The correlation between hemostatic parameters and mortality rate in patients with non-small cell lung cancer

The increasing level of hemostatic parameters and tumor markers were associated with cancer progression and poor prognosis, particularly in NSCLC. The objective of this study is to determine whether there was a correlation between hemostatic parameters and mortality rate in patients with NSCLC. This was a prospective analytical study with a pretest-posttest design which included 41 patients with diagnosis of NSCLC. Plasma levels of PT, APTT, TT, D-dimer, and fibrinogen were measured before initiation of chemotherapy and remeasured after 4 cycles or 6 cycles of chemotherapy, based on the clinical condition of patients. Then, patients were followed up for 1 year to evaluate the mortality rate. The majority of subjects were male (85.4%) with adenocarcinoma (75.6%). There was no significant difference in mean between adenocarcinoma and squamous cell carcinoma (P>0.05). Most patients died after one month of follow up (61%). The parameters which could predict high mortality rate in NSCLC were prolonged PT and the increased of D-dimer with RR>1, although they had not significant in statistical analysis (P>0.05). There is no correlation between hemostatic parameters and mortality rate in patients with NSCLC.

Thromboembolic involvement and its possible pathogenesis in COVID-19 mortality: lesson from post-mortem reports

The emergence of Coronavirus Disease 19 (COVID-19) as a pandemic has claimed hundreds of thousands of lives worldwide since its initial breakout. With increasing reports from clinical observations and autopsy findings, it became clear that the disease causes acute respiratory distress syndrome (ARDS), as well as a broad spectrum of systemic and multiorgan pathologies, including angiopathy, endothelialitis, and thrombosis. Coagulopathy is associated with the activity of megakaryocytes, which play crucial roles in modulating the platelet homeostasis. Only a few autopsy reports include findings on thrombosis formation and the presence of megakaryocytes. Here we review and summarize the possible involvement and the pathophysiology of the thromboembolic events in COVID-19 patients based on post-mortem reports. We reviewed post-mortem reports from March 2020 to September 2020. Eleven autopsy reports that demonstrated thromboembolic involvement findings, either macroscopically or microscopically, were included in this review. All studies reported similar pulmonary gross findings. Not all studies described thrombi formation and megakaryocyte findings. Pulmonary embolism, coagulopathy, severe endothelial injury, and widespread thrombosis are frequent in COVID-19 patients, following many patients with high-level D-Dimer, increased fibrinogen, abnormal prothrombic coagulation, and thrombocytopenia. Reports showed that thrombus was also found in the lower extremities' deep veins and the prostatic venous plexus. In conclusion, a complex interaction of SARS-CoV-2 virus invasion with platelets, leukocytes, endothelial cells, inflammation, immune response, and the possible involvement of megakaryocytes may increase the cumulative risk of thrombosis by a yet unclear cellular and humoral interaction.

The Influence of −174 G/C Interleukin 6 Promoter Gene Polymorphism to Interleukin 6 Concentration in the End Stage Renal Disease Patients with Dialysis: A Single-center Experience in Indonesia

BACKGROUND: Chronic kidney disease (CKD) is classified as a multifactorial disease as a combination of genetic and environmental factors that affect the onset and progression of end-stage renal disease (ESRD). In the last decades are recognized that inflammation, where the critical modulator is cytokines, can occur before the onset of kidney disease and can be a causative factor in the development of CKD. Interleukin (IL)-6 has several polymorphisms in the promoter region, such as 174 G-C, 634 C-G, 572 G-C, and 597 G-A. G/C single nucleotide polymorphism of the IL-6 gene at position 174 in the promoter region is reported to affect the level of IL-6 expression. Unfortunately, there is a lack of data about the genotype frequencies of -174 G/C IL-6 promoter gene polymorphism in Indonesian with ESRD. AIM: This study aimed to analyze whether −174 G/C IL-6 promoter gene polymorphism influences the concentration of IL-6 in ESRD patients with dialysis in Indonesia. METHODS: We recruited 95 outpatients who were undergoing regular hemodialysis for ≥3 months at the Rasyida Renal Hospital, Medan, in this cross-sectional study. IL-6 genotype polymorphism was analyzed using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. The enzyme-linked immunosorbent assay method was performed to assess the quantitative IL-6 serum. RESULTS: PCR-RFLP examination showed the frequency distribution of the IL-6 genotype -174 G/C gene; 72 (75.8%) respondents had GG genotypes; 22.1% of respondents had the CG genotype, and (2.1%) had the CC genotypes. Patients with the CC genotype were statistically significant to have higher IL-6 concentration compared to other genotypes (p < 0.001). Likewise, with diabetic patients, statistics showed higher IL-6 concentration compared to non-diabetics patients (p < 0.001). CONCLUSION: This is the first study showing that -174 G/C IL-6 promoter gene polymorphism influences the IL-6 concentrations in ESRD patients with dialysis in Indonesia. Multicenter studies are needed to validate these findings.

