The Mount Sinai journal of medicine, New York
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Review
Thrombotic microangiopathy: differential diagnosis, pathophysiology and therapeutic strategies.
Several disease states manifest as thrombotic microangiopathies (TMA), most prominently thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). The recent discovery of the von Willebrand factor cleaving protease ADAMTS-13 (a disintegrin and metalloprotease with thrombospondin type 1 motif), found to be deficient in TTP, has helped separate these entities. ⋯ Although enormous progress has been made towards understanding these syndromes, the diagnostic tools and therapies used have hardly changed in the last 20 years, with the standard of care remaining plasma exchange in most cases. In this review, we will cover the multiple etiologic factors for TMAs, with the resultant differential diagnoses, as well as provide insight into the latest pathophysiologic findings and possible implications for treatment.
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Although a patent foramen ovale (PFO) is often found in younger patients with transient ischemic attacks or stroke, paradoxical embolization through PFO is rarely considered as a cause of acute limb ischemia. We report a single-center experience of 5 consecutive patients with limb-threatening ischemia due to paradoxical embolization within a one-year period. All patients were treated by catheter thrombectomy and long-term oral anticoagulation after surgery. The fact that the 5 embolectomies made up 10% of all embolectomies performed in our center during this time interval may indicate that the role of paradoxical embolization is still underestimated in peripheral embolic disease.
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Cardiovascular complications following noncardiac surgery constitute an enormous burden of perioperative morbidity and mortality. Annually, more than one million operations are complicated by adverse cardiovascular events, such as perioperative myocardial infarction or death from cardiac causes. In order to combat this problem, cardiac evaluation prior to noncardiac surgery should ask two questions about the patient: What is the risk of cardiac complications during and after surgery? How can that risk be reduced or eliminated? Risk assessment evaluates patients' co-morbidities and exercise tolerance, as well as the type of surgery to be performed, to determine the overall risk of perioperative cardiac complications. ⋯ Noninvasive testing offers only limited assistance in estimating risk for these patients. The best risk reduction strategy for these patients is perioperative beta blockade use. The role of coronary revascularization specifically to reduce perioