Clinical Pearls Covid 19 for ER practitioners

329,662 Views | 254 Replies | Last: 2 yr ago by plain_o_llama
momlaw
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ChandaKomatsu, it might be helpful if you left contact information.
If you prefer a more private conduit my email is in my profile.
Email me contact info and I'll message nawlinsag, though, imagine he is inundated with requests.
momlaw
Ag00Ag
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Quote:

Hello..
Not a physician, a former EMT that is absorbing a lot of information quickly. I signed up here after making an association that I want to put in front of qualified eyes. Someone please take a look at it and consider if it has worth.

From OP:
"An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes."

From a reply to op on first page:
"Also, some of these patients have incredible IL-6 levels. I've never seen numbers this high even in my AIDS patients with KICS. One guy had a level above assay which were pretty sure has never been reported by our lab before."

Recent reporting, such as:
https://www.washingtonpost.com/climate-environment/2020/03/19/coronavirus-kills-more-men-than-women/

"The coronavirus is killing far more men than women"
Same article:
"... Studies have also found that estrogen was protective in female mice infected with the virus that caused the 2003 SARs outbreak."

Hormone replacement therepy is less common in Italy and Spain than Germany and France.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5019289/

Some research in mice shows a protective effect of Estrogen against Sars
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5450662/

My associations -

IL-6 seems to be important to the progression of Covid-19 and the cytokine storm.

Estrogen inhibits Il6.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC146754/

Estrogen levels drop quickly in menopause and Covid-19 death rate rises quickly after age 55

Could estrogen also be used as a protective tool?
----------------------
Thank you for your evaluation. Ill leave it to those more experienced with all this in the small chance that its helpful. Pardon if it was not. I won't post it further.


Or other non specific interleukin inhibitors in general? Maybe some of the FDA approved allergy meds?
TelcoAg
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momlaw said:

ChandaKomatsu, it might be helpful if you left contact information.
If you prefer a more private conduit my email is in my profile.
Email me contact info and I'll message nawlinsag, though, imagine he is inundated with requests.


I'm not going to pretend to speak for Nawlins, but I feel like he already gave his response to these requests.

These are his observations but not his specialty, and believes this thread makes up the bulk of the information he feels comfortable providing.
nonameag99
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ChandaKomatsu said:

Dr. Amy Wagner of UPMC
http://neuroscience.pitt.edu/people/amy-k-wagner-md
The Aggie number specified has already been linked with another TexAgs account.
Sliver on the East Side
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Thanks for sharing your expertise!
aaronag02
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More going viral
https://www.citizenfreepress.com/breaking/er-doctor-offers-lessons-on-treating-covid-19-patients-cheat-sheet-for-physicians-excellent-read/

Looks like they changed your school at some point to unc
mode67ag
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My wife is a physician and just saw this on an AMA private practice physician list serve posted by a pediatrician in Virginia. She said she nearly fell out of her chair when the post about it had the Tex Ags url. This is the kind of viral that the world needs right now! God Bless You and God Bless Aggie Docs!
ham98
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TelcoAg said:

momlaw said:

ChandaKomatsu, it might be helpful if you left contact information.
If you prefer a more private conduit my email is in my profile.
Email me contact info and I'll message nawlinsag, though, imagine he is inundated with requests.


I'm not going to pretend to speak for Nawlins, but I feel like he already gave his response to these requests.

These are his observations but not his specialty, and believes this thread makes up the bulk of the information he feels comfortable providing.
I think other medical professionals keep trying to contact him because he is akin to a battalion commander in a war zone. He has a good understanding and access to the strategy coming from above but also has his feet on the ground which gives him a good understanding of the tactical issues on the front lines. I can't really fault other front line doctors from wanting to make contact and try to benefit from his experience.
mathglot
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Glossary of medical abbreviations used in nawlinsag's OP, for the non-specialist:

These abbreviations are used in the article:

I am not medically trained; please report any errors, so I can fix them.
Only abbreviations are included; you can look up "cytokine storm" et al. on your own, right?
Some places to try:

(Did I miss a particularly good glossary? Message me in the comments, and I'll add it.)
law80
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On 2nd page is the same original post with the meanings in bold.

https://texags.com/forums/84/topics/3102444/replies/56250066
KidDoc
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mathglot said:

Glossary of medical abbreviations used in nawlinsag's OP, for the non-specialist:

These abbreviations are used in the article:

