Hemoadsorption by extracorporeal cytokine adsorption therapy (CytoSorb®) in the management of septic shock: A retrospective observational study

INTRODUCTION

Sepsis results in immunologic disturbances with the release of various inflammatory mediators such as cytokines. Cytokines can damage the cells, and the continuous release of inflammatory mediators leads to severely impaired immunity. Therefore, the reduction in cytokine levels by hemoadsorption represents a new concept for blood purification. CytoSorb^® as a hemoadsorption device is a detoxification system, which aims to decrease the cytokines levels. This study was conducted to understand any beneficial effects of CytoSorb^® therapy in septic patients.

METHODOLOGY

This was a retrospective and observational study, approved by the scientific and ethics committee of Max Super Specialty Hospital, Patparganj, Delhi, India and conducted in compliance with current International Council for Harmonization, Good Clinical Practice, Schedule Y, and Indian Council of Medical Research guidelines. Subjects of either gender (age > 18 year) were included in the study. The data were presented as mean ± standard deviation and categorical as frequency and percentage (%). A p value less than 0.05 (p < 0.05) was considered to be statistically significant.

RESULTS

A total number of 36 patients were included in the study. Majority of the patients were male with mean age (56.36 ± 14.83). After therapy, procalcitonin and total leucocyte count levels decreased within 24 h. Post therapy, sepsis-related organ failure assessment (SOFA) score of Day (D)1, D2, and D3 reduced to 10.4 ± 3.63, 8.7 ± 4.02, and 7.8 ± 3.67, respectively. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality were lower in the survivor group as compared to the non-survivor group.

CONCLUSION

Hemoadsorption using the extracorporeal adsorption device (CytoSorb^®) might be an effective rescue therapy in stabilizing septic shock patients.

The influence of meteorological parameters on indoor radon in selected traditional Kenyan dwellings

The effects of outdoor temperature, rainfall and wind speed on the indoor radon concentration in four types of traditional hut in Kenya were investigated by performing short-term (about 48 h) measurements with activated charcoal canisters. The concentrations vary widely (30.2-315.4 Bq m(-3)) during the study period, and the overall mean is 170.3 +/- 39.6 Bq m(-3). The indoor radon concentration correlates negatively with both the outdoor temperature (R(2) = 0.06) and the wind speed (R(2) = 0.11) but positively with rainfall (R(2) = 0.03). The results showed that changes in meteorological parameters cause more variations in indoor radon concentrations than the differences in the buildings' characteristics (i.e., designs, materials, etc). However, these variations are not significant (at 1% significance level).

Traditional antimalarial phytotherapy remedies used by the Kwale community of the Kenyan Coast

In Kenya, most people especially in rural areas use traditional medicine and medicinal plants to treat many diseases including malaria. Malaria is of national concern in Kenya, in view of development of resistant strains of Plasmodium falciparum to drugs especially chloroquine, which had been effective and affordable. There is need for alternative and affordable therapy. Many antimalarial drugs have been derived from medicinal plants and this is evident from the reported antiplasmodial activity. The aim of the study was to document medicinal plants traditionally used to treat malaria by the Digo community of Kwale district. Traditional health practitioners were interviewed with standardized questionnaires in order to obtain information on medicinal plants traditionally used for management of malaria. Twenty-five species in 21 genera and 16 families were encountered during the study. Celestraceae, Leguminosae and Rubiaceae families represented the species most commonly cited. Three plant species, namely; Maytenus putterlickioides, Warburgia stuhlmannii and Pentas bussei are documented for the first time for the treatment of malaria.

Antimalarial activity of some plants traditionally used in treatment of malaria in Kwale district of Kenya

Methanolic and water extracts of five medicinal plant species used for treatment of malaria in traditional/cultural health systems of Kwale people in Kenya were tested for antimalarial activity against Plasmodium falciparum and Plasmodium berghei, respectively and for their cytotoxic effects. The most active extracts (IC(50)<10 microg/ml) screened against chloroquine (CQ) sensitive (D6) and resistant (W2) P. falciparum clones, were the water and methanol extracts of Maytenus undata (Thunb.) Blakelock (Celasteraceae), methanol extracts of Flueggea virosa (Willd.) Voigt (Euphorbiaceae), Maytenus putterlickioides (Loes.) Excell and Mendoca (Celastraceae), and Warburgia stuhlmannii Engl. (Canellaceae). These extracts showed various cytotoxic levels on Vero E6 cells with the water extract of M. undata exhibiting least cytotoxicity. At least one of the extracts of the plant species exhibited a high chemo suppression of parasitaemia >70% in a murine model of P. berghei infected mice. These results indicate that there is potential for isolation of a lead compound from the extracts of the five plants. W. stuhlmannii and M. putterlickioides have not been reported before for antiplasmodial activity.

Antimalarial activity of some plants traditionally used in Meru district of Kenya

Ten plant extracts commonly used by the Meru community of Kenya were evaluated for the in vitro antiplasmodial, in vivo antimalarial, cytotoxicity and animal toxicity activities. The water and methanol extracts of Ludwigia erecta and the methanol extracts of Fuerstia africana and Schkuhria pinnata exhibited high antiplasmodial activity (IC(50) < 5 microg/mL) against chloroquine sensitive (D6) and resistant (W2) Plasmodium falciparum clones. The cytotoxicity of these highly active extracts on Vero E6 cells were in the range 161.5-4650.0 microg/mL with a selectivity index (SI) of 124.2-3530.7. In vivo studies of these extracts showed less activity with chemosuppression of parasitaemia in Plasmodium berghei infected mice of 49.64-65.28%. The methanol extract of Clerodendrum eriophyllum with a lower in vitro activity (IC(50) 9.51-10.56 microg/mL) exhibited the highest chemosuppression of 90.13%. The methanol and water extracts of Pittosporum viridiflorum were toxic to mice but at a lower dose prolonged survival of P. berghei infected mice (p < 0.05) with no overt signs of toxicity. However, the extracts were cytotoxic (SI, 0.96-2.51) on Vero E6 cells. These results suggest that there is potential to isolate active non-toxic antimalarial principles from these plants.

Anti-plasmodial activity of some Kenyan medicinal plant extracts singly and in combination with chloroquine

Sixty organic and aqueous extracts of eleven plants used for the control of malaria by local communities in Kisii District, Kenya were screened for in vitro anti-plasmodial activity. The plants selection was based on existing ethnobotanical information and interviews with local communities. The extracts were tested against chloroquine sensitive and resistant laboratory adapted strains of Plasmodium falciparum. The study revealed that 63.6% of the plants were active (IC50 < or = 100 microg/mL). Extracts of four plants, Ekebergia capensis, Stephania abyssinica, Ajuga remota and Clerodendrum myricoides gave IC50 values below 30 microg/mL against both chloroquine sensitive and resistant P. falciparum strains. Combination of extracts of E. capensis and C. myricoides with chloroquine against the multi-drug resistant P. falciparum isolate (V1/S) revealed synergistic effect. The plants which showed activity may be useful as sources for novel anti-plasmodial compounds.

Brine shrimp toxicity and antiplasmodial activity of five Kenyan medicinal plants

The organic extracts of leaves and roots of five plants used for treating malaria in Central, Nairobi and Rift Valley Provinces, Kenya were tested for brine shrimp lethality and in vitro antiplasmodial activity against chloroquine sensitive and resistant strains of Plasmodium falciparum. Of the plants tested, 60% were toxic to the brine shrimp (LC(50)<30 microg/ml) and eight out of ten plant parts (80%) showed in vitro antiplasmodial activity (IC(50)<50 microg/ml). Among the extracts screened, the leaves of Cyathula polcephala had the highest toxicity to the brine shrimp (LC(50)=2.9 microg/ml) while the leaves of Pentas longiflora had the best antiplasmodial activity (IC(50)=11. /ml). The plant extracts with low IC(50) values are potential sources for novel antiplasmodial compounds.

In vitro antiplasmodial activity of some plants used in Kisii, Kenya against malaria and their chloroquine potentiation effects

Fifty-five organic and aqueous extracts of 11 plants used in malaria therapy in Kisii District, Kenya were tested in vitro against chloroquine (CQ)-sensitive and resistant strains of Plasmodium falciparum. Of the plants tested, 73% were active (IC(50) < 100 microg/ml). Three plants, Vernonia lasiopus, Rhamnus prinoides and Ficus sur afforded extracts with IC(50) values ranging less than 30 microg/ml against both CQ-sensitive and resistant strains. Combination of some extracts with CQ against the multi-drug resistant P. falciparum isolate V1/S revealed some synergistic effect. The plant extracts with low IC(50) values may be used as sources for novel antimalarial compounds to be used alone or in combination with CQ.

