scholarly journals Dentoalveolar procedures in immune thrombocytopenia; systematic review and institutional guidelines

TH Open ◽  
2021 ◽  
Author(s):  
Wobke Else Maria van Dijk ◽  
Robert J.J. Van Es ◽  
Maria Elvira Pizzigatti Correa ◽  
Roger E.G. Schutgens ◽  
Karin PM van Galen
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenia ◽  
Case Reports ◽  
Therapeutic Interventions ◽  
Medical Attention ◽  
Risk Of Bleeding ◽  
Increase Platelet Count ◽  
Life Threatening ◽  
Poor Outcomes ◽  
Invasive Techniques

Background Dentoalveolar procedures in immune thrombocytopenia (ITP) pose a risk of bleeding, due to thrombocytopenia, and infection, due to immunosuppressive treatments. We aimed to systematically review the safety and management of dentoalveolar procedures in ITP patients in order to create practical recommendations. Methods Pubmed, Embase, Cochrane and Cinahl were searched for original studies on dentoalveolar procedures in known primary ITP patients. We recorded bleeding- and infection-related outcomes and therapeutic strategies. Clinically relevant bleeding was defined as needing medical attention. Results Seventeen articles were included, of which twelve case reports/series. Overall, the quality of the available evidence was poor. Outcomes and administered therapies (including hemostatic therapies and prophylactic antibiotics) were not systematically reported. At least 73 dentoalveolar procedures in 49 ITP patients were described. The range of preoperative platelet count was 2-412*109/L. Two clinically relevant bleedings (2%) were reported in the same patient, of which one was life-threatening. Strategies used to minimalize the risk of bleeding were heterogeneous and included therapies to increase platelet count, antifibrinolytics, local measures and minimally invasive techniques. Reports on the occurrence of bleedings due to anesthetics or infection were lacking. Conclusion Based on alarmingly limited data, clinically relevant bleedings and infections after dentoalveolar procedures in ITP patients seem rare. Awaiting prospective and controlled studies to further evaluate these risks and the efficacy of therapeutic interventions, we provided our institutional guideline to guide the management of dentoalveolar procedures in ITP patients.

Clinical Toxicology of Yew Poisoning

2018 ◽  
Vol 52 (6) ◽  
pp. 591-599 ◽  
Author(s):  
Alexander W. Labossiere ◽  
Dennis F. Thompson
Keyword(s):  
English Language ◽  
Life Support ◽  
Extracorporeal Life Support ◽  
Case Reports ◽  
Data Extraction ◽  
Case Series ◽  
Therapeutic Interventions ◽  
Plant Materials ◽  
Search Terms ◽  
Life Threatening

Objectives: Yew plant materials contain highly toxic taxine alkaloids. Serious ingestions can result in life-threatening toxicity. The purpose of this article is to summarize the literature on the treatment of acute yew poisoning. Data Sources: PubMed (January 1946 to November 2017) was searched using the search terms “taxus/po”. EMBASE (1980 to November 2017) was searched using the search terms “taxus/to” and “yew.mp.” Web of Science (1945 to November 2017) was searched using the text words taxus, taxine, and yew. Study Selection and Data Extraction: Available English language articles involving case reports, epidemiology, treatment, and outcomes were included. Data Synthesis: Although not uncommon, unintentional yew poisoning rarely results in significant morbidity or mortality. A total of 26 case reports of yew poisoning were evaluated along with 4 case series articles (totaling 22 additional cases). Only 4 of the 48 total cases (8%) were accidental poisonings, the rest being deliberate ingestions. In 20 patients (42%), it resulted in fatalities. Severe, acute yew poisoning results in symptomatology largely resistant to pharmacotherapy intervention. Conclusions: Most nonintentional ingestions of yew plant constituents are asymptomatic and require little intervention. Severe poisoning can result in life-threatening cardiac toxicity and require aggressive supportive care. Therapeutic interventions, such as sodium bicarbonate, digoxin immune fab, and hemodialysis that have been utilized in case studies and case series in the literature have little proven benefit. Extracorporeal life support should be considered in severe yew poisoning.

scholarly journals Poor Platelet Function on Sonoclot Signature Is Associated with High Incidence of Bleeding in Severe Immune Thrombocytopenia

