Decline In Count Research Articles

ACUTE HEPARIN-INDUCED THROMBOCYTOPENIA WITH DELAYED IN-STENT SUBACUTE THROMBOSIS OF DRUG ELUTING STENTS, INTRACARDIAC THROMBOSIS, BIVENTRICULAR HEART FAILURE, AND HYPOXIA

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Heparin-induced thrombocytopenia (HIT) is a fatal complication in patients with an average exposure of one to two weeks or can be rapid (< 24hrs) on re-exposure. In susceptible patients, antibodies directed against platelet factor 4 and heparin complexes cause HIT with thrombosis (HITTS). An average incidence of HIT is 0.1%-5% in patients on heparin therapy [1] CASE PRESENTATION: A 73-year-old female with a history of coronary disease, hypertension, and hyperlipidemia came to an outside hospital with a persistent cough, dyspnea, and acute hypoxia. She was treated for acute heart failure exacerbation and non-ST segment elevation myocardial infarction (NSTEMI) based on workup. An echocardiogram (ECHO) revealed an ejection fraction (EF) of 50%. She underwent staged percutaneous coronary intervention (PCI) and placement of an everolimus-based stent in the left anterior descending artery (LAD) followed by another stent in the left circumflex artery (LCX) after three days. Following stent placements, she went into pulmonary edema and was placed on noninvasive ventilation and was transferred to our institute to further manage acute hypoxic respiratory failure. Her hypoxia worsened, requiring endotracheal intubation, vasopressor support. She was treated for heart failure exacerbation and pneumonia. A repeat ECHO revealed two right ventricular thrombi with a severe decline in biventricular EF (Figure A). Anticoagulation with heparin was started, followed by a decline in platelet count > 50% due to HIT on day two, and was switched to argatroban (Figure B). Blood work showed NSTEMI, and a coronary angiogram revealed in-stent thrombosis of both stents (Figure C). Repeat successful PCI to LAD, and LCX with thrombus aspiration was completed. The patient had a complicated clinical course and never recovered DISCUSSION: As age increases, the risk of HIT gets higher [1]. HIT increases early mortality by 50% and embolic events by 20%-50%[2,3]. An increased HIT risk in females with cardiopulmonary bypass, hemodialysis, and vascular surgery was observed [4]. Venous thrombosis may be associated with surgery and arterial thrombosis with cardiovascular disease [5]. HIT antibody rate in patients with ACS is high and can induce symptoms in the absence of thrombocytopenia [6]. The odds of early stent thrombosis are < 1%[7]. The occurrence of thrombosis during therapeutic heparin anticoagulation is a concern for HITTS regardless of platelet counts and duration of therapy. Acute NSTEMI due to in-stent and intracardiac thrombosis due to HITTS is rare CONCLUSIONS: HITTS should be suspected in coronary thrombosis of unknown origin. Immediate heparin discontinuation and alternate anticoagulation are a must in HITTS, which can present with normal platelet counts REFERENCE #1: Hogan M, Berger JS. Heparin-induced thrombocytopenia (HIT): Review of incidence, diagnosis, and management. Vasc Med. 2020;25(2):160-73 REFERENCE #2: Solanki J, Shenoy S, Downs E, Palkimas S, Goldman S, Sharma AM. Heparin-Induced Thrombocytopenia and Cardiac Surgery. Semin Thorac Cardiovasc Surg. 2019;31(3):335-44 REFERENCE #3: Warkentin TE. Think of HIT. Hematology Am Soc Hematol Educ Program. 2006;408-414. doi:10.1182/asheducation-2006.1.408 DISCLOSURES: No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by SACHIN PATIL, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response No relevant relationships by Tushar Tarun, source=Web Response No relevant relationships by Ritika Verma, source=Web Response

Data-driven analysis of the kinetics of the JAK2V617F allele burden and blood cell counts during hydroxyurea treatment of patients with polycythemia vera, essential thrombocythemia, and primary myelofibrosis.

Hydroxyurea (HU) treatment of patients with essential thrombocythemia (ET), polycythemia vera (PV), and primary myelofibrosis (PMF) (MPNs) normalizes elevated blood cell counts within weeks in the large majority of patients. Studies on the impact of HU upon the kinetics of the JAK2V617F allele burden, leukocyte, and platelet counts over time are scarce. Using data-driven analysis as a novel tool to model the kinetics of the JAK2V617F allele burden and blood cell counts over time during treatment with HU. Using serial measurements of JAK2V617F and correlation analysis of routine hematological values (the Hb-concentration, leukocyte count, platelet count, and lactic dehydrogenase), we present a detailed description and analysis of the kinetics of the JAK2V617F, leukocyte, and platelet counts and lactic dehydrogenase in 27 patients (PV=18; ET=7; PMF=2), who were followed in the Danish randomized trial (DALIAH). To further analyze the JAK2V617F kinetics, we use a machine learning clustering algorithm to group the response patterns. Response patterns were highly heterogeneous, with clustering resulting in 3 groups and 3 outliers. In the large majority of patients, HU treatment was initially associated with a modest decline in the JAK2V617F allele burden in concert with a decline in leukocyte and platelet counts. However, HU did not induce a sustained and continuous decrease in the JAK2V617F allele burden. Using data-driven analysis of the JAK2V617F allele burden, leukocyte, and platelet kinetics during treatment with HU, we have shown that HU does not induce a sustained decrease in the JAK2V617F allele burden and neither induces sustained normalization of elevated cell counts in MPN patients. Our results may explain why MPN patients during treatment with HU still have a substantially increased risk of thrombosis.