The Vascular Endothelium in Patients with Dengue Haemorrhagic Fever

BACKGROUND:

Dengue fever is the most serious consequence of mosquito-borne infection worldwide. The pathophysiology of DHF in human is complex, which involve endothelial cell activation and impaired endothelial barrier leading to plasma leakage triggering the activation of the haemostatic system. The increased vascular permeability may lead to hypovolemia, hypotension and shock, which is life-threatening.

AIM:

The objective of the study was to determine the effects of dengue haemorrhagic fever on the vascular endothelium.

METHODS:

Fifty patients (males 34, females 16), were recruited, Grade 1 (n = 41), Grade 2 (n = 6), Grade 3 (n = 2) and Grade 4 (n = 1) DHF. Blood sampling was performed at the febrile, defervescence and convalescent phases for the determination of haemoglobin, haematocrit, platelets, prothrombin fragment F1 + 2, Von Willebrand Factor (VWF), vascular endothelial growth factor (VEGF) and D-dimer levels. Fifteen normal subjects were recruited to serve as normal controls.

RESULTS:

The patients aged between 4 and 54 years old. Grades 1 & 2 DHF showed no significant differences in the parameters studied. However, thrombocytopenia, elevated F1 + 2, VWF, VEGF and D-dimer levels were evident in febrile, defervescence and convalescent phases suggesting endothelial activation and plasma leakage. Pleural effusion was observed only in severe DHF. The three patients with Grades 3 and 4 DHF had similar study results. No mortality was recorded in the study.

CONCLUSION:

In dengue haemorrhagic fever, the vascular endothelium is activated, causing plasma leakage triggering the activation of the haemostatic system creating a hypercoagulable and enhanced fibrinolytic state evident by marked fibrinolysis.

The Role of Placental Growth Factor, Soluble Endoglin, and Uterine Artery Diastolic Notch to Predict the Early Onset of Preeclampsia

BACKGROUND:

Reducing maternal mortality is one of the targets in the Millennium Development Goals (MDGs). In a systematic review, 4.6 per cent (95% CI 2.7-8.2) of pregnancies were complicated by preeclampsia worldwide. Preeclampsia occurs in around 10% of pregnancies in the world whereas developing countries contribute more than developed countries. In developing countries, there are 13 cases of preeclampsia in every 1,000 births, whereas in developed countries only 2-3 cases of preeclampsia are found in every 10,000 deliveries. Variations in prevalence among countries reflect, at least in part, differences in the distribution of maternal age and the proportion of nulliparous pregnant women in the population.

AIM:

We aimed to investigate the role of placental growth factor, soluble endoglin, and uterine artery diastolic notch to predict the early onset of preeclampsia.

METHODS:

This study used an analytical study with a nested case-control design. The study was conducted at Bunda Thamrin Hospital, Tanjung Mulia Mitra Medika Hospital, Sundari Hospital and a private clinic, from March to November 2018 with a total sample of 70 research subjects.

RESULTS:

Uterine artery diastolic notch was not found in 50% of subjects. A total of 27 subjects (38.6%) had a unilateral diastolic notch, and 8 subjects (11.4%) had a bilateral diastolic notch. Cut-off point PIGF levels was 441 pg/ml, and Area Under Curve (AUC) 82.5% (95% CI 61.5%-100%), with sensitivity 80% and specificity 87.7%. The levels sEng in this study could not predict the incidence of early-onset preeclampsia (p = 0.113). Combined PlGF and pulsatile index of uterine arteries may predict early onset preeclampsia with sensitivity 40% and specificity 90.77%. From these results, pregnant women o 22-24 weeks of pregnancy, the levels of PlGF and the uterine artery pulsatility index can be a predictor of early-onset preeclampsia. Examination of PlGF levels alone is sufficient as a predictor of early-onset preeclampsia.

CONCLUSION:

From these results, it can be concluded that in pregnant women of 22-24 weeks, the diastolic notches in uterine arteries cannot predict the incidence of early-onset preeclampsia. PlGF levels and pulsatile index of uterine arteries can be used as predictors of early-onset preeclampsia although examination of PlGF levels alone is sufficient as a predictor of early-onset preeclampsia.

