Clinical parameters of therapeutic apheresis induction in clinically amyopathic dermatomyositis patients with rapid progressive interstitial lung disease.

INTRODUCTION: The purpose of this study is to clarify the clinical parameters of therapeutic apheresis (TA) induction in clinically amyopathic dermatomyositis patients with rapid progressive interstitial lung disease. METHODS: Literature publications prior to November 2021 from PubMed and Ichushi-Web were used. We collected details of TA and clinical features. The data were divided into two groups determined by the outcome, survived and deceased. Then, we estimated clinical parameters between them. RESULTS: There were 151 cases, 134 of which had reported outcomes and 64 of which were positive for the anti-MDA5 antibody. Eighty patients survived. Forty-eight patients were treated with plasma exchange and 34 with polymyxin-B immobilized fibers direct hemoperfusion. Regarding clinical parameters, only the PaO2 to FiO2 (P/F) ratio was useful. The cut-off point of the P/F ratio was 174 on the ROC curve. CONCLUSION: The parameter for induction is considered when the P/F ratio is lower than 200.

Blood purification could tackle COVID-19?

Coronavirus disease 2019 (COVID-19) threatened human lives worldwide since first reported. The current challenge for global intensivists is to establish an effective treatment for severe COVID-19. Blood purification has been applied to the treatment of various critical illnesses. Theoretically, its technique also has an enormous possibility of treating severe COVID-19 in managing inflammatory cytokines and coagulopathy. Recent clinical studies have revealed the positive clinical effect of therapeutic plasma exchange. Other studies have also indicated the considerable potential of other blood purification techniques, such as Cytosorb, AN69 surface-treated membrane, and polymyxin b hemoperfusion. Further research is needed to elucidate the actual effects of these applications.

Tocilizumab and PMX-DHP have efficacy for severe COVID-19 pneumonia.

In coronavirus disease 2019 pneumonia, a cytokine storm resulting from an excessive inflammatory response to the viral infection is thought to play a role in the exacerbation of the pneumonia and its prognosis. Favipiravir and ciclesonide are not effective in the inhibition of the cytokine storm. In this case report, we describe the experience of tocilizumab administration and polymyxin B immobilized fiber direct hemoperfusion in severe coronavirus disease 2019 pneumonia patient. A 52-year-old man presented with fever and dyspnea and was diagnosed with coronavirus disease 2019 pneumonia based on a polymerase chain reaction test. Mechanical ventilation and favipiravir administration were started for respiratory failure. However, favipiravir could not be continued due to hepatic dysfunction. Consequently, tocilizumab was administered, and continuous hemodiafiltration and endotoxin adsorption therapy (polymyxin B immobilized fiber direct hemoperfusion) were performed for acute renal failure. C-reactive protein decreased from 44 to 3.52 mg/dL, and the patient's respiratory status improved over time, enabling mechanical ventilation to be withdrawn. This case indicates that adding polymyxin B immobilized fiber direct hemoperfusion to tocilizumab administration may further increase efficacy in coronavirus disease 2019 treatment; however, more case-control studies are needed.

Polymyxin B haemoperfusion treatment for respiratory failure and hyperferritinaemia due to COVID-19.

A 69-year-old man with a history of type 2 diabetes and high blood pressure was diagnosed with coronavirus disease 2019 (COVID-19). He had hyperferritinaemia and respiratory failure. Despite the initiation of favipiravir and high-dose corticosteroid and ceftriaxone, his respiratory failure progressed and serum ferritin levels increased. After polymyxin B-immobilized fibre column direct haemoperfusion (PMX-DHP) therapy, there was improvement of the respiratory failure and hyperferritinaemia. We report the first case of COVID-19-induced hyperferritinaemia and severe respiratory failure successfully treated by PMX-DHP.

"Impact of timing of polymyxin B-immobilized fiber column direct hemoperfusion on outcome in patients with septic shock: a single-center observational study".

