Feasibility of Universal Screening for Preeclampsia Risk and Aspirin Recommendation in the Ultrasound Unit.

OBJECTIVE: To evaluate the feasibility and impact of using the first-trimester ultrasound visit to identify and counsel women at increased risk of preeclampsia about the benefits of low-dose aspirin (LDA) for preventing preeclampsia. We also assessed patient-reported utilization of LDA, perceived risk for preeclampsia, and clinical outcomes. STUDY DESIGN: Women presenting for routine first-trimester nuchal-translucency (NT) ultrasounds were screened for clinical preeclampsia risks using a self-administered risk assessment. Women at moderate or high risk for preeclampsia were counseled to take LDA, if not already taking it. LDA utilization and perceived risk for preeclampsia were assessed during the second-trimester ultrasound. Factors associated with LDA utilization were analyzed. Pregnancy outcomes were compared between those who used LDA and those who did not. RESULTS: Slightly more than 20% of patients (765/3,669) screened at increased risk for developing preeclampsia. Of those, 67.8% (519/765) had not received LDA recommendations from their referring obstetrician and 97 had not been taking LDA despite being advised to do so. Combined, 94.6% (583/616) of these patients eligible to start LDA prophylaxis received the indicated counseling during the ultrasound visit. A total of 61.4% (358/583) of women completed the follow-up form and of those 77.9% (279/358) reported taking LDA. Screening at increased risk for preeclampsia and perception of increased risk were positively associated with LDA utilization, whereas concerns for LDA safety were negatively associated with use. African American/Black patients and Medicaid recipients were less likely to use LDA. Pregnancy outcomes were similar between those who used LDA and those who did not. CONCLUSION: Assessing preeclampsia risk and counseling patients about LDA at the time of the NT ultrasound are feasible in the ultrasound unit and led to good LDA utilization among women at increased risk for preeclampsia. This intervention may standardize patient care and help close the disparity in maternal health. KEY POINTS: · A simple intervention captured 2/3 of eligible patients.. · Aspirin utilization rate was good after the intervention.. · Screening high risk for preeclampsia and self-perception of risk correlated with aspirin use..

Ventral tegmental area GABAergic inhibition of cholinergic interneurons in the ventral nucleus accumbens shell promotes reward reinforcement.

The long-range GABAergic input from the ventral tegmental area (VTA) to the nucleus accumbens (NAc) is relatively understudied, and therefore its role in reward processing has remained unknown. In the present study, we show, in both male and female mice, that long-range GABAergic projections from the VTA to the ventral NAc shell, but not to the dorsal NAc shell or NAc core, are engaged in reward and reinforcement behavior. We show that this GABAergic projection exclusively synapses on to cholinergic interneurons (CINs) in the ventral NAc shell, thereby serving a specialized function in modulating reinforced reward behavior through the inhibition of ventral NAc shell CINs. These findings highlight the diversity in the structural and functional topography of VTA GABAergic projections, and their neuromodulatory interactions across the dorsoventral gradient of the NAc shell. They also further our understanding of neuronal circuits that are directly implicated in neuropsychiatric conditions such as depression and addiction.

Late diagnosis of chronic hypocalcemia due to autoimmune hypoparathyroidism.

Hypoparathyroidism is most often the result of postsurgical damage to the parathyroid glands but may occasionally be autoimmune hypoparathyroidism. In the latter context, activating antibodies directed against the calcium-sensing receptor (CaSR) have been described. We hereby present the case of a patient suffering from chronic recurrent muscle cramps and paresthesia, presenting for a seizure due to hypocalcaemia. After eliminating the possibility of a genetic disorder, we searched for autoimmune hypoparathyroidism as there was no obvious cause of hypoparathyroidism. The search for anti-CaSR antibodies was positive. There was no argument for autoimmune polyendocrine syndrome type 1 so we concluded that it was isolated autoimmune hypoparathyroidism caused by activating antibodies to the CaSR. The patient was treated with vitamin D and calcium supplementation. The search for complications of hypoparathyroidism and hypercalciuria revealed basal ganglia calcification. The patient's hypocalcaemia is now being kept under control with oral supplementation.

Humanized anti CD-20 as an alternative in chronic management of relapsing thrombotic thrombocytopenic microangiopathy resistant to rituximab due to anti chimeric antibody.

Acquired Immune thrombotic thrombocytopenic purpura (iTTP) is considered among clinical situations that needs not only urgent treatment in acute setting but also long term management to prevent relapses. Important progresses have been made in management of these patients that are definitely associated with reduced mortality and relapse rate. However, there are still noticeable percentage of patients that may relapse despite application of modern treatment strategies including preemptive rituximab infusions. Hereby, we share our experience concerning a frequently relapsing iTTP due to development of anti-rituximab antibody. In our case administration of obinutuzumab, a humanized type II anti CD-20 antibody was associated with complete peripheral blood B cell depletion and increasing plasma ADAMTS-13 activity.

Physiological role of plasma and its components and the clinical implications of different methods of apheresis: A narrative review.

Nowadays, therapeutic plasmapheresis (TP) is accepted as part of the treatment for specific groups of diseases. The availability of different methods, including double filtration and adsorption, increases selectivity for the removal of substances. However, the use of these techniques requires a thorough understanding of the characteristics and components of plasma. By considering pivotal papers from several databases, the aim of this narrative review is to describe the characteristics of plasma related to apheresis techniques. We have tried to cover the clinical implications including physiology, estimation of plasma volume, viscosity, and a description of its components including the size, volume of distribution, and half-lives of the different substances to be removed or maintained depending on the clinical situation and applied apheresis technique. Applying this knowledge will help us to choose the right method and dosage and improve the efficacy of the procedure by preventing or addressing any complications.