Effect of Physiological Concentrations of Vasopressin on Components of the Fibrinolytic System

High physiological concentrations of plasma vasopressin (aVP) when achieved by infusion cause an increase in plasma factor VIII coagulant activity and shortening of the euglobulin clot lysis time (ECLT). To investigate the effects of aVP on components of the fibrinolytic pathway and on thrombin generation, t healthy volunteers were infused with saline for 30 min followed by aVP for L hour and blood samples taken every 30 min for measurement of aVR ECtf tissue-type plasminogen activator (t-PA), t-PA inhibition (tPA-I), plasminogen activator inhibitor L (PAI-1 Ag), activated partial thromboplastin time (APTT), fibrinopeptide A (FPA), fibrinopeptide B 15-42 (FPBß 15-42) and crosslinked fibrin breakdown products (XL-FDP). Plasma aVP rose to a median of 75 pg/ml after 90 min and fell to 13.8 pdml 30 min later. The APTT fell from 43.5 to 35 sec (p <0.01) but there was no change in plasma FPA or in XL-FDP. Plasminogen activator activity (106/ECLT2) increased from 25 to 736 units (p <0.01) and t-PA from 200 to 1012 mlU/ml (p <0.01). tPA-I fell from 8.0 to 2.7 IU/ml at 90 min (p <0.05) but PAI-1 Ag remained unchanged. Plasma FPBß 15-42 was 2.4 and 1.2 pmol/ml before infusion with aVP and showed a small rise to 3.5 pmol/ml after 60 min (p <0.05). The results show the effects of aVP on fibrinolysis are mediated by an increase in t-PA. In the absence of thrombin generation the rise in t-PA was not accompanied by changes in XL-FDP.

Soluble Fas Ligand as a Potential Marker of Severity of Dengue Infection

BACKGROUND

The apoptosis of microvascular endothelial cells causes plasma leakage in dengue haemorrhagic fever patients. The soluble Fas ligand is a protein with molecular weight of 40 kDa that acts as a mediator of apoptosis. This study aimed to prove whether soluble Fas ligand can be used as a potential marker to predict the severity of dengue infection by comparing the soluble Fas ligand levels in dengue fever (DF) and dengue haemorrhagic fever (DHF) patients early in the course of illness.

METHOD

This was a prospective study. It included 42 dengue patients (22 DF patients and 20 DHF patients) and 20 healthy people as a control group. The soluble Fas ligand was measured by the enzyme-linked immunosorbent assay (ELISA).

RESULT

Soluble Fas ligand was increased significantly (P < 0.001) in DHF patients (median = 130.19, IQR = 36.26) compared to DF patients (median = 104.73, IQR = 53.94) and the control group (median = 87.16, IQR = 24.91).

CONCLUSION

Soluble Fas ligand can be used as a potential marker to predict the severity of dengue infection in the early course of the illness. However, a larger sample size and further objective studies are needed to confirm these findings.

Soluble vascular cell adhesion molecule-1 and magnesium sulfate with nifedipine treatment in Indonesian women with severe pre-eclampsia

BACKGROUND

Endothelial cell activation in pre-eclampsia is associated with elevated soluble vascular cell adhesion molecule-1 (sVCAM-1) levels. The objective of the study was to determine whether sVCAM-1 levels in Indonesian women with pre-eclampsia were similar to other ethnic studies and to determine the effects of magnesium sulfate with nifedipine on blood pressure.

METHODS

A total of 61 pregnant women were admitted, who had normal pregnancy (n = 25) and severe pre-eclampsia (n = 36). Blood sampling was performed at admission to the study, 1 h after placental separation, and 24 h postpartum. sVCAM-1 and blood pressure levels were determined.

RESULTS

The mean ages in normal pregnancy (n = 25) and in severe pre-eclampsia (n = 36) are 30.0 ± 3.4 years and 27.1 ± 6.1 years, respectively. Significantly elevated sVCAM-1 was seen in pre-eclampsia. No significant variation in sVCAM-1 levels during the study periods was seen in both groups of cohorts. Magnesium sulfate infusion and nifedipine significantly lowered the blood pressure level.

CONCLUSION

Elevated sVCAM-1 levels were also seen in Indonesian women with severe pre-eclampsia. The placenta may not be the only source of elevated sVCAM-1 and that endothelial dysfunction persists beyond the postpartum period. Magnesium sulfate together with nifedipine significantly lowered blood pressure. The determination of elevated sVCAM-1 in pregnancy as a risk marker for endothelial dysfunction is therefore suggested.