Screening covid-19 in apparently healthy individuals

Background: A pneumonia outbreak with an unknown etiology broke out in Wuhan, China, and quickly spread worldwide. Coronavirus 2 is a new coronavirus that causes severe acute respiratory syndrome (SARS-CoV-2). This study will look at coronavirus in people who don’t have any symptoms and test the sensitivity, specificity, and accuracy of the tests used to detect COVID-19. Methods: This study included 300 people who appeared to be in good health. Nasal swabs were taken and placed in a viral transport media (VTM), which was then tested using real-time polymerase chain reaction (RT-PCR) and a rapid test for anti-COVID-19 antibody (IgM, IgG). The reverse method was used to look at blood groups. Finally, a Hemolyzer III was used to count total leukocytes and granulocytes in peripheral blood. Results: The present study included 176 males (58.7 %) and 124 females (41.3%). The age range was between 10 to 69 years. There is a non-significant difference (p ˃ 0.05) between the blood group and carry coronavirus in apparently healthy individuals. There was a highly significant decline (p ≤ 0.01) in total leukocytes count in positive RT-PCR subgroup was 4.1 ± 0.1*10⁹. Also total leukocytes count significantly decline (p ≤ 0.05) in positive of both RT-PCR and the rapid test was 4.5 ± 0.1*10⁹/L, a non-significant difference (p ˃ 0.05) between total leukocytes count and favorable rapid test subgroup comparison with negative test subgroup. This result shows a significant decrease (p ≤ 0.05) in granulocyte count in the positive RT-PCR test subgroup and in the positive of both RT-PCR and rapid test subgroup was 4.07 ± 0.11*10⁹/L, 4.1 ± 0.10*10⁹, respectively. There is a non-significant difference (p ˃ 0.05) in the positive rapid test subgroup 4.5 ± 0.12*10⁹/L and compared with the negative test subgroup. © 2021, Dr. Yashwant Research Labs Pvt. Ltd.. All rights reserved.

Cytomegalovirus reactivation in esophageal cancer patients receiving chemoradiotherapy: A retrospective analysis.

BackgroundAlthough rare, cytomegalovirus (CMV) reactivation can be lethal in patients with cancer. However, the criteria for the prevention of cytomegalovirus reactivation during cancer treatment are unclear. This study aimed to identify factors associated with CMV reactivation in patients with esophageal cancer who were receiving chemoradiotherapy.MethodsThis retrospective study included esophageal cancer patients receiving definitive or palliative chemoradiotherapy during April 2013–March 2020. Patients with fever during chemoradiotherapy underwent a systemic work‐up to detect the primary focus of infection, and CMV antigenemia was assessed in cases of unidentifiable infection.ResultsAmong 132 patients (80.3% male, median age 69 years [range, 39–86 years]), 124 received 5‐fluorouracil plus cisplatin and 8 received oxaliplatin–5‐fluorouracil–levofolinate chemotherapy. Overall, 19 patients had CMV reactivation, 37 had other infections, and 76 had no identified infection (groups 1, 2, and 3, respectively). Median minimum lymphocyte counts were 81.0/µl (interquartile range: 52.0–144.0/µl), 120.0/µl (81.0–162.5/µl), and 185.5/µl (120.5–328.0/µl) in groups 1, 2, and 3, respectively, with counts being significantly lower in groups 1 and 2 than in group 3 (p < 0.001). In multiple logistic regression analysis, the minimum lymphocyte count was associated with CMV reactivation (odds ratio 0.983, 95% confidence interval: 0.973–0.994, p = 0.002).ConclusionCMV reactivation is not rare in patients with esophageal cancer who were receiving chemoradiotherapy and is associated with the minimum lymphocyte counts. CMV reactivation should be considered during differential diagnosis for patients with a severe decline in lymphocyte counts when receiving chemoradiotherapy.

Пул гемопоэтических стволовых клеток в периферической крови хронически облученных лиц в отдаленном периоде

Changes in the peripheral blood cellular composition were observed in the long term period in the residents of the Techa riverside villages chronically exposed to radiation, which may be the consequence of structural and functional disorders in the pool of hematopoietic stem cells (HSC) and progenitor cells. Therefore, the study was aimed to quantify peripheral blood CD34+ cell pool in individuals chronically exposed to radiation over a long-term period. Sixty years after the onset of exposure, a total of 153 individuals were examined, who were divided into four groups: individuals exposed in utero and postnatally (the average postnatal absorbed dose was 570 mGy); individuals exposed only postnatally (the average postnatal absorbed dose was 790 mGy), and two comparison groups, in which the average postnatal absorbed dose to red bone marrow did not exceed 70 mGy. Absolute and relative peripheral blood CD34+ cell counts in chronically exposed individuals were assessed by flow cytometry. No changes in CD34+ cell counts compared to comparison group were revealed in the group of individuals exposed in utero and postnatally; no age-related changes were registered as well. However, a significant decline in absolute HSC and progenitor cell counts with increased absorbed dose to red bone marrow was observed. In the group of individuals exposed only postnatally, there was a significant increase in peripheral blood CD34+ cell counts compared to comparison group (p = 0.004 for absolute cell count; p = 0.009 for relative cell count), dose-dependent increase in peripheral blood HSC and precursor cell counts (p = 0.02 for absolute cell count; p = 0.03 for relative cell count), along with age-related decline in these cells’ counts (р = 0.02 for absolute cell count; p = 0.04 for relative cell count).

