Redefining the role of therapeutic plasma exchange in complications of Echis carinatus sochureki envenomation refractory to anti-snake venom: A case series.

INTRODUCTION: Saw-scaled viper (Echis carinatus) belongs to the Viperidae family. Its venom is hemotoxic and contains several small peptides and proteins affecting the coagulation system. Commonly used anti-snake venom (ASV) products in India are reported to be ineffective or less effective in cases with bites by Echis carinatus sochureki which are commonly found in desert areas in Rajasthan. Although therapeutic plasma exchange (TPE) has been successful in patients with snakebite envenomation in the past, American Society for Apheresis guidelines 2019 included this indication under category III with grade 2C recommendation. AIM AND OBJECTIVES: To report the safety and efficacy of therapeutic plasma exchange procedures in the setting of ASV refractory E. c. sochureki envenomation. MATERIALS AND METHODS: Four patients admitted to our institute in 2021 September with an alleged history of snake bites and who underwent at least one cycle of therapeutic plasma exchange were assessed for clinical outcome, laboratory parameters, and blood product consumption. RESULTS: Three adult patients and one pediatric patient are included in this case series, all of them males. Indication for TPE in one case was suspected diffuse alveolar hemorrhage (DAH), while in all the other cases was thrombotic microangiopathy (TMA). All received a variable number of sessions from 2 to 5 and 1.3-1.5 plasma volume was removed on an average per cycle. The endpoint of TPE was the resolution of DAH in one while a reduction in lactate dehydrogenase and an increase in platelet count was in TMA cases. Consumption of blood products was drastically reduced in all four patients after starting the procedure. All the adult patients fared well on follow-up while the child had developed acute cortical necrosis and was dialysis-dependent. It has been noted in the previous studies too that a subset of snakebite-induced TMA cases was getting converted to chronic kidney disease and becoming dialysis dependent in the long run. CONCLUSIONS: In regions where ASV treatment failure is very common, therapeutic plasma exchange is a safe and effective complementary treatment modality along with supportive care.

Comparing novel versus conventional technique of platelet-rich plasma therapy in periorbital hyperpigmentation: A randomized prospective split-face study.

BACKGROUND: Platelet-rich plasma (PRP) has been found to be effective in treating periorbital hyperpigmentation (POH). PRP prepared by double-spin (DS) method and activated by calcium has been used conventionally. PRP can be prepared by single spin (SS) and activated at low temperature (novel method), but the evidence is limited. OBJECTIVE: To compare the novel and conventional PRP in the treatment of periorbital hyperpigmentation. METHODS: We selected 21 patients of POH and randomly divided the face into two halves. One-half of the face (group A) was treated with novel PRP (SS and low-temperature activation). The other half (group B) was treated with conventional PRP (DS and calcium activation). A total of 3 PRP injections were given at 4 weekly intervals. Patients were observed and assessed on 12th week by photography, dermoscopy, visual analog scale (VAS) score, and Dermatology life quality index (DLQI). Platelet counts and growth factors were assessed in PRP. RESULTS: Mean platelet count in novel and conventional PRP was 7.41 ± 1.76 lacs and 8.17 ± 2.23 lacs (p = 0.348). Mean photographic and dermoscopic assessment at the end of the study in group A and group B was 52.33 ± 6.468 and 53.14 ± 6.99 (p = 0.151). Change in VAS in groups A and B was 3.85 ± 1.27 and 3.90 ± 1.04 (p = 0.895). Levels of various growth factors assessed by ELISA did not differ significantly. There was significant decline in DLQI. CONCLUSION: The novel method is not inferior to conventional method of PRP in the treatment of periorbital hyperpigmentation.

Clinical Post-operative Bleeding During Minor Oral Surgical Procedure and In Vitro Platelet Aggregation in Patients on Aspirin Therapy: Are they Coherent?

AIM: The risk of excessive bleeding prompts physicians to discontinue aspirin in patients on low-dose, long-term therapy which in turn puts them at the risk from adverse cardiovascular and thrombotic events. Effect of low-dose aspirin therapy on platelet function was assessed using platelet aggregation method. The aim was to correlate the laboratory platelet function with cutaneous and clinical oral bleeding time (BT). MATERIALS AND METHODS: One hundred one patients were enrolled in this prospective trial and were allocated into two groups. Interventional or test group consisted of patients who were on aspirin therapy (75 mg/100 mg) for primary or secondary prevention of angina, myocardial infarction and stroke. Minor oral surgical procedure was performed in this group without discontinuing aspirin therapy. Control group consisted of healthy patients (under no medication) undergoing minor oral surgical procedure. Cutaneous and clinical oral BT were recorded in both the groups. Venous blood sample was drawn, and percentage platelet aggregation function was analysed using adenosine diphosphate (ADP) and arachidonic acid (AA) reagents. The percentage of platelet aggregation was then correlated with cutaneous and clinical oral BT. RESULTS: A significant decrease in percentage platelet aggregation using ADP (aspirin-74.7 21.39; control-89.2 13.70) and AA (aspirin-47.6 23.11; control-82.3 20.17) was observed. However, there were no significant difference in mean cutaneous BT (aspirin-1.5 0.65 min; control-1.6 0.71 min) and clinical oral BT (aspirin-5.0 2.48 min; control-4.8 2.60 min) in aspirin and control groups. CONCLUSION: Majority of the minor oral surgical procedures can be carried out safely without discontinuing aspirin in patients on low-dose long-term therapy. This is possible because despite significant platelet aggregation evident in laboratory evaluation there is lack of its clinical corroboration owing to aspirin resistance. CLINICAL TRIAL REGISTRATION: CTRI/2018/02/012055.