Differential diagnosis of hereditary and acquired thrombocytopenia by the immature platelet fraction (IPF) and thrombopoietin plasmatic levels (TPO)

Orientador: Erich Vinícius de PaulaDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências MédicasResumo: Introdução: Nos últimos anos, novas gerações de analisadores de hematologia expandiram o arsenal de parâmetros hematológicos para a avaliação de pacientes com trombocitopenia. Entre estes, a determinação da fração de contagem de plaquetas imaturas (IPF) figura entre os marcadores mais promissores por relacionar-se com a atividade trombopoiética. De uma forma análoga à contagem de reticulócitos para série vermelha, a IPF aumenta em condições em que há maior atividade trombopoiética, constituindo-se em um potencial auxiliar no diagnóstico diferencial nas diferentes causas de trombocitopenia. Entre estas, o diagnóstico diferencial entre a plaquetopenia imune (PTI) e as trombocitopenias hereditárias (TH) pode ser desafiador, particularmente no grupo de pacientes em que a apresentação clínica não aponte claramente para um destes dois grupos. Além disso, embora o comportamento da IPF tenha sido demonstrando em diferentes etiologias de trombocitopenia, a avaliação da reprodutibilidade deste parâmetro, aspecto essencial para seu uso clínico, é ainda limitada. Metodologia: Neste estudo, avaliamos o IPF, o VPM (volume médio de plaquetas) e a TPO em um coorte de pacientes com trombocitopenia pós-quimioterapia (n= 56), insuficiências medulares (mielodisplasia e anemia aplástica; n = 22), PTI (n = 105) e TH (n = 27). A determinação da IPF foi realizada no analisador hematológico Sysmex XE5000 e, em um subgrupo de pacientes com TH, testes de reprodutibilidade intra e inter-ensaios foram realizados. Para refinamento da análise da atividade trombopoiética de pacientes com PTI e TH, níveis plasmáticos de trombopoietina (TPO) foram dosados por ELISA. Resultados e Conclusões: A contagem da IPF mostrou o comportamento esperado em pacientes com trombocitopenia pós-quimioterapia e insuficiência medular, com valores significativamente menores do que na PTI. Ao contrário do esperado, valores significativamente maiores de IPF foram observados em pacientes com TH, conferindo à IPF uma acurácia diagnóstica significativa para o diagnóstico diferencial entre PTI e TH. Considerando um valor de corte de 17,45%, a IPF foi capaz de diferenciar estas duas condições com uma sensibilidade de 77,78% e uma especificidade de 71,43%. Testes de reprodutibilidade confirmaram que a contagem de IPF é um parâmetro robusto, mesmo no subgrupo com contagens elevadas e diagnóstico de TH. Durante a realização do estudo, resultados de um outro grupo japonês também observaram valores elevados para IPF em uma coorte inferior de pacientes com TH. Em conclusão, a IPF é um parâmetro atrativo para auxiliar no diagnóstico diferencial entre TH e PTIAbstract: Introduction: In recent years, new generations of hematology analyzers expanded the arsenal of hematological parameters for the evaluation of patients with thrombocytopenia. Among these, the determination of the immature platelet fraction (IPF) count figure among the most promising markers for relate with the thrombopoietic activity. In an analogous manner to the reticulocyte count for red series, the IPF increases in conditions where there is greater thrombopoietic activity, thus becoming a potential aid in the differential diagnosis in different causes of thrombocytopenia. Among these, the differential diagnosis of immune thrombocytopenia (ITP) and hereditary thrombocytopenia (HT) can be challenging, particularly in patients where the clinical presentation does not point clearly to one of this two groups. Furthermore, although the IPF behavior has been demonstrated in different etiologies of thrombocytopenia, the evaluation of the reproducibility of this parameter, essential aspect for it clinical use, is still limited. Methodology: In this study, we evaluated the IPF, the MPV (mean platelet volume) and TPO in a cohort of patients with post-chemotherapy thrombocytopenia (n = 56), medullary insufficiencies (myelodysplasia and aplastic anemia; n = 22), ITP (n = 105) and HT (n = 27). The IPF determination was realized in Sysmex XE5000 hematology analyzer and a subgroup of patients with HT, intra- and inter-testing assays were performed. For refinement analysis of thrombopoietin activity in patients with ITP and HT, plasma levels of thrombopoietin (TPO) were measured by ELISA. Results and Conclusions: The IPF count showed a expected behavior in patients with post-chemotherapy thrombocytopenia and bone marrow failure, with significantly lower values than ITP. Contrary to expectations, significantly higher IPF values were observed in patients with HT, giving to IPF a significant diagnostic accuracy for differential diagnosis between PTI and TH. Considering a cutoff value of 17.45%, the IPF was able to differentiate these two conditions with a sensitivity of 77.78% and a specificity of 71.43%. Reproducibility tests confirmed that the IPF count is a robust parameter even in the subgroup with elevated scores and HT diagnostic. During this study, results of another Japanese group also noted high IPF values in a smaller cohort of patients with HT. In conclusion, the IPF is an attractive parameter to aid in the differential diagnosis between TH and PTIMestradoClinica MedicaMestre em Ciências2013/09319-0CAPE

Head‐to‐Head comparison of consensus‐recommended platelet function tests to assess P2Y12 Inhibition : insights for multi‐center trials