Disease progression and mortality with untreated HIV infection: evidence synthesis of HIV seroconverter cohorts, antiretroviral treatment clinical cohorts and population‐based survey data

IntroductionModel‐based estimates of key HIV indicators depend on past epidemic trends that are derived based on assumptions about HIV disease progression and mortality in the absence of antiretroviral treatment (ART). Population‐based HIV Impact Assessment (PHIA) household surveys conducted between 2015 and 2018 found substantial numbers of respondents living with untreated HIV infection. CD4 cell counts measured in these individuals provide novel information to estimate HIV disease progression and mortality rates off ART.MethodsWe used Bayesian multi‐parameter evidence synthesis to combine data on (1) cross‐sectional CD4 cell counts among untreated adults living with HIV from 10 PHIA surveys, (2) survival after HIV seroconversion in East African seroconverter cohorts, (3) post‐seroconversion CD4 counts and (4) mortality rates by CD4 count predominantly from European, North American and Australian seroconverter cohorts. We used incremental mixture importance sampling to estimate HIV natural history and ART uptake parameters used in the Spectrum software. We validated modelled trends in CD4 count at ART initiation against ART initiator cohorts in sub‐Saharan Africa.ResultsMedian untreated HIV survival decreased with increasing age at seroconversion, from 12.5 years [95% credible interval (CrI): 12.1–12.7] at ages 15–24 to 7.2 years (95% CrI: 7.1–7.7) at ages 45–54. Older age was associated with lower initial CD4 counts, faster CD4 count decline and higher HIV‐related mortality rates. Our estimates suggested a weaker association between ART uptake and HIV‐related mortality rates than previously assumed in Spectrum. Modelled CD4 counts in untreated people living with HIV matched recent household survey data well, though some intercountry variation in frequencies of CD4 counts above 500 cells/mm3 was not explained. Trends in CD4 counts at ART initiation were comparable to data from ART initiator cohorts. An alternate model that stratified progression and mortality rates by sex did not improve model fit appreciably.ConclusionsSynthesis of multiple data sources results in similar overall survival as previous Spectrum parameter assumptions but implies more rapid progression and longer survival in lower CD4 categories. New natural history parameter values improve consistency of model estimates with recent cross‐sectional CD4 data and trends in CD4 counts at ART initiation.

Peripheral blood cytopenias in the aging general population and risk of incident hematological disease and mortality

AbstractPeripheral blood cytopenias may precede the development of hematological malignancies and frequently pose clinical challenges in the older population. The natural course of (mild) cytopenias during aging and their association with hematological disorders in community-dwelling individuals are not well studied. Within the population-based Lifelines cohort (n = 167729), we studied changes in peripheral blood counts, occurrence of cytopenias, and associated hematological outcomes in the context of aging. Development of hematological malignancies and (cause-specific) mortality were evaluated by linkage to nationwide registries. Anemia and thrombocytopenia emerged with older age, in line with a general age-related decline in these blood counts. For neutropenia, no increase in prevalence with older age was observed. Using standard reference limits to define cytopenias, anemia (hazard ratio [HR], 1.84; 95% confidence interval [CI], 1.59-2.12), thrombocytopenia (HR, 1.58; 95% CI, 1.32-1.89), and, especially the concomitant presence of anemia and thrombocytopenia (HR, 4.75; 95% CI, 2.98-7.55) were associated with inferior overall survival. Only a minor proportion of deaths was explained by diagnosed hematological malignancies, with the majority attributable to other causes. Neutropenia, either isolated (HR, 0.88; 95% CI, 0.73-1.06) or combined with another cytopenia, did not affect overall survival. For individuals aged ≥60 years, 5-year cumulative incidence of hematological malignancies was 0.60% (95% CI, 0.50-0.70), with higher incidences among those with anemia (P < .001) or thrombocytopenia (P < .001) but not neutropenia (P = .201). Highest cumulative incidences of diagnoses and mortality from hematological malignancies were observed in individuals with >1 cytopenia. We conclude that anemia and thrombocytopenia, but not neutropenia, are associated with inferior overall survival of community-dwelling individuals. Hematological malignancies develop in a small fraction of these cases.

Testicular deficiency associated with exposure to cypermethrin, imidacloprid, and chlorpyrifos in adult rats

The testicular deficiency associated with exposure to three widely used insecticides in Egyptian agriculture was evaluated. Animals were orally treated with sub-lethal dose (1/50 of the oral LD50) of cypermethrin (CYP), imidacloprid (IMC), and chlorpyrifos (CPF) at 5, 9 and 1.9 mg/kg/day, respectively, five times a week for one month. The CYP, IMC, and CPF exposure resulted in a significant decline in animal body weight, sperm count, motility, normality, and viability with increased head and tail deformities. Significant reduction in serum testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), testis superoxide dismutase (SOD), and reduced glutathione (GSH) levels. In contrast, catalase (CAT), lipid peroxidation (LPO), and protein carbonyl content (PCC) levels were significantly stimulated. Jointly, obtained results were confirmed by microscopic examination of testis sections. The present data concluded that the CYP, IMC, and CPF have a public health impact and violently interferes with male rat reproductive system.

