In hospitalized patients undergoing therapeutic plasma exchange, major bleeding prevalence depends on the bleeding definition: An analysis of The Recipient Epidemiology and Donor Evaluation Study-III

BACKGROUND

Major bleeding in patients undergoing therapeutic plasma exchange (TPE) has been studied in large databases; but without standardizing bleeding definitions. Therefore, we used standardized definitions to evaluate major bleeding in hospitalized patients undergoing TPE using public use data files from the Recipient Epidemiology and Donor Evaluation Study-III (REDS-III).

STUDY DESIGN AND METHODS

In a retrospective cross-sectional analysis, we identified TPE-treated adults in a first inpatient encounter. We evaluated major bleeding prevalence using (1) International Classification of Diseases (ICD) or Current Procedural Terminology (CPT) codes, (2) packed red blood cell (PRBC) transfusion, or (3) hemoglobin (Hgb) decline. Patients with major bleeding prior to their first TPE were excluded from the analysis.

RESULTS

Among 779 patients undergoing TPE, major bleeding by at least one of the three bleeding definitions occurred in 135 patients (17.3%). For each of the ICD/CPT, PRBC, and Hgb definitions, the prevalence of major bleeding was 2.8% (n = 31), 7.4% (n = 81), and 5.4% (n = 59), respectively. Only 3.7% of bleeds (5/135) were captured by all three definitions and 19.3% (26/135) exclusively by any two pairwise definitions. The addition of PRBC transfusion and Hgb decline to ICD/CPT code definitions increased bleeding prevalence threefold.

CONCLUSION

Among hospitalized adults undergoing TPE in the REDS-III study, the prevalence of major bleeding was 17.3%. The addition of PRBC and Hgb decline to ICD codes increased bleeding prevalence threefold. Future studies are needed to develop validated models that identify patients at risk for major bleeding during TPE.

In patients with suspected immune TTP, admission source impacts hospital length of stay and time to therapeutic plasma exchange impacts clinical outcomes

INTRODUCTION

When immune thrombotic thrombocytopenic purpura (TTP) is suspected, outcomes are impacted by time to therapeutic plasma exchange (TPE). We evaluated the impact of time to TPE on outcomes in suspected TTP cases admitted through the Emergency Department (ED) vs. transferred from another facility (Transfer).

MATERIALS AND METHODS

In a retrospective analysis of the National Inpatient Sample, we examined the association between TTP outcomes and admission source (ED vs. Transfer) for the primary outcome of time to TPE. A second stratified analyses within each analytic group examined the association of time to TPE (<1 day, 1 day, 2 days, and >2 days) and outcomes for the composite outcome of mortality, major bleeding and thrombosis.

RESULTS

Of 1195 cases, 793 (66 %) were admitted through the ED and 402 (34 %) were transferred. Compared to ED cases, Transfers had a longer hospital length of stay (14.69 vs. 16.65 days, p = 0.0060). For ED cases, TPE after >2 days was associated with higher odds of the composite outcome (OR = 1.68 95 % CI: 1.11-2.54; p = 0.0150) and mortality (OR = 3.01 95 % CI: 1.38-6.57; p = 0.0056). For Transfers, TPE on day 2 was associated with higher odds of the composite outcome (OR = 3.00 95 % CI: 1.31-6.89; p = 0.0096) and mortality (OR = 4.95 95 % CI: 1.12-21.88; p = 0.0350).

CONCLUSIONS

In suspected TTP admitted through the ED or transferred, there was no significant difference in time to TPE. A longer time to TPE was associated with worse outcomes. Future studies should evaluate strategies to decrease initial time to TPE.

Etiology, diagnosis, and treatment of nonepileptic seizures

Psychogenic nonepileptic seizures (NES) can be classified into five categories. This review focuses on NES associated with emotional conflict, by far the most common and important group. Etiology is speculative, but the background histories of these patients are often similar. The presence of a trauma history, depression, post-traumatic stress symptoms, and the use of dissociation plus cognitive dysfunction possibly point to an organic etiology. The presentation of NES in children and adults is discussed, along with the differential diagnosis. The diagnostic differential is lengthy, with epileptic seizures of frontal lobe origin presenting a unique challenge. Diagnostic procedures are reviewed with an emphasis on the utility of hypnosis with seizure induction. Presenting the diagnosis to the patient, the role of the neurologist, and the role of the mental health consultant are reviewed. Issues in the doctor-patient relationship are also addressed, as well as the overall prognosis.

Salivary cortisol levels in socially phobic adolescent girls

Anxiety disorders such as social phobia (SP) often have their onset during adolescence and frequently precede the onset of major depression. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis is well-documented in major depression. Consequently, there is considerable interest in HPA function in anxiety disorders. We examined salivary cortisol levels in 27 SP adolescent girls and 21 matched controls during normal daily activities, and immediately before and after a modified Trier Social Stress Test (TSST). Both SP subjects and controls showed significant elevations in cortisol levels prior to the TSST, and prior to attending school. These results suggest that salivary cortisol is a sensitive measure of anticipatory anxiety, but we failed to find significant differences between SP subjects and controls.

