Why does my patient have thrombocytopenia?

Impact of Thrombocytopenia on Preoperative Hematoma Expansion for Acute Traumatic Subdural Hematoma

BACKGROUND

Acute subdural hematoma is a neurosurgical emergency. Thrombocytopenia poses a management challenge for these patients. We aimed to determine the impact of thrombocytopenia on preoperative hemorrhage expansion and postoperative outcomes.

METHODS

This retrospective study evaluated patients presenting at our institution with acute subdural hematoma between 2009 and 2019. Patients who underwent surgery, had thrombocytopenia (platelets <150,000/μL), and had multiple preoperative computed tomography scans were included. Case control 1:1 matching was performed to generate a matched cohort with no thrombocytopenia. Univariate analyses were conducted to determine changes in subdural thickness and midline shift, postoperative Glasgow Coma Scale score, mortality, length of stay, and readmission rates.

RESULTS

We identified 19 patients with both thrombocytopenia and multiple preoperative computed tomography scans. Median platelet count was 112,000/μL (Q1 69,000, Q3 127,000). Comparing the thrombocytopenia cohort with the control group, there was a statistically significant difference in change in subdural thickness (median 5 mm [Q1 2, Q3 7.4] vs. 0 mm [Q1 0, Q3 1.5]; P = 0.001) and change in midline shift (median 3 mm [Q1 0, Q3 9.5] vs. median 0.5 mm [Q1 0, Q3 1.5]; P = 0.018). The thrombocytopenia cohort had higher in-hospital mortality (10 [52.6%] vs. 2 [10.5%]; P = 0.003). No significant differences were found in postoperative Glasgow Coma Scale score, length of stay, number of readmissions, and number of reoperations.

CONCLUSIONS

Thrombocytopenia is significantly associated with expansion of hematoma preoperatively in patients with acute subdural hematoma. While the benefit of early platelet correction cannot be determined from this study, patients who present with thrombocytopenia will benefit from close monitoring, a low threshold to obtain repeat imaging, and anticipating early surgical evacuation after platelet optimization.

Leucocyte count predicts cardiovascular risk in heart failure with preserved ejection fraction: insights from TOPCAT Americas

AIMS

Prior evidence has implicated leucocyte expansion in several cardiovascular disorders, including heart failure (HF) with reduced ejection fraction (rEF). However, the prognostic importance of leucocyte count in HF with preserved EF (HFpEF) remains largely unexplored.

METHODS AND RESULTS

The Americas cohort of the treatment of preserved cardiac function heart failure with an aldosterone antagonist (TOPCAT-Americas) was used to evaluate the association between total leucocyte count and clinical outcomes in HFpEF. The primary outcome was a composite of aborted cardiac arrest, cardiovascular mortality, or hospitalization for HF. Secondary outcomes were hospitalization for HF, aborted cardiac arrest, stroke, non-fatal myocardial infarction (MI), cardiovascular mortality, non-cardiovascular mortality, and all-cause mortality. Survival models were used to identify the risk of the primary and secondary outcomes in those with leucocyte count above the median (7100 cells/μL), as compared to those with leucocyte count below the median, during the follow-up period. A total of 1746 (out of 1767; 99%) patients from TOPCAT-Americas were available for the analyses with a median follow up of 2.4 (25th to 75th percentile 1.4-3.9) years. Patients with leucocyte count >7100 cells/μL were 36% more likely to experience the primary endpoint compared to those with ≤7100 cells/μL (hazard ratio: 1.36, 95% confidence interval: 1.14-1.61). This association remained significant after extensive adjustment for potential confounders (hazard ratio: 1.27, 95% confidence interval: 1.06-1.52). We also observed a greater incidence of HF hospitalization and non-fatal MI in patients with higher leucocyte count. These associations remained robust on sensitivity analyses, suggesting a low probability of confounding. Exploratory analyses suggested that both higher leucocyte count (integrating the combined influence of both myeloid and lymphoid immune cells) and augmented platelet count (as a surrogate for myeloid immune cell expansion) in the same model were associated with the primary outcome (both P < 0.05).