Coagulation and Fibrinolysis in Preeclampsia and Neonates

Coagulation and fibrinolysis were determined in 67 Indonesian women admitted to the University Hospitals for delivery in Medan. They were diagnosed to be at term gestation (mean 39.3 ± 1.1 weeks) with moderate and severe preeclampsia (n=32) and in labor, and 8 had preterm labor (gestation mean 33.5 ± 2.6 weeks). Twenty-seven normal pregnant women in labor (gestation mean 39.7 ± 1.0 weeks) served as controls. Cord blood from 23 neonates from normal pregnancy and 31 neonates from preeclampsia was also evaluated. Preeclamptic women in labor showed further enhanced coagulation activation (F1+2) with raised urokinase-like plasminogen activator (u-PA) activity and reduced plasminogen activator inhibitor-2 (PAI-2) levels. In preterm preeclampsia, significantly reduced antithrombin III (ATIII) and PAI-2 levels with further elevated tissue-type PA (t-PA) antigen and plasminogen activator inhibitor-1 (PAI-1) antigen were seen compared to normal pregnancy. These would suggest a state of enhanced thrombin generation with elevated fibrinolytic/inhibitor proteins in preterm preeclampsia. The reduced PAI-2 levels seen in preeclampsia have been suggested to be associated with reduced placental function. Neonates born to mothers of either normal pregnancy or preeclampsia at term showed similar hemostatic changes with reduced fibrinogen, ATIII, t-PA, u-PA antigen, PAI-1 levels, and coagulation activation compared to their respective maternal plasma levels. No significant differences in hemostatic parameters studied between the neonates of both cohorts were seen, and this would suggest that the neonates were protected from the adverse effects of preeclampsia and their hemostatic system was physiologically balanced.

Extracorporeal methods in the treatment of poisoning

Among the various ways of managing poisoning, haemodialysis may help in enhancing excretion of the toxic substance. We report a case, a Russian male, 35 years old, who was rushed to the Gleneagles Hospital Medan from the airport after being evacuated from Banda Aceh together with another older Russian who died as they arrived at the admission and Emergency Department. From the result of intensive allo anamnesis and the high anion gap metabolic acidosis, in the absence of disturbed renal and liver function, we presumed this patient was suffering from methanol intoxication. The time of exposure was approximately 70 hours before. The exact length of dialysis time to excrete the noxious substance from the blood without plasma methanol determination was difficult. Moreover the time elapsed from exposure to treatment had been approximately 70 hours, which means the optic nerve had been so long exposed to formic acid, the toxic metabolite of methanol, that the damage should have been very severe. Ethanol is also known to be an antidote of methanol, which can be given orally by nasogastric tube, or i.v. It should be given early, and plasma ethanol level should be closely monitored to make it effective and safe. This was also unavailable. Another antidote is fomepizole which is also as yet unavailable in Medan. Folic acid, thiamin, and i.v. folinic acid are also recommended by the literature, as well as oral steroid.

Effect of physiological concentrations of vasopressin on components of the fibrinolytic system

High physiological concentrations of plasma vasopressin (aVP) when achieved by infusion cause an increase in plasma factor VIII coagulant activity and shortening of the euglobulin clot lysis time (ECLT). To investigate the effects of aVP on components of the fibrinolytic pathway and on thrombin generation, 9 healthy volunteers were infused with saline for 30 min followed by aVP for 1 hour and blood samples taken every 30 min for measurement of aVP, ECLT, tissue-type plasminogen activator (t-PA), t-PA inhibition (tPA-I), plasminogen activator inhibitor 1 (PAI-1 Ag), activated partial thromboplastin time (APTT), fibrinopeptide A (FPA), fibrinopeptide B 15-42 (FPB beta 15-42) and cross-linked fibrin breakdown products (XL-FDP). Plasma aVP rose to a median of 75 pg/ml after 90 min and fell to 13.8 pg/ml 30 min later. The APTT fell from 43.5 to 35 sec (p less than 0.01) but there was no change in plasma FPA or in XL-FDP. Plasminogen activator activity (10(6)/ECLT2) increased from 25 to 736 units (p less than 0.01) and t-PA from 200 to 1012 mIU/ml (p less than 0.01). tPA-I fell from 8.0 to 2.7 IU/ml at 90 min (p less than 0.05) but PAI-1 Ag remained unchanged. Plasma FPB beta 15-42 was 2.4 and 1.2 pmol/ml before infusion with aVP and showed a small rise to 3.5 pmol/ml after 60 min (p less than 0.05). The results show the effects of aVP on fibrinolysis are mediated by an increase in t-PA. In the absence of thrombin generation the rise in t-PA was not accompanied by changes in XL-FDP.