Combined immune score predicts the prognosis of newly diagnosed multiple myeloma patients in the bortezomib-based therapy era.

ABSTRACT: To investigate the effect of a combined immune score including the lymphocyte-to-monocyte ratio (LMR) and uninvolved immunoglobulin (u-Ig) levels on the prognosis of newly diagnosed multiple myeloma (NDMM) patients treated with bortezomib.Clinical data of 201 NDMM patients were retrospectively analyzed. Patients with LMR ≥ 3.6 and LMR < 3.6 were scored 0 and 1, respectively. Patients with preserved u-Ig levels, suppression of 1 u-Ig, and suppression of at least 2 u-Igs were scored 0, 1, and 2, respectively. The immune score, established from these individual scores, was used to separate patients into good (0-1 points), intermediate (2 points), and poor (3 points) risk groups. The baseline data, objective remission rate (ORR), whether receive maintenance treatment regularly and overall survival of patients before treatment were analyzed.The ORR of the good-risk group was significantly higher than that of the intermediate-risk group (75.6% vs 57.7%, P = .044) and the poor-risk group (75.6% vs 48.2%, P = .007). The multivariate analysis results showed that age ≥ 65 years, International Staging System stage III, platelet count ≤ 100 × 109/L, lactate dehydrogenase (LDH) > 250 U/L, serum calcium > 2.75 mmol/L, no receipt of regular maintenance treatment, LMR < 3.6, suppressed u-Igs = 1, suppressed u-Igs ≥ 2, intermediate-risk group and poor-risk group were independent predictors of poor overall survival.In the bortezomib era, the LMR, u-Ig levels, and the immune score play an important role in the prognosis of NDMM patients. Among them, the immune score showed the strongest prognostic value, and it could be a beneficial supplement for the early identification of high-risk patients.

Covid-19 and diabetes in primary care - How do hematological parameters present in this cohort?

Objectives: Changes in hematological parameters are becoming evident as important early markers of COVID-19. Type 2 Diabetes Mellitus (T2DM) has been shown to be associated with increased severity of COVID-19. In this study, we aim to explore the various hematological variables in COVID-19 positive patients with T2DM, so as to act early and improve patient outcomes.Methods: Medical e-records of seventy adult patients with T2DM who were COVID-19 positive have been analyzed in this retrospective cohort study. Demographic, clinical and laboratory parameters for these patients were examined.Results: Of the seventy patients with T2DM, 48.88% had poorly controlled diabetes. 70.69% were pyrexial, 56.25% were tachycardic and 38.58% were asymptomatic on presentation. Amongst the hematological parameters, anemia was seen in 10% of males and 15.38% of females. 20% had a high red-blood-cell-distribution-width (RDW). 7.27% had thrombocytosis and 3.64% had thrombocytopenia. 73.3% had a high platelet-distribution-width (PDW) and 44.44% had an increased mean-platelet-volume (MPV). 16.36% were neutropenic and 16.67% had lymphocytopenia.Conclusion: Diabetic COVID-19 positive patients have been shown to have prominent manifestations of the hemopoietic-system with varied hematological profiles. Recognizing the implications of these variables early in primary-care, can help clinicians aid management decisions and dictate early referral to secondary-care services, to help improve prognosis.

Dexamethasone plus oseltamivir versus dexamethasone in treatment-naive primary immune thrombocytopenia: a multicentre, randomised, open-label, phase 2 trial.