Impact of HIV-1 CRF55_01B infection on the evolution of CD4 count and plasma HIV RNA load in men who have sex with men prior to antiretroviral therapy

BackgroundCRF55_01B is a newly identified HIV-1 circulating recombinant form originated from MSM in China. However, its impact on the disease progression and transmission risk has not been investigated. This study aimed to determine the impact of CRF55_01B infection on viral dynamics and immunological status so as to provide scientific evidence for further control and prevention effort on CRF55_01B. Linear mixed effect models were applied to evaluate CD4 cell count decline and viral load increase by subtype.ResultsOf the 3418 blood samples, 1446 (42.3%) were CRF07_BC, 1169 (34.2%) CRF01_AE, 467 (13.7%) CRF55_01B, 249 (7.3%) type B, and 87 (2.5%) other subtypes (CRF_08BC, CRF_01B, C). CRF55_01B had become the third predominant strain since 2012 in Shenzhen, China. CRF55_01B-infected MSM showed lower median of CD4 count than CRF07_BC-infected MSM (349.5 [IQR, 250.2–474.8] vs. 370.0 [IQR, 278.0–501.0], P < 0.05). CRF55_01B infection was associated with slower loss of CD4 count than CRF01_AE (13.6 vs. 23.3 [cells/µl]¹/²/year, P < 0.05)among MSM with initial CD4 count of 200–350 cells/µl. On the other hand, those infected with CRF55_01B showed higher median plasma HIV RNA load (5.4 [IQR, 5.0–5.9]) than both CRF01_AE (5.3 [IQR, 4.8–5.7], P < 0.05) and CRF07_BC (5.0 log10 [IQR, 4.5–5.5], P < 0.001) at the initiation of antiretroviral therapy. Furthermore, the annual increasing rate of viral load for CRF55_01B infection was significantly higher than that of CRF07_BC (2.0 vs. 0.7 log10 copies/ml/year, P < 0.01).ConclusionsThe relatively lower CD4 count and faster increase of plasma HIV RNA load of CRF55_01B-infected MSM without antiretroviral therapy suggest that CRF55_01B may lead to longer asymptomatic phase and higher risk of HIV transmission. Strengthened surveillance, tailored prevention strategies and interventions, and in-depth research focusing on CRF55_01B are urgently needed to forestall potential epidemic.

Spleen Size and Thrombocytopenia After Transcatheter Aortic Valve Implantation

The pathophysiology of thrombocytopenia after transcatheter aortic valve implantation (TAVI) thrombocytopenia is still poorly understood. We assessed the association of spleen size with acquired thrombocytopenia in patients undergoing TAVI. We included 732 patients who underwent TAVI with new generation transcatheter heart valves (THVs) at our center from February 2016 to July 2019. We measured splenic volume index in consecutive patients derived from multidetector row computed tomographic datasets. Patients were stratified according to post-TAVI thrombocytopenia, which was defined as a decline in platelet count (DPC) ≥50% at nadir, and evaluated regarding baseline characteristics and outcome parameters. After the procedure, platelet counts declined from 212.9 ± 67.4×109/L at baseline to 138.8 ± 49.8×109/L at nadir after a median of 2 days (interquartile range [IQR] 2 to 3). Of all patients, 10.1% showed a DPC ≥50%. Compared with patients with DPC <50%, patients with DPC ≥50% had significantly lower splenic volume index (95.5 ml/m2 [IQR 78.0 to 123.7] vs 85.8 ml/m2 [IQR 71.4 to 102.6], p=0.008). A multivariable analysis revealed that the splenic volume index was negatively associated with a DPC ≥50% (OR 0.89, 95% CI 0.82 to 0.97, p=0.005), independent of the type of THV (balloon-expandable THV: OR 2.06, 95% CI 1.13 to 3.76, p=0.02), major bleeding (OR 13.40, 95% CI 3.58 to 50.40, p <0.001), blood transfusion (OR 3.63, 95% CI 1.54 to 8.56, p=0.003), or postprocedural paravalvular leakage ≥moderate (OR 5.48, 95% CI 1.23 to 24.40, p=0.03). Furthermore, DPC ≥50% was independently associated with 1-year mortality (HR 3.36, 95% CI 1.66 to 6.81, p <0.001). In conclusion, acquired thrombocytopenia remains prevalent in modern TAVI patients. Spleen size appears to be associated with the occurrence of thrombocytopenia after TAVI, which is independently correlated with 1-year mortality.

Effects of mobile phone radiofrequency radiation on sperm quality.

In the last decades, the universal use of mobile phones has contributed to radiofrequency electromagnetic radiation environmental pollution. The steady growth in mobile phone usage has raised concerns about the effects of phone radiation on male reproductive health. Epidemiological studies report a sharp decline in sperm counts in developing countries, and worldwide with c. 14% of couples having difficulties to conceive, many of which are attributed to a male infertility factor. Environment and lifestyle factors are known to contribute to male infertility. Exposure to heat, radiation, or radioactivity might induce damage to biological tissue organs, including the testis. Given the ubiquitous use of mobile phones, the potential adverse effects of the resulting environmental radiation needs to be elucidated further. It seems to be an apparent relationship between the increased exposure to mobile phone radiofrequency and sperm quality decline, but the evidence is not conclusive. Our review summarizes the evidence concerning the possible adverse effects of cell phone radiation on the male reproductive system, with a focus on sperm quality. Also, we critically analyze the effects of elevated testicular temperature and oxidative stress on male fertility and how these factors could interfere with the physiological activities of the testis.

