen levels (434.65±366.15 vs 482.24± 299.64mg /dl; p = 0.048). PAI -1 levels were lowest among diabetics treated with Metformin + DPP4 inhibitors, while fibrinogen levels were lowest among those treated with Metformin + sulfonylurea combination.Conclusion:Oral hypoglycaemic treatment, combination therapy in particular, improves fibrinolysis in type 2 diabetics thereby reducing the risk of cardiovascular disease in type 2 diabetes mellitus patients

Successful systemic fibrinolysis in a patient with Covid-19: Case report / Fibrinólisis sistémica exitosa en un paciente con Covid- 19: Reporte de Caso

Abstract The new coronavirus 2019-nCov or SARS-Cov-2 is responsible for the most important pandemic in the 21st century: the coronavirus disease (COVID-19). The 2019-nCov infection elicits a hyper-coagulable state, conditioning a worse outcome in these patients. The pathophysiology of the exaggerated coagulation activation in these patients is still unknown, and probably involves several mechanisms, different from those involved in sepsis-associated coagulopathy. This article discusses the case of a patient with no remarkable medical history, who after 7 days of fever, diarrhea and epigastric pain was diagnosed with COVID-19 bilateral pneumonia, further aggravated by severe Acute Respiratory Distress Syndrome. In this context, the patient experienced a massive acute pulmonary thromboembolism accompanied by an acute thrombus in the heart's right ventricle, leading to hemodynamic instability. For the first time in our center in these patients, systemic fibrinolysis was successfully performed, with resolution of the intracavitary thrombus and the acute hemodynamic shock.

Resumen El nuevo coronavirus 2019-nCov o SARS-Cov-2 es responsable de la pandemia más importante del siglo XXI: la enfermedad del coronavirus (COVID-19). La infección por 2019-nCov produce un estado de hipercoagulabilidad, que promueve peores desenlaces en estos pacientes. La fisiopatología de la exagerada activación de la coagulación en estos pacientes aún se desconoce y posiblemente involucre varios mecanismos, diferentes a los participan en la coagulopatía asociada a sepsis. El presente artículo presenta el caso de un paciente sin antecedentes médicos y quien luego de 7 días de fiebre, diarrea y dolor epigástrico, fue diagnosticado con neumonía bilateral por COVID-19, agravada por la presencia de Síndrome de Dificultad Respiratoria Aguda. En este contexto, el paciente desarrolla un tromboembolismo pulmonar agudo masivo, acompañado de un trombo agudo en el ventrículo derecho, produciéndole inestabilidad hemodinámica. Por primera vez en nuestro centro, se realizó exitosamente una fibrinólisis sistémica, con resolución del trombo intracavitario y del shock hemodinámico agudo.

Mortalidad por infarto agudo de miocardio en el registro continuo ARGEN-IAM-ST. Su relación con las diferentes terapias de reperfusión / Mortality of Acute Myocardial Infarction in the Continuous Registry ARGEN-AMI-ST and its Relationship with the Different Reperfusion Therapies

RESUMEN Introducción: El tratamiento de reperfusión es la terapéutica de mayor eficacia para reducir la mortalidad del infarto agudo de miocardio con elevación del segmento ST (IAMCEST) , y su efectividad es inversamente proporcional al tiempo total de isquemia. El mayor desafío es instrumentar su aplicación en la vida real y corregir en forma continua los desvíos o las barreras que se presentan en la práctica cotidiana. Objetivos: Evaluar la mortalidad con las diferentes modalidades de reperfusión, su relación con el tiempo de tratamiento y su efectividad en un registro prospectivo multicéntrico del mundo real de Argentina. Material y Métodos: estudio prospectivo, multicéntrico de carácter nacional, incluidos los pacientes con IAMCEST hasta las 36 h del comienzo de los síntomas (ARGEN-IAM-ST registro continuo). Resultados: participaron 2464 pacientes de 78 centros entre 2015 y 2019. El 88,5% recibió tratamiento de reperfusión. La mortalidad fue de 8,68%. Los pacientes tratados con reperfusión tuvieron una mortalidad de 7,81% versus 15,38% sin tratamiento (p <0,001). La mortalidad con angioplastia primaria fue 7,51%, con trombolíticos 9,03%, con estrategia farmacoinvasiva 2,99% y con angioplastia de rescate 9,40%, sin diferencia estadísticamente significativa entre angioplastia primaria y trombolíticos (OR 0,81 IC 95% 0,56-1,18, p = ns). Los pacientes fallecidos fueron de mayor edad, con mayor proporción de mujeres e insuficiencia cardíaca. El tratamiento de reperfusión e ingreso a la institución dentro de 3 horas del comienzo de los síntomas se asoció a menor mortalidad. Los pacientes fallecidos con angioplastia primaria tuvieron mayor tiempo total de isquemia (378 minutos versus 285 minutos, p < 0,001). Conclusiones: La mortalidad por IAMCEST se relacionó con el acceso a la reperfusión y su precocidad. Fue mucho mayor en los pacientes no reperfundidos, y menor cuando la reperfusión se efectuó en forma precoz dentro de las primeras tres horas del comienzo de los síntomas. En los pacientes tratados con angioplastia primaria la mortalidad se incrementó con mayor tiempo total de isquemia. Este registro de la práctica real del tratamiento del IAMCEST refuerza la necesidad de una mejor articulación del sistema de atención para bajar los tiempos y utilizar la estrategia mejor y más oportuna.

ABSTRACT Background: reperfusion treatment is the most effective therapy in reducing mortality from acute ST elevation myocardial infarction and its effectiveness is inversely proportional to the total time of ischemia. The greatest challenge is to implement its application in real life and continuously correct the deviations or barriers that arise in daily practice. Objectives: to evaluate mortality with the different reperfusion modalities, its relationship with treatment time and to evaluate its effectiveness. Methods: a prospective, multicenter national study, including patients with STEMI up to 36 h after symptoms began (ARGENAMI-ST continuous registry). Results: 2464 patients were included from 2015 to 2019 in 78 centers. 88.5% received reperfusion treatment. Mortality was 8.68%. The patients treated with reperfusion had a mortality of 7.81% versus 15.38% without treatment (p <0.001). Mortality with primary angioplasty was 7.51%, thrombolytics 9.03%, pharmacoinvasive strategy 2.99%, and rescue angioplasty 9.40%, with no statistically significant difference between primary angioplasty and thrombolytics (OR 0.81; 95% CI 0.56-1.18, p = ns). The deceased patients were older, a higher proportion of women, and heart failure. Reperfusion treatment and admission to the institution within 3 hours of starting symptoms were associated with lower mortality. Patients who died with primary angioplasty had a longer total ischemia time (378 minutes versus 285 minutes, p <0.001). Conclusions: mortality from STEMI was related to access to reperfusion and its earliness. It was much higher in non-reperfused patients, and lower when reperfusion was carried out early within the first three hours of the onset of symptoms. In patients treated with primary angioplasty, mortality increased with a longer total ischemia time. This record of the actual practice of the treatment of infarction reinforces the need for a better articulation of the care system to reduce times and use the best timely strategy.

Administración intrapleural de estreptoquinasa recombinante en tres niños graves con derrame pleural paraneumónico complicado / Intrapleural administration of recombinant streptokinase in three seriously ill children with complicated parapneumonic pleural effusion

Introducción: El derrame pleural paraneumónico es la enfermedad pleural más frecuente de la infancia, el 40-60 por ciento de los casos se presenta como complicación de neumonía adquirida en la comunidad. Ante la aparición de líquido pleural viscoso, con fibrina o tabiques, la fibrinólisis intrapleural aporta beneficios en la resolución de esta grave afección. Objetivo: Describir la evolución clínica e imagenológica de tres niños graves con derrame pleural paraneumónico complicado complejo y empiema. Presentación de casos: Pacientes ingresados en la Unidad de Terapia Intensiva del Hospital Pediátrico Provincial "Dr. Eduardo Agramonte Piña" con el diagnóstico de neumonía adquirida en la comunidad complicada con derrame pleural paraneumónico complicado complejo, tratados con estreptoquinasa recombinante por vía intrapleural; la primera paciente presentó crecimiento de Pseudomona en el cultivo de líquido pleural, patógeno no habitual en las infecciones respiratorias agudas procedentes de la comunidad. El segundo caso, se recibió complicada con shock séptico y el tercer paciente con ecografía torácica que mostró derrame pleural multitabicado, con grandes bolsones y gruesos tabiques. Los tres casos evolucionaron satisfactoriamente, sin necesidad de tratamiento quirúrgico, ni aparición de reacciones adversas atribuibles al fibrinolítico. Conclusiones: La administración intrapleural de la estreptoquinasa recombinante en niños graves con derrame pleural paraneumónico complicado complejo y empiema, resulta un método eficaz y seguro en la evacuación del foco séptico pleural, lo que favorece el control de la infección, sin aparición de complicaciones. Los casos presentados tuvieron evolución satisfactoria y en ninguno se produjo evento adverso relacionado con la administración de la estreptoquinasa recombinante intrapleural(AU)