BACKGROUND: Primary immune thrombocytopenia is an autoimmune bleeding disorder. Preclinical reports suggest that the sialidase inhibitor oseltamivir induces a platelet response in the treatment of immune thrombocytopenia. This study investigated the activity and safety of dexamethasone plus oseltamivir versus dexamethasone alone as initial treatment in adult patients with primary immune thrombocytopenia. METHODS: This multicentre, randomised, open-label, parallel group, phase 2 trial was done in five tertiary medical hospitals in China. Eligible patients were aged 18 years or older with newly diagnosed, treatment-naive primary immune thrombocytopenia. Participants were randomly assigned (1:1), using block randomisation, to receive either dexamethasone (orally at 40 mg per day for 4 days) plus oseltamivir (orally at 75 mg twice a day for 10 days) or dexamethasone monotherapy (orally at 40 mg a day for 4 days). Patients who did not respond to treatment (platelet counts remained <30 × 109 cells per L or showed bleeding symptoms by day 10) were given an additional cycle of dexamethasone for 4 days in each group. Patients in the dexamethasone plus oseltamivir group who relapsed (platelet counts reduced again to <30 × 109 cells per L) after an initial response were allowed a supplemental course of oseltamivir (75 mg twice a day for 10 days). The coprimary endpoints were 14-day initial overall response and 6-month overall response. Complete response was defined as a platelet count at or above 100 × 109 cells per L and an absence of bleeding. Partial response was defined as a platelet count at or above 30 × 109 cells per L but less than 100 × 109 cells per L and at least a doubling of the baseline platelet count and an absence of bleeding. A response lasting for at least 6 months without any additional primary immune thrombocytopenia-specific intervention was defined as sustained response. All patients who were randomly assigned and received the allocated intervention were included in the modified intention-to-treat population analysis. This study has been completed and is registered with ClinicalTrials.gov, number NCT01965626. FINDINGS: From Feb 1, 2016, to May 1, 2019, 120 patients were screened for eligibility, of whom 24 were ineligible and excluded, 96 were enrolled and randomly assigned to receive dexamethasone plus oseltamivir (n=47) or dexamethasone (n=49), and 90 were included in the modified intention-to-treat analysis. Six patients did not receive the allocated intervention. Patients in the dexamethasone plus oseltamivir group had a significantly higher initial response rate (37 [86%] of 43 patients) than did those in the dexamethasone group (31 [66%] of 47 patients; odds ratio [OR] 3·18; 95 CI% 1·13-9·23; p=0·030) at day 14. The 6-month sustained response rate in the dexamethasone plus oseltamivir group was also significantly higher than that in the dexamethasone group (23 [53%] vs 14 [30%]; OR 2·17; 95 CI% 1·16-6·13; p=0·032). During the median follow-up of 8 months (IQR 5-14), two of 90 patients discontinued treatment due to serious adverse events (grade 3); one (2%) patient with general oedema in the dexamethasone plus oseltamivir group and one (2%) patient with fever in the dexamethasone group. The most frequently observed adverse events of any grade were fatigue (five [12%] of 43 in the dexamethasone plus oseltamivir group vs eight [17%] of 47 in the dexamethasone group), gastrointestinal reactions (eight [19%] vs three [6%]), insomnia (seven [16%] vs four [9%]), and anxiety (five [12%] vs three [6%]). There were no grade 4 or 5 adverse events and no treatment-related deaths. INTERPRETATION: Dexamethasone plus oseltamivir offers a readily available combination therapy in the management of newly diagnosed primary immune thrombocytopenia. The preliminary activity of this combination warrants further investigation. Multiple cycles of oseltamivir, as a modification of current first-line treatment, might be more effective in maintaining the platelet response. FUNDING: National Natural Science Foundation of China.

Baseline clinical characteristics and prognostic factors in hospitalized COVID-19 patients aged ≤ 65 years: A retrospective observational study.

BACKGROUND: Individual differences in susceptibility to SARS-CoV-2 infection, symptomatology and clinical manifestation of COVID-19 have thus far been observed but little is known about the prognostic factors of young patients. METHODS: A retrospective observational study was conducted on 171 patients aged ≤ 65 years hospitalized in Alessandria's Hospital from 1st March to 30th April 2020 with laboratory confirmed COVID-19. Epidemiological data, symptoms at onset, clinical manifestations, Charlson Comorbidity Index, laboratory parameters, radiological findings and complications were considered. Patients were divided into two groups on the basis of COVID-19 severity. Multivariable logistic regression analysis was used to establish factors associated with the development of a moderate or severe disease. FINDINGS: A total of 171 patients (89 with mild/moderate disease, 82 with severe/critical disease), of which 61% males and a mean age (± SD) of 53.6 (± 9.7) were included. The multivariable logistic model identified age (50-65 vs 18-49; OR = 3.23 CI95% 1.42-7.37), platelet count (per 100 units of increase OR = 0.61 CI95% 0.42-0.89), c-reactive protein (CPR) (per unit of increase OR = 1.12 CI95% 1.06-1.20) as risk factors for severe or critical disease. The multivariable logistic model showed a good discriminating capacity with a C-index value of 0.76. INTERPRETATION: Patients aged ≥ 50 years with low platelet count and high CRP are more likely to develop severe or critical illness. These findings might contribute to improved clinical management.

Associations Between Subclinical Inflammatory Markers and OCD: A Retrospective Study.