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 4991-4991 ◽  
Author(s):  
Kundan Mishra ◽  
Aditya Jandial ◽  
Rajeev Sandal ◽  
Pradakshna Porchezhian ◽  
Samson Charan ◽  
...  
Keyword(s):  
Platelet Count ◽  
Platelet Function ◽  
Immune Thrombocytopenia ◽  
Blood Samples ◽  
Risk Of Bleeding ◽  
Normal Platelet ◽  
Function Analyzer ◽  
Clinically Significant ◽  
Platelet Function Analyzer

Abstract Introduction: Patients of immune thrombocytopenia (ITP) are at an high risk of bleeding, and the risk of bleeding is maximum when platelet counts fall below 30,000/μL (severe ITP). Though it is not known not all patients have a similar risk of bleeding at a given platelet count. In 59th ASH annual meeting, 2017 (poster 2320) Mishra K et al showed that the platelet function measured by 'Sonoclot coagulation and platelet function analyzer' is significantly different in bleeders as compared to non-bleeders severe ITP patients. We aimed to investigate and follow up the non-bleeder severe ITP patients, whose platelet count remains <30,000 with or without treatment, and find out the incidence of bleed. Method: The study was conducted at the department of internal medicine, postgraduate institute of medical education and research, Chandigarh, India. In this prospective observational study, severe ITP (newly diagnosed) and without active bleeding (WHO bleeding grade <2) were included. All these patient were clinically evaluated, and blood samples were collected as per unit protocol for ITP including Sonoclot analysis. For Sonoclot analysis, fresh blood samples were drawn in citrated vacutainer and analyzed by Sonoclot coagulation and platelet function analyzer made by Sienco, Inc, model SCP1 (USA). The sonoclot signature assessment gives activated clotting time (ACT), clot rate (R1) and platelet function (PF). The samples for sonoclot analysis were monthly drawn for six months in patients who continued to have severe ITP. Results: A total of 50 patients with severe ITP were included. Twenty patients were not included in the final analysis as their platelet remained above 30,000/μL during follow up. The remaining 30 patients were divided into two groups based on normal platelet function (PF) (>1.5) and low PF (<1.5) as measured by the Sonoclot analyzer. The normal PF group (n= 17) had only one patient who had clinically significant bleeding (WHO grade > 2), while low PF group had four patients with clinically significant bleeding (Figure 1). Though the statistical significance level could not be achieved, likely due to a small cohort of patients, the results look promising and shows the potential of sonoclot to give valuable input regarding the risk of bleeding in severe ITP. Conclusion: The patients with poor platelet function as measured by 'Sonoclot coagulation and platelet function analyzer' had more bleeding episodes as compared to patients with normal platelet function. Therefore, Sonoclot may work as a point of care investigation to predict the risk of bleeding in severe ITP patients. This will help the clinician in being more conservative in the management of severe ITP patients with low risk of bleeding and avoid unnecessary therapy. We conclude that the use of Sonoclot during follow-up in severe ITP patients has prognostic significance. Disclosures No relevant conflicts of interest to declare.

Thrombocytopenia in Pregnancy: Approach to Diagnosis and Management

2020 ◽  
Vol 46 (03) ◽  
pp. 256-263
Author(s):  
Annemarie E. Fogerty
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenia ◽  
Thrombocytopenic Purpura ◽  
Gestational Thrombocytopenia ◽  
Life Threatening ◽  
Immune Thrombocytopenia Purpura ◽  
The Impact ◽  
Underlying Pathophysiology ◽  
In Pregnancy ◽  
Management Issues

AbstractThe impact of thrombocytopenia varies widely depending on the underlying pathophysiology driving it. The biggest challenge in managing thrombocytopenia in pregnancy is accurately identifying the responsible pathophysiology—a task made difficult given the tremendous overlap in clinical and laboratory abnormalities associated with different thrombocytopenia processes. The most common etiologies of thrombocytopenia in pregnancy range from physiology deemed benign to those that are life-threatening to the mother and fetus. Even in cases in which the responsible etiology is deemed benign, such as gestational thrombocytopenia, there are still implications for the management of labor and delivery, a time where hemostatic challenges may prove life-threatening. In most institutions, a minimum platelet count will be mandated for epidural anesthesia to be deemed a safe option. The causes of thrombocytopenia can also include diagnoses that are pregnancy-specific (such as preeclampsia or gestational thrombocytopenia), potentially triggered by pregnancy (such as thrombotic thrombocytopenic purpura), or unrelated to or predating the pregnancy (such as liver disease, infections, or immune thrombocytopenia purpura). It is imperative that the source of thrombocytopenia is identified accurately and expeditiously, as intervention can range from observation alone to urgent fetal delivery. In this review, the approach to diagnosis and the pathophysiological mechanisms of the most common etiologies of thrombocytopenia in pregnancy and associated management issues are presented.

scholarly journals Identification of occult cerebral microbleeds in adults with immune thrombocytopenia

Blood ◽  
2020 ◽  
Vol 136 (25) ◽  
pp. 2875-2880
Author(s):  
Nichola Cooper ◽  
Melanie A. Morrison ◽  
Camelia Vladescu ◽  
Alice C. J. Hart ◽  
Deena Paul ◽  
...  
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenia ◽  
Treatment Guidelines ◽  
Prognostic Significance ◽  
Multivariate Regression Analysis ◽  
Current Treatment ◽  
Cerebral Microbleeds ◽  
Cross Sectional ◽  
Life Threatening ◽  
Cerebral Microhemorrhage

Abstract Management of symptoms and prevention of life-threatening hemorrhage in immune thrombocytopenia (ITP) must be balanced against adverse effects of therapies. Because current treatment guidelines based on platelet count are confounded by variable bleeding phenotypes, there is a need to identify new objective markers of disease severity for treatment stratification. In this cross-sectional prospective study of 49 patients with ITP and nadir platelet counts &lt;30 × 109/L and 18 aged-matched healthy controls, we used susceptibility-weighted magnetic resonance imaging to detect cerebral microbleeds (CMBs) as a marker of occult hemorrhage. CMBs were detected using a semiautomated method and correlated with clinical metadata using multivariate regression analysis. No CMBs were detected in health controls. In contrast, lobar CMBs were identified in 43% (21 of 49) of patients with ITP; prevalence increased with decreasing nadir platelet count (0/4, ≥15 × 109/L; 2/9, 10-14 × 109/L; 4/11, 5-9 × 109/L; 15/25 &lt;5 × 109/L) and was associated with longer disease duration (P = 7 × 10−6), lower nadir platelet count (P = .005), lower platelet count at time of neuroimaging (P = .029), and higher organ bleeding scores (P = .028). Mucosal and skin bleeding scores, number of previous treatments, age, and sex were not associated with CMBs. Occult cerebral microhemorrhage is common in patients with moderate to severe ITP. Strong associations with ITP duration may reflect CMB accrual over time or more refractory disease. Further longitudinal studies in children and adults will allow greater understanding of the natural history and clinical and prognostic significance of CMBs.

scholarly journals First-Line Therapy for Immune Thrombocytopenia

2019 ◽  
Vol 39 (03) ◽  
pp. 259-265 ◽  
Author(s):  
Siraj Mithoowani ◽  
Donald M. Arnold
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenia ◽  
Bleeding Complications ◽  
High Dose ◽  
First Line ◽  
Risk Of Bleeding ◽  
First Line Therapy ◽  
Line Therapy ◽  
Increased Risk ◽  
Count Response

AbstractImmune thrombocytopenia (ITP) is an autoimmune disease affecting blood platelets that causes thrombocytopenia and an increased risk of bleeding. First-line therapy is indicated for patients with bleeding complications or who are at increased risk of bleeding, and the decision to initiate therapy depends not only on the platelet count, but also on other endpoints including quality of life. The choice of first-line therapy depends primarily on how quickly a platelet count response is required, with intravenous immune globulin providing the more rapid response, followed by high-dose dexamethasone and prednisone. In this narrative review, we discuss key issues with first-line therapy in ITP including when to initiate therapy, treatment options and special considerations for children. Evidence-based guidelines are lacking for the emergency management of patients with ITP who present with significant bleeding; we provide our approach to this critical situation.

