Lombardy diagnostic and therapeutic network of thrombotic microangiopathy

Background

Thrombotic thrombocytopenic purpura (TTP) is a rare, life-threatening thrombotic microangiopathy (TMA) requiring urgent treatment. Standardization of its diagnosis and optimal management is challenging. This study aimed to evaluate the role of centralized, rapid testing of ADAMTS13 in patients experiencing acute TMAs requiring plasma-exchange (PEX) and to estimate the incidence of TTP in a large Italian Region.

Methods

We perfomed a cohort study in the frame of the project “Set-up of a Lombardy network for the study and treatment of patients undergoing apheresis”, including 11 transfusion centers in the Region. Consecutive patients referred from 2014 to 2016 with acute TMAs requiring PEX were enrolled. Centralized ADAMTS13 activity testing was performed at the Milan Hemophilia and Thrombosis Center within 24 h.

Results

Forty-three TMA patients (44 events) were enrolled, of whom 35 (81%) had severe ADAMTS13 deficiency. Patients with severe ADAMTS13 deficiency were younger, mainly women, with a higher prevalence of autoimmune disorders and a lower prevalence of cancer. Clinical and laboratory characteristics of patients with and without severe ADAMTS13 deficiency largely overlapped, with a lower platelet count being the only baseline marker that significantly differed between the two patient groups (ADAMTS13 activity < 10% vs ≥ 10%: median difference of -27 × 10⁹/l, 95% CI − 37 to − 3). PEX treatment was initiated in all patients, but soon discontinued in cases without severe ADAMTS13 deficiency. In this group, the mortality rate was higher and no episode exacerbations or relapses within 6 months occured. The estimated average annual incidence of acute acquired TTP events was 1.17 [0.78–1.55] per million people.

Conclusions

Severe ADAMTS13 deficiency distinguished two groups of patients with largely overlapping clinical features but different treatment and disease course. This study provides a feasible model implemented in a large Italian region for the practical clinical approach to TMAs and underlines the importance of urgent ADAMTS13 activity testing for an accurate differential diagnosis and therapeutic approach.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13023-022-02400-y.

[Hand management in recessive dystrophic bullous epydermolysis]

PURPOSE

Recessive distrofic epidermolysis bullosa creates severe hand deformities with disabling functional limitations. Hand surgeon should perform surgery when deformity inibits function, in order to restore the pinch.

MATERIALS AND METHOD

We present our experience on 44 patients and 58 operated hands, with the following schema: hand degloving, grafting of the first web and intraoperative dynamic splinting.

RESULTS

In 30 patient with an 8 years follow up, 25 had had good or excellent results, and the 5 remaining shows early recurrence.

CONCLUSION

Association of a correct surgical approach and adequate intra and post-operative rehabilitation improve hand function and a slow down inevitable recurrence.

Cytomegalovirus in peripheral blood leukocytes of infants with congenital or postnatal infection

BACKGROUND

Cytomegalovirus (CMV) is the most frequent agent of viral infection in the fetus; it causes varying damage, particularly neurologic, which becomes evident at birth or in infancy in about 20% of infected individuals. Postnatal acquisition is usually asymptomatic and without sequelae. Laboratory diagnosis of congenital and postnatal infection is based on the demonstration of virus in urine.

OBJECTIVES

To investigate the systemic spread of CMV in neonates with congenital or postnatal infection and to evaluate its significance in diagnosis and in monitoring anti-CMV treatments.

DESIGN

Quantitative determinations of infective CMV (viremia) and viral antigen pp65 (antigenemia) were performed on peripheral blood leukocytes (PBL) from the buffy coat of heparinized blood from children with a diagnosis of congenital (n = 19) or postnatal (n = 19) infection based on viral isolation from urine.

RESULTS

Antigen pp65 in PBL was detected particularly in children with symptomatic infection, both congenital (100%) and postnatal (79%; P > 0.05), and significantly less frequently (50%; P < 0.001) in those with asymptomatic infection. Viremia was observed less often but always in association with antigenemia. Both tests became negative within 6 months. Neither viral titer nor persistent positivity was related to clinical manifestations. In the nine infants given anti-CMV therapy (ganciclovir and/or hyperimmune gamma-globulins) an early suspension of treatment resulted in the appearance of antigenemia and/or viremia.

CONCLUSIONS

Cytomegalovirus was detected in PBL mainly in the most severely affected children. Monitoring antigenemia and viremia in CMV-infected infants is recommended to demonstrate persistent systemic infection and to evaluate virologic results of treatment.

[The action on bacterial plaque of the mastication of a sorbitol chewing gum]

The authors made a clinical evaluation of mastication of sorbitol chewing gum and its interference on plaque accumulation on teeth in 14 volunteers, 10 men and 4 women with an age average of 27 y.o., who joined both control and gum groups for 1 or 2 or 3 days. Both groups, after perfectly cleaning their teeth, were requested to avoid any measure of oral hygiene for the whole time of the study and the gum group was advised to chew one sorbitol chewing gum immediately after every assumption of solid food for unless than 30' minutes with a minimum of 4 pieces a day (after breakfast, after lunch, during the afternoon, after dinner). They were supplied with one of two most diffused sorbitol chewing gums in Italy: Vivident in 8 and Happydent in 6 cases. The choice of sorbitol was made because it can be considered a non-cariogenic sweetener and because in our country it is the most used in the so called "senza zucchero" gums and sweets. Plaque extension was evaluated by Quigley-Hein plaque index with the same procedure of the original work and taken as a parametric value in order to apply parametric tests as media, normal distribution, standard deviation, variance, Student's tests, etc. These evaluations were made on Ramfjord's teeth: 1.6, 2.1, 2.4, 3.6, 4.1, 4.4 each one divided in two half. Results, so processed, showed a significant reduction (-0.96%; p < 0.01) of plaque index for 1 day with best effect on vestibular half of frontal teeth (p between < 0.01 and < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)