AIM: The effect of polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is controversial. The present study investigates whether outcome in septic shock patients is affected by the time until PMX-DHP initiation and the location of the infection site (intra- or extra-abdominal infection (IAI/EAI)]. METHODS: This retrospective observational study included patients receiving PMX-DHP for septic shock but excluded those treated after cardiac surgery or cardiac arrest. Based on the median and/or quartile time from catecholamine treatment to PMX-DHP initiation, the patient cohort was divided into four groups and the IAI and EAI groups into two subgroups. RESULTS: Among the 49 eligible patients, overall 90-day mortality in group 1 (PMX-DHP within 6 h) at 8.3% was significantly lower than in groups 2 (6-9 h; 46.1%), 3 (9-29 h; 58.3%) and 4 (>29 h; 75.0%) (P = 0.021). Multivariate logistic regression analysis showed that the duration from catecholamine treatment to PMX-DHP initiation correlated with 90-day mortality (odds ratio 1.060; 95% confidence interval, 1.004-1.117; P = 0.028). Among the 29 IAI patients, 90-day mortality was significantly lower in the early (within 9 h) than the late group (>9 h) (13.3% versus 64.2%; P = 0.003), but no significant intergroup difference was noted among the 20 EAI patients. CONCLUSION: Our results suggest that early PMX-DHP initiation (within 9 h after catecholamine treatment) reduces mortality from septic shock, especially in IAI patients.

Sphingosine-1-Phosphate (S1P) Is a Feasible Biomarker in Predicting the Efficacy of Polymyxin B-Immobilized Fiber Direct Hemoperfusion (PMX-DHP) in Patients with Septic Shock.

PURPOSE: The aim of this study was to identify a useful biomarker to predict the efficacy of polymyxin B-immobilized fiber direct hemoperfusion (PMX-DHP) in patients with septic shock. METHODS: The 44 patients included in this study were divided into two groups. Group A had an increase in systolic blood pressure (SBP) over 30 mmHg after PMX-DHP treatment. Group B had an increase in SBP less than 30 mmHg after PMX-DHP treatment. We evaluated the clinical characteristics and demographics of both groups. We also assessed whether the cause of sepsis affected the efficacy of PMX-DHP and compared the prognosis of both groups. Finally, we investigated whether there were any significant differences in the levels of sepsis-related biomarkers, including sphingosine-1-phosphate (S1P), between both groups before PMX-DHP in an effort to identify a biomarker that could predict the efficacy of PMX-DHP. RESULTS: PMX-DHP significantly increased SBP regardless of the cause of sepsis. Although there was some tendency, PMX-DHP did not significantly improve the prognosis of effective cases in comparison with non-effective cases, probably because of the limited number of patients included. Among the sepsis-related biomarkers, only S1P values were significantly different between the two groups before PMX-DHP, and S1P levels were significantly increased after treatment in the effective cases. CONCLUSION: S1P levels prior to PMX-DHP can be used to predict its efficacy. In addition, continuous monitoring of S1P levels can indicate the effectiveness of PMX-DHP in patients with septic shock.

Efficacy of direct hemoperfusion with a polymyxin B-immobilized fiber column in miliary tuberculosis.

Case: A 75-year-old woman presented with a 10-day history of intermittent fever, general fatigue, and progressive dyspnea. Although she had a low PaO2/FIO2 ratio, the cause of acute respiratory distress syndrome was not clear until day 9 in hospital. Outcome: We treated the patient with direct hemoperfusion with a polymyxin B-immobilized fiber column incidentally; the PaO2/FIO2 ratio improved following this therapy. Acid-fast bacilli, which were not seen in the sputum on admission, were detected in cultures from sputum, urine, bone marrow, liver biopsy, and blood samples, with a real-time polymerase chain reaction assay confirming tuberculosis. She was immediately transferred to a specialized tuberculosis hospital, and after a 3-month treatment, was discharged. Conclusion: Treatment with polymyxin B-immobilized fiber column may provide good results for pulmonary oxygenation in acute respiratory distress syndrome caused by tuberculosis.

