Therapeutic Plasma Exchange: A Lifesaving Therapy in Case of ANCA-associated Vasculitis with Diffuse Alveolar Hemorrhage.

How to cite this article: Tripathi PP, Sharma RR, Chhabria B, Hans R, Sehgal IS. Therapeutic Plasma Exchange: A Lifesaving Therapy in Case of ANCA-associated Vasculitis with Diffuse Alveolar Hemorrhage. Indian J Crit Care Med 2021;25(7):828-829.

Cost-minimization analysis in the Indian subcontinent for treating Guillain Barre Syndrome patients with therapeutic plasma exchange as compared to intravenous immunoglobulin.

BACKGROUND: Therapeutic Plasma Exchange (TPE) and Intravenous Immunoglobulin both are first-line treatments for Guillain Barre Syndrome; however, there is a significant difference in cost. We undertook this study to assess the cost minimization for treating Guillain Barre Syndrome patients. METHODS: A prospective randomized controlled trial was undertaken, in which 40 Guillain Barre Syndrome (GBS) patients with a GBS disability score of grade four and five were enrolled. A societal perspective was adopted for the analysis and assessment of both the health system cost and out-of-pocket expenditures. Cost-minimization analysis was undertaken as both the treatments were equally effective at the end of 12 weeks. RESULTS: No statistically significant differences were observed in the GBS Disability scores during overall treatment course in both treatment groups. The Out-of-pocket cost for the immunoglobulin (IVIG) group was INR 219 247 (4298 USD) and for the TPE group was INR 104 070 (2040.5 USD). Overall INR 86 685 ($1700), that is, 53% higher cost was observed in IVIG group without any concomitant health outcome benefit. CONCLUSION: In comparison with IVIG, TPE appears to be the better option for treatment of GBS in cost-constraint countries like ours to provide an economic treatment option to most average people.

Quality of Life Outcomes and Determining Factors in Breast Cancer Patients Reporting to a Tertiary Care Centre in the Sub-Himalayan Region of India.

PURPOSE: Breast cancer is the most common malignancy among women worldwide. This study was conducted to determine the quality of life (QOL) outcomes among breast cancer patients in the sub-Himalayan region and, secondly, to identify factors affecting them. METHOD: The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 and BR-45 questionnaires in English and Hindi translations were used. The BR-45 Hindi translation was obtained using the forward-backward translation method. To check internal consistency and validity, Cronbach's alpha was employed. EORTC scoring manuals were used to score the questionnaires. The analysis of variance test was used to determine the impact of different treatment and sociodemographic factors on QOL domains. RESULTS: The English and Hindi translations had Cronbach's alpha values of 0.949 and 0.950, respectively, suggesting that the data gathered were reliable. The mean score for global health status was 64.4 ± 29.7, the functional scale (FS) of QLQ_C30 was 76.9 ± 21.5, the FS of BR45 was 64.6 ± 24.1, the symptom scale (SS) of QLQ_C30 was 20.3 ± 19.2, and the SS of BR45 was 22.5 ± 19.1. Factors adversely affecting global health status included younger age, pre/perimenopausal status, and ongoing chemotherapy. Functional scales were significantly affected by marital status and earlier stages of the disease. Symptom scales were adversely affected by ongoing chemotherapy, an earlier stage of the disease, and a duration of treatment of less than six months. CONCLUSION: Tailoring treatment to reduce radiotherapy, surgery, and systemic therapy-related side effects may improve QOL. Counselling and social support groups may help patients cope with the burden of family and societal roles.

Factors Impacting Quality of Life of Caregivers of Cancer Patients in the Sub-Himalayan Region: A Cross-Sectional Study.