Effects of in-season (5 weeks) creatine and pyruvate supplementation on anaerobic performance and body composition in American football players

The purpose of this investigation was to study the efficacy of two dietary supplements on measures of body mass, body composition, and performance in 42 American football players. Group CM (n = 9) received creatine monohydrate, Group P (n = 11) received calcium pyruvate, Group COM (n = 11) received a combination of calcium pyruvate (60%) and creatine (40%), and Group PL received a placebo. Tests were performed before (T1) and after (T2) the 50 week supplementation period, during which the subjects continued their normal training schedules. Compared to P and PL, CM and COM showed significantly greater increases for body mass, lean body mass, 1 repetition maximum (RM) bench press, combined 1 RM squat and bench press, and static vertical jump (SVJ) power output. Peak rate of force development for SVJ was significantly greater for CM compared to P and PL. Creatine and the combination supplement enhanced training adaptations associated with body mass/composition, maximum strength, and SVJ; however, pyruvate supplementation alone was ineffective.

Purification, primary structure, and immunological characterization of the 26-kDa calsequestrin binding protein (junctin) from cardiac junctional sarcoplasmic reticulum

Previously we identified a protein of apparent M(r) = 26,000 as the major calsequestrin binding protein in junctional sarcoplasmic reticulum vesicles isolated from cardiac and skeletal muscle (Mitchell, R. D., Simmerman, H. K. B., and Jones, L. R. (1988) J. Biol. Chem. 263, 1376-1381). Here we describe the purification and primary structure of the 26-kDa calsequestrin binding protein. The protein was purified 164-fold from cardiac microsomes and shown by immunoblotting to be highly enriched in junctional membrane subfractions. It ran as a closely spaced doublet on SDS-polyacrylamide gel electrophoresis and bound 125I-calsequestrin intensely. Cloning of the cDNA predicted a protein of 210 amino acids containing a single transmembrane domain. The protein has a short N-terminal region located in the cytoplasm, and the bulk of the molecule, which is highly charged and basic, projects into the sarcoplasmic reticulum lumen. Significant homologies were found with triadin and aspartyl beta-hydroxylase, suggesting that all three proteins are members of a family of single membrane-spanning endoplasmic reticulum proteins. Immunocytochemical labeling localized the 26-kDa protein to junctional sarcoplasmic reticulum in cardiac and skeletal muscle. The same gene product was expressed in these two tissues. The calsequestrin binding activity of the 26-kDa protein combined with its codistribution with calsequestrin and ryanodine receptors strongly suggests that the protein plays an important role in the organization and/or function of the Ca2+ release complex. Because the 26-kDa calsequestrin binding protein is an integral component of the junctional sarcoplasmic reticulum membrane in cardiac and skeletal muscle, we have named it Junctin.

Proteolipid protein gene expression in demyelination and remyelination of the central nervous system: a model for multiple sclerosis

We asked whether nonlethal injury to the oligodendrocyte as manifested by altered myelin gene expression is an early event in the pathogenesis of demyelinating disease and subsequent remyelination. Using simultaneous in situ hybridization and immunocytochemistry, we studied expression of proteolipid protein (PLP) antigen and mRNA in spinal cords of normal adult mice and of mice infected with Theiler's virus which provides an excellent model for multiple sclerosis. Downregulation of PLP mRNA was observed within 3 days and persisted for as long as 367 days following intracerebral virus infection of SJL/J mice which are susceptible to chronic demyelination. Downregulation of myelin gene products preceded the development of prominent inflammation and demyelination observed following virus infection. In contrast, no change from control uninfected mice was observed in the expression of PLP mRNA following infection of C57BL/10SNJ mice which are resistant to demyelination. Treatment of chronically infected susceptible SJL/J mice with a regimen which promotes CNS-type (oligodendroglial) remyelination resulted in a 3- to 4-fold increase in PLP mRNA expression in oligodendrocytes. Actin mRNA expression in PLP antigen-positive cells was unchanged following TMEV-induced demyelination or remyelination indicating up- or downregulation of myelin gene products as compared to constitutively expressed actin gene. These experiments support the hypothesis that early regulation of myelin gene expression may be an important determinant in demyelination and in remyelination following nonlethal injury to oligodendrocytes.

Effects of atropine and methacholine on deposition and clearance of inhaled particles in the donkey

The influence of sympathetic and parasympathetic controls on regional particle deposition and mucociliary clearance rates was studied in the donkey in vivo. The deposition and clearance characteristics for gamma-tagged monodisperse ferric oxide microspheres were determined for inhalation tests after atropine and methacholine injections and were compared with the characteristics determined for control tests with the same animals and aerosols. Additional tests were performed in which methacholine was injected immediately after the test aerosol inhalation and 2 1/2 h before the particle inhalation. Particle deposition is shifted distally by atropine. Methacholine produces a proximal shift initially and a distal shift 2 1/2 h later. Atropine slows mucociliary transport. Methacholine produces an acceleration in bronchial clearance initially but causes a reduced rate of clearance 2 1/2 h later. Atropine slows mucociliary transport. Methacholine produces an acceleration in bronchial clearance initially but causes a reduced rate of clearance 2 1/2 h later. It also produces an initial surge in tracheal transport, which frequently leads to tracheal mucus refluxing and thereby an increase in average tracheal residence time. The drugs were used to modify the normal deposition and clearance characteristics of a particular animal so that they resembled the normal characteristics of a different animal, suggesting that much of the large intersubject variability may be attributable to different levels of autonomic tone.