Nifedipine Poisoning in a Child

PEDIATRICS ◽  
1990 ◽  
Vol 86 (1) ◽  
pp. 91-94
Author(s):  
Thomas G. Wells ◽  
Charles J. Graham ◽  
M. Michele Moss ◽  
Gregory L. Kearns
Keyword(s):  
Mechanical Ventilation ◽  
Vital Signs ◽  
Cortical Blindness ◽  
Therapeutic Interventions ◽  
Medical Attention ◽  
Life Threatening ◽  
Posterior Parietal ◽  
Occipital Lobes ◽  
Life Threatening Event ◽  
Third Degree Atrioventricular Block

A 14-month-old child ingested approximately 800 mg (70 mg/kg) of nifedipine. When first examined, the child was unresponsive, markedly hypotensive, and hyperglycemic. According to electrocardiographic results, there was a third-degree atrioventricular block that rapidly progressed to cardiac arrest. Following successful cardiopulmonary resuscitation, mechanical ventilation and resuscitation with intravenous normal saline, calcium chloride and dopamine were required to restore perfusion, reverse metabolic acidosis, and stabilize vital signs. Complications related to nifedipine intoxication included the development of pulmonary edema and possible infarction in the posterior parietal and occipital lobes associated with cortical blindness and the development of seizures with an abnormal electroencephalogram. The patient recovered without clinically apparent residua. Massive nifedipine overdose in infants represents a potentially life-threatening event that requires prompt medical attention. Reported cases of nifedipine intoxication were reviewed and therapeutic interventions Received for publication Jan 23, 1989; accepted Aug 16, 1989. were discussed.

Dynamic dosing of romiplostim in patients with immune thrombocytopenia purpura: Two case reports

2018 ◽  
Vol 25 (3) ◽  
pp. 719-723
Author(s):  
Jeffrey A Gilreath ◽  
Mei Wei ◽  
Shilpa Paul ◽  
Charles J Parker ◽  
David D Stenehjem ◽  
...  
Keyword(s):  
Platelet Count ◽  
Immune Thrombocytopenia ◽  
Case Reports ◽  
Mitigation Strategies ◽  
Patient Harm ◽  
Platelet Counts ◽  
Thrombopoietin Receptor ◽  
Thrombopoietin Receptor Agonist ◽  
Immune Thrombocytopenia Purpura ◽  
Precipitous Decline

Romiplostim is a thrombopoietin receptor agonist approved for the treatment of immune thrombocytopenia purpura. When following FDA-approved romiplostim prescribing recommendations to withhold treatment for platelet counts above 400k/µL, some patients exhibit a precipitous decline in their platelet count potentially causing patient harm. We present two cases where stable platelet counts were achieved only through persistent weekly dosing of romiplostim despite platelet counts above 400k/µL on the day of administration. Therefore, continuous weekly dosing of romiplostim despite platelet count being above 400k/µL combined with twice weekly vigilant monitoring is an alternative method of romiplostim dosing that mitigates severe fluctuations in platelets. We also discuss important details, postulated mechanisms, and evidence-based mitigation strategies.

scholarly journals Hemangioma of the Sphenoid and Ethmoid Sinuses: Two Case Reports

2003 ◽  
Vol 82 (3) ◽  
pp. 217-221 ◽  
Author(s):  
John D. Kilde ◽  
John S. Rhee ◽  
Andre A. Balla ◽  
Michelle M. Smith ◽  
Timothy L. Smith
Keyword(s):  
Paranasal Sinuses ◽  
Case Reports ◽  
Ethmoid Sinus ◽  
Therapeutic Interventions ◽  
Diagnosis And Management ◽  
Risk Of Bleeding ◽  
Histologic Appearance ◽  
Ethmoid Sinuses ◽  
Sphenoid Sinuses

Hemangiomas of the paranasal sinuses are rare, particularly those of the sphenoid and ethmoid sinuses. Although imaging of the sinuses is key to determining the extent of involvement, the diagnosis is based on the lesion's histologic appearance. Obtaining an adequate biopsy can be difficult in light of the risk of bleeding and the relative inaccessibility of lesions in this region. These obstacles can make the diagnosis and management of these lesions particularly challenging. We describe two new cases of sinonasal hemangioma—one in the ethmoid sinus and one in the ethmoid and sphenoid sinuses—and we discuss the diagnostic and therapeutic interventions that are needed to manage these lesions.

The Role of Cytomegalovirus in Immune Thrombocytopenia Purpura.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 2101-2101
Author(s):  
Dina M. Di Maggio ◽  
James B. Bussel
Keyword(s):  
Platelet Count ◽  
Antiviral Therapy ◽  
Immune Thrombocytopenia ◽  
Case Reports ◽  
Dramatic Improvement ◽  
Cmv Infection ◽  
Elevated Liver Enzymes ◽  
Recurrent Epistaxis ◽  
Immune Thrombocytopenia Purpura ◽  
Refractory Itp

Abstract Immune thrombocytopenia purpura(ITP) is one of the most common causes of acquired thrombocytopenia. Although ITP is believed to result from autoreactive antibodies that lead to platelet destruction, its exact pathogenesis is not known. Cytomegalovirus(CMV) has been implicated as a possible causative agent of ITP. Based on three case reports described here we believe that CMV may be a cause of refractory ITP in certain patients and that eradication of CMV with antiviral therapy will improve the ITP. A 72-year-old man experienced recurrent epistaxis and was found to be thrombocytopenic. He was diagnosed with ITP, and treated with IVIG and solumedrol, with platelets transiently rising to 45K/ul. He suffered a subdural hematoma and was placed on IVIG and prednisone daily and referred for splenectomy. Rituximab was ineffective. Testing for CMV revealed a positive PCR and ganciclovir IV qd, valganciclovir, and cytogam 2 times per week were initiated. With this regimen, the CMV PCR became undetectable and steroids and his anti-CMV medications were weaned off. He now maintains a normal count on no treatment. A 48-year-old male developed ITP which was refractory to treatment with steroids, IVIG, rituximab, danazol, vincristine, anti-thymocyte globulin, and IV anti-D; his platelet count was &lt;20,000/ul and he had marked skin and oral bleeding. After being diagnosed with CMV, he was started on IV ganciclovir and cytogam for several months and was weaned after his PCR became undetectable. In retrospect, he had had mild transaminitis and atypical lymphocytes reported at presentation at another center. He experienced a reactivation of his CMV while being treated with 1 week of steroids for asthma, requiring a second 4 month course of ganciclovir. Currently he receives IVIG every 2-8 weeks. A 3-year-old female was well until 4 months of age, when she developed fevers, thrombocytopenia, elevated liver enzymes and a positive CMV PCR for which she was started on ganciclovir. She developed pancytopenia; bone marrow biopsy was consistent with ITP. She had poor responses to IVIG, IV anti-D and pulse steroids. She suffered from chronic CMV infection for which she received cytogam BIW and initially ganciclovir daily, until its discontinuation secondary to myelosuppression. Once her CMV PCR was negative and her platelets improved to near normal, cytogam was discontinued. Soon after discontinuation her platelet count dropped below 10,000K/ul. She was restarted on the ganciclovir and cytogam without effect. She experienced an intracranial hemorrhage, RSV bronchiolitis, gram positive bacteremia, and respiratory failure with multiple failed extubations and expired at 3 years of age. Toll like receptors 2, 7, and 9 were normal. Several reports have implicated CMV in the pathogenesis of rare cases of ITP. Our previous study suggested that it was at most rarely involved in ITP (Levy, A., 2002; BJH). We describe three cases of refractory ITP associated with CMV. The presentations include severe symptomatic treatment-refractory ITP, fever of unknown origin, and transaminitis. Treatment with immunosuppressive medication may have worsened the CMV-ITP. All cases showed dramatic improvement in platelet counts within 1-2 weeks when ganciclovir and cytogam were instituted. The relationship between CMV and ITP may be explained by immune-mediated destruction of infected platelets or by direct infection of megakaryoblasts by cytomegalovirus(Xiao,Y., 2006). Based on these case reports we believe that CMV infection needs to be considered in cases of refractory ITP and antiviral therapy instituted when infection is identified.

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