Background Caregivers of cancer patients experience excessive emotional and financial stress. Objective To determine the quality of life (QOL) of caregivers of cancer patients and factors affecting it in caregivers attending the OPD of a governmental tertiary care cancer center in the sub-Himalayan region. Methods A cross-sectional observational study was used. A pre-validated caregiver quality of life (CQOL) questionnaire was completed by consenting caregivers of 96 outpatient attendees. Results The mean total QOL scores were higher in attendants of subjects who did not undergo surgery versus those who underwent surgery (p-value: 0.04) and in those who received 0-5 versus >5 chemotherapy cycles (p-value: 0.015). On subdomain analyses, the burden was significantly greater in caregivers of patients who did not undergo surgery (p-value: 0.02) and had a higher Eastern Cooperative Oncology Group (ECOG) scale (p-value: 0.03). Disruptiveness was significantly higher in married individuals (p-value: 0.01) and those aged between 36 and 60 years (p-value: 0.003). Positive adaptation was worse in caregivers with another family member suffering from chronic illness (p-value: 0.041) and in professional and skilled workers (p-value: 0.03). The greater financial burden was experienced by caregivers belonging to lower socioeconomic status (p-value: 0.03). On putting these factors in the regression model, the non-specific domain of 0-5 cycles had poor CQOL, i.e., higher scores. The burden score was more in ECOG stages 3 and 4 in comparison with stages 1 and 2. Married individuals had significant disruption. Individuals aged between 36 and 60 years perceived more disruption in their lives. A more financial impact was observed on the lower middle and lower class compared to the upper and upper middle class. Conclusion Caregivers of cancer patients experience significant stress and burden. Counseling and social and financial support to caregivers may help improve CQOL.

Chronic Abruptio Placentae With Multiple Alloantibodies: An Obstetrician's Challenge.

The current case highlights the management of abruptio placentae in pregnant women with an O Rhesus (Rh)-negative blood group with multiple alloantibodies. We describe a unique case of chronic placental separation in a young primigravida presenting with intrauterine hematoma and intrauterine fetal death (IUFD), who had an O Rhesus-negative blood group with alloimmunization against D, C, and S antigens. The implications in management were the dilemma in diagnosis, the ABO blood grouping discrepancy, multiple alloantibodies including Rh alloimmunization, chronic placental abruption with postpartum hemorrhage, and scope for further pregnancies. Chronic placental separation or abruption can occur silently in some cases. On presentation, they may be mistaken with or for other lesions. In Rh-negative pregnancies, chronic abruption can lead to alloimmunization against Rh and other clinically significant antigens as well. Women with suspicion for chronic abruption must undergo detailed blood group testing as well as immunohematological workup at a nearby transfusion medicine department with a facility for complex immunohematological resolutions.

A Comparison of the Toxicities in Patients With Locally Advanced Head and Neck Cancers Treated With Concomitant Boost Radiotherapy Versus Conventional Chemoradiation.

PURPOSE: To compare the objective and patient-reported toxicities of concomitant boost radiotherapy (CBRT) and concurrent chemoradiation (CRT) in patients with locally advanced head and neck cancers. METHODS AND MATERIAL: In this prospective study, 46 patients with histologically proven stage III-IVA head and neck cancer were randomly assigned to receive either concurrent chemoradiation to a dose of 66 Gy in 33 fractions over 6.5 weeks with concurrent cisplatin (40 mg/m2 IV weekly; control arm) or accelerated radiotherapy with concomitant boost radiotherapy (study arm) to a dose of 67.5 Gy in 40 fractions in five weeks. Acute toxicity was evaluated using RTOG toxicity criteria. The assessment was done weekly after initiation of treatment, at the first follow-up (six weeks), and at three months. The four main patient-reported symptoms of pain, hoarseness of voice, dryness of mouth, and loss of taste were also compared between the two groups to assess patient quality of life during treatment. RESULTS: The mean treatment duration was 37 days in the CBRT arm and 49 days in the CRT arm. Treatment-related interruptions were less in the study group,17.3% in the study, and 27.2% in the control with insignificant P-value. Grade III laryngeal toxicity was significantly higher in the study group (P=0.029). Other acute grade I-III toxicities (pharyngeal, skin, mucositis, and salivary) were comparable in both CRT and CBRT arms. Grade IV toxicities were seen only in the CBRT arm but were resolved at the first follow-up. Haematological toxicities and renal toxicities were significantly higher in the CRT arm, with significant P-values of 0.0004 and 0.018, respectively. CONCLUSION: In patients with locally advanced head and neck cancer, concomitant boost radiotherapy is well tolerated with acceptable local toxicity and minimal systemic toxicity as compared to conventional chemoradiation. It is a feasible option for patients with locally advanced head and neck cancer not fit for concurrent chemoradiation.

