Predictors of acute ischemic cerebral lesions in immune-mediated thrombotic thrombocytopenic purpura and hemolytic uremic syndrome

BACKGROUND

The immune form of thrombotic thrombocytopenic purpura (iTTP) and the hemolytic and uremic syndrome (HUS) are two major forms of thrombotic microangiopathy (TMA). Their treatment has been recently greatly improved. In this new era, both the prevalence and predictors of cerebral lesions occurring during the acute phase of these severe conditions remain poorly known.

AIM

The prevalence and predictors of cerebral lesions appearing during the acute phase of iTTP and Shiga toxin-producing Escherichia coli-HUS or atypical HUS were evaluated in a prospective multicenter study.

METHODS

Univariate analysis was performed to report the main differences between patients with iTTP and those with HUS or between patients with acute cerebral lesions and the others. Multivariable logistic regression analysis was used to identify the potential predictors of these lesions.

RESULTS

Among 73 TMA cases (mean age 46.9 ± 16 years (range 21-87 years) with iTTP (n = 57) or HUS (n = 16), one-third presented with acute ischemic cerebral lesions on magnetic resonance imagery (MRI); two individuals also had hemorrhagic lesions. One in ten patients had acute ischemic lesions without any neurological symptom. The neurological manifestations did not differ between iTTP and HUS. In multivariable analysis, three factors predicted the occurrence of acute ischemic lesions on cerebral MRI: (1) the presence of old infarcts on cerebral MRI, (2) the level of blood pulse pressure, (3) the diagnosis of iTTP.

CONCLUSION

At the acute phase of iTTP or HUS, both symptomatic and covert ischemic lesions are detected in one third of cases on MRI. Diagnosis of iTTP and the presence of old infarcts on MRI are associated with the occurrence of such acute lesions as well as increased blood pulse pressure, that may represent a potential target to further improve the therapeutic management of these conditions.

Blood pressure changes at the Dead Sea (a low altitude area)

The Dead Sea (barometric pressure: 800 mm Hg) is an important balneotherapeutic centre for chronic dermatologic and arthritic diseases. In the past, hypertensive patients have complained sporadically of weakness and dizziness during a stay in the Dead Sea. It was therefore recommended that hypertensives do not stay at these health centres. The aim of our study was to investigate the changes in blood pressure (BP) parameters of 72 hypertensive and normotensive osteoarthritic and rheumatoid arthritic elderly patients during a 2-week stay in the Dead Sea, and to further evaluate the effect of different balneotherapeutic means on these BP changes. Following a primary BP assessment at the out-patient clinic (Beer Sheva barometric pressure: 745 mm Hg), the patients were divided into four groups: (1)thermomineral pool; (2)Dead Sea water baths; (3) combination of the aforementioned treatments; and (4) controls (no balneotherapy). We demonstrated that the systolic BP (SBP) of hypertensives and normotensives decreased by an average of 17 mm Hg and that diastolic BP (DBP) decreased by an average of 8 mm Hg from their basic clinic-measured values. These favourable results were sustained during the first 10 days duration, and by the end of their stay they had diminished slightly. Thermomineral water had an additional lowering effect on the BP of the normotensives, but the SBP of hypertensives increased. Immediately following Dead Sea bath immersion, we noted a temporary increase of SBP in normotensives only. No patient, hypertensive or normotensive, complained of dizziness, malaise, or any other complaint. In our experience, patients feel well at low altitudes, and there is no justification in upholding hypertension as a contraindication to balneotherapy in the Dead Sea.

Three teams improving thrombolytic therapy

BACKGROUND

The American Heart Association (AHA) standard for delivering thrombolytic therapy to chest pain patients is 30 to 60 minutes after patient presentation to the emergency department. Three acute care hospitals in an integrated health system in northern California shortened the time of administration of thrombolytic agents to appropriate patients presenting with chest pain in the emergency department.

FINDING THE SOLUTIONS

Physician-led multidisciplinary teams developed algorithms to reduce variation and decrease the thrombolytic administration process to 30 minutes. Changes were made to prehospital and hospital thrombolytic policies and staff practices.

REALIZING RESULTS

Each of the three acute care hospitals reduced their thrombolytic administration time by 48% to 59% to levels within the AHA standard.