Obsessive-compulsive disorder (OCD) is characterized by unwanted, intrusive and disturbing thoughts or images that cause anxiety and repetitive behaviours or mental acts to relieve these thoughts or images. Considering controversial aetiology of OCD and growing evidence for the role of inflammation in OCD, the aim of this study was to examine the association between OCD and subclinical inflammatory markers, namely neutrophil-to-lymphocyte ratio(NLR) and platelet-to-lymphocyte ratio(PLR) in adult patients and to investigate the association between antidepressant medications and NLR, PLR. Electronic medical records(EMR) of 24,635 patients aged 18-64 were reviewed and after exclusion of comorbid psychiatric and medical diagnosis 135 EMR of OCD patients were included into final analyses and compared with the healthy control group (n=133). Blood cell counts were noted to calculate NLR and PLR. Medications of patients were gathered from all patients to calculate fluoxetine-equivalent-dose(FED) to examine the effects of antidepressants on NLR and PLR. NLR and PLR were significantly higher in OCD. Contrary to the correlation of FED with NLR, PLR was found to not correlate with FED. Hence, PLR would be considered as a robust biomarker to medication effect contrary to NLR. OCD was significantly predicted by both NLR and PLR in logistic regression analyzes.

High, As Well As Low, Preoperative Platelet Counts Correlate With Adverse Outcomes After Elective Posterior Lumbar Surgery.

STUDY DESIGN: Retrospective cohort study of prospectively collected data. OBJECTIVE: Assess correlation between preoperative platelet counts and postoperative adverse events after elective posterior lumbar surgery procedures. SUMMARY OF BACKGROUND DATA: Preoperative low platelet counts have been correlated with adverse outcomes after posterior lumbar surgery. Nonetheless, the effect of varying platelet counts has not been studied in detail for a large patient population, especially on the high end of the platelet spectrum. METHODS: Patients who underwent elective posterior lumbar surgery were identified in the 2011 to 2016 National Surgical Quality Improvement Program database. Preoperative platelet counts were considered relative to 30-day perioperative adverse outcomes. Patients were classified into platelet categories based on determining upper and lower bounds on when the adverse outcomes crossed a relative risk of 1.5. Univariate and multivariate analyses compared 30-day postoperative complications, readmissions, operative time, and hospital length of stay between those with low, normal, and high platelet counts. RESULTS: In total, 137,709 posterior lumbar surgery patients were identified. Using the relative risk threshold of 1.5 for the occurrence of any adverse event, patients were divided into abnormally low (≤140,000/mL) and abnormally high (≥447,000/mL) platelet cohorts. The abnormally low and high platelet groups were associated with higher rates of any, major, minor adverse events, transfusion, and longer hospital length of stay. Furthermore, the abnormally low platelet counts were associated with a higher risk of readmissions. CONCLUSION: The data-based cut-offs for abnormally high and low platelet counts closely mirrored those found in literature. Based on these definitions, abnormally high and low preoperative platelet counts were associated with adverse outcomes after elective posterior lumbar surgery. These findings facilitate risk stratification and suggest targeted consideration for patients with high, as well as low, preoperative platelet counts. LEVEL OF EVIDENCE: 3.

Therapeutic Plasma Exchange in Neonatal Septic Shock: A Retrospective Cohort Study.

OBJECTIVE: This study aimed to examine the use of therapeutic plasma exchange (TPE) as adjunctive therapy in neonatal septic shock. STUDY DESIGN: This retrospective cohort study was performed on a convenience sample of neonates in a quaternary children's hospital between January 2018 and February 2019. RESULTS: We identified three neonates with septic shock who received TPE. Two neonates had adenovirus sepsis, and one had group B streptococcal sepsis. All neonates were on extracorporeal life support (ECLS) when TPE was started. The median duration of TPE was 6 days (interquartile range [IQR]: 3-15), with a median of four cycles (IQR: 3-5). Lactate levels decreased significantly after TPE (median before TPE: 5.4 mmol/L [IQR: 2.4-6.1] vs. median after TPE: 1.2 mmol/L [IQR: 1.0-5.8]; p < 0.001). Platelet levels did not change (median before TPE: 73,000/mm3 [IQR: 49,000-100,000] vs. median after TPE: 80,000/mm3 (IQR: 62,000-108,000); p = 0.2). Organ failure indices improved after TPE in two of the three neonates. Hypocalcemia was seen in all cases despite prophylactic calcium infusions. One neonate died, and two survived to ICU discharge. CONCLUSION: TPE can be safely performed in neonates with septic shock. TPE may have a role as an adjunctive therapy in neonates with septic shock requiring ECLS.

Transjugular Liver Biopsy: Safe Even in Patients With Severe Coagulopathies and Multiple Biopsies.

OBJECTIVES: To investigate the safety profile and diagnostic efficacy of transjugular liver biopsy (TJLB), with a focus on patients with severe coagulopathies and with multiple biopsies. METHODS: Clinical, laboratory, and demographic information was collected on 1,321 TJLBs in 932 patients (mean age 43.5 ± 23.2 years) performed between January 2009 and May 2017 to determine the diagnostic success rate and incidence of both major and minor complications in the 3-day and 30-day period post-biopsies. These outcomes were also analyzed for severely coagulopathic patients and a subgroup of patients who underwent multiple biopsies. RESULTS: The overall success rate (diagnostic yield) of the TJLB procedure was 97.7% (1,291/1,321). Overall, the major and minor complication rates were 1.0% (13/1,321) and 9.5% (126/1,321), respectively. In patients with multiple biopsies, the overall complication rate was similar to the entire study cohort, which was 10.4% (57/550). Patients were also stratified according to the platelet counts of 0-50, 51-100, 101-200, 201-300 and >300 × 10 platelets/µL. The overall complication rates were 8.0% (10/124), 11.6% (36/310), 9.9% (54/547), 11.9% (28/235), and 14.3% (11/77), respectively, and these were not statistically significant from each other. Patients were also stratified by international normalized ratio into 0-1, 1.1-2, 2.1-3, and >3. The overall complication rates of these patients were 8.0% (19/237), 11.8% (113/954), 16.3% (7/43), and 0% (0/9), respectively, and were not statistically significant from each other. DISCUSSION: TJLB is a highly efficacious, well-tolerated and safe procedure. It can be safely performed multiple times in the same patient or in critically ill, severely coagulopathic patients with no significant increase in the rate of complication while maintaining an extremely favorable diagnostic yield.

Romiplostim for the management of pediatric immune thrombocytopenia: drug development and current practice.

Since successful cloning of thrombopoietin (TPO) in 1994, significant advances have been made in the development of recombinant TPO receptor agonists. The US Food and Drug Administration (FDA) has approved 2 agents for use in patients with immune thrombocytopenia (ITP): eltrombopag and romiplostim. Romiplostim is a once-weekly subcutaneous injection that has been shown to increase the platelet count, lessen bleeding, and reduce concurrent medication use in adults with ITP. In December 2018, the US FDA approved romiplostim for use in pediatric patients ≥1 year of age with ITP of >6 months' duration and insufficient response to corticosteroids, immunoglobulins, or splenectomy, based on similarly favorable clinical trial data. In addition, romiplostim is well tolerated, making it an attractive option for the treatment of children. Expansion of off-label romiplostim use is being reported in children for ITP <6 months, neonatal thrombocytopenia, hereditary thrombocytopenias, and chemotherapy- and bone marrow transplant-associated thrombocytopenia. We review here the development of romiplostim with a focus on pediatric use.

Association of platelet count with all-cause mortality and risk of cardiovascular and respiratory morbidity in stable COPD.

BACKGROUND: Platelet count is a prognostic indicator in the general population and elderly. Thrombocytosis during acute exacerbation of COPD (AECOPD) has been associated with mortality; however, the relationship between platelet count and mortality in stable COPD is unknown. METHODS: We performed post hoc secondary analysis on a subsample of 1797 patients in the Study to Understand Mortality and Morbidity in COPD (SUMMIT) who had blood samples drawn at baseline. Participants were current or former smokers, 40-80 years old with moderate COPD and history or increased risk of cardiovascular (CV) disease. The primary outcome was on and post-treatment all-cause mortality. Secondary outcomes included first-on-treatment moderate/severe AECOPD and on-treatment CV composite event (CV death, myocardial infarction, stroke, unstable angina and transient ischemic attack). Multivariable Cox proportional hazards models were used to investigate study endpoint associations with platelet count quintile grouping, continuous platelet count utilizing two-term fractional polynomials, and categories of low, normal and high platelet count (< 150, ≥150 to < 300, ≥300 × 109/L). RESULTS: Patients were followed for 2.3 ± 0.9 years for vital status and 1.6 ± 1.1 years for morbidity endpoints during which 105 (5.8%) died, 651 (36.2%) experienced AECOPD (159 with severe AECOPD) and 86 (4.8%) experienced a CV event. A U-shaped association between platelet count and all-cause mortality was observed. Compared to the third quintile group (Q3) of platelet count, risk of death was increased in the lowest quintile group (Q1; hazard ratio [HR]: 1.73; 95% confidence interval [CI]: 0.93-3.23) and highest quintile group (Q5; HR: 1.66; 95%CI: 0.89-3.10), though point estimates were imprecise. Using clinical cutoffs, compared with normal platelet counts (≥150 to < 300 × 109/L), risk of all-cause mortality was nominally increased among patients with thrombocytopenia (HR: 1.46; 95%CI: 0.81-2.64) and high platelet count (HR: 1.66; 95%CI: 0.96-2.86). Compared with Q3, CV events were nominally increased for Q5 (HR: 1.71; 95%CI: 0.83-3.49) and Q1 (HR: 1.41; 95%CI: 0.70, 2.85). There was no association between platelet count and AECOPD. CONCLUSIONS: In stable COPD platelet count demonstrated a U-shaped association with increased risk of 3-year all-cause mortality, though a platelet count level above or below which risk of mortality was increased could not be definitively identified. TRIAL REGISTRATION: ClinicalTrials.gov NCT01313676 .