Endotoxin adsorption: Direct hemoperfusion with the polymyxin B-immobilized fiber column (PMX).

Toraymyxin® is a medical device developed to adsorb circulating endotoxins in the blood using direct hemoperfusion therapy for patients with septic shock. In 1994, the Japanese National Health Insurance system approved the use of Toraymyxin for the treatment of endotoxemia and septic shock. Since then, Toraymyxin has been safely used in more than 100,000 cases in emergency and intensive care units in Japan. Toraymyxin is currently available for use in the clinical setting in 14 countries worldwide. In this study, we reviewed and introduced the development, clinical use, and efficacy of Toraymyxin and commented on its anticoagulant use and cartridge clotting issue in the treatment of severe sepsis and septic shock. We also highlighted potential new applications of Toraymyxin for longer duration therapy and pulmonary diseases.

Efficacy of direct hemoperfusion using polymyxin B-immobilized fiber column (PMX-DHP) in rapidly progressive interstitial pneumonias: results of a historical control study and a review of previous studies.

BACKGROUND: Direct hemoperfusion using polymyxin B-immobilized fiber column (PMX-DHP) therapy has been approved for sepsis-associated acute respiratory distress syndrome, but its efficacy for other rapidly progressive interstitial pneumonias (RPIPs) is unclear. The purpose of this study was to examine the efficacy of PMX-DHP therapy for acute respiratory failure in patients with RPIPs, when compared with a historical control receiving conventional treatment without PMX-DHP. METHODS: This study comprised 77 patients with RPIPs in our institute between January 2002 and December 2015. The initial 36 patients between January 2002 and March 2007 were treated without PMX-DHP (historical control group), and the following 41 patients between April 2007 and December 2015 were treated with PMX-DHP (PMX-DHP group) once daily for two successive days concurrently with corticosteroids and/or immunosuppressive agents. The 90-day mortality and clinical factors were compared between the groups. Cox proportional hazards models were constructed to analyze 90-day mortality and identify predictors. RESULTS: The 90-day mortality rate was significantly lower in the PMX-DHP group than in the controls (41.5% versus 66.7%, p = 0.019). PMX-DHP therapy was significantly associated with mortality (hazard ratio 0.505; 95% confidence interval, 0.270-0.904; p = 0.032). There were significant differences in the serial changes in the PaO2/FiO2 ratio, SOFA score, and blood neutrophil counts from days 0-5 after PMX-DHP between the survivor and non-survivor groups ( p = 0.015, p < 0.001, p = 0.035, respectively). The improved PaO2/FiO2 ratio on day 3 significantly correlated with the change in blood neutrophil counts (rs = -0.431, p = 0.006). CONCLUSIONS: PMX-DHP therapy may be effective in RPIPs patients accompanied by acute respiratory failure and is expected to reduce mortality rates.

Prolonged direct hemoperfusion using a polymyxin B immobilized fiber cartridge provides sustained circulatory stabilization in patients with septic shock: a retrospective observational before-after study.