I am not medically trained; please report any errors, so I can fix them.
Only abbreviations are included; you can look up "cytokine storm" et al. on your own, right?
Some places to try:

(Did I miss a particularly good glossary? Message me in the comments, and I'll add it.)
AST/ALT are liver enzymes we use them to measure active/acute liver damage.LFT's=AST/ALT

PEEP definition is correct but it is usually used on vent settings as well as CPAP. Think of it as back pressure to keep the air pockets in the lung open. PEEP 5 is typical for healthy post op patients these are needing MUCH higher PEEP of 15 + (in mmHg)

Vent management is not simple and it varies based on the individual patient and that is my concern nationally. You cannot just make vents and think they will manage themselves. It takes VERY well trained physicians to manage these, Something I have not done since 2002 but can re-learn if I have to. I do have a few patients with special needs on home vents so that keeps me up to date somewhat.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
Diyala Nick
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Very interesting study from Yale released a few hours ago regarding cytokine storm.

https://threadreaderapp.com/thread/1244409779667206145.html
jparkeria
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Nawlinsag,

I'm an RN in IA and I have a brother down in BR that's an NP. I came across your post via FB and I found your post insightful. Now that we are 5 days out from your original post can you add any additional observations that are either validating or changing your opinion on the diagnostic profile you shared. I only investigate the data clinically while at work and give myself a break from it all when I'm home so I definitely limit my consumption. I spent 4 years in our ED and am now working toward a PMHNP. The MEB fallout on this I expect to be significant in the coming weeks.

Thank you for your work. Thank you for your insights.

JP
CT75
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Diyala Nick said:

Very interesting study from Yale released a few hours ago regarding cytokine storm.

https://threadreaderapp.com/thread/1244409779667206145.html
My Class of '50 dad (94 and still living) had a cytokine storm "type event" (not a doctor and can not say that is what it was) when in the hospital about 1 1/2 years ago. I thought I was watching him die in front of me and it came on quickly immediately after he was given an antibiotic 'cocktail' by hospital staff he was apparently allergic to (affecting his respiratory system and ability to breathe). He is DNR and his cardiologist had low dose morphine administered to make him comfortable. Thankfully it eased his symptoms and he came out of it OK about 2-3 hours later. It could have been something totally unrelated (not a cytokine storm)...but the symptoms seemed very similar to what is being described.

To the Doctors out there.....does the temporary use of morphine 'calm' a cytokine storm???
Tabasco
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jparkeria said:

Nawlinsag,

I'm an RN in IA and I have a brother down in BR that's an NP. I came across your post via FB and I found your post insightful. Now that we are 5 days out from your original post can you add any additional observations that are either validating or changing your opinion on the diagnostic profile you shared. I only investigate the data clinically while at work and give myself a break from it all when I'm home so I definitely limit my consumption. I spent 4 years in our ED and am now working toward a PMHNP. The MEB fallout on this I expect to be significant in the coming weeks.

Thank you for your work. Thank you for your insights.

JP
Good question for nawlinsag. Anything you would change from OP or any update?
AggieChemist
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CT75 said:

Diyala Nick said:

Very interesting study from Yale released a few hours ago regarding cytokine storm.

https://threadreaderapp.com/thread/1244409779667206145.html
My Class of '50 dad (94 and still living) had a cytokine storm "type event" (not a doctor and can not say that is what it was) when in the hospital about 1 1/2 years ago. I thought I was watching him die in front of me and it came on quickly immediately after he was given an antibiotic 'cocktail' by hospital staff he was apparently allergic to (affecting his respiratory system and ability to breathe). He is DNR and his cardiologist had low dose morphine administered to make him comfortable. Thankfully it eased his symptoms and he came out of it OK about 2-3 hours later. It could have been something totally unrelated (not a cytokine storm)...but the symptoms seemed very similar to what is being described.

To the Doctors out there.....does the temporary use of morphine 'calm' a cytokine storm???
Not a medical doctor, but one of the PhD variety... I found this

https://www.ncbi.nlm.nih.gov/pubmed/10825330

Morphine can have an immunosuppressive effect on T cells. The IL-6 in the cytokine storm is coming, I assume from macro****es... really need an immunologist to get into the weeds of this one... my immunology is shade tree, at best.
CT75
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AggieChemist said:

CT75 said:

Diyala Nick said:

Very interesting study from Yale released a few hours ago regarding cytokine storm.

https://threadreaderapp.com/thread/1244409779667206145.html
My Class of '50 dad (94 and still living) had a cytokine storm "type event" (not a doctor and can not say that is what it was) when in the hospital about 1 1/2 years ago. I thought I was watching him die in front of me and it came on quickly immediately after he was given an antibiotic 'cocktail' by hospital staff he was apparently allergic to (affecting his respiratory system and ability to breathe). He is DNR and his cardiologist had low dose morphine administered to make him comfortable. Thankfully it eased his symptoms and he came out of it OK about 2-3 hours later. It could have been something totally unrelated (not a cytokine storm)...but the symptoms seemed very similar to what is being described.