Clinical characteristics of pulmonary hypertension patients living in plain and high-altitude regions.

OBJECTIVE: The demographic characteristics, ratio of aetiologies and biochemical parameters of adult patients with pulmonary hypertension (PH) living in plain and high-altitude regions were investigated and analysed. METHODS: In total, 2846 adult patients with PH hospitalized from 2010 to 2015 in the Second Xiangya Hospital of Central South University and Qinghai Red Cross Hospital were retrospectively investigated. RESULTS: (1) In the present study, the numbers of patients with PH in both the plain and high-altitude regions increased annually (P < 0.05), and the in-hospital prevalence of PH significantly increased over time in the high-altitude region. PH was more common in women in the plain region. Furthermore, compared with PH patients living in the plain region, those living in the high-altitude region were older (P < 0.05) and had higher smoking rates (P < 0.05). In the plain region, the greatest proportion of patients with PH belonged to group 2 (PH because of left heart disease), while in the high-altitude region, group 3 (PH because of lung diseases and/or hypoxia) was the most common (P < 0.05). (2) Haemoglobin levels, red blood cell counts, mean platelet volumes and platelet volume distribution widths were lower in PH patients living in the plain region than in those living in the high-altitude region. Furthermore, platelet counts were higher in patients living in the plain region than in those living in the high-altitude region (P < 0.05). The BNP/NT-proBNP levels were higher in PH patients living in the plain region (45.5%), which were mostly in group 4, than in those living the high-altitude region (P < 0.05). CONCLUSIONS: The data from the hospitals in both the plain and high-altitude regions show a tendency towards increased in-hospital prevalence of PH over the last 6 years. The most common aetiologies of PH in patients living in the plain region and high-altitude regions were left heart disease and lung disease, respectively. Compared with PH patients living in the plain region, those living in the high-altitude region had better cardiac function and less severe PH.

Endovascular Thrombectomy, Platelet Count, and Intracranial Hemorrhage.

BACKGROUND: Intracranial hemorrhage can be a devastating complication of endovascular thrombectomy (ET) after acute ischemic stroke increasing disability and mortality. Patients with low platelet count were excluded from major ET trials. This study explores the association between platelet count and intracranial hemorrhage after ET. METHODS: A retrospective review of patients undergoing ET for anterior circulation large vessel occlusions at a single comprehensive stroke center between January 2015 and February 2018 was performed. Demographic and clinical information including National Institutes of Health Stroke Scale score, intravenous tissue plasminogen activator administration, ASPECTS, platelet count, international normalized ratio, time from symptom onset to recanalization, and modified thrombolysis in cerebral infarction score were analyzed. Radiological imaging and clinical course in the hospital was evaluated to identify parenchymal hemorrhage and symptomatic intracranial hemorrhage (sICH). Univariable and multivariable analyses were conducted. RESULTS: A total of 555 patients underwent ET and 43% were male. The mean age and National Institutes of Health Stroke Scale score were 71 ± 14 years and 17 ± 6, respectively. Parenchymal hemorrhage-2 and sICH (European-Australian Cooperative Acute Stroke Study-III criteria) were noted in 9.7% and 5.8% patients, respectively. Rates of sICH in patients with platelet count <100,000 (n = 15), 100,000 to <150,000 (n = 59), and ≥150,000 (n = 481) were 6.7% (n = 1), 10.1% (n = 6), and 5.2% (n = 25), respectively (P = 0.25), and rates of modified Rankin Scale 0-2 at 90 days were 26.7%, 23.7%, and 36.4%, respectively (P = 0.12). Low ASPECTS was a significant predictor of sICH per European-Australian Cooperative Acute Stroke Study-III definition (P value = 0.046). Platelet count was not a predictor (P = 0.386) of sICH. CONCLUSIONS: Risk of sICH after ET is low and comparable in patients with low and normal platelet counts. Low platelets should not exclude patients from undergoing intra-arterial therapy.