The hematological diversity of human parvovirus B19 infection after allo-hematopoietic stem cell transplantation in pediatric patients

目的探讨异基因造血干细胞移植（allo-HSCT）患儿造血重建后人类细小病毒B19（HPV-B19）感染的血液学表现。方法对9例allo-HSCT后合并HPV-B19感染的患儿进行回顾性分析。结果9例患儿占同期接受allo-HSCT患儿的8.04％（9/112），男8例，女1例，中位年龄9（3～13）岁，均采取清髓性预处理方案。HPV-B19感染中位时间为移植后61（36～114）d。allo-HSCT并发HPV-B19感染患儿血液学表现具有异质性，9例患儿以血红蛋白伴网织红细胞下降为主要特点，7 d内网织红细胞比例、绝对值下降幅度中位数分别为90.4％（24.7％～98.7％）、90.7％（18.6％～99.0％）。除常见红系造血停滞表现外，allo-HSCT后合并HPV-B19感染的患儿还具有非红系的血象及骨髓变化：5例患儿外周血出现中性粒细胞下降，但骨髓涂片未见粒系增生受抑；6例患儿骨髓涂片查见巨核系增生减低，其中5例患儿外周血血小板下降。同时，allo-HSCT造血重建后合并HPV-B19感染的患儿骨髓红系受抑并非必要表现，9例患儿虽然均出现血红蛋白下降，但仅5例患儿骨髓红系增生减低。结论血液病患儿allo-HSCT造血重建后合并HPV-B19感染的血液学表现具有异质性，血红蛋白伴网织红细胞下降对HPV-B19感染早期诊断可能具有重要意义。

Traffic Accident Risk Assessment Framework for Qassim, Saudi Arabia: Evaluating the Impact of Speed Cameras

Saudi Arabia is one of the countries with the highest number of road accidents and associated fatalities in the world. Speeding has been identified as an important cause of increased traffic accidents, which also aggravate their severity. Road safety improvement strategies are primarily based on the accurate identification of accident hotspots. Installing speed cameras at a network level is an expensive road safety measure, and its spatiotemporal effectiveness should be assessed. In this study, a traffic accident risk assessment framework has been developed and implemented on the 84 km long Buraydah Ring Road in the Qassim region of Saudi Arabia. The selected highway was divided into 42 (×2 km long) segments using the ArcGIS software. A risk scoring scheme was developed to incorporate both the frequency and severity of road accidents. Speed cameras installation at various segments showed a 70% decline in total accident counts, 53% in accidents with property damage, 84% decline in accidents causing injury, and complete absence of accidents with fatalities. The 48% segments were identified as hotspots with risk level ≥ medium, while the speed cameras installation completely eliminated the hotspots from the study area. The proposed framework can be implemented on major high-speed highways, accommodating high traffic volumes, for hotspot identification and evaluation of various road safety measures in Saudi Arabia and elsewhere.

Crimean-Congo Hemorrhagic Fever Mimicking Multisystem Inflammatory Syndrome in Children Associated With COVID-19: A Diagnostic Challenge