To the Doctors out there.....does the temporary use of morphine 'calm' a cytokine storm???
Not a medical doctor, but one of the PhD variety... I found this

https://www.ncbi.nlm.nih.gov/pubmed/10825330

Morphine can have an immunosuppressive effect on T cells. The IL-6 in the cytokine storm is coming, I assume from macro****es... really need an immunologist to get into the weeds of this one... my immunology is shade tree, at best.
Thanks....I guess calming the storm is not what I really meant....I meant 'ease the severity of the storm'.
jasontaylor7
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Dr. Not Yet Dr. Ag said:

Dr. Not Yet Dr. Ag said:


Many of them don't have fever.

I think this is important because (due to the issues with testing) some entities seem to be using temperature readings as a basis for things like involuntary quarantine.

Probably someone else has said this (it's a long thread so I don't know) but at the risk of pointing out the obvious, I wanted to chime in here and make sure it is said that because hypoxia is also a symptom of COVID-19, even cyanosis, the net energy production of the body will be reduced, thus lowering temperatures and indirectly appetite. This doesn't mean to me that the viral load is now low. Therefore, in the more advanced cases (with systemic lung damage) temperature readings might not be a reliable diagnostic anymore.
Infection_Ag11
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jasontaylor7 said:

Dr. Not Yet Dr. Ag said:

Dr. Not Yet Dr. Ag said:


Many of them don't have fever.

I think this is important because (due to the issues with testing) some entities seem to be using temperature readings as a basis for things like involuntary quarantine.

Probably someone else has said this (it's a long thread so I don't know) but at the risk of pointing out the obvious, I wanted to chime in here and make sure it is said that because hypoxia is also a symptom of COVID-19, even cyanosis, the net energy production of the body will be reduced, thus lowering temperatures and indirectly appetite. This doesn't mean to me that the viral load is now low. Therefore, in the more advanced cases (with systemic lung damage) temperature readings might not be a reliable diagnostic anymore.


You can see hypothermia in the very chronically ill and especially the elderly presenting as a fever equivalent, but generally most of these patients are febrile (at least 80%, as high as 98% in hospitalized patients based on some data sets).
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
JDEiman
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Thank you - NawlinsAg! Your post has done exactly what you wanted it to do. I am a primary care PA - about to be cross trained to work ED/hospital as need arises. I feel more informed from this thread. I was given your OP from a doc in our clinic - her husband works ED, so I hope our ED knows all this and will share with our hospitalists. We are rural and only now starting to have CV19 here - but preparing. I did an internet search today to find out who you were and can't tell you how proud (and confident) I was when it was written by an Aggie! Whoop! Class of 1989, farmers fight!
tshirt40
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How thick does the plastic sheets need to be? I have 50 sheets of 11"17" laser jet transparencies. Will that work? I am near Austin Texas.
PJYoung
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https://threadreaderapp.com/thread/1244795551595614210.html



Quote:

In my 7 days on one of our (now 12!) non ICU #COVID19 units, I admitted 58 patients for COVID rule out, of whom 50 tested positive. Two died (DNR), 2 went to hospice, and 5 went to the ICU. That is not my typical gen med service week. Following, some clinical observations.

My experience perfectly matched published reports. Procal universally low. Ferritin, CRP, d-dimer elevated. Lymphopenia prominent. Patchy infiltrates on CXR. Diarrhea common. So, I want to share some other things I haven't seen talked about as much.

1st, I was shocked by the persistence of fevers. My patients had fevers every day, often all day, often >39, for days on end, not especially Tylenol responsive. And they had all had several days fevers before admission.

2nd, the fevers did not seem particularly related to outcome. In fact most of my ICU transfers did not have persistent fever. They did, however, make patients miserable.

3rd, this is not your usual sepsis picture. NONE of my patients, even the deaths/ICUs, developed meaningful AKI or liver failure (most had trivial transaminitis). There is no multiorgan failure. Just respiratory failure (I know reported later cardiac; I didn't see those).