Management of Helicobacter pylori in Patients with Immune Thrombocytopenia.

There is an association between Helicobacter pylori infection and immune thrombocytopenia (ITP), and few studies have suggested that eradicative treatment of H. pylori infection may improve platelet counts in patients with ITP. Conventional treatments for ITP include immunosuppressive agents, and more recently thrombopoietic agents. However, based on clinical reports of association between H. pylori and ITP, several medical societies increasingly suggest detection and eradication of H. pylori as a treatment for ITP. In this article, we reappraise recent medical literature to determine the effectiveness of platelet response after treatment of H. pylori infection in patients with ITP. We searched two online databases (MEDLINE and Google Scholar) for full articles published between January 2008 and May 2018, and found a total of 11 studies that presented data and outcomes of treatment of H. pylori infection in ITP patients. All the studies administered triple therapy (amoxicillin 500 mg, clarithromycin 250 mg and a proton-pump inhibitor each given twice daily for either 7- or 14-day course) for eradication of H. pylori. Median overall platelet response ranged from 27 to 69.2% with a complete response rate ranging from 0 to 65.4% and a partial response rate ranging from 0 to 29.4%. Although there is variability in the effectiveness between different populations, it appears to be of benefit to ITP patients with concomitant H. pylori infection when treated with triple therapy. However, further studies to understand the pathogenesis of H. pylori-associated ITP is necessary for the development of new therapeutic approaches for ITP.

Thrombocytopenia and declines in platelet counts: predictors of mortality and outcome after mechanical thrombectomy.

BACKGROUND AND PURPOSE: Acute ischemic stroke (AIS) has well-known risk factors. The role of platelets in patients treated using mechanical thrombectomy (MT) has not been studied. The aim of this study was to study if there is an association of initial thrombocytopenia (TP) and a decline of platelets counts (DPC) with the clinical outcomes, mortality and intracranial hemorrhage (ICH) rates in AIS patients treated with MT. MATERIALS AND METHODS: In a case-control study consecutive MT-stroke patients were analyzed. A multivariate logistic regression model was used to test for good clinical outcome (mRS 90 days <= 2) and mortality adjusting for age, initial NIHSS, pretreatment with tPA, statins and platelet inhibitors, occlusion site, time from symptom onset to recanalization, initial TP (< 150 × 109/L) and DPC (> 26%). Additionally, rates of ICH were compared. RESULTS: Of 294 patients included, 9.6% had an initial TP and 23.8% a DPC > 26%. The mortality rate in patients with normal platelet counts was 26.1% vs. 48.3% (p = 0.002) in patients with initial TP with an aOR of 3.47 (CI 1.28-9.4, p = 0.005). No difference regarding the rate of good clinical outcome (p = 0.204) and ICH (p = 0.18) was observed. A DPC of more than 26% during the first 5 days of hospitalization predicted the rate of mortality (aOR 2.4 CI 1.14-5.04, p = 0.021) and the chances of a good clinical outcome (aOR 0.291 CI 0.128-0.666, p = 0.003) without significant differences of ICH rates (p = 0.735). CONCLUSION: In AIS patients treated with MT an initial TP was independently associated with higher mortality rates and a marked DPC with higher mortality rates as well as poorer clinical outcomes.

Impact of statin therapy on the immature platelet count in patients with coronary artery disease: A single centre cohort study.

BACKGROUND: Statins represent a pivotal therapy among patients with coronary artery disease (CAD), providing both lipid-lowering and pleiotropic, anti-thrombotic and anti-inflammatory benefits. Immature platelet count (IPC) has been proposed as the fraction of younger and potentially more reactive platelets, therefore potentially affecting the risk of major cardiovascular ischemic events. The aim of the present study was to evaluate the impact of statin therapy on IPC in patients with CAD. METHODS: Patients undergoing coronary angiography in a single centre were included. IPC levels were measured by routine blood cells count (A Sysmex XE-2100) as the product of immature platelet fraction (IPF) and platelet count, in patients naïve or chronically treated with statins at admission. RESULTS: We included in our study 642 patients, 61.2% treated with statins at admission. Patients on chronic statins were more often males, with a worse metabolic profile, but for lower total and LDL cholesterol, and a higher prevalence of major cardiovascular risk factors. The mean levels of IPC did not differ between statin treated and naive patients (7.9 ±â€¯4.7 vs 7.7 ±â€¯5, p = 0.60) and neither the distribution of IPC across tertiles (p = 0.36). In fact, at multivariate regression analysis, statin use was not independently associated with the rate of IPC above the 3rd tertile (adjusted OR[95%CI] = 1.19[0.80-1.79], p = 0.39). Moreover, among the 190 patients that introduced the therapy with statins at admission, the levels of IPC and major platelet parameters did not differ at a median follow-up of 32 days, as compared to chronically treated or non-treated patients. CONCLUSION: The present study shows that among patients with CAD the use of statins does not affect the immature platelet count or main platelet parameters.