The vasodilator‐associated stimulated phosphoprotein (VASP) phosphorylation level is a highly specific method to assess P2Y12 receptor inhibition. Traditionally, VASP phosphorylation is analyzed by flow cytometry, which is laborious and restricted to specialized laboratories. Recently, a simple ELISA kit has been commercialized. The primary objective of this study was to compare the performance of VASP assessment by ELISA and flow cytometry in relation to functional platelet aggregation testing by Multiplate® whole‐blood aggregometry. Blood from 24 healthy volunteers was incubated with increasing concentration of a P2Y12 receptor inhibitor (AR‐C 66096). Platelet function testing was carried out simultaneously by Multiplate® aggregometry and by VASP assessment through ELISA and flow cytometry. As expected, increasing concentrations of the P2Y12 receptor inhibitor induced a proportional inhibition of platelet aggregation and P2Y12 receptor activation across the modalities. Platelet reactivity index values of both ELISA‐ and flow cytometry‐ based VASP assessment methods correlated strongly (r = 0.87, p < 0.0001) and showed minimal bias (1.05%). Correlation with Multiplate® was slightly higher for the flow cytometry‐based VASP assay (r = 0.79, p < 0.0001) than for the ELISA‐based assay (r = 0.69, p < 0.0001). Intraclass correlation (ICC) was moderate for all the assays tested (ICC between 0.62 and 0.84). However, categorization into low, optimal, or high platelet reactivity based on these assays was strongly concordant (κ between 0.86 and 0.92). In conclusion, the consensus‐recommended assays with their standardized cut‐offs should not be used interchangeably in multi‐center clinical studies but, rather, they should be standardized throughout sites

Persistent Cutaneous <i>Leishmania major</i> Infection Promotes Infection-Adapted Myelopoiesis

Hematopoietic stem/progenitor cells (HSPC) are responsible for the generation of most immune cells throughout the lifespan of the organism. Inflammation can activate bone marrow HSPCs, leading to enhanced myelopoiesis to replace cells, such as neutrophils, which are attracted to inflamed tissues. We have previously shown that HSPC activation promotes parasite persistence and expansion in experimental visceral leishmaniasis through the increased production of permissive monocytes. However, it is not clear if the presence of the parasite in the bone marrow was required for infection-adapted myelopoiesis. We therefore hypothesized that persistent forms of Leishmania major (cutaneous leishmaniasis) could also activate HSPCs and myeloid precursors in the C57Bl/6 mouse model of intradermal infection in the ear. The accrued influx of myeloid cells to the lesion site corresponded to an increase in myeloid-biased HSPCs in the bone marrow and spleen in mice infected with a persistent strain of L. major, together with an increase in monocytes and monocyte-derived myeloid cells in the spleen. Analysis of the bone marrow cytokine and chemokine environment revealed an attenuated type I and type II interferon response in the mice infected with the persistent strain compared to the self-healing strain, while both strains induced a rapid upregulation of myelopoietic cytokines, such as IL-1β and GM-CSF. These results demonstrate that an active infection in the bone marrow is not necessary for the induction of infection-adapted myelopoiesis, and underline the importance of considering alterations to the bone marrow output when analyzing in vivo host-pathogen interactions

Growth phenotypes of very low birth weight infants for prediction of neonatal outcomes from a Brazilian cohort: comparison with INTERGROWTH

Objective: To assess the predictive value of selected growth phenotypes for neonatal morbidity and mortality in preterm infants 97th percentile of BW. Stunting as being 95%) and positive predictive value (70-90%), with poor sensitivity and low negative predictive value. Conclusion: The BNRN phenotypes at birth differed markedly from the IG21 standard and showed poor accuracy in predicting adverse neonatal outcomes

Núcleos de Ensino da Unesp: artigos 2011: volume 3: tecnologias da informação e comunicação e material pedagógico

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP

International Nosocomial Infection Control Consortiu (INICC) report, data summary of 43 countries for 2007-2012. Device-associated module

We report the results of an International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2007-December 2012 in 503 intensive care units (ICUs) in Latin America, Asia, Africa, and Europe. During the 6-year study using the Centers for Disease Control and Prevention's (CDC) U.S. National Healthcare Safety Network (NHSN) definitions for device-associated health care–associated infection (DA-HAI), we collected prospective data from 605,310 patients hospitalized in the INICC's ICUs for an aggregate of 3,338,396 days. Although device utilization in the INICC's ICUs was similar to that reported from ICUs in the U.S. in the CDC's NHSN, rates of device-associated nosocomial infection were higher in the ICUs of the INICC hospitals: the pooled rate of central line–associated bloodstream infection in the INICC's ICUs, 4.9 per 1,000 central line days, is nearly 5-fold higher than the 0.9 per 1,000 central line days reported from comparable U.S. ICUs. The overall rate of ventilator-associated pneumonia was also higher (16.8 vs 1.1 per 1,000 ventilator days) as was the rate of catheter-associated urinary tract infection (5.5 vs 1.3 per 1,000 catheter days). Frequencies of resistance of Pseudomonas isolates to amikacin (42.8% vs 10%) and imipenem (42.4% vs 26.1%) and Klebsiella pneumoniae isolates to ceftazidime (71.2% vs 28.8%) and imipenem (19.6% vs 12.8%) were also higher in the INICC's ICUs compared with the ICUs of the CDC's NHSN

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine