Coronary Artery By-Pass Grafting in Patient With Paroxysmal Nocturnal Hemoglobinuria (Case Report)

Paroxysmal nocturnal haemoglobinuria (PNH) is a clonal haematopoietic stem cell disease that presents with haemolytic anaemia, thrombosis and bone marrow failure. We report a case of a 51-year-old male with a history of PNH in treatment with Eculizumab admitted to our Hospital for acute chest pain and dyspnoea. The diagnosis was a triple vessel disease and patient was scheduled for coronary artery bypass grafting surgery. To balance the risk between thrombosis and bleeding in this particular clinical setting, we decided to use thromboelastography (TEG) as point of care solution and we used the R parameter as the target of our anticoagulant therapy. The R parameter between 11 and 14 sec can be used as a target value to balance the risk; in addition, there was no evidence of acute hemolysis during the surgery and supplemental dose of Eculizumab was administered in order to minimize any potential exacerbation of intravascular hemolysis.

Ascorbic Acid as an Adjunctive Therapy in Critically Ill Patients with COVID-19: A Multicenter Propensity Score Matched Study

Background: Ascorbic acid represents an appealing option for clinicians to utilize in the context of a global health pandemic of COVID-19 patients due to its proposed clinical efficacy, relative safety, and low cost.Objectives:The aim of this study was to evaluate the efficacy and safety of using ascorbic acid in supplemental dose as adjunctive therapy in critically ill patients with COVID-19. Methods: This was a multi-center, non-interventional, retrospective cohort study. All critically ill adult patients admitted to ICU with a confirmed COVID-19 between March 1st to December 31st, 2020 were included in the final analysis. The study was conducted at two large governmental tertiary hospitals in Saudi Arabia. The purpose was to investigate the association between clinical outcomes with ascorbic acid use as an adjunctive therapy in COVID-19 after propensity score matching using baseline severity scores, systemic use of corticosteroids and study centers. Results:A 739 patients were included in this study; 296 patients were included after propensity score matching. There was no association between the administration of ascorbic acid and in-hospital mortality nor 30-day ICU mortality (OR (95%CI): 0.77 (0.476, 1.234), p-value=0.2738 and OR (95%CI): 0.73 (0.438 ,1.204), p-value=0.215 respectively). Using ascorbic acid was associated with lower incidence of thrombosis compared with the non-ascorbic acid group (6.1% vs. 13% respectively); OR (95%CI): 0.42 (0.184, 0.937), p-value=0.0342).Conclusion:Supplemental dose of ascorbic acid as an adjunctive therapy in COVID19 critically ill patients was not associated with mortality benefits; but associated with lower incidence of thrombosis. Further studies are required to confirm these findings.

Perioperative Hypocortisolism – An Ongoing Conundrum (Preprint)

UNSTRUCTURED Adrenal crisis can be triggered by surgery leading to dire consequences. Based on early evidence in the 1950s, the medical fraternity has been pre-emptively providing supplemental dose of steroids for patients with known adrenal insufficiency and to those at risk. However, this approach has been refuted by subsequent studies. This led to a quandary as whilst adrenal crisis is to be avoided, patients should not be exposed to superfluous administration of steroids which can cause detrimental effects. Numerous studies have ineffectually attempted to identify the patients at risk by means of quantifying the amount of preoperative steroids consumed and by utilising basal and dynamic testing. Studies indicate that given the significant variability between individuals on the requirements of perioperative supplemental steroids, a standard encompassing guideline should not be implemented. Instead a personalized approach should be taken for each case. Steroids at preoperative doses will be adequate in the perioperative period for most cases. However, all patients must be closely monitored for any possible features of hypocortisolism and the threshold for supplemental steroid administration should be low. For patients given supplemental steroids, the dose should be titrated down to preoperative doses at the soonest based on the patient’s clinical progression. A short duration of high dose supplemental steroids is unlikely to result in any adverse effects.