CONCLUSIONS

Leucocyte count >7100 cells/μL was independently associated with adverse clinical outcomes in HFpEF patients from TOPCAT-Americas. These results were primarily driven by the HF hospitalization outcome but were also accompanied by an excess of non-fatal MI. Further research is needed to define the mechanisms underlying our findings and their prognostic implications.

My patient is thrombocytopenic! Is (s)he? Why? And what shall I do?

Solving the riddle of a thrombocytopenic patient is a difficult and fascinating task. The spectrum of possible aetiologies is wide, ranging from an in vitro artefact to severe treatment-resistant thrombocytopenic bleeding conditions, or even life-threatening prothrombotic states. Moreover, thrombocytopenia by itself does not protect from thrombosis and sometimes a patient with a low platelet count requires concomitant antithrombotic treatment as well. In order to identify and treat the cause and the effects of the thrombocytopenia, you have to put together several pieces of information, solving a unique jig-jaw puzzle.

The present work is not a textbook article about thrombocytopenia, rather a collection of differential diagnostic thoughts, treatment concepts, and some basic knowledge, that you can retrieve when facing your next thrombocytopenic patient. Enjoy reading it, but most importantly enjoy taking care of patients with a low platelet count. I bet the present work will assist you in this challenging and rewarding clinical task.

Mean platelet diameter measurements to classify inherited thrombocytopenias

INTRODUCTION

Mean platelet volume (MPV) assists the differential diagnosis of inherited thrombocytopenia (IT) but lacks standardisation and varies between automated analysers. Classification of IT based on mean platelet diameter (MPD) has been proposed by an international collaborative study but has not been validated.

METHODS

To assess the applicability of MPD to classify forms of IT, digital images of blood films from patients with established genetic causes for IT were generated, and the MPD measured (ZEISS Axio-scanner and Image J software) by a blinded reviewer. Comparison was made to the proposed classification system.

RESULTS

Mean platelet volume was measured in thrombocytopenia with different genetic aetiologies, bilallelic BSS (bBSS) (n = 1), monoallelic BSS (mBSS) (n = 2), MYH9-related disorders (MYH9-RD) (n = 11), GFI1B-related thrombocytopenia (RT) (n = 15), FLI1-RT (n = 2), TUBB1-RT (n = 3), ITGA2B/ITGB3-RT (n = 1), RUNX1-RT (n = 2) and controls (n = 54). bBSS and 82% of MYH9-RD samples had MPD >4 μm which correlated with "IT with giant platelets." Only 55% of samples expected in the "large platelet group" had MPD meeting the classification cut-off (MPD >3.2 μm). FLI1-RT MPD were significantly larger than expected whilst ITGA2B/ITGB3-RT MPD were smaller than proposed. MPD in FPD/AML were "normal."

CONCLUSION

Platelet MPD measurements are a useful guide to classify IT, but the time taken to record measurements may limit clinical applicability.

Evaluation of the immature platelet fraction contribute to the differential diagnosis of hereditary, immune and other acquired thrombocytopenias

The differential diagnosis of immune (ITP) and hereditary macrothrombocytopenia (HM) is key to patient management. The immature platelet fraction (IPF) represents the subset of circulating platelets with higher RNA content, and has been shown to distinguish hypo- from hyperproliferative thrombocytopenias. Here we evaluated the diagnostic accuracy of IPF in the differential diagnosis between HM and other thrombocytopenias in a population of patients with post-chemotherapy thrombocytopenia (n = 56), bone marrow failure (n = 22), ITP (n = 105) and HM (n = 27). TPO levels were also measured in HM and ITP matched for platelet counts. Platelet counts were similar in all patient groups. Higher IPF values were observed in both ITP (12.3%; 2.4–65.6%) and HM (29.8%; 4.6–65.9%) compared to hypoproliferative thrombocytopenias. IPF values were also higher in HM compared to ITP, yielding a diagnostic accuracy of 0.80 (95%CI 0.70–0.90; P < 0.0001) to distinguish these two conditions. Intra- and inter-assays reproducibility of IPF in HM patients revealed that this is a stable parameter. In conclusion, IPF is increased in HM compared to both ITP and other thrombocytopenias and contributes to the differentiation between ITP and HM. Further studies are warranted to understand the biological rationale of these findings and to its incorporation in diagnostic algorithms of HM.