Evaluation of Thrombocytopenia in Critically Ill Patients Receiving Continuous Renal Replacement Therapy.

BACKGROUND: Continuous renal replacement therapy (CRRT) may be associated with thrombocytopenia in critically ill patients. A confounding factor is concomitant use of unfractionated heparin (UFH) and suspicion for heparin-induced thrombocytopenia (HIT). OBJECTIVE: To determine the impact of CRRT on platelet count and development of thrombocytopenia. METHODS: Retrospective analyses evaluated the intrapatient change in platelet count following CRRT initiation. Critically ill adult patients who received CRRT for at least 48 hours were included. The primary outcome was intrapatient change in platelet count from CRRT initiation through the first 5 days of therapy. Secondary outcomes included thrombocytopenia incidence, identification of concomitant factors associated with thrombocytopenia, and frequency of HIT. RESULTS: 80 patients were included. Median platelet count at CRRT initiation (D0) was 128000/µL (81500-212500/µL), which was higher than those on subsequent post-CRRT days (D1: 104500/µL [63000-166750/µL]; D2: 88500/µL [53500-136750/µL]; D3: 91000/µL [49000-138000/µL]; D4: 93000/µL [46000-134000/µL]; and D5: 76000/µL [45500-151000/µL]; P < 0.05 for all). Twenty-five (35%) patients had thrombocytopenia on CRRT D0 compared with D2 (56.3%), D3 (58.7%), and D5 (59.1%); P < 0.05 for all. Controlling for potential confounders, Sequential Organ Failure Assessment score at the time of CRRT initiation was the only independent factor associated with thrombocytopenia. One (1.3%) patient had confirmed HIT. Conclusion and Relevance: This study is the first to demonstrate serial decreases in platelet count across multiple days after CRRT initiation. These data may provide additional insight to thrombocytopenia development in critically ill patients receiving heparin while on CRRT that is not associated with HIT.

Platelet Count Affects Efficacy of Folic Acid in Preventing First Stroke.

BACKGROUND: The role of platelets and important effect modifiers on the risk of first stroke is unknown. OBJECTIVES: This study examined whether low platelet count (PLT) and elevated total homocysteine (tHcy) levels jointly increase the risk of first stroke, and, if so, whether folic acid treatment is particularly effective in stroke prevention in such a setting. METHODS: A total of 10,789 Chinese hypertensive adults (mean age 59.5 years; 38% male, with no history of stroke and myocardial infarction) were analyzed from the China Stroke Primary Prevention Trial, where participants were randomly assigned to daily treatments of 10 mg enalapril and 0.8 mg folic acid (n = 5,408) or 10 mg enalapril alone (n = 5,381). The primary endpoint was first stroke. RESULTS: During 4.2 years of follow-up, a total of 371 first strokes occurred. In the enalapril-alone group, the lowest rate of first stroke (3.3%) was found in patients with high PLT (quartiles 2 to 4) and low tHcy (<15 µmol/l); and the highest rate (5.6%) was in patients with low PLT (quartile 1) and high tHcy (≥15 µmol/l) levels. Following folic acid treatment, the high-risk group had a 73% reduction in stroke (hazard ratio: 0.27; 95% confidence interval: 0.11 to 0.64; p = 0.003), whereas there was no significant effect among the low-risk group. CONCLUSIONS: Among Chinese hypertensive adults, the subgroup with low PLT and high tHcy had the highest risk of first stroke, and this risk was reduced by 73% with folic acid treatment. If confirmed, PLT and tHcy could serve as biomarkers to identify high-risk individuals who would particularly benefit from folic acid treatment. (China Stroke Primary Prevention Trial [CSPPT]; NCT00794885).

Prognostic significance of the combination of preoperative hemoglobin and albumin levels and lymphocyte and platelet counts (HALP) in patients with renal cell carcinoma after nephrectomy.