To the Editors: Crimean-Congo hemorrhagic fever (CCHF), which is endemic in our country, is a zoonotic disease characterized by fever and hemorrhage that may be severe and even fatal. The primary transmission route to humans is tick bite; however, other forms of transmission are also reported including direct contact with blood or other bodily fluids of infected animals, nosocomial and vertical transmission.1 The clinical diagnosis of CCHF is difficult to establish because symptoms are nonspecific in the prehemorrhagic phase of the disease and laboratory findings are similar to other childhood infectious diseases.1,2 Here, we report two cases with fever, elevated inflammatory markers, and multisystem organ involvement initially considered as multisystem inflammatory syndrome in children (MIS-C), but subsequently diagnosed with CCHF—highlighting the diagnostic challenge in distinguishing MIS-C from other infectious diseases. To our knowledge, no CCHF cases misdiagnosed as MIS-C have been reported to date. Case 1 A 9-year-old boy was referred to our clinic with a preliminary diagnosis of MIS-C because of persisting fever, abdominal pain, conjunctivitis and increasing levels of acute phase reactants despite intravenous antibiotic treatment. His mother had been diagnosed with coronavirus disease-2019 (COVID-19) 2 months prior to admission. On admission, he had tachycardia (130 beats/min), conjunctivitis and maculopapular rash. His laboratory examination revealed lymphocytopenia, thrombocytopenia and elevated levels of liver function tests, troponin, pro-brain natriuretic peptide (pro-BNP) and inflammatory markers including procalcitonin (Table 1). Although all MIS-C criteria were met, CCHF diagnosis was also suspected, despite lack of tick bite, since the patient had progressively decreasing platelet count, and had a history of living in an endemic area and his family was engaged in animal husbandry. Polymerase chain reaction (PCR) test for CCHF was positive, and the patient was treated and discharged without any complications. TABLE 1. - Clinical and Laboratory Findings of Patients Case 1 Case 2 Demographics Age, years 9 15 Gender Male Male Presenting symptoms Fever (duration) Yes (4 days) Yes (3 days) Abdominal pain Yes Yes Vomiting Yes Yes Diarrhea Yes Yes Headache No Yes Nonpurulent conjunctivitis Yes Yes Rash Maculopapular rash Malar rash Admission laboratory findings White blood cell count (×103/µL) 3.49 2.33 Absolute lymphocyte count (/µL) 730 460 Absolute neutrophil count (/µL) 2630 1410 Hemoglobin (g/dL) 14.3 15 Platelet count (/μL) 43,000 130,000 Ferritin (normal range: 6–40 ng/mL) 20,880 1940 D-dimer (normal range: 0–550 ng/mL) 18,100 2150 CRP (normal range: 0–4 mg/L) 78 37 LDH (normal range:140–260 IU/L) 787 455 Albumin level (g/dL) 2.9 4.6 AST/ALT (U/L) 120/115 98/68 Procalcitonin (< 0.5 ng/mL) 8 Not performed Troponin (< 0.05 ng/mL) 0.08 0.03 Pro-BNP (< 71 pg/mL) 160 Not performed Imaging results Abdominal ultrasound Normal Hepatosplenomegaly Echocardiogram Mitral regurgitation Normal Organ system involvement Cardiovascular ✓ No Respiratory No No Gastrointestinal ✓ ✓ Hematologic ✓ ✓ Renal No No Neurologic No No Dermatologic ✓ ✓ SARS-CoV-2 RT-PCR Negative Negative SARS-CoV-2 antibody Negative Negative History of COVID-19 exposure Yes Yes CCHF-related characteristics History of tick bite No No History of close contact with animals Yes Yes CCHF PCR Positive Positive Treatment Ribavirin Ribavirin ALT indicates alanine aminotransferase; AST, aspartate aminotransferase; BNP, brain natriuretic peptide; CCHF, Crimean-Congo hemorrhagic fever; COVID-19, coronavirus disease 19; CRP, C-reactive protein; LDH, lactate dehydrogenase; MIS-C, multisystem inflammatory syndrome; RT-PCR, reverse transcriptase polymerase chain reaction; SARS-CoV-2, severe acute respiratory system coronavirus 2. Case 2 A 15-year-old boy was referred to our hospital with a preliminary diagnosis of MIS-C because of having fever, conjunctivitis, gastrointestinal symptoms, elevated inflammatory markers and history of exposure to his father who had documented COVID-19 infection three months ago. On admission, he had fever, bilateral conjunctivitis, and malar rash. Laboratory analysis revealed lymphocytopenia and thrombocytopenia in addition to elevated inflammatory markers (Table 1). Detailed questioning revealed that he had a history of close contact with animals; however, history of tick bite was not present. On the following days, his fever persisted and platelet count continued to decrease. CCHF PCR was positive and he was treated successfully. To conclude, similar to MIS-C, clinical manifestations of CCHF include fever, headache, myalgia, rash, conjunctivitis, abdominal pain, nausea, vomiting and diarrhea.1,3 Detailed patient history and differential diagnosis are important to avoid unnecessary treatment and protect healthcare providers since infection control measures are essential in CCHF. Our two cases highlight that CCHF should be ruled out when evaluating possible MIS-C, even in the absence of tick bite history, especially in patients with progressive decline in platelet count, those living in endemic areas, and those with a history of close contact with animals.

Incidence and Clinical Outcomes of Thrombocytopenia after Transcatheter Aortic Valve Replacement in Thai Patients

Background: Post-transcatheter aortic valve replacement (TAVR) thrombocytopenia has been reported to be a predictor of higher mortality and worse clinical outcomes in published studies mostly from Western countries; however, data from Asian countries are generally limited, while data from Thai population are lacking. Objective: To evaluate the incidence and outcomes of Thai patients who developed thrombocytopenia after TAVR. Materials and Methods: The present research was a retrospective observational study. The authors collected data from patients underwent TAVR at Siriraj Hospital between 2009 and 2019. The patients were stratified into four groups according to nadir platelet count, no thrombocytopenia with platelet of 150,000/uL or more, mild with platelet of 100,000 to 149,999/uL, moderate at 50,000 to 99,999/uL and severe at less than 50,000/uL. In addition, the patients with moderate to severe thrombocytopenia were stratified into two groups according to the percentage decline in platelet count (DPC) post procedure as DPC of less than 50% or DPC of 50% or more from the baseline platelet count. Results: Eighty-three patients were reviewed. One patient who died intraoperatively was excluded. Thrombocytopenia occurred in 62 patients (75.6%), in which 36.6% (n=30) of the cases were classed as moderate, and 8.5% (n=7) as severe thrombocytopenia. The platelet count returned to baseline before discharge or during the follow-up period in 83.8% (n=52) of patients. The incidence of in-hospital mortality was significantly higher in patients with severe thrombocytopenia than those with mild thrombocytopenia at 28.6% versus 4% (p=0.011). The duration of admission, length of stay in the CCU, incidence of life-threatening bleeding, clopidogrel discontinuation, platelet transfusion, rate of infection, shock, and acute kidney injury were also significantly higher in patients with moderate to severe thrombocytopenia. Conclusion: Acquired thrombocytopenia after TAVR is a common phenomenon in Thai patients (75%) but usually transient with a nadir platelet count greater than 50,000/uL. Most patients had spontaneous platelet recovery. The presence of severe thrombocytopenia with a nadir platelet count of less than 50,000 is a red flag sign for concomitant infection. The severity of thrombocytopenia is significantly associated with higher mortality and post-procedural adverse events. Keywords: Thrombocytopenia; Transcatheter aortic valve replacement (TAVR)

Prognostic values of procalcitonin and platelet in the patient with urosepsis.