BACKGROUND: Direct hemoperfusion therapy with polymyxin B immobilized fiber cartridges (PMX-DHP) is widely used for septic shock in Japan and parts of Europe. Although this treatment is usually administered for 2 h, the optimal duration has not been established. METHODS: This retrospective study compared the effects of prolonged and conventional PMX-DHP durations (2 and 12 h, respectively) for septic shock. Between October 2013 and March 2015, 18 patients underwent conventional PMX-DHP, and between April 2015 and May 2016, 18 patients underwent prolonged PMX-DHP. The primary outcome was the vasopressor dependency index during the 12 h after starting the first PMX-DHP session. The vasopressor dependency index was calculated as (inotropic score)/(mean blood pressure). RESULTS: The patients' characteristics were almost similar in the conventional and prolonged PMX-DHP groups. The major site of infection was the abdomen in both groups (61 and 72%, respectively). The conventional PMX-DHP group had mean blood pressure values of 68.4 ± 8.9 mmHg and 78.2 ± 16.9 mmHg at 0 and 12 h after starting PMX-DHP (P = 0.13). The prolonged PMX-DHP group had mean blood pressure values of 70.3 ± 15.7 mmHg and 87.7 ± 16.9 mmHg at 0 and 12 h after starting PMX-DHP (P = 0.004). The conventional PMX-DHP group had vasopressor dependency index values of 0.52 ± 0.29 and 0.39 ± 0.25 at 0 and 12 h after starting PMX-DHP (P = 0.29). The prolonged PMX-DHP group had vasopressor dependency index values of 0.50 ± 0.26 and 0.28 ± 0.18 at 0 and 12 h after starting PMX-DHP (P = 0.01). Hospital mortality was similar in both groups (8/18 [44%] and 8/18 [44%]). CONCLUSIONS: These findings suggest that prolonged PMX-DHP provides more sustained circulatory stabilization compared to conventional PMX-DHP. However, our study failed to detect any improvement in mortality. Well-designed prospective trials are needed to examine the clinical outcomes of prolonged PMX-DHP and to identify the optimal duration of PMX-DHP.

Rapidly progressive interstitial lung disease due to anti-MDA-5 antibody-positive clinically amyopathic dermatomyositis complicated with cervical cancer: Successful treatment with direct hemoperfusion using polymyxin B-immobilized fiber column therapy.

The anti-melanoma differentiation-associated gene 5 (MDA-5) antibody is a marker of clinically amyopathic dermatomyositis (CADM) and rapidly progressive interstitial lung disease (ILD) with acute respiratory failure. A 35-year-old woman with cervical cancer showed Gottron's papules, severe hypoxemia, and diffuse ground-glass opacities on chest computed tomography. She was diagnosed with rapidly progressive ILD associated with CADM. Her serum was positive for the anti-MDA-5 antibody. Combination therapy with corticosteroids, immunosuppressants, and direct hemoperfusion using polymyxin B-immobilized fiber column (PMX-DHP) improved her respiratory dysfunction. Eventually, surgery for the cancer was performed successfully. This is the first case to demonstrate the efficacy of PMX-DHP for rapidly progressive ILD with anti-MDA-5 antibody-positive CADM and a malignancy.

Successful treatment of sepsis due to Pantoea agglomerans by polymyxin B-immobilized fiber column direct hemoperfusion therapy in a small cell lung carcinoma patient.

Sepsis is a life-threatening condition caused by the inflammatory response to invading organisms. Polymyxin B-immobilized fiber column direct hemoperfusion (PMX-DHP) is used to reduce blood endotoxin levels and modulate circulating inflammatory cytokine levels in sepsis patients. Here we report that severe sepsis caused by an infection of the gram-negative bacterium Pantoea agglomerans in a patient with small cell lung carcinoma was treated successfully with antibiotics and PMX-DHP. The patient, a 49-year-old Japanese male smoker whose condition was complicated with hyponatremia due to SIADH (syndrome of inappropriate secretion of antidiuretic hormone), rapidly developed sepsis and disseminated intravascular coagulation (DIC) after the administration of cisplatin and irinotecan. Despite initial antibiotics therapy, severe host responses including hypotension, high body temperature and tachycardia were noted. We initiated PMX-DHP, and the patient's Sequential Organ Failure Assessment score was greatly reduced and his DIC improved immediately. To our knowledge, this is the first reported case of PMX-DHP therapy for severe sepsis caused by P. agglomerans infection. Although the efficacy of PMX-DHP in sepsis is not well defined, PMX-DHP therapy should be considered in cases of sepsis from gram-negative infections.

Initial central venous pressure could be a prognostic marker for hemodynamic improvement of polymyxin B direct hemoperfusion: a retrospective cohort study.