Yield responses of Macrotyloma axillare (family Fabaceae) to combinations of doses of phosphorus and calcium

The present study aimed to assess the effects of combinations of doses of phosphorus and calcium on the yield characteristics of Macrotyloma axillare access NO 279 (family Fabaceae) in a Red-Yellow Argisol with average P level (24 mg dm-3). The experiment was carried out in greenhouse in Nova Odessa/SP, Brazil, from August to December 2015. A 52 fractional factorial design with 13 combinations for doses of phosphorus and calcium in mg dm-3: 0-0; 0-40; 0-80; 15-20; 15-60; 30-0; 30-40; 30-80; 45-20; 45-60; 60-0; 60-40; 60-80, in a randomized complete block design with four replications. Two cuttings were made on the plants. The phosphorus x calcium interaction and the isolated doses of calcium were not significant for the parameters assessed. The production of dry biomass of the aerial part, the leaf area, the number of leaves and the number of branches of Macrotyloma showed significant responses to the isolated doses of phosphorus applied in the primary growth. In the secondary growth, only the number of branches and the dry biomass production of the dead material responded to the doses of phosphorus. Phosphorus was a modulator of dry biomass production of roots and of the production of nodules and the number of nodules of macrotyloma. The content of calcium present in the soil, together with the increase of the value of base saturation to 50%, was sufficient for the establishment and growth of the legume. Therefore, a supplemental dose of this nutrient was not required.

Effects of activated charcoal-herb extractum complex on the growth performance, immunological indices, intestinal morphology and microflora in weaning piglets

This study was conducted to evaluate the effects of activated charcoal-herb extractum complex (CHC) on the growth performance, immunological indices, intestinal morphology and microflora in weaning piglets to determine the optimal supplemental dose.

Clinically relevant doses of vitamin A decrease cortical bone mass in mice

Excess vitamin A has been associated with decreased cortical bone thickness and increased fracture risk. While most studies in rodents have employed high dosages of vitamin A for short periods of time, we investigated the bone phenotype in mice after longer exposure to more clinically relevant doses. For 1, 4 and 10 weeks, mice were fed a control diet (4.5 µg retinyl acetate/g chow), a diet modeled from the human upper tolerable limit (UTL; 20 µg retinyl acetate/g chow) and a diet three times UTL (supplemented; 60 µg retinyl acetate/g chow). Time-dependent decreases in periosteal circumference and bone mineral content were noted with the supplemented dose. These reductions in cortical bone resulted in a significant time-dependent decrease of predicted strength and a non-significant trend toward reduced bone strength as analyzed by three-point bending. Trabecular bone in tibiae and vertebrae remained unaffected when vitamin A was increased in the diet. Dynamic histomorphometry demonstrated that bone formation was substantially decreased after 1 week of treatment at the periosteal site with the supplemental dose. Increasing amount of vitamin A decreased endocortical circumference, resulting in decreased marrow area, a response associated with enhanced endocortical bone formation. In the presence of bisphosphonate, vitamin A had no effect on cortical bone, suggesting that osteoclasts are important, even if effects on bone resorption were not detected by osteoclast counting, genes in cortical bone or analysis of serum TRAP5b and CTX. In conclusion, our results indicate that even clinically relevant doses of vitamin A have a negative impact on the amount of cortical bone.

Supplemental dose of antithrombin use in disseminated intravascular coagulation patients after abdominal sepsis

SummaryThe effectiveness of supplemental dose antithrombin administration (1,500 to 3,000 IU/ day) for patients with sepsis-associated disseminated intravascular coagulation (DIC), especially sepsis due to abdominal origin, remains uncertain. This was a retrospective cohort study of patients with mechanically ventilated septic shock and DIC after emergency surgery for perforation of the lower intestinal tract using a nationwide administrative database, Japanese Diagnosis Procedure Combination inpatient database. A total of 2,164 patients treated at 612 hospitals during the 33-month study period between 2010 and 2013 were divided into an antithrombin group (n=1,021) and a control group (n=1,143), from which 518 propensity score-matched pairs were generated. Although there was no significant 28-day mortality difference between the two groups in the unmatched groups (control vs antithrombin: 25.7 vs 22.9 %; difference, 2.8 %; 95 % confidence interval [CI], –0.8–6.4), a significant difference existed between the two groups in propensity-score weighted groups (26.3 vs 21.7 %; difference, 4.6 %; 95 % CI, 2.0–7.1) and propensity-score matched groups (27.6 vs 19.9 %; difference, 7.7 %; 95 % CI, 2.5–12.9). Logistic regression analyses showed a significant association between antithrombin use and lower 28-day mortality in propensity-matched groups (odds ratio, 0.65; 95 % CI, 0.49–0.87). Analysis using the hospital antithrombin-prescribing rate as an instrumental variable showed that receipt of antithrombin was associated with a 6.5 % (95 % CI, 0.05–13.0) reduction in 28-day mortality. Supplemental dose of antithrombin administration may be associated with reduced 28-day mortality in sepsis-associated DIC patients after emergency laparotomy for intestinal perforation.