Background:The patient suffering from urinary sepsis is often accompanied by elevated serum procalcitonin (PCT) levels and a decline in the average platelet count (PLT), which could result in a poor prognosis. This study aimed to evaluate the value of PCT and PLT in determining the severity of urinary sepsis.Methods:A total of 120 urosepsis patients enrolled were divided into a survival group and a death group, respectively, according to their status within 14 days after admission. Changes in PCT and PLT levels between the 2 groups were compared at different time points. A receiver operating characteristic (ROC) curve was eventually obtained to predict the prognostic value of PCT and PLT.Results:The PCT levels in the survival group declined gradually after admission, and the PLT decreased at first but increased rapidly in subsequence. The PCT level in the death group, however, declined in a flat-slope trend or was hardly noticeable together with the number of PLT reduced significantly. In particular, it is on the 3rd day that PCT tended to positively correlate with acute physiological and chronic health score II (APACHE II) score (r = 0.730, P < .05), but negatively with PLT (r = 0.472, P < .05). The APACHE II score and PLT (r = 0.612, P < .05) were also negatively correlated with each other. As indicated by the ROC curve, the PCT level on the 3rd day after admission was of great value for the clinical mortality prognosis, and the area under the curve was 0.858. Moreover, PLT also has a high predictive value for prognosis. Area under the curve is 0.951. When the PLT was more than 51 × 109 /L, the sensitivity was up to 90%, and the specificity was 90%.Conclusion:PLT and PCT levels are closely related to the APACHE II score, which could indicate the severity of urosepsis in patients. The contribution of this study was to confirm that dynamic monitoring of the changes in PCT and PLT helps determine the prognosis of urosepsis patients.

Therapeutic evaluation of Murraya koenigii in bovine subclinical mastitis

The present study was aimed to evaluate Murraya koenigii leaves for in vitro antibacterial activity of its hydro-alcoholic extract against common bovine mastitogens, and thereafter, in vivo therapeutic efficacy in subclinical mastitis affected dairy cows. The final yield of herbal extract (g/ 100g of herb) from M. koenigii leaves was 7.8%. The antibacterial activity of the hydro-alcoholic extract in terms of the average zone of inhibition shown by M. koenigii against S. aureus and E. coli were 14.13 mm and 16.00 mm respectively and the respective minimum inhibitory concentration was 31.25 mg/ml and 125 mg/ml. In vivo therapy of the herb against specific subclinical mastitis of cows revealed significant decline in total bacterial count, California Mastitis Test score, Somatic Cell Count, electrical conductivity, pH and lymphocytes while there was significant increase in milk neutrophils, and effect on the elimination of intra mammary infections (50.00%) against control (25.00%) on day 28 of treatment was found non-significant (&chi;2 at 01df, N=64 = 1.641, p &gt; 0.5). Therapy with M. koenigii showed significant effect on minimizing the udder inflammation and improvement of milk quality; however, nonsignificant effect on elimination of intra mammary infections warrants more research while using this herb or its pure active constituents in bovine sub-clinical mastitis.

Quinoa Mitigates Chlorfenapyr-Induced Testicular Toxicity in Rats

Chlorfenapyr (Chf), belongs to a new chemical class calledhalogenated pyrroles, used extensively in Egypt. Negative effects of pesticides on the male reproductive system have been shown broadly. In recent years, the use of medicinal herbs in reducing pesticide toxicity has increased worldwide; one of these herbals is Quinoa seeds (QS), contains high amount of protein, vitamins, and minerals. Our study evaluated the effects of QS on testicular toxicity in rats exposed to Chf. Twenty rats were divided into four groups; group (I) as control was fed on basal diet only, group (II) QS at 30% from the basal diet, group (III) 180 mg/kg b.w/day of Chf, was fed on basal diet only and group (IV) Chf at 180 mg/kg b.w/day plus QS at 30% from the basal diet, the experimental period was four weeks. Rats were sacrificed and blood serum, sperm, and sexual organs samples were collected for biochemical and histomorphological studies. Results revealed that Chf treated animals showed sagging testicles with increased the testis relative weights. This effect was associated with a decline in count, motility, and viability of sperms, and increased sperm abnormality, and a decrease in sex hormones level (P<0.05). On the other hand, QS showed improvement in almost all estimated parameters and mitigated all the toxic effects of Chf, which was confirmed with the histological examination of the testis. So, we can encourage QS consumption as a clue for the toxicity and infertility problems revealed as a result of chlorfenapyr exposure.