BACKGROUND: Direct hemoperfusion with polymyxin B-immobilized fiber column (PMX-DHP) could improve the hemodynamic status of septic shock patients. As PMX-DHP is an invasive and costly procedure, it is desirable to estimate the therapeutic effect before performing the therapy. However, it is still unclear when this therapy should be started and what type of sepsis it should be employed for. In this study, we retrospectively examined the clinical effect of patients treated with PMX-DHP by using central venous pressure (CVP). METHODS: Seventy patients who received PMX-DHP for septic shock during the study period were recruited and divided into a low CVP group (n = 33, CVP < 12 mmHg) and a high CVP group (n = 37, CVP≧12 mmHg). The primary endpoint was vasopressor dependency index at 24 hours after starting PMX-DHP, and the secondary endpoint was the 28-day survival rate. Additionally, we performed a multivariate linear regression analysis on the difference in the vasopressor dependency index. RESULTS: The vasopressor dependency index significantly improved at 24 h in the low CVP group (0.33 to 0.16 mmHg-1; p < 0.01) but not in the high CVP group (0.43 to 0.34 mmHg-1; p = 0.41), and there was a significant difference between the two groups in the index at 24 h (p = 0.02). The 28-day survival rate was higher in the low CVP group (79 vs. 43 %; p < 0.01). Multivariate linear regression analysis showed that CVP (p = 0.04) was independently associated with the difference in the vasopressor dependency index. CONCLUSIONS: Our study indicates that the clinical effect of PMX-DHP for septic shock patients with higher CVP (≧12 mmHg) might be limited and that the initial CVP when performing PMX-DHP could function as an independent prognostic marker for the hemodynamic improvement.

Polymyxin-B-immobilized-fiber column hemoperfusion with oseltamivir treatment for ARDS due to influenza H1N1/09.

Acute respiratory distress syndrome (ARDS) is one of the severe complications of influenza H1N1/09 infection, resulting in high mortality. Effective treatment strategies for ARDS are needed. This report presents two cases of ARDS due to influenza in Vietnam. Both cases were similar in terms of starting symptoms, the rapid progression to ARDS, and the treatment strategy, direct hemoperfusion with a polymyxin-B-immobilized fiber column (PMX-DHP) and oseltamivir. However, the clinical course of disease and the outcomes were different. For case 1, treatment was initiated on day 4 following the onset of hypoxemia due to ARDS. Symptoms improved rapidly after treatment and the patient was discharged on day 12. For case 2, treatment was initiated on day 9 after the onset of symptoms. Despite intensive therapy, the patient died on day 18. In conclusion, treatment with PMX-DHP and oseltamivir is effective on ARDS due to influenza but only if initiated early.

Scedosporium aurantiacum brain abscess after near-drowning in a survivor of a tsunami in Japan.

Many victims of the tsunami that occurred following the Great East Japan Earthquake on March 11, 2011 developed systemic disorders owing to aspiration pneumonia. Herein, we report a case of tsunami lung wherein Scedosporium aurantiacum was detected in the respiratory tract. A magnetic resonance image of the patient's head confirmed multiple brain abscesses and lateral right ventricle enlargement. In this case report, we describe a potential refractory multidrug-resistant infection following a tsunami disaster.

Effective use of polymyxin B hemoperfusion in septic shock complicated by urosepsis.

Direct hemoperfusion using polymyxin B-immobilized fiber (PMX-DHP) is an established treatment method for septic shock caused by Gram-negative infections. Here we report one instance in which PMX-DHP therapy has been used successfully in a patient with septic shock from urosepsis. After antibiotic therapy, direct hemoperfusion using polymyxin B helped in cardiovascular stability. The patient recovered from the shock within a few days after treatment with polymyxin-B hemoperfusion. As far as we are aware, this is the first reported case of effective treatment of urosepsis complicated by septic shock using PMX-DHP therapy in India.