4th I did have a bunch of mild troponin elevations, but mostly demand ischemia. No EKGs c/w myocarditis. Suspect too late a complication for me to see.

5rd, as noted by others, just about all of my patients had had symptoms for 7-10 days before needing admit for O2. This posed a conundrum for the few who were admitted with <5d sx (all on RA) keep to await nadir? Can't afford the beds. Had to discharge with warning.

6th, I found CRP and ferritin often to move in opposite directions (usually CRP while ferritin still ; CRP leading indicator?). This was confusing. Moreover, I had patients with ferritin >3,000 who did well and others with <800 who struggled. So, not universally helpful.

7th, as noted by others, these patients deteriorate fast. Really fast. I started calling ICU for any patient who went from RA to 6L in <24 hours; nearly all wound up at least on 100% NRB or high flow if not intubation.

8th I kept underestimating their exertional hypoxia. Learned my lesson when I transferred one pt to lower acuity floor and he had a syncopal event getting from wheelchair to new bed. Walked all patients with pulse ox prior to d/c.

9th On the topic of syncope, I admitted 3-4 COVID+ patients with presenting complaint of syncope (2 with head lacs), all early in course, with orthostatic hypotension without significant antecedent fevers. Could COVID be having some effect on autonomic system?

10th Our standard protocol right now is azithro/hydroxychloroquine/zinc but I have little faith in efficacy. For the patients I really worried about (fast O2 requirement rise, high inflammatory markers) I gave tocilizumab off label. Clinical trial of sarilumab starting this week.

11th Proning is now standard in our ICU and I tried hard to get my sicker patients to do it too to head off intubation. This is much harder than it sounds. Most patients couldn't get into position on their own, found it uncomfortable (back pain), refused.

12th Most of my patients didn't eat anything. Partly lack of taste/smell, partly misery with fever, partly hypoxia with exertion, partly lack of visitors/staff in room to encourage and help. Several asked me for soft diet to reduce effort of chewing. Must attend to nutrition.

13th Lastly, one of the biggest concerns for non-critically ill patients was persistent painful cough. Most had paroxysmal dry, wheezy coughing spasms, often precipitating desaturations. Tried cough syrup, albuterol MDI with spacer (avoiding nebs), codeine, with little effect.
Keegan99
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This thread makes an appearance here:



Theory is that coronavirus hijacks red blood cells, causing the elevated ferritin.
cbeadling
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This is great information that could be useful in a lot of places "catching up" to New Orleans. I'm a DoD doc and want to let you know that a journal, Disaster Medicine and Public Health Preparedness (DMPHP) is doing rapid review/acceptance of articles like this for immediate ePublication with free access. Accepted manuscripts will be copy edited later for hard copy publication, but the intent is to get useful information to the front lines as quickly as possible. Please consider writing this up for publication! Website for journal is: https://mc.manuscriptcentral.com/dmp
Dayton Loyd
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I am currently working in Chicago preparing for the likely virus surge expected in two weeks. I would like to forward your observations to the hospitals in our region, but before doing so I would like your permission. I saw that your comments went through the VA system already, but that is outside my lane.
Can I get you to email me. Thanks
Dayton Loyd dayton.a.loyd.mil@mail.mil
McInnis 03
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He posted on a free forum in the public domain with intent to share his experience. I think you're good.
lfis492a
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God bless you, from the bottom of my heart Praying for you all.

When you mentioned cytokine storm my mind went to Anakinara (Kineret). And I looked and see SOBI (manufacturer) is running trials at the request of Italian Doctors. Perforin pathway genetic mutations have been implicated in susceptibility in developing the storm.

From an article: "A protein called serum ferritin tends to get very high in this disorder," he said. "If you are sick enough to be in a hospital and you have a fever, you should get a serum ferritin. It typically comes back in less than 24 hours and almost every hospital can do it, and if it's high you can work them up for cytokine storm syndrome." - Randy Cron, M.D., Ph.D., professor of pediatrics and medicine at UAB

It's hypothesized that 10 to 15% of the population has the mutation.

Praying we get this under control and over with.

L.F.