Role of Sesame Oil in Ameliorating Testicular Damage in a Rat Model of Acute Kidney Injury: A Histological and Immunohistochemical Study

Background: Acute kidney injury (AKI) is characterized by rapid deterioration of renal functions causing many distant organ injuries. Testicular dysfunction was reported upon chronic renal failure, yet little is known about the underlying mechanism of the damaging effect of AKI on testicular structure and function. Sesame oil was proved to have antioxidant effects.Aim of the work: to assess the effects of AKI on the rat testis and the possible protective role of sesame oil.Material and Methods: Twenty-four adult male albino rats were allocated into 4 groups; control, sesame oil-treated (0.5ml/kg orally for 1week), AKI-induced (10mL/kg of 50% glycerol), and AKI-pretreated with sesame oil. Serum testosterone was assayed. Sperms were analyzed. Biochemical assay of tissue malondialdehyde (MDA), reduced glutathione (GSH), and superoxide dismutase (SOD) were performed. Testes specimens were processed for histological staining and immunohistochemical detection of Bcl2, Ki67, and Androgen receptor (AR). Results: AKI group showed a significant decline in serum testosterone, tissue GSH, and SOD with a significant rise in tissue MDA. Sperms revealed a significant rise in abnormal sperm morphology percentage with a significant decline in sperm count. Histological examination depicted various nuclear and cytoplasmic alterations in the testicular histoarchitecture with a significant rise in the collagen fiber deposition. A significant decline in Bcl2, Ki67, and AR immunohistochemical expression were recorded. Sesame oil pretreatment significantly ameliorated all studied parameters.Conclusions: AKI significantly impacted the testicular structure and function through different mechanisms. Sesame oil efficiently ameliorated this adverse effect through its antioxidant, antiapoptotic, antiproliferative, anti-inflammatory, and antifibrotic activities.

Usefulness of Thrombopoietin Receptor Agonists for Thrombocytopenia after Allogeneic Stem Cell Transplantation. An Eight-Year Single Center Experience

IntroductionProlonged isolated thrombocytopenia (PT) and secondary failure of platelet recovery (SFPR) after allogeneic hematopoietic stem cell transplantation (allo-HSCT) are well known complications that could lead to a potentially lethal bleeding. To date, there are not specific guidelines for the treatment of post allo-HSCT thrombocytopenia, being platelet transfusion the mainstay of the management. Thrombopoietin receptor agonists (TRA), e.g. Eltrombopag (ETP) and Romiplostim have been approved for the treatment of primary immune thrombocytopenia and thrombocytopenia in other conditions (e.g. aplastic anemia) but information on their role in the allo-HSCT is scarce. The aims of our study were a) to analyze the effectiveness, in terms of platelet recovery and length of the response, and b) the safety profile of TRA for the treatment of thrombocytopenia after allo-HSCT in our Institution.MethodsWe performed a retrospective study on 467 patients who underwent to allo-HSCT from 2010 to 2017 in our center, of which a total of 17 patients were treated with TRA as compassionate use for thrombocytopenia after peripheral blood allo-HSCT. In order to be subsidiary to receive a TRA, patients had to be in complete remission with complete chimerism. Patients with thrombocytopenia related to cytomegalovirus and/or thrombotic microangiopathy were excluded. PT was defined as the engraftment of all peripheral blood cell lines but with a platelet (PLT) count <20,000/μL or dependence on PLT transfusions for more than 60 days after allo-HSCT. SFPR was defined as a decline in PLT count <20,000/μL for 7 consecutive days, or requirement of transfusion support after achievement of sustained PLT count ≥50,000/μL without transfusions for 7 consecutive days post-HSCT. The effectiveness or response consisted on achieving platelet recovery (≥20,000/μL) and transfusion independence of at least 7 days.ResultsPatient characteristics are detailed in table 1. One patient was excluded due to short course of treatment that was not evaluable. Platelet recovery and transfusion independence was achieved in 9 out of 16 patients (56%) with a median of 71 days (range: 8-176 days). Three of these responder-patients (R-patients) were switched to an alternative TRA in order to achieve response. Most of the R-patients had SFPR (n=7; 78%). Four patients (44%) were previously treated with mesenchymal stromal cells (MSC; n=2), immunoglobulins (n=3) and/or rituximab (n=1). The median of treatment duration was 181 days (21-350) and all R-patients (n=9) discontinued TRA. At the last follow-up, with a median of 282 days (67-1617), 7 out 9 patients (78%) maintained the response [P=152,000/μL (11,000-358,000)] and 6 (67%) are alive.Among NR-patients (n=7; 43.7%), the median duration of TRA treatment was 14 days (8-82) and 3 patients (43%) were previously treated (MSC and/or immunoglobulins). The main characteristics of NR-patients related to poor response were: active acute graft-versus host disease (GVHD) (n=2; p=0,038), active chronic GVHD (n=1; p=0,025), decreased number of bone marrow megakaryocytes (<++) (n=6; p>0,05), 5 (71%) required platelet transfusion frequency >2 times per week (p>0,05) and all NR-patients received packed red blood cell transfusions (p=0,09). In this group, at the last follow-up, with a median of 86 days (9-144), all except one patient died due to infection (n=5; 83%) or relapse disease (n=1). Finally, no adverse events were related to TRA.ConclusionsTreatment of thrombocytopenia after allo-HSCT with TRA is feasible. Further prospective studies are necessary to determine if these treatments may be considered as a potentially therapeutic alternative. [Display omitted] DisclosuresSanchez-Guijo:Pfizer: Consultancy, Honoraria; Incyte: Consultancy, Honoraria; BMS: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding.