Acute Pulmonary Embolism Post COVID-19 Pneumonia – A Case Report

COVID-19 has been associated with multiple venous thromboembolism events such as pulmonary embolism and deep vein thrombosis. Here we report a 64-year male with COVID-19 pneumonia who developed pulmonary thromboembolism following the COVID illness. This patient developed VTE complication in spite of receiving anti-coagulation therapy during admission. This case brings out the need for evidence-based post-discharge VTE prophylaxis approach and guidelines in patients who recover from COVID-19.

Percutaneous Microwave Coagulation Therapy: A Promising Therapeutic Method for Breaking the Barrier of the Intertumor Heterogeneity

Intertumor heterogeneity is common in various cancers and has been widely accepted as the primary cause of the diversity and variation of the effect of the same treatment on patients with the same type of tumor. Percutaneous microwave coagulation therapy (PMCT) is a minimally invasive and effective approach for destroying tumors by microwave beam under image guidance, which has been applied in lung cancer. However, no previous study has investigated the capability of PMCT solving intertumor heterogeneity. Here, we performed a component analysis of four lung cancer patients’ tumor microenvironment (TME) via single-cell RNA sequencing (scRNA-seq) and treated all four cases with PMCT. One patient’s TME could be classified into a hot tumor, mainly proinflammatory cytokines, and T cell infiltration. The other three patients’ TMEs were cold tumors, where immunosuppressive cells occupied a large proportion, including tumor-associated macrophages and cancer cells. Despite a high level of heterogeneity among their tumor microenvironment compositions, disease type and stage, and basic physical conditions, all four patients presented a stable disease (SD) without any cancer cell detected in the TME of cancer tissues after PMCT. In conclusion, this report uniquely contributed to the knowledge of the PMCT adaptation to tumor heterogeneity. Therefore, PMCT is promising to demonstrate a stable and robust antitumor efficacy in unresectable lung cancers with various TMEs.

Potential of pharmacological and herbal for COVID-19: a narrative review

The pandemic coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) presents an unprecedented challenge to identify effective drugs in the prevention and treatment process. At present, there is no proven therapy for this disease, although therapeutic approaches continue to be carried out using traditional medicines (herbal) and pharmacological therapy. Information about SARS-CoV-2 virology has rapidly developed and scientists try to provide a number of potential drugs. Remdesivir has strong in vitro activity against SARS-CoV-2. Several potential drugs are currently underway in a clinical trial. Chloroquine, hydroxychloroquine, and oseltamivir have not been proven to have efficacy, and the benefits of corticosteroids are still diverse. Current clinical evidence does not support the termination of angiotensin-converting enzyme 2 (ACE2) inhibitors or angiotensin receptor blockers, coagulation therapy in patients with COVID-19 concomitant with comorbidities.

Patent Foramen Ovale Device Closure in a 27 Years Old Young Lady with Cryptogenic Ischaemic Stroke - First Case Report from Bangladesh

A patent foramen ovale (PFO) is highly prevalent in patients with strokes of unknown cause or cryptogenic strokes (CSs). It has been remained an unsolved question as to whether a PFO should be closed or not to prevent recurrent strokes in patients diagnosed with cryptogenic stroke (CS). A paradoxical embolism through a PFO is pointed as a leading cause of CS, especially in younger patients with low risk factors for stroke. It also remains an unsolved matter on type of anti-coagulation therapy, which would be better for patients with CS and a PFO. In addition, surgical and transcutaneous closure of a PFO has been proposed for the secondary prevention of stroke in patients with CS with PFO. Several randomized controlled trials have been conducted in recent years to test whether a PFO closure gives a significant benefit in the management of CS. Many investigators believed that a PFO was an incidental finding in patients with CS. However, meta-analyses and more recent specific trials have eliminated several confounding factors and possible biases and have also emphasized the use of a shunt closure over medical therapy in patients with CS. Therefore, these latest studies can possibly change the treatment paradigm in the near future. We are reporting a case of cryptogenic ischaemic stroke in middle cerebral artery territory due to paradoxical embolism through a PFO which was successfully closed with a device solely by a Bangladeshi Consultant & his team first time in Bangladesh. Cardiovasc. j. 2021; 13(2): 227-234

Release characteristics of enoxaparin sodium-loaded polymethylmethacrylate bone cement