Pomegranate Supplementation Accelerates Recovery of Muscle Damage and Soreness and Inflammatory Markers after a Weightlifting Training Session

Purpose

The aim of this study was to investigate the effect of natural Pomegranate juice supplementation on performance and acute and delayed responses of muscle soreness and biomarkers of muscle damage after a weightlifting training session.

Methods

Nine elite weightlifters (21±0.5 years) performed two Olympic-Weightlifting-sessions after either placebo (PLA) or natural pomegranate juice (POMj) supplementations. Heart rate, blood pressure and blood samples (hematological parameters, muscle damage and C-reactive protein (CRP)) were collected at rest, 3min and 48h after each session. Weightlifting performance, RPE, and DOMS were also assessed after each training session.

Results

T-test showed higher performance (+8.30%) and lower RPE values (-4.37%) using POMj supplementation (p<0.05) in comparison with PLA. For the DOMS values, a significant improvement (13.4%) was shown only for the knee extensors (p<0.01) using the POMj. Compared to PLA condition, POMj attenuated the acute (i.e., 3min) increase of systolic blood pressure (SBP), HR, CK and LDH (p<0.05; -4.46%, -1.81%, -8.75%, -1.64%, respectively) and blunted the significant increase of ASAT, PAL and CRP (p>0.05). Additionally, during the 48h following the training session, POMj improved the recovery kinetic of SBP (p<0.01, 7.97%), CK (p<0.001, 11.34%), LDH (p<0.05, 7.30%) and ASAT (p<0.05, 6.77%). Indeed, the present study showed that 48h of recovery associated to natural POMj supplementation was sufficient to reach the resting values of the selected muscle damage markers after intensive training session.

Conclusion

Natural POMj seems to ameliorate the capacity to adhere to an intensive training program. Therefore, elite weightlifters are advised to use natural POMj during intensive training program and competition to accelerate muscle recovery.

Trial Registration

ClinicalTrials.gov NCT02697903

Platelet Abnormalities in the Oral Maxillofacial Surgery Patient

Platelet abnormalities result from a wide range of congenital and acquired conditions, which may be known or unknown to patients presenting for oral maxillofacial surgery. It is critical to obtain a thorough history, including discussion of any episodes of bleeding or easy bruising, to potentially discern patients with an underlying platelet disorder. If patients indicate a positive history, preoperative laboratory studies are indicated, with potential referral or consultation with a hematologist. Appropriate preoperative planning may reduce the risk of bleeding associated with platelet dysfunction, potentially avoiding serious perioperative and postoperative complications.

Blood transfusion practices in cancer surgery

Cancer patients are commonly transfused with blood products immediately before, during or after major surgery. Blood loss and haemodilution are the most common causes of red blood cells (RBCs) administration and coagulopathies are the indications for the infusion of fresh-frozen plasma (FFP), cryoprecipitates and platelets. Transfusion-related immune modulation is a complication associated with the administration of blood products. A decreased immune surveillance as a consequence of blood transfusions has been linked to cancer recurrence and progression. Moreover, soluble factors present in packed RBCs, platelets and FFP can directly stimulate tumour growth and spread. Two meta-analyses suggest that the administration of blood products is associated with shorter recurrence-free survival and overall survival after colorectal cancer surgery. More studies are needed to show such association in different cancer patient populations.