A Pilot Study to Evaluate the Feasibility of Anti-Fibrinolytic Agents in Reducing Hemorrhagic Complications in Pediatric Patients with Thrombocytopenia

Background: The risk of bleeding remains high in thrombocytopenic pediatric hematology-oncology patients despite the use of prophylactic platelet transfusions. In one study, WHO grade 2 or higher bleeding occurred in >80% of pediatric subjects receiving hematopoietic stem cell transplantation or chemotherapy despite a platelet transfusion threshold of 10,000/µl. The risk of bleeding is not decreased with higher transfusion thresholds or increased platelet doses. Bleeding episodes are associated with increased mortality rates, greater utilization of resources and increased transfusion requirements. We examined the use of anti-fibrinolytic agents in decreasing bleeding events and platelet transfusions. Methods: We conducted a randomized double-blinded Phase 2 trial of tranexamic acid versus placebo in inpatient pediatric patients undergoing chemotherapy or HSCT expected to have prolonged thrombocytopenia. All patients admitted to the Oncology or HSCT services were screened for eligibility. Patients consenting for enrollment received either tranexamic acid 10m/kg/dose or normal saline every 8 hours while the platelet count as <30,000/ul until discharge or spontaneous platelet recovery (maximum 30 days). We conducted daily hemostatic assessments using the WHO bleeding scale and monitored adverse events and platelet transfusion requirements. Follow-up assessments took place at 7 and 30 days following completion of study medication. Primary aims were to assess safety and feasibility of tranexamic acid in children with hypoproliferative thrombocytopenia. Results: We screened 697 admissions over 11 months, 31 patients were eligible for enrollment. Enrollment was suspended in March 2020 for COVID reasons though screening continued through July 2020. An additional 10 eligible patients were identified in this period. The most common reasons for ineligibility included recent asparaginase administration, predicted inpatient stay <5 days and age ≤ 2 or ≥ 18 years. Eleven patients enrolled and completed all study procedures. There were no missed doses of medication, 88.4% of doses were administered within one hour of prescribed time. Patients remained on study for a mean of 11.1 days. Five patients each met criteria for spontaneous platelet count recovery or discharge, 1 patient received the study medication for 30 days. Bleeding (all grades) occurred on 29.5% of days. Grade 2 or higher bleeding occurred on 4.9% of days and was experienced by 27.3% of patients. The most common sites of bleeding were oral/nasal and cutaneous. Subjects received a median of 2 platelet transfusions per patient. There were no thromboembolic events or serious adverse events. Conclusion: Tranexamic acid is well tolerated can be safely administered to pediatric oncology patients as an adjunct to therapy. We are planning a multi-center randomized controlled trial to assess the efficacy of tranexamic acid in reducing bleeding complications in this population. Disclosures Triulzi: Fresenius Kabi: Consultancy; Cerus Corp: Research Funding. OffLabel Disclosure: Tranexamic Acid - This medication is being studied as an adjuvant to therapy to prevent bleeding complications and reduce platelet transfusions in pediatric patients with hypoproliferative thrombocytopenia.

Streptokinase: An Efficient Enzyme in Cardiac Medicine

: An imbalance in oxygen supply to cardiac tissues or formation of thrombus leads to deleterious results like pulmonary embolism, coronary heart disease and acute cardiac failure. The formation of thrombus requires clinical encounter with fibrinolytic agents including streptokinase, urokinase or tissue plasminogen activator. Irrespective to urokinase and tissue plasminogen activator, streptokinase is still a significant agent in treatment of cardiovascular diseases. Streptokinase, being so economical, has an important value in treating cardiac diseases in developing countries. This review paper will provide the maximum information to enlighten all the pros and cons of streptokinase up till now. It has been concluded that recent advances in structural/synthetic biology improved SK with enhanced half-life and least antigenicity. Such enzyme preparations would be the best thrombolytic agents.

Pola Pengobatan Pada Pasien Infark Miokard Akut Di Rumah Sakit Abdul Wahab Sjahranie Samarinda

Acute myocardial infarction is a major health problem that needs special attention because of the mortality prevalence and costs is quite high. Generally caused by plaque rupture and thrombus of coronary arteries so that the oxygen-containing blood supply is reduced to the myocardium. The purpose of this study was to determine the characteristics of acute myocardial infarction patients and acutemiokardial infarction drug use pattern at Abdul Wahab Sjahranie Hospital, Samarinda City in the January-December 2018 period. This study was a non-experimental study with a retrospective method and analyzed descriptively. Sampling using a purposive sampling method. The results of the most characteristic study were obtained in patients with acute myocardial infarction in men, namely 7,4%, age characteristics 46-55 years 37,1%, private work 48,6%, and high school education 47,1%. The most treatment pattern used in STEMI patients out of 32 patients was Nitrate + DAPT + Anticoagulant + ACE-I + Statin for 6 patients (18.7%) and the most treatment pattern used in NSTEMI patients out of 38 patients was Nitrate + DAPT + Anticoagulant + ß-Blocker + Statins in 7 patients (18.4%). The use of most drugs ISDN (antiangina) as much as 90%, morphine and petidine (potency analgesic) 8.6%, aspirin (antiplatelet) 84.3%, fondaparinuks (anticoagulants) 68.6% and streptokinase (fibrinolytic agents) 5.7% . To prevent reinfarction the most used drug is bisoprolol (ß-Blocker) 28.6%. The most commonly used left ventricular damage inhibitor candesartan (ARB) is 22.8%. The most given antidislipidemia was simvastatin 47.1%.

Postoperative ‘STEMI’ in Intracerebral Hemorrhage due to Arteriovenous Malformation: A Case Report and Review of Literature

Electrocardiogram (ECG) changes suggestive of cardiac ischemia are frequently demonstrated in patients with ischemic stroke and subarachnoid hemorrhage. However, little is known of such changes particularly acute ST segment myocardial infarction (STEMI) in patients with intracerebral hemorrhage (ICH), especially after neurosurgery. We present a patient with intraparenchymal hemorrhage due to cerebral arteriovenous malformation (AVM) who exhibited acute STEMI after neurosurgery. Serial cardiac biomarkers and echocardiograms were performed which did not reveal any evidence of acute myocardial infarction. The patient was managed conservatively from cardiac stand point with no employment of anticoagulants, antiplatelet therapy, fibrinolytic agents, or angioplasty and recovered well with minimal neurological deficit. This case highlights that diffuse cardiac ischemic signs on the ECG can occur in the setting of an ICH after neurosurgery, potentially posing a difficult diagnostic and management conundrum.

Efficacy of Shunthi-Lodhra Churna in the Management of Asrigdara (DUB)

Objectives: The most common bleeding disorders in women are described as Asrigdara in Ayurveda, characterized by Pradirana (excessive excretion) of Raja (menstrual blood). It can be correlated to ‘Dysfunctional Uterine Bleeding’ in modern medicine. In modern medicine hormonal therapy, anti-prostaglandins & anti-fibrinolytic agents have not proven their definitive efficacy in spite of high costs; their side effects have led to hormonal imbalances. Methods: In order to overcome the above abnormalities, we conducted a clinical trial for 90 days on 30 patients of age group 18-45 yrs. We administered Shunthi Churna (2 gms.) and Lodhra Churna (3gms) mixed with Sharkara (5 gms.) i.e. total (10gms) thrice daily with cold water, after food. Two observations were taken, 1st after 45 days of treatment and the 2nd one after completion of treatment on various parameters like amount and duration of blood loss, inter-menstrual period, passage of clots and pain during menstruation. Results: Based on the parameters studied, we observed 60% of patients improved moderately, 36.7% showed mild-improvement, 3.3% showed marked-improvement in different symptoms. The results are highly significant on most parameters. Conclusion: Drug formulation Shunthi Churna and Lodhra Churna with Sharkara, proved to be effective in treating most of the symptoms of Asrigdara..