Human parvovirus infection

Fifth disease (erythema infectiosum) has recently been linked to human parvovirus (HPV) infection. HPV is also capable of causing aplastic anemia, arthritis and perinatal complications, including hydrops fetalis and spontaneous abortion. Clinically suspected cases of HPV infection can now be confirmed serologically. IgM antibodies peak early in the course of infection and are usually undetectable by two months. New procedures, including HPV-specific DNA probes, are being used to confirm in utero infections.     

Comparison of high‐ and low‐fidelity mannequins for clinical performance assessment

Objective: A pilot study exploring the differences between high‐ and low‐fidelity mannequins in the assessment of clinical performance. Methods: Standardized clinical scenarios were used to test 12 intensive care paramedics (ICP). Each ICP was randomly assigned to a scenario using either a high‐fidelity (SimMan) or low‐fidelity mannequin (Laerdal Heart Start 2000), followed by a crossover assessment using the alternative scenario. We examined both the objective and subjective outcomes. Objective performance was assessed by three independent assessors, all accredited Advanced Paediatric Life Support instructors. Subjective outcomes were measured by assessment questionnaires and a rating scale. Results: The overall proportion that passed the high‐fidelity mannequin scenario was 0.47 compared with 0.58 in the low‐fidelity mannequin scenario. The difference was ?0.11 (95% CI ?0.32–0.11). The subjective outcomes were charted and presented within the article. The ICP preferred the use of high‐fidelity mannequin for assessment purpose. Conclusion: There was no significant objective difference between the two mannequins.     

Thrombocytopenia in high‐risk patients with antiphospholipid syndrome

Essentials

• The prevalence of thrombocytopenia in patients with antiphospholipid syndrome is not well defined.
• We studied triple positive patients with antiphospholipid syndrome and its catastrophic variant.
• Prevalence of thrombocytopenia was 6% and 100% in patients who developed the catastrophic form.
• In triple positive patients thrombocytopenia is low and platelets drop during the catastrophic form.

Summary

Background

Thrombocytopenia is the most common non‐criteria hematological feature in patients with antiphospholipid syndrome (APS). This condition is more common in patients with catastrophic APS (CAPS).

Objectives

To evaluate the prevalence of thrombocytopenia in a large series of high‐risk patients with APS, and to assess the behavior of the platelet count during CAPS.

Methods/Patients

This was a cross‐sectional study in which we analyzed the platelet counts of a homogeneous group of high‐risk APS patients (triple‐positive). Six of these patients developed a catastrophic phase of the disease, and the platelet count was recorded before the acute phase, during the acute phase, and at recovery.

Results

The mean platelet count in 119 high‐risk triple‐positive patients was 210 × 10⁹ L^?1. With a cut‐off value for thrombocytopenia of 100 × 10⁹ L^?1, the prevalence of thrombocytopenia was 6% (seven patients). No difference between primary APS and secondary APS was found. In patients who suffered from CAPS, a significant decrease from the basal count (212 ± 51 × 10⁹ L^?1) to that at the time of diagnosis (60 ± 33 × 10⁹ L^?1) was observed. The platelet count became normal again at the time of complete remission (220 ± 57 × 10⁹ L^?1). A decrease in platelet count always preceded the full clinical picture.

Conclusions

This study shows that, in high‐risk APS patients, the prevalence of thrombocytopenia is low. A decrease in platelet count was observed in all of the patients who developed the catastrophic form of the disease. A decrease in platelet count in high‐risk APS patients should be considered a warning signal for disease progression to CAPS.

     

The effect of high‐ and low‐frequency transcutaneous electrical nerve stimulation upon cutaneous blood flow and skin temperature in healthy subjects

The reported non‐analgesic effects of transcutaneous electrical nerve stimulation (TENS) include alterations to the local circulation; however, research in this area has produced equivocal findings. In the present study, the effect of low‐ (4 Hz) and high‐frequency (110 Hz) TENS on forearm skin blood perfusion was assessed using laser Doppler flowmetry. The effect on skin temperature was also assessed using a skin thermistor. Thirty healthy human volunteers were recruited and randomly assigned to a control or one of the two treatment groups. TENS was applied to the skin overlying the median nerve under double‐blind conditions for 15 min. Blood flow and skin temperature readings were recorded pre‐TENS, during TENS application and continued for 15 min post‐TENS application. Analysis of results showed significant increases in blood perfusion during the treatment period in the low‐frequency group when compared to the other two groups (P = 0·0106; ANOVA). No significant changes in skin temperature were observed. The results of this study demonstrate that low‐frequency TENS produces a local increase in cutaneous blood flow.     

Cognitive reactivity among high‐risk individuals at the first and recurrent episode of depression symptomology: A structural equation modelling analysis

Understanding the particular mechanisms by which vulnerability and capability factors influence cognitive reactivity (CR) can contribute to an enhanced capacity to adequately react to depression. However, few studies have explored the CR model. The main aim of the present study was to develop a model that specifies the predictive effects of CR for depression among individuals at high risk for first‐episode and recurrent depression. A national cross‐sectional, online study using convenience sampling was conducted among 587 vulnerable healthy individuals and 224 depressed patients in China. A battery of indices, including measures of CR, social support, resilience, self‐compassion, life events, neuroticism, sleep condition, and negative emotion, were collected. A structural equation model was applied to analyse the data. The final first‐episode and recurrent depressive symptoms of the CR models showed good model fit. According to the models, 45%–52% of the variance in depressive symptom was predicted by CR. Social support, self‐compassion, resilience, and positive life events directly influenced CR, with β values ranging from ?0.18 to ?0.24 (P < 0.01). Neuroticism, negative emotion, poor sleep conditions, and negative life events also directly and positively influenced CR (P < 0.01). The relationship between these negative or positive contributing factors and depression was also indirectly influenced by CR (P < 0.01). Our findings demonstrate the role of CR in the prevention and treatment of depression. The first‐episode and recurrent depressive symptoms of the CR models considering both vulnerabilities and capabilities of CR in the psychopathology of depression provide a theoretical basis for interventions that reduce CR in high‐risk populations.     

High‐risk myocardial infarction patients appear to derive more mortality benefit from short door‐to‐balloon time than low‐risk patients

Objectives: To evaluate reduction of door‐to‐balloon (DTB) time and its impact on in‐hospital mortality of high‐risk infarct patients in a collaboration of district general hospitals (DGH) with a physician‐to‐patient model. Methods: Primary percutaneous coronary interventions (PPCI) with short DTB time offer mortality benefit for ST‐segment elevation myocardial infarction but literatures are conflicting on this benefit for high‐ vs. low‐risk patients. In a unique model at Sandwell and West Birmingham Hospitals, five interventional cardiologists provide 24‐h PPCI at whichever one of its two DGH that patients present to. A retrospective audit was performed on 3 years (July 2005–June 2008) of PPCI data in the British Cardiovascular Intervention Society database. Data were analysed in four periods corresponding to change from daytime‐only to 24‐h PPCI. DTB time and in‐hospital mortality were the main outcome measures. Results: Of the 459 patients, median DTB time improved from 89 min (interquartile range: 49–120) to 68 min (50–91) (p = 0.005) and proportion of patients achieving target 90‐min DTB time increased from 53% (21/40) to 75% (93/124) (p = 0.005). In‐hospital mortality was less for short DTB time [4.6% (13/284) vs. 11.5% (20/174); odds ratio (OR) 0.37, 95% confidence interval (CI): 0.18–0.75; p = 0.008]. With the proviso that our study was limited in power, long DTB time (> 90 min vs. ≤ 90 min) was associated with higher in‐hospital mortality in high‐risk patients [15.6% (20/128) vs. 7.1% (12/168); OR 2.41, 95% CI: 1.14–5.06; p = 0.024] and not in low‐risk patients [0% (0/46) vs. 0.9% (1/117); OR 0, 95% CI: 0–9.88; p = 1.000]. Conclusions: A collaboration of DGH with a physician‐to‐patient model can deliver timely PPCI that appear to translate into mortality benefit more so in high‐risk patients. Low‐risk patients would therefore probably tolerate delays associated with transfer to large centres while high‐risk patients would not and need alternative strategy. A collaboration of smaller hospitals with a pool of mobile interventional cardiologists could be such an alternative.     

Clinical course of high‐risk patients diagnosed with antiphospholipid syndrome

See also Galli M. The antiphospholipid triangle. This issue, pp 234–6. Summary. Background: The characteristics and the clinical course of antiphospholipid syndrome (APS) in high‐risk patients that are positive for all three recommended tests that detect the presence of antiphospholipid (aPL) antibodies have not been described. Methods: This retrospective analysis of prospectively collected data examined patients referred to Italian Thrombosis Centers that were diagnosed with definite APS and tested positive for aPL [lupus anticoagulant (LA), anti‐cardiolipin (aCL), and anti‐β2‐glycoprotein I (β2GPI) antibodies]. Laboratory data were confirmed in a central reference laboratory. Results: One hundred and sixty patients were enrolled in this cohort study. The qualifying events at diagnosis were venous thromboembolism (76 cases; 47.5%), arterial thromboembolism (69 cases; 43.1%) and pregnancy morbidity (11 cases; 9.7%). The remaining four patients (2.5%) suffered from catastrophic APS. The cumulative incidence of thromboembolic events in the follow‐up period was 12.2% (95%CI, 9.6–14.8) after 1 year, 26.1% (95%CI, 22.3–29.9) after 5 years and 44.2% (95%CI, 38.6–49.8) after 10 years. This was significantly higher in those patients not taking oral anticoagulants as compared with those on treatment (HR=2.4 95%CI 1.3–4.1; P < 0.003). Major bleeding associated with oral anticoagulant therapy was low (0.8% patient/years). Ten patients died (seven were cardiovascular deaths). Conclusions: Patients with APS and triple positivity for aPL are at high risk of developing future thromboembolic events. Recurrence remains frequent despite the use of oral anticoagulants, which significantly reduces the risk of thromboembolism.