Iron content of some edible leafy vegetables and medicinal plants used traditionally for anaemia treatment in East Africa

The medicinal plant parts used by local communities in East Africa to treat anaemia were analysed both for total iron content in the plant parts and extractable iron content in their decoctions. As a basis for comparison, six edible leafy vegetables known to be good dietary iron sources were also analysed for the iron content. The iron contents were determined using Atomic Absorption .Spectrophotometry in mg/100 g dry weight of the material analysed. The amounts of iron in the prepared decoctions and total iron contents in the plant parts were compared with the total amount of iron found in the dietary edible leafy vegetables. Of all the plant parts used for anaemia treatment, the iron content in the rootbarks of Adenia gummifera and Bridelia cathartica, and their respective decoctions compared well with those found in the vegetables. Comparison of the respective iron contents in the stembarks and leaves of the plants with the edible leafy vegetables was in favour of the latter.

Determination of iron content in different parts of herbs used traditionally for anaemia treatment in East Africa

The iron content in different parts of eight plants traditionally used to treat anaemia in Eastern Africa was determined using atomic absorption spectrophotometry. Extracts were made of plant samples using both wet and dry oxidation procedures. Results obtained from both procedures agree significantly and the average of both methods was taken as the iron content in each plant part. In most cases, the values obtained for the rootbark had a higher total iron content than the corresponding leaves and stembark. The prominent iron contents of 35.69 and 35.21 mg/100 g were found in the rootbark of Bridelia cathartica and Lannea stuhlmannii, respectively. The iron content of the decoctions prepared in the traditional way was low. However, the therapeutic potential of the herbs cannot be established on the basis of available iron content alone as other factors play a role in the absorption of iron in the body.

Antiplasmodial activity of four Kenyan medicinal plants

A preliminary antiplasmodial and phytochemical screening of four Kenyan medicinal plants was carried out. The medicinal plants were extracted and tested for in vitro antiplasmodial activity against chloroquine-sensitive (K67) and chloroquine-resistant (ENT36) strains of Plasmodium falciparum. Out of 16 extracts, 12 were active against ENT36 strain while seven were active against K67 strain, that is, IC50 < or = 50 micrograms/ml. The most active extracts on both strains were those of leaves of Phyllanthus reticulatus Poir, and Suregada zanzibariensis Baill. (Euphorbiaceae) with IC50 < or = 10 micrograms/ml. The stembark of Terminalia spinosa Engl. (Combretaceae) and the stems of Dissotis brazzae Cogn. (Melastomataceae) had IC50 < or = 10 micrograms/ml for strains K67 and ENT36, respectively. A preliminary phytochemical analysis of these plants revealed the presence of different classes of primary and secondary metabolites.

Analysis of the essential oil of Juniperus procera Endl. growing in Kenya

The essential oil of the wood of Juniperus procera Endl. (Cupressaceae) from the Aberdares mountains, Central Province, Kenya has been extracted by steam distillation for varying times and analyzed using GC and GC-MS. The optimum time has been found to be 8 hours with the yield of the oil and cedrol as 0.48 and 79.10%, respectively. Other constituents include 3,4-dimethylbiphenyl, a-cedrene, camphor, trans-geraniol, eugenol, and a-terpineol.

Susceptibility of Helicobacter pylori and Candida spp. to the east African plant Terminalia spinosa

Trees of the genus Terminalia have long been used in the traditional medicine of Kenya (East Africa). In an ethnopharmacological approach, extracts of the stem bark of Terminalia spinosa were investigated for antibacterial and antifungal activity. The extracts were active against Helicobacter pylori, with the following minimum inhibitory concentrations (MIC): MIC50 of 125 mg/l, MIC90 of 250 mg/l, and MIC-range of 62.5-500 mg/l. Yeasts of the genus Candida showed a similar susceptibility. The results indicate that the plant if a source of antimicrobial compounds with therapeutic potential.

Holter monitoring in chronic renal failure before & during dialysis

Holter monitoring was done prospectively in 50 adult patients of chronic renal failure (CRF) before and during haemodialysis. Frequent premature ventricular contractions (PVC's) were present in 3 (6%), all during dialysis (Gp I). Sporadic PVC's were seen in 6 (12%) and rest 41 (82%) had no PVC (Gp II). Premature atrial contractions (PAC's) were frequent in 5 (10%) (one had precipitation during dialysis), sporadic in 7 (14%) and none in 38 (76%). Ventricular tachycardia (VT) was not seen. Supraventricular tachycardia (SVT) was observed in 5. No biochemical parameter correlated with arrhythmias. There was no correlation between hypotension episodes and arrhythmias. Sinus tachycardia occurred during the third and fourth hours of dialysis. This correlated with hypotensive episodes observed in 13 patients. Episodes of silent myocardial ischaemia (SMI) observed in 12 patients occurred predominantly during this period of tachycardia. Cardiac arrhythmias are infrequent in CRF and are mainly seen in patients with preexisting coronary artery disease with low ejection fractions (EF) (EF 0.37 +/- 0.2 in Gp I and 0.80 +/- 0.1 in Gp II P < 0.01) and abnormal Q waves in baseline ECG. They do not seem to contribute to occurrence of episodes of dialysis induced hypotension.

Plants used in traditional medicine in eastern Tanzania. VI. Angiosperms (Sapotaceae to Zingiberaceae)

Fifty-three Angiosperm species (Sapotaceae to Zingiberaceae), which are used by traditional healers in five regions of Eastern Tanzania (Coast, Dar es Salaam, Kilimanjaro, Morogoro and Tanga) are listed. For each species, the botanical name, vernacular name, collection number, locality, habit, geographic distribution and medicinal uses are given. Additionally, information from the literature on medicinal uses, chemical constituents and pharmacological effects are also provided. Data analysis and conclusions to cover all the six parts of the papers previously published are presented.

Mitral annular calcification in untreated chronic renal failure

Clinical, biochemical, radiological and echo-cardiographic (echo) evaluation was done prospectively in 50 patients of untreated end stage chronic renal failure (CRF). While clinically congestive cardiac failure (CCF) was diagnosed in 24%, low ejection fraction on echo was found in only 16%. Echo in these cases showed evidence of cardiac chamber dilatation in most (mean LVID (D) 54.1 +/- 6.51 and (S) 36.4 +/- 6.9 mm, but parameters of cardiac functions were normal in most. Mitral annular calcification (MAC) was detected on echo in 26%. On comparing patients with MAC (Group I) and those without MAC (Group II), the aetiological factor found more frequently in Group I was diabetes (61.5% vs 35.1%, P less than 0.05). Clinical features such as older age (mean age 54 years vs 45.5 years), severe hypertension, and grade IV and above murmur (15.2% vs none) were more common among group I patients. However, the difference was not statistically significant. Parameters of calcium metabolism were similar in the two groups. Conduction disturbances (30.7% vs 5.4%) were significantly more common in Group I (P = 0.05). The mitral regurgitation due to MAC was of no haemodynamic significance. Complications of MAC syndrome were rare.

Multiple forms of alkaline phosphatase in plasma of hemodialysis patients

We used quantitative assays to measure the activity of the bone, liver, and intestinal forms of alkaline phosphatase in plasma in 75 patients with endstage chronic renal failure undergoing hemodialysis. The results were correlated with radiological and other biochemical indices of bone disease and with biochemical indices of liver disease. The total activity of alkaline phosphatase in plasma increased in 28 patients. In 10 of these patients, nine of whom had increased activity of gamma-glutamyltransferase in plasma, the increase in total activity of alkaline phosphatase was from the liver isoenzyme alone (nine patients) or from the liver and bone isoenzymes together (one patient). Intestinal alkaline phosphatase in plasma, although greater than 23 U/L in eight patients, was solely responsible for the increase in total alkaline phosphatase in one patient (who had normal gamma-glutamyltransferase). Bone alkaline phosphatase in plasma was increased in 25 patients, seven of whom had normal total alkaline phosphatase, and was closely correlated (r = 0.78) with osteocalcin concentration in plasma, which was increased in a much greater proportion of patients (99%). Both total and bone alkaline phosphatase were correlated with parathyrin in plasma (r = 0.46 and 0.50, respectively) and with osteocalcin (r = 0.60 and 0.78, respectively). Osteocalcin and bone alkaline phosphatase, but not parathyrin, decreased with age, implying that the skeletal response to parathyrin may be age dependent. In patients with increased total alkaline phosphatase undergoing hemodialysis, the concurrent measurement of gamma-glutamyltransferase may help identify whether the enzyme increase originates from the liver or bone, but this approach wrongly identified the source of the increase in three of 28 patients. Therefore, we recommend a separate measurement of the bone isoenzyme of alkaline phosphatase.