LEARNING FROM THE PROCESS

Internal benchmarking for clinical processes promotes a synergy between hospitals and medical staffs for the improvement of patient care. Multidisciplinary teams, which include community representatives, achieve a thorough understanding of a process, which in turn reduces variation in practice and improves quality.

Fibromyalgia in familial Mediterranean fever

OBJECTIVE

To determine whether chronic lower body pain in a subpopulation of patients with familial Mediterranean fever (FMF) is due directly to the musculoskeletal manifestations of FMF or whether they are connected to mechanical problems in the low back and leg/foot or to other factors operative in fibromyalgia (FM).

METHODS

In 93 consecutive patients with FMF a point count of 14 tender points (TP) was conducted by thumb palpation. Tenderness thresholds were assessed in some of the TP and of control point sites by Chatillon dolorimeter.

RESULTS

In female patients with FMF dolorimeter thresholds of fibrositic and control point sites were significantly lower than in male patients with FMF (p < 0.004). Also patients with FMF with back pain and foot/leg pain are more tender than patients with FMF without this characteristic (p < 0.001).

CONCLUSION

The detection of FM and definition of tenderness thresholds is relevant to this disease, since musculoskeletal complaints are common in this group of patients but not always explained by objective findings.

Environmental and genetic factors of hypertension in a biracial Beduin population

This study attempts to understand the various factors involved in the pathophysiology of hypertension in black Beduins. Parameters known to differentiate US black from white hypertensives were examined. Sixty Beduin families (thirty families each of black and white, total of 205 subjects) were evaluated for environmental risk factors: a traditional nomad shepherd life-style compared with working in a city, living in tents or in western style housing and dietary habits related to cardiovascular risk factors. Blood pressure, body mass index (BMI), sodium-lithium counter transport rate and 24 hour urinary sodium excretion (UNa) were measured and the data obtained were compared between normotensives and hypertensives, within each racial group. The mean value of the BMI of the white population was greater than that of the black population while the BMI of hypertensives was greater than that of the normotensives in each of the racial groups. The mean systolic BP of black hypertensives was greater than that of the corresponding whites. There were no significant differences in UNa between the four groups. Sodium-lithium countertransport was significantly higher in the hypertensive whites compared with the normotensive population (0.46 versus 0.22 mmol Li efflux/IRBC/hr). The countertransport rate for black hypertensives was lower than that of white hypertensives (0.20 versus 0.46). Black families had lower socio-economic scores than did white families and families with a hypertensive member scored lower than did families with a normotensive history. These results demonstrate some similarities between the American and Beduin black hypertensive populations, in spite of entirely different life-styles, indicating that in these populations genetic factors, rather than environmental influences, appear to be dominant in the pathophysiology of hypertension.

Serum and synovial fluid levels of serum amyloid A protein and C-reactive protein in inflammatory and noninflammatory arthritis

Serum and synovial fluid (SF) levels of serum amyloid A (SAA) and C-reactive protein (CRP) were measured in 46 cases of various inflammatory arthritis (Group 1), and in 40 cases of noninflammatory arthritis: 18 cases of osteoarthritis (Group 2) and 22 cases of traumatic arthritis (Group 3). Serum and SF SAA levels were markedly elevated in Group 1: 126.4 micrograms/ml +/- 19.2 SEM and 46.4 micrograms/ml +/- 10.5 SEM, respectively; moderately elevated in Group 2: 10.1 micrograms/ml +/- 2.9 SEM, 4.0 micrograms/ml +/- 1.1 SEM and moderately elevated in Group 3: 10.4 micrograms/ml +/- 1.2 SEM, 4.0 micrograms/ml +/- 1.2 SEM, respectively. Serum/SF SAA ratios were similar in all 3 groups and ranged between 2.52-2.72. In comparison to SAA, the increment of serum and SF CRP above normal levels was moderate. A positive strong correlation was found between serum SAA and serum CRP: r = 0.64 (p less than 0.001) and between SF SAA and SF CRP: r = 0.59 (p less than 0.0001). SF SAA did not correlate with the number of SF white blood cells but did correlate with the percent of SF polymorphonuclear cells: r = 0.23 (p less than 0.05).