Autologous bone marrow-derived stem cells in amyotrophic lateral sclerosis: a pilot study.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder with no effective treatment. Stem cell therapy may be one of the promising treatment options for such patients. AIM: To assess the feasibility, efficacy and safety of autologous bone marrow-derived stem cells in patients of ALS. SETTINGS AND DESIGN: We conducted an open-label pilot study of autologous bone marrow-derived stem cells in patients with ALS attending the Neurology Clinic of a tertiary care referral centre. MATERIALS AND METHODS: Ten patients with ALS with mean revised ALS Functional Rating Scale (ALSFRS-R) score of 30.2 (± 10.58) at baseline received intrathecal autologous bone marrow-derived stem cells. Primary end point was improvement in the ALSFRS-R score at 90, 180, 270 and 365 days post therapy. Secondary endpoints included ALSFRS-R subscores, time to 4-point deterioration, median survival and reported adverse events. Paired t-test was used to compare changes in ALSFRS-R from baseline and Kaplan-Meier analysis was used for survival calculations. RESULTS: There was no significant deterioration in ALSFRS-R composite score from baseline at one-year follow-up (P=0.090). The median survival post procedure was 18.0 months and median time to 4-point deterioration was 16.7 months. No significant adverse events were reported. CONCLUSION: Autologous bone marrow-derived stem cell therapy is safe and feasible in patients of ALS. Short-term follow-up of ALSFRS-R scores suggests a trend towards stabilization of disease. However, the benefit needs to be confirmed in the long-term follow-up period.

Report of plasma exchange in a rare case of association of myasthenia gravis with thymoma and parathyroid adenoma.

Myasthenia with thymoma and parathyroid adenoma is a rare presentation. Very few cases have been reported of this association without much role of plasma exchange in these patients. Here, we present our experience of plasma exchange in this rare clinical entity.

Therapeutic Plasma Exchange in Neuromyelitis Optica Spectrum Disorders-Experience from Tertiary Care Center in North India.

Background: Therapeutic plasma exchange (TPE) is indicated in the acute presentation of neuromyelitis optica spectrum disorders (NMOSD) as category II indication as per American Society for Apheresis guidelines 2016. Aim: To assess the efficacy of TPE in symptomatic patients of NMOSD not responding to high dose intravenous steroids. Patients and Methods: We retrospectively reviewed the record of TPE procedures in NMOSD patients over a period of 3 years (2013-2016). TPEs were done on Cobe® spectra (Terumo BCT, Lakewood Co., USA) using 5% human serum albumin or fresh frozen plasma as replacement fluid. Clinical improvement was recorded post-procedure and adverse reactions if any was noted. Results: We performed TPE in 11 clinically diagnosed patients of NMOSD. Three (27%) patients had only visual symptoms, five (46%) had both visual as well as muscular symptoms, whereas three (27%) patients presented with only muscular symptoms. Out of seven tested, three patients were aquaporin-4-immunoglobulin-G-positive (AQP4-IgG positive). Visual symptoms improved from no vision pre-TPE therapy to finger counting or 6/24 post-therapy.The muscle power of the limbs improved by grade one to grade two post-therapy. Adverse events were observed in 8% (5/62) of the procedures; allergic reactions to replacement fluid as the most common event (n = 3) followed by hypotension (n = 2). Follow-up was available in 81% (9/11) patients. Two patients died at 3 and 12 months of follow-up. One patient had relapsed and underwent a second TPE cycle. Conclusion: The addition of TPE as a part of therapy is effective and safe in acute exacerbations of NMOSD.