Background This study aimed to prepare the polymethylmethacrylate (PMMA) bone cement release system with different concentrations of enoxaparin sodium (ES) and to investigate the release characteristics of ES after loading into the PMMA bone cement. Methods In the experimental group, 40 g Palacos®R PMMA bone cement was loaded with various amount of ES 4000, 8000, 12,000, 16,000, 20,000, and 24,000 AXaIU, respectively. The control group was not loaded with ES. Scanning electron microscopy (SEM) was used to observe the surface microstructure of the bone cement in the two groups. In the experiment group, the mold was extracted continuously with pH7.4 Tris-HCL buffer for 10 days. The extract solution was collected every day and the anti-FXa potency was measured. The experiment design and statistical analysis were conducted using a quantitative response parallel line method. Results Under the SEM, it was observed that ES was filled in the pores of PMMA bone cement polymer structure and released from the pores after extraction. There was a burst effect of the release. The release amount of ES on the first day was 0.415, 0.858, 1.110, 1.564, 1.952, and 2.513, respectively, from the six groups with various ES loading amount of 4000, 8000, 12,000, 16,000, 20,000, and 24,000 AXaIU, all reaching the peak of release on the first day. The release decreased rapidly on the next day and entered the plateau phase on the fourth day. Conclusion The prepared ES-PMMA bone cement has high application potential in orthopedic surgery. ES-PMMA bone cement shows good drug release characteristics. The released enoxaparin sodium has a local anti-coagulant effect within 24 h after application, but it will not be released for a long time, which is complementary to postoperative anti-coagulation therapy.

Severe heat stroke complicated by multiple cerebral infarctions: a case report

Background Heat-related illnesses include symptoms such as heat syncope/cramps, heat exhaustion, and life-threatening heat stroke. Usually, a heat stroke causes cerebellar ataxia, cognitive impairment, dysphagia, and aphasia. We report a very rare case of a patient who developed severe heat stroke complicated by multiple cerebral infarctions. Case presentation An 80-year-old Asian woman was found lying unconscious at her house, with no air conditioner and closed windows; the highest outside temperature was 36.1 °C. She was brought to our hospital unconscious with a high bladder temperature (42.5 °C) and disseminated intravascular coagulation (DIC score 4). She was diagnosed with severe heat stroke and managed with rapid cooling, intravenous fluids therapy, antibiotic therapy, and anti-coagulation therapy for DIC. Anti-coagulation therapy consisted of treatment with recombinant thrombomodulin for 4 days (days 1–4) and recombinant antithrombin for 1 day (day 1). A head computed tomography (CT) and magnetic resonance imaging (MRI) examination were performed on day 3, because she was still unconscious. Diffuse-weighted imaging showed high-signal intensities, indicating multiple lesions. An intracranial magnetic resonance angiography showed normal results. Imaging indicated new multiple cerebellar infarctions complicated with DIC. A tracheotomy was performed on day 9 because her conscious condition had not improved. She was transferred to another hospital for subacute care on day 23. Conclusions Early management of heat stroke using anti-DIC, anti-bacterial, and fluid resuscitation therapy can help prevent complications such as intracranial hemorrhaging.

Liver transection with pre-coagulation therapy in liver cirrhosis ~ Effective usage of an energy device at hepatectomy ~

Hepatectomy for liver cirrhosis patients requires skillful surgical technique and careful attention caused by the fibrotic parenchyma, elevated portal pressure, and impaired coagulation. This report evaluated short- and long-term outcomes for liver cirrhosis patients receiving pre-coagulation therapy on the parenchymal transection plane, as compared to non-coagulation cases. 73 patients diagnosed with cirrhosis via post-operative pathological findings were selected upon reviewing 887 hepatectomy patient files. They were divided into a pre-coagulation group (n=20) and a non-coagulation group (n=53). There were no significant differences in patient and tumor factors between two groups. Pre-coagulation group had significantly less blood loss compared with non-coagulation group [282 vs 563g (p < 0.05)], shorter operative time [214 vs 276min (p = 0.06)], and shorter postoperative hospital stays [14.5 vs 22.5 days (p = 0.12)]. The median recurrence free survival rates time in the pre-coagulation group (733 days) was significantly longer than that in the non-coagulation group (400 days) (p < 0.05). Overall survival rates showed rates showed no difference among the two groups (p = 0.62). Pre-coagulation therapy may be one of the a preferred treatment application for hepatectomy patients with severe liver fibrosis.

FEATURES OF THE COURSE OF THE NEW CORONAVIRUS INFECTION (SARS-COV-2) IN CHILDREN

The review presents data on the features of COVID-19 infection course in children of different ages. It has been shown that children carry the disease much easier than adults. However, the younger the child, the more often he has a severe infection. Infants and newborns suffer the most severe COVID-19 disease. In the future, the older the child (up to 18 years old), the easier his illness progresses, less often severe pneumonia accompanied by acute respiratory respiratory syndrome (ARDS) occurs and there is practically no multiple organ. The most common symptoms in affected children with COVID-19 are short-term fever, easy fatigue, myalgia, nasal congestion, runny nose, sneezing, sore throat, headache, and dizziness. Less common is nausea, vomiting, abdominal pain, diarrhea. In children, in contrast to adults, neutrophilia, thrombocytopenia, lymphocytopenia occur less often, the content of pro-inflammatory cytokines increases moderately, and only in isolated cases does the state of cytokine storm occur. In children, it is extremely rare for the D-dimer to reach high numbers, indicating the presence of intense intravascular blood coagulation. Therapy for children with COVID-19 should be based on the severity and age of the child. A significant role in the fight against COVID-19 is assigned to immunocorrective drugs (INF-γ, tocilizumab, azithromycin, doxycycline, etc.) and antiviral drugs (favipiravir, etc.) play a significant role in the fight against COVID-19. We believe that thymalin, which has proven itself well in pneumonia and various infectious diseases in both adults and children.

Abstract 17422: Transcatheter Mitral Valve Thrombosis: A Case Report and Literature Review

Background: Trans-catheter mitral valve replacement (TMVR) is an exciting alternative therapy for complex patients with mitral valve disease. The experience with TMVR is new and there is a lot yet to discover about their durability, long-term outcomes, and complications including, mitral transcatheter heart valve (THV) thrombosis. Many factors have been speculated to be associated with the increased risk of THV thrombosis. Here, we report a case of mitral THV thrombosis then discuss published data on the subject. Case presentation: A 72-year-old woman who underwent TMVR for severe mitral regurgitation with mitral annular calcification. She was discharged on aspirin and clopidogrel for thromboprophylaxis. She presented after 30 days with symptomatic heart failure. Her transesophageal echocardiogram showed increased mean trans-mitral gradient with severe subvalvular thickening with immobile neo-anterior leaflet. She was subsequently started on a heparin drip with bridge to warfarin with international normalized ratio goal of 2.5 to 3.5. Discussion: Since most patients undergoing TMVR are within a high-risk population, caution should be implemented to minimize complications, valve dysfunction, and failure. We reviewed 42 TMVR papers with total of 1484 patients including 60 with mitral THV thrombosis. We discussed the most common strategies used for mitral THV thromboprophylaxis and treatment. Conclusion: Given current evidence, post-TMVR anticoagulation should be considered for at least 3 months, especially in those without significant bleeding risk. Longer anti-coagulation therapy should be considered for patients with multiple risk factors for thrombus formation. Additionally, systematic active screening with close clinical follow up help promptly identify those with subclinical THV thrombosis or need longer anti-coagulation therapy.

Institutional Anticoagulation Protocol for Septic DIC is Associated with Differences in In-Hospital Mortality. J-SEPTIC DIC STUDY (A Nationwide Registry Study)

Background: We analyzed data from Japanese nationwide registry study of severe sepsis/septic shock to determine the influence of institutional treatment protocol, which has not been evaluated, on in-hospital mortality rate in septic DIC. Methods: From among all sepsis patients (n=3193), we selected those (n=1856) diagnosed with DIC according to the JAAM criteria, then divided them into three groups depending on DIC treatment protocol: patients admitted to hospitals providing basically no anti-coagulation therapy (NO-TX group: n=287); those admitted to hospitals routinely providing such treatment (anti-thrombin concentrate and/or rh-thrombomodulin or other anti-coagulants such as heparin/heparinoids: DO-TX group: n=1202); and those admitted to hospitals providing treatment at the discretion of the physician-in-charge (DEP-TX group: n=446). Results: In DIC patients only, in-hospital mortality was much higher in the NO-TX group (46.2%) than in the DO-TX group (34.1%) despite comparable APACHE II scores. The hazard ratio (HR) of mortality was much lower in the DO-TX group (0.76, 95% CI: 0.61-0.96) than in the NO-TX group (set at 1.0). When non-DIC subjects whose records contained complete information on JAAM and ISTH scores were also included (n=2513), however, different treatment protocols were no longer associated with differences in HR. Nevertheless, in-hospital mortality rates still differed among the three groups even after non-DIC patients were included. Conclusions: Thus, the present results support the use of anti-coagulation treatments for septic DIC and suggest that outcomes are affected by other institutional factors besides anti-coagulation protocol, such as an institutional approach to sepsis. The mechanisms underlying this effect should be clarified.