Articles: https://www.uab.edu/reporter/know-more/publications/item/8909-here-s-a-playbook-for-stopping-deadly-cytokine-storm-syndrome

https://www.trialsitenews.com/sobis-anakinra-emapalumab-requested-for-use-in-targeted-clinical-study-in-italy-to-address-severe-covid-19-cases/
TelcoAg
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I probably need to stop monitoring this thread because I feel like 20% of the words you folks use are actually names of Star Wars characters.
Doug Ross
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2:28 AM and I am breaking

ER doc here. Yeah things are really hard, but sadly it will prob get worse. At this point our hospitals are at minimal capacity. I do believe texas has done a great job thus far of preparing for Armageddon. We are at roughly 35% capacity in TX. However I believe **** could/will hit the fan, in the next 2 weeks.

hey i know we are all strung out, but stay frosty, and alert.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
nawlinsag
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https://journals.lww.com/em-news/blog/breakingnews/pages/post.aspx?PostID=508
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
Infection_Ag11
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Posted in another thread but probably best served here:

An interesting finding in post-mortem analysis from China is that bacterial superinfection rates are unusually low in this disease (as opposed to most other viral pneumonias) and they are finding occasional cases of secondary pulmonary aspergillosis. An interesting consideration for patients not improving on maximal therapy.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
PJYoung
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https://threadreaderapp.com/thread/1240824140472483843.html



Quote:

1\ Our hospitalists have now cared for over 100 #COVID19 critically and non-critically ill patients.
2\ There appear to be 2 phenotypes of disease:
A) Those with mild-mod hypoxia, need 02 and improve slowly over time.

B) Those with rapidly escalating 02 needs proceeding quickly to intubation.

Presentation doesn't depend on age, health. This dz doesn't discriminate.
Clinical symptoms vary but high grade, hectic, oscillating fevers are common.

Cough and shortness of breath also up there.

GI symptoms much less frequent but def exist.

Hypoxia and rapid 02 needs are hallmarks of the dz. CXR with periph hazy GGOs key.
The lung injury from #coronavirus leads to high 02 requirements, even in clinically stable patients.

This is a single organ dz for the most part.

Not uncommon to see young, healthy people with no med probs end up on the vent.

This last part is scary. Hard to predict course.
Sky high d dimers and #VTE appears common. I wonder how many cardiac arrests (mostly PEA/Asystole) were actually PE rather than myocarditis.

We have started to pharmacologically prophylax critically ill patients given this observation.
Have not seen a lot of myocarditis; but some pts do develop worsening cardiac dysfunction days after extubation. Almost all of these have been patients with pre existing structural or ischemic heart dz.
During recovery, pts continue to have a high PEEP requirement. Lung compliance doesn't seem to be affected much during illness, but the need for prolonged positive pressure is peculiar.

Take them off PEEP too early, and Sats drop precipitously.
Toci and other IL6 blockers really seem to work - if you give it early enough in the dz. Peri intubation is too late.

We follow biomarkers and 02 needs when making this decision. Also talk to #ID and #IDPharm who are our besties.

FYI - we are a trial site for Sarilumab.
Really have not seen any clinical benefit from hydroxychloroquine. Rather have seen a lot of GI ADRs and LFT bumps coming out of it.

Not sure this has as much of a role in disease care TBH.
There is profound physical weakness during recovery. Those that get better need help with basic ADLs.

Yes, even a 30 yr old needs assist to get up and go to the bathroom.

Early PT and ambulation is key.
Finally, I have never seen a dz that needs so many of us to come together to deliver care.

#COVID19 care needs MDs, RNs, resp therapists, APPs, pharmacists, PT, Social workers, sub specialties and palliative care.

It takes a village to fight - fortunate to have one @UMich.
Pelayo
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Doug Ross said:

2:28 AM and I am breaking

ER doc here. Yeah things are really hard, but sadly it will prob get worse. At this point our hospitals are at minimal capacity. I do believe texas has done a great job thus far of preparing for Armageddon. We are at roughly 35% capacity in TX. However I believe **** could/will hit the fan, in the next 2 weeks.

hey i know we are all strung out, but stay frosty, and alert.
good to know everyone else is ridic slow too
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
IVFvet
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Thank you for taking the time to post valuable clinical information. After considering lab values, I wonder if the low platelet count is more significant than we realize, especially if patients are on anti-platelet medication. I have done small studies with the effect of PRP on inflammation-both acute and chronic-and found that PRP treatment inhibits IL-6 mRNA expression by 2.5-fold, as well as other inflammatory cytokine regulation. I wonder if plasma may be more effective than hyperimmune serum in treatment, and if platelet concentration may be beneficial.
Thank you too for all you do. Such courage in the face of vulnerability.
insulator_king
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AG
ADL's = Activities of Daily Living.
 
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