Multiple forms of alkaline phosphatase in plasma of hemodialysis patients

We used quantitative assays to measure the activity of the bone, liver, and intestinal forms of alkaline phosphatase in plasma in 75 patients with endstage chronic renal failure undergoing hemodialysis. The results were correlated with radiological and other biochemical indices of bone disease and with biochemical indices of liver disease. The total activity of alkaline phosphatase in plasma increased in 28 patients. In 10 of these patients, nine of whom had increased activity of gamma-glutamyltransferase in plasma, the increase in total activity of alkaline phosphatase was from the liver isoenzyme alone (nine patients) or from the liver and bone isoenzymes together (one patient). Intestinal alkaline phosphatase in plasma, although greater than 23 U/L in eight patients, was solely responsible for the increase in total alkaline phosphatase in one patient (who had normal gamma-glutamyltransferase). Bone alkaline phosphatase in plasma was increased in 25 patients, seven of whom had normal total alkaline phosphatase, and was closely correlated (r = 0.78) with osteocalcin concentration in plasma, which was increased in a much greater proportion of patients (99%). Both total and bone alkaline phosphatase were correlated with parathyrin in plasma (r = 0.46 and 0.50, respectively) and with osteocalcin (r = 0.60 and 0.78, respectively). Osteocalcin and bone alkaline phosphatase, but not parathyrin, decreased with age, implying that the skeletal response to parathyrin may be age dependent. In patients with increased total alkaline phosphatase undergoing hemodialysis, the concurrent measurement of gamma-glutamyltransferase may help identify whether the enzyme increase originates from the liver or bone, but this approach wrongly identified the source of the increase in three of 28 patients. Therefore, we recommend a separate measurement of the bone isoenzyme of alkaline phosphatase.

Plants used in traditional medicine in eastern Tanzania. V. Angiosperms (Passifloraceae to Sapindaceae)

Sixty-one Angiosperms (Passifloraceae to Sapindaceae) are listed, which are used by traditional healers in five regions of Eastern Tanzania, namely, Coast, Dar es Salaam, Kilimanjaro, Morogoro and Tanga. For each species listed, the botanical name, vernacular name, collection number, locality, habit, distribution and medicinal uses are given. Additionally, information from the literature on medicinal uses, chemical constituents and pharmacological effects are also provided.

Plants used in traditional medicine in eastern Tanzania. III. Angiosperms (Euphorbiaceae to Menispermaceae)

Seventy-seven Angiosperms (Euphorbiaceae to Menispermaceae) are listed, which are used by traditional healers in five regions of Eastern Tanzania; namely, Coast, Dar es Salaam, Kilimanjaro, Morogoro and Tanga. For each species listed, the botanical name, vernacular name, collection number, locality, habit, distribution and medicinal uses are given. Additionally, information from the literature on medicinal uses, chemical constituents and pharmacological effects is also provided.

Plants used in traditional medicine in eastern Tanzania. II. Angiosperms (Capparidaceae to Ebenaceae)

Sixty-nine plants are listed, which are used by traditional healers in five regions of Eastern Tanzania, Coast, Dar es Salaam, Kilimanjaro, Morogoro and Tanga. For each species the botanical name, vernacular name, collection number, locality, habit, distribution and medicinal uses are given. Results of a literature survey on medicinal uses, isolated constituents, and pharmacological effects are also provided.

Phytochemical screening of Tanzanian medicinal plants. I

To evaluate traditional medicine, which is an important part of the health-care system in Tanzania, three different regions, Coast, Morogoro and Kilimanjaro were surveyed for the herbs used by traditional healers. For each species, the botanical name, vernacular name, collection number and medical uses are given. Phytochemical screening of the 52 plant samples collected representing 49 species, 42 genera and 28 families was carried out. The analyses indicated that 94% plant samples contained steroids/triterpenoids, 50% saponins, 40% carotenoids and 17% alkaloids.