Primary antiphospholipid syndrome associated with anti-phospholipase A2 receptor antibody-positive membranous nephropathy.

BACKGROUND: The kidney is a major target in primary antiphospholipid syndrome. Several types of nephropathy have been reported, the most frequent being acute or chronic specific vascular nephropathies and membranous nephropathy. CASE PRESENTATION: A 59-year-old male presented in our unit with nephrotic syndrome. He had a history of primary antiphospholipid syndrome with lupus anticoagulant treated with vitamin K antagonist therapy. On admission, antiphospholipid (lupus anticoagulant) and anti-PLA2R antibodies were positive. Screening for secondary etiologies was negative. In the context of primary antiphospholipid syndrome treated with vitamin K antagonist therapy, we did not perform a biopsy and we treated the patient with angiotensin-converting-enzyme inhibitor. No remission was observed at 6 months with persistent anti-PLA2R antibodies while antiphospholipid antibody level became negative. Consequently, kidney biopsy was performed showing both membranous nephropathy with PLA2R in deposits on immunohistochemistry with IgG4 dominance and antiphospholipid syndrome chronic vascular nephropathy. Following that, treatment with rituximab was started with secondarily a decrease in serum PLA2R antibody levels and partial remission. CONCLUSION: We report the first association between primary antiphospholipid syndrome and membranous nephropathy with anti-PLA2R antibodies. Our observations could suggest a causal link between primary antiphospholipid syndrome and PLA2R-related membranous nephropathy. Consequently, it would be interesting to screen for anti-PLA2R antibodies for further cases of nephrotic syndrome in patients with primary antiphospholipid syndrome and to search antiphospholipid antibodies in all membranous nephropathies.

Use of double filtration plasmapheresis for the treatment of acquired thrombocytopenic thrombotic purpura.

Double filtration plasmapheresis (DFPP) could be an alternative method to simple plasma exchange plasmapheresis in the treatment of acquired thrombotic thrombocytopenic purpura (aTTP). In a retrospective single center case series, we studied clinical presentation, management care, and prognosis of aTTP patients from our academic center treated with DFPP and IV infusion of fresh frozen plasma (FFP) between 2009 and 2018. Nine patients were included for 11 episodes. Median age was 38 years old (IQR 26-53) with 78% women. Six episodes (55%) required admission to the ICU, four of which required mechanical ventilation. Median FFP volume transfused was 35.2 mL/kg/d of session. Response was complete for nine episodes (82%). Four patients presented an early relapse, two a late relapse. Four patients died: one had an active untreated HCV infection, and two were over 80-year-old polymorbid patients. DFPP seems to be an efficient method of therapeutic plasmapheresis in TTP when combined with FFP transfusion and immunosuppressive treatments.

Spontaneous renal artery dissection with renal infarction.

Spontaneous renal artery dissection (SRAD) is a rare entity, which often presents diagnostic difficulties because of its non-specific clinical presentation. We report six cases complicated with renal infarction, occurring in middle-aged male patients without risk factors, illustrating the difficulty and delay for diagnosing SRAD. Ultrasound and Doppler imaging were not sensitive enough to confirm the diagnosis, and contrast-enhanced abdominal computed tomography was used to correct the diagnosis and allow the clinicians to propose appropriate treatment. We conclude that considering the urgency in diagnosing and treating SRAD, contrast enhanced abdominal tomography and/or abdominal magnetic resonance imaging should be proposed as soon as a suspicion of SRAD is evoked by the clinical presentation.

Optimal therapeutic conditions for online hemodiafiltration.

The safety of online hemodiafiltration (ol-HDF) relies on very strict rules of use. The use of ultrapure water to feed an ol-HDF machine is a basic requirement for ol-HDF. Technical aspects and microbial monitoring have been precisely described in the European Best Practice Guidelines. Specifically designed and certified ol-HDF machines are needed. All these machines share the production of substitution fluid by the cold sterilization process of fresh dialysate based on ultrafilters. Hygiene handling is a crucial measure to ensure permanent safety of the ol-HDF system. Frequent disinfection of the water treatment system and dialysis machine, destruction of biofilm by chemical agents and/or thermochemical disinfection, change of filters at regular intervals, and maintenance of a permanent circulation of water are among the basic measures required to ensure ultra-purity of water and dialysis fluid. Optimal performances of ol-HDF require the use of high blood flow (300-400 ml/min), highly permeable and adequately sized hemodiafilters, a high volume of substitution (5-6 l/h) and high dialysate flow (500 ml/min). The site and type of substitution (pre-, post-, mixed, and mid-dilution) should be customized to each patient according to its blood hemorheology and its filtration fraction limitation (transmembrane pressure). All attempts should be made to maximize the fluid volume exchange per session (convective dose) in any cases. The treatment schedule in terms of session duration and weekly frequency need to be adjusted individually to improve hemodynamic tolerance, to facilitate correction of fluid overload and to increase dialysis dose (for middle-sized solutes) in order to reduce circulating levels of major uremic toxins. ol-HDF is the more advanced form of renal replacement therapy offering high efficiency over a large spectrum of toxins, high biocompatibility profile and high flexible modality. ol-HDF may help to improve global care of chronic kidney disease patients and may be considered the renal replacement therapy of the future.