Effect of high intensity exercise training on central hemodynamic responses to exercise in men with reduced left ventricular function.

OBJECTIVES: The aim of this study was to evaluate the effects of high intensity exercise training on left ventricular function and hemodynamic responses to exercise in patients with reduced ventricular function. BACKGROUND: Results of studies on central hemodynamic adaptations to exercise training in patients with chronic heart failure have been contradictory, and some research has suggested that training causes further myocardial damage in these patients after a myocardial infarction. METHODS: Twenty-five men with left ventricular dysfunction after a myocardial infarction or coronary artery bypass graft surgery were randomized to an exercise training group (mean age +/- SD 56 +/- 5 years, mean ejection fraction [EF] 32 +/- 7%, n = 12) or a control group (mean age 55 +/- 7 years, mean EF 33 +/- 6%, n = 13). Patients in the exercise group performed 2 h of walking daily and four weekly sessions of high intensity monitored stationary cycling (40 min at 70% to 80% peak capacity) at a residential rehabilitation center for a period of 2 months. Ventilatory gas exchange and upright hemodynamic measurements (rest and peak exercise cardiac output; pulmonary artery, wedge and mean arterial pressures; and systemic vascular resistance) were performed before and after the study period. RESULTS: Maximal oxygen uptake (VO2max) increased by 23% after 1 month of training, and by an additional 6% after month 2. The increase in VO2max in the trained group paralleled an increase in maximal cardiac output (12.0 +/- 1.8 liters/min before training vs. 13.7 +/- 2.5 liters/min after training, p < 0.05), but maximal cardiac output did not change in the control group. Neither stroke volume nor hemodynamic pressures at rest or during exercise differed within or between groups. Rest left ventricular mass, volumes and EF determined by magnetic resonance imaging were unchanged in both groups. CONCLUSIONS: High intensity exercise training in patients with reduced left ventricular function results in substantial increases in VO2max by way of an increase in maximal cardiac output combined with a widening of maximal arteriovenous oxygen difference, but not changes in contractility. Training did not worsen hemodynamic status or cause further myocardial damage.

Cardiac rehabilitation in Switzerland. Efficacy of the residential approach following bypass surgery.

BACKGROUND: The traditional central European approach to cardiac rehabilitation involves sending patients to an idyllic setting, where they reside for a specified period following a cardiac event. Favorable results have been demonstrated using this approach in Germany, but to our knowledge no data have been reported from Switzerland, where these programs tend to be short (4 weeks) and exercise training is concentrated (2 h daily, 6 days per week). METHODS AND RESULTS: Seventeen patients (aged 58 +/- 6 years) who resided in a rehabilitation center for 4 weeks were compared with 11 patients (aged 54 +/- 7 years) given usual community care beginning approximately 6 weeks after coronary artery bypass surgery (CABS). Exercise training consisted of 1 h of group walking twice daily, with the intensity stratified into 4 levels based on clinical status and initial exercise capacity. All patients underwent pulmonary function testing and maximal ramp exercise testing on a cycle ergometer with continuous ventilatory gas exchange and lactate analysis before and after the study period. Patients receiving beta-blockers and those with cardiomyopathy or valvular heart disease were excluded. Medication status was not changed during the study period. Although maximal oxygen uptake increased by approximately 12 percent within both groups, the change was not significant between groups. Analysis of variance demonstrated that mean lactate levels were reduced throughout exercise within both groups (p < 0.001); however, there were no differences between groups. Oxygen uptake at the lactate threshold was not different in either group after the study period. CONCLUSIONS: Similar changes occur in the functional status of post-CABS patients regardless of their participation in the short but concentrated rehabilitation programs common in Switzerland, suggesting that these programs either begin too soon after CABS or are too short to achieve training benefits.

Application of a WHO protocol on medical therapy for oncologic pain in an internal medicine hospital.

Pain symptomatology is present in 60% - 80% of patients affected by advanced cancer, but in most cases it is not adequately treated. Our series, composed of 45 patients affected by cancer in an advanced stage, demonstrates how the application of common concepts of pharmacotherapy, standardized according to a sequential scheme proposed by the WHO, makes it possible to reach total control (in 24.4% of our cases) or only slight residual persistence (in 68.8% of our cases) of pain from cancer, with scarce side effects that are easily controlled with symptomatic therapy. According to the type of pain, its behavior in relation to the therapy effected and any previous pharmacologic treatment, the proposed pharmacologic scheme foresees, as the first step, the use of non-narcotic drugs, eventually associated or substituted with weak narcotics or finally with strong narcotics. Attention is given to modulation of the administration, to guarantee an analgesic effect throughout the day, thus preventing the pain. Irrespective of the analgesic scheme employed, it is more effective if patients affected by chronic oncologic pain (who present an important emotional component) are treated contemporaneously with anxiolytic and antidepressive drugs and those in which nerve structures are involved are treated with steroids. In conclusion, pain of an oncologic patient in an advanced stage can almost always be alleviated or often eliminated by the rigorous application of therapeutic concepts well known by physicians but for various reasons often neglected in clinical practice.

[Anti-ischemia drug therapy]. / Medikamentöse antiischämische Therapie.

Nitrates, molsidomin, betablockers, calcium antagonists, inhibitors of platelet aggregation and anticoagulants are the most important drugs for the management of the different forms of angina pectoris. Their use in chronic stable, unstable and vasospastic angina pectoris and for secondary prophylaxis are discussed.

Analysis of adverse events and predisposing factors in voluntary and replacement whole blood donors: A study from north India.

BACKGROUND: Lack of awareness and community motivation, compounded with fragmented blood transfusion services in our country, Often leads to shortage of blood. Donor recruitment and retention are essential for ensuring adequate blood supply. However, adverse events (AEs) in donors have a negative impact on donor return. AIMS AND OBJECTIVES: The present study was aimed to assess the frequency of AEs in whole blood donors and analyze the predisposing factors for AEs. MATERIAL AND METHODS: The study was conducted on allogeneic whole blood donors over a period of 14 months, i.e., from January 2002 to February 2003. A total of 37,896 donors were monitored for any AEs: 22587 (59.6%) were voluntary donors (VD) and 15,309 (40.4%) were replacement donors (RD). RESULTS: Overall reaction rate was 2.5% with vasovagal reactions constituting 63.5% and hematomas 35.0% of all reactions. Vasovagal reactions showed a significant association with young age, lower weight, first time donation status, female gender, and nature of blood donation camps. Amongst male donors, RDs had more reactions (P=0.03) than VDs. Majority of donors (85%) with vasovagal reactions admitted to some fear or anxiety prior to donation. Hematoma formation occurred significantly more when less trained staff performed phlebotomy. CONCLUSION: Donor safety is an essential prerequisite to increase voluntary blood donation. AE analysis helps in identifying the blood donors at risk of donor reactions and adopting appropriate donor motivational strategies, pre-donation counseling, and care during and after donation.

[Blood pressure reaction during exertion]. / Das Blutdruckverhalten unter Belastung.

There are three types of abnormal blood pressure responses during exercise: hypotensive reaction, inadequate rise in blood pressure, and hypertensive reaction. At rest, an abnormal high blood pressure has an adverse prognostic implication. This is not true for a low blood pressure at rest. During exercise, however, the contrary is observed: an inadequate rise or even a fall in blood pressure below resting values indicates a significantly increased risk for cardiac events, whereas a hypertensive reaction in patients with a normal resting blood pressure has no adverse prognostic implications.