Introduction: Parapneumonic pleural effusion is the most common pleural disease in childhood; 40-60 percent of cases occur as a complication of community-acquired pneumonia. Given the onset of viscous pleural fluid, with fibrin or septums, intra-pleural fibrinolysis provides benefits to solve this serious condition. Objective: Describe the clinical and imaging evolution of three seriously ill children with complex complicated parapneumonic pleural effusion and empyema. Case presentation: Patients admitted to the Intensive Therapy Unit of "Dr. Eduardo Agramonte Piña" Provincial Pediatric Hospital with the diagnosis of pneumonia acquired in the community worsen with complex complicated parapneumonic pleural effusion, and treated in the intrapleural way with recombinant streptokinase. The first patient showed growth of Pseudomona in the culture of pleural fluid, a pathogen which is not common in acute respiratory infections from the community. The second case was complicated with septic shock; and the third patient had a chest ultrasound that showed multi-sited pleural effusion, with large bags and thick septums. All three cases evolved satisfactorily, without needing surgical treatment, or having adverse reactions attributable to fibrinolytic ones. Conclusions: Intrapleural administration of recombinant streptokinase in seriously ill children with complex complicated parapneumonic pleural effusion and empyema is an effective and safe method in the evacuation of pleural septic focus, which favors infection control, without complications. The cases presented had satisfactory evolution and none of them occurred adversely related to the administration of intrapleural recombinant streptokinase(AU)

A REVIEW ARTICLE ON THERAPEUTIC POTENTIAL OF GARLIC

Garlic or Lashun is the member Liliaceae family, is use as spice in food cooking as well as medicine to treat various ailments. Garlic is also acting as a flavoring agent for the cooking, and however it has also been used as a drug from very ancient and modern times in all over the world, it is used to inhibit and cure the vast range of ailments and disorders. Allicin found in the garlic is the chemically active substance of fresh garlic extract, possess the capacity of readily permeable through phospholipid membranes which contributes to its possible pharmacological activity and also contain sulfur compounds, which are believed to bring some of the health benefits. Currently, garlic is broadly used for different diseases related with the systemic circulation and heart, which includes atherosclerosis, HDL, LDL & heart attack, coronary heart disease, and hypertension. Garlic is also reported to treat the lung cancer, and various other cancers such as colon cancer& skin diseases too, it also has hypolipidemic, immunomodulator, aphrodisiac, & Antifungal actions. This article reviews the importance of garlic (Allium sativum), and, their active constituents to show whether or not can be further used as potential natural sources for the development of any novel drug formulations.

Uso y resultados de la fibrinolisis intravenosa en una unidad cerebrovascular / Use and results of intravenous fibrinolysis in a stroke unit

Resumen La fibrinólisis intravenosa con activador del plasminógeno tisular recombinante (rTPA) y la utilización de unidades cerradas, demostraron disminuir sustancialmente la morbimortalidad en pacientes con accidente cerebrovascular isquémico (ACVi). Sin embargo, los datos publicados en Argentina son escasos. Describimos la experiencia en la utilización de fibrinólisis en pacientes con ACVi agudo antes y después de la implementación de una unidad cerebrovascular (UCV) en un Centro Integral de Neurología Vascular de la Ciudad de Buenos Aires durante 17 años. Se realizó un análisis retrospectivo de pacientes consecutivos tratados con rTPA entre enero 2003 y diciembre 2019. Se evaluaron tiempos de tratamiento, de internación, complicaciones post tratamiento y discapacidad a 3 meses. Para su análisis se evaluaron los períodos pre y post apertura de la UCV, período 1 (P1 de 2003-2011) y P2 (2012 -2019). Se realizó fibrinolisis intravenosa en 182 pacientes. La apertura de UCV resultó en aumento del porcentaje de fibrinólisis sobre el total de los ACVi ingresados (4% en P1 vs. 10% en P2, p < 0.001), acortamiento del tiempo puerta-aguja (75 minutos en P1 vs. 53 minutos en P2, p < 0.00001) y mayor proporción de pacientes tratados dentro de los 60 minutos del ingreso hospitalario (36% en P1 vs. 76% en P2, p < 0.00001). Además, hubo reducción de la mediana de internación de 9 días en P1 a 5 días en P2 (p < 0.00001). En conclusión, la UCV parece optimizar la utilización de fibrinólisis en el ACVi agudo, aumentando el porcentaje de pacientes tratados, reduciendo el tiempo puerta-aguja y disminuyendo el de internación.

Abstract Intravenous fibrinolysis with recombinant tissue plasminogen activator (rTPA) and use of stroke units improve morbidity and mortality in patients with acute ischemic stroke (AIS). However, data published in Argentina are scarce. We describe the experience in the use of fibrinolysis in patients with acute ischemic stroke (AIS) before and after the implementation of a stroke unit in a Comprehensive Stroke Center in Buenos Aires during the last 17 years. Retrospective analysis of consecutive patients treated with rTPA between January 2003 and December 2019. Treatment times, hospitalization time, post-treatment complications and disability at 3 months were evaluated. For the analysis, the pre and post opening periods of the stroke unit were evaluated, Period 1 (P1, from 2003 to 2011) and Period 2 (P2, from 2012 to 2019). Intravenous fibrinolysis was performed in 182 patients. Opening of the stroke unit resulted in an increase in the percentage of fibrinolysis over the total number of admitted strokes (4% in P1 vs. 10% in P2, p < 0.001), shortening of the door-to-needle time (75 minutes in P1 vs. 53 minutes in P2, p < 0.00001) and higher proportion of patients treated within 60 minutes of hospital admission (36% in P1 vs. 76% in P2, p < 0.00001). In addition, there was a reduction in the median hospital stay from 9 days in P1 to 5 days in P2 (p < 0.00001). In conclusion, stroke units seem to optimize the use of fibrinolysis in acute stroke, increasing the percentage of patients treated, reducing door-to-needle time, and reducing hospitalization time.

Effects of Buyang Huanwu Decoction on Hemorheology and Platelet Related Biological Indexes in Hyperlipidemia Model Rats / 中国药房

OBJECTIVE：To investigate the effe cts of Buyang huanwu decoction on hemorheology and platelet related biological indexes of hyperlipidemia model rats. METHODS ：Male Wistar rats were randomly divided into blank control group （10 rats）and model group （40 rats）. Blank control group was given normal diet ，and model group was given high-lipid diet for 6 weeks at least to induce hypelipidemia model. After modeling ，rats were randomly divided into model control group ，positive control group （simvastatin，0.004 g/kg），Buyang huanwu decoction low-dose and medium-dose groups （3.5，14.0 g/kg，by crude drug），with 10 rats in each group. Blank control group and model control group were given normal saline intragastrically ， administration groups were given relevant drug intragastrically ，0.01 mL/g，once a day ，for consecutive 4 weeks. Thirty min after last medication ，hemorheological indexes （whole blood viscosity ，plasma viscosity ），platelet adhesion related indexes [adhesion rate，von Willebrand factor （vWF），fibronectin（FN）]，platelet release related indexes [ β-thromboglobulin（β-TG），platelet factor 4 （PF4）] and platelet fibrinolytic system related indexes [tissue plasminogen activator （t-PA），plasminogen activator inhibitor （PAI-1）]，platelet parameters （PLT，PDW，MPV，PCT，PLCR），4 kinds of coagulation parameters （APTT，TT，PT，FIB）were detected. RESULTS ：Compared with blank control group ，the whole blood viscosity （low，medium and high shear rate ），plasma viscosity，platelet adhesion rate ，the contents or levels of vWF ，FN，β-TG，PAI-1，PLT，MPV，PCT，PLCR and FIB in model control group were increased significantly （P＜0.05 or P＜0.01），and t-PA content was significantly decreased （P＜0.05）. Compared with model control group ，the whole blood viscosity （except for whole blood viscosity of high shear rate in Buyang huanwu decoction high-dose group ），plasma viscosity ，platelet adhesion rate ，the contents or levels of vWF ，FN，β-TG，PAI-1， PLT，PDW（except for Buyang huanwu decoction low-dose and high-dose groups ），MPV，PCT，PLCR（except for Byang huanwu decoction low-dose group ）and FIB were decreased significantly （P＜0.05 or P＜0.01），while t-PA content （except for positive control group ） was increased significantly （P＜0.05）. CONCLUSIONS ：Buyang huanwu decoction can significantly improve the pathological state in hyperlipidemia model rats by reducing blood viscosity and FN content ，improving platelet adhesion，enhancing fibrinolytic activity ，improving platelet aggregation ，inhibiting hypercoagulability and hyperplatelet release.

Effect of adequate amount of tranexamic acid before operation on blood loss and safety in posterior lumbar fusion with multiple segments / 中国输血杂志

【Objective】 To investigate the effect of adequate amount of tranexamic acid(TXA)before operation on blood loss and safety in posterior lumbar fusion with multiple segments. 【Methods】 A retrospective analysis was conducted on 105 patients with lumbar spinal stenosis, submitted to our hospital for multilevel PLIF, from March 2017 to December 2019. According to the intervention method, they were divided into control group, group A and group B (n =30, 39 and 36, respectively). TXA was not used in the control group. Dripping of saline solution(100 mL) containing TXA 2g and 1g was given in Group A and Group B, and extra intravenous pumping of TXA [10 mg/(kg·h)] during surgery was conducted in Group B besides the pre-operation dripping of TXA. Total blood loss, dominant blood loss, recessive blood loss, intraoperative blood loss, postoperative drainage volume, transfusion rate and hemoglobin (Hb), hematocrit (Hct), prothrombin time international standardized ratio (PT - INR), platelet count (Plt), D - dimer (D - D), C-reactive protein (CRP), neutrophil percentage (NP), alanine aminotransferase (ALT), and blood urea nitrogen (BUN) before and after operation were compared in the three groups. Postoperative drug-related adverse events were traced. 【Results】 1)The total blood loss, dominant blood loss(mL), intraoperative blood loss(mL), drainage volume(mL) within and after 24h after surgery, and the transfusion rate(%) in group A and B were 892.6±193.5 vs 887.7±320.8, 409.1±109.2 vs, 408.6±98.3, 193.7±69.3 vs 189.6±65.6, 130.5±53.4 vs 128.3±53.5, 63.1±17.6 vs 60.9±13.5 and 7.7 (3/39) vs 8.3 (3/36), respectively, which were significantly lower than that in group C as 1 296.8±329.2, 807.6±231.5, 270.9±65.5, 365.4±127.8, 172.3±66.4 and 36.7(11/30), respectively (P< 0.05). There were no significant differences in the above indexes between group A and group B (P < 0.05). The differences in recessive blood loss was not significant by groups(P<0.05). 2) Compared with pre-operation, the levels of Hb, Hct and Plt in the three groups at 3d after operation decreased: Hb(g/L) 91.5±14.0, 107.6±16.4 and 105.9±17.1; Hct(%) 25.6±3.1, 31.2±3.9 and 30.5±4.4; Plt(×109/L)146.6±31.8, 172.8 ±40.1 and 169.7±39.5(P < 0.05); while D-D, CRP and NP increased: D-D(mmol/L)365.6±67.1, 280.9±50.5 and 286.1±53.1; CRP(mg/L): 65.4±22.0, 53.4±19.6 and 56.8±17.7; NP(%): 87.3±15.6, 73.1±13.7, and 71.9±11.8(P < 0.05), and Pt-INR, ALT and BUN showed no significant changes (P > 0.05). The changes of Hb, Hct, Plt, D-D, CRP and NP in group A and B were significantly lower than those in group C at 3 days after operation [Hb (g/L) : 107.6±16.4, 105.9±17.1, 91.5±14.0; Hct (%) : 31.2±3.9, 30.5±4.4, 25.6±3.1; Plt (×109/L) : 172.8 ±40.1, 169.7±39.5, 146.6±31.8; D-D (mmol/L) : 280.9±50.5, 286.1±53.1, 365.6±67.1; CRP (mg/L) : 53.4±19.6, 56.8±17.7, 65.4±22.0; NP (%) : 73.1±13.7, 71.9±11.8, 87.3±15.6] (P < 0.05), and no significant differences in the above index were noticed between group A and B(P> 0.05).3)No lower limb deep vein thrombosis nor pulmonary embolism were found in group A and group B after operation, and all the incisions were healed in the first stage, and no serious complications such as drug allergy, cardiovascular and cerebrovascular accident, epidural hematoma, epilepsy occurred. 【Conclusion】 The preoperative TXA administration with sufficient single dose showed equivalent hemostatic effect in comparison with intraoperative continuous administration additional to preoperative dripping, which is simple and convenient and does not increase the risk of thrombosis.