BACKGROUND: To evaluate the prognostic significance of the novel index combining preoperative hemoglobin and albumin levels and lymphocyte and platelet counts (HALP) in renal cell carcinoma (RCC) patients. METHODS: We enrolled 1360 patients who underwent nephrectomy in our institution from 2001 to 2010. The cutoff values for HALP, neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio were defined by using X-tile software. Survival was analyzed by the Kaplan-Meier method, with differences analyzed by the log-rank test. Multivariate Cox proportional-hazards model was used to evaluate the prognostic significance of HALP for RCC. RESULTS: Low HALP was significantly associated with worse clinicopathologic features. Kaplan-Meier and log-rank tests revealed that HALP was strongly correlated with cancer specific survival (P < 0.001) and Cox multivariate analysis demonstrated that preoperative HALP was independent prognostic factor for cancer specific survival (HR = 1.838, 95%CI:1.260-2.681, P = 0.002). On predicting prognosis by nomogram, the risk model including TNM stage, Fuhrman grade and HALP score was more accurate than only use of TNM staging. CONCLUSIONS: HALP was closely associated with clinicopathologic features and was an independent prognostic factor of cancer-specific survival for RCC patients undergoing nephrectomy. A nomogram based on HALP could accurately predict prognosis of RCC.

Impact of a negative D-dimer result on the initial assessment of acute aortic dissection.

BACKGROUND: D-dimer shows high sensitivity but low specificity for the diagnosis of acute aortic dissection (AAD). Previous reports indicated that negative D-dimer patients have shorter dissection length. However, whether patients with negative D-dimer results have a good prognosis is unknown. This study aimed to elucidate the clinical characteristics and implications of a negative D-dimer result on AAD diagnosis. METHODS: The study group comprised 126 patients (71 males, 55 females; mean age, 69 ±â€¯11 years) with AAD admitted to our hospital between April 2009 and March 2015. Blood samples on presentation were used for D-dimer measurement. Clinical characteristics and outcomes were assessed. RESULTS: Nine (7.1%) and 117 (92.9%) exhibited negative and positive D-dimer results, respectively. The negative group showed a significantly lower extension score and a higher platelet count than the positive group. Multivariate analysis demonstrated that platelet count (odds ratio, 1.31 (1.09-1.58), p = 0.003) and extension score (odds ratio, 0.56 (0.33-0.96), p = 0.03) were significantly related to a negative result. Notably, 44% of patients in the negative group had type A dissection and 33% underwent an emergency operation due to cardiac tamponade. CONCLUSION: We found that high platelet count and low extension score were independent factors related to a negative D-dimer result. Even if the length of the dissection is short, an emergency operation is necessary in some patients with a negative D-dimer result. Physicians should recognize that a negative D-dimer result alone cannot exclude patients with fatal AAD conditions.

Life-threatening bleeding episodes in primary immune thrombocytopenia: a single-center retrospective study of 169 inpatients.

Bleeding is the most important clinical outcome in patients with immune thrombocytopenia (ITP), and the goal of therapy in such cases is to treat or prevent bleeding. The frequency of and risk factors for bleeding events in ITP have only recently been identified in several large-scale studies. However, there is little published information about severe life-threatening bleeding in ITP. To clarify the clinical features of life-threatening bleeding in patients with primary ITP, we systematically reviewed the medical records of all ITP patients that were admitted to our hospital between January 1, 1992, and December 31, 2015. Of 169 consecutive inpatients with primary ITP, 8 suffered life-threatening bleeding (10 episodes: gastrointestinal, 4 cases; pulmonary, 1 case; and intracranial, 5 cases). All of these patients were ≥ 60 years of age and had platelet counts of < 20 × 109/L. The highest incidence of such bleeding was found among elderly patients in their 80s with platelet counts of < 5 × 109/L. Among the patients aged ≥ 60 years with platelet counts of < 20 × 109/L, the background data of the patients with and without life-threatening bleeding episodes were compared. It was shown that the patients in the bleeding group were older than those in the non-bleeding group (80.13 ± 2.31 vs. 73.39 ± 2.51 years, p = 0.0266). Hypertension, diabetes mellitus, anticoagulant use, ITP phase, and sex were not identified as strong risk factors for life-threatening bleeding. Combining age and the platelet count might be a useful way of identifying ITP patients that are at risk of life-threatening bleeding. Most intracranial hemorrhaging (4/5) was spontaneous and multifocal, suggesting that these might be characteristics of ITP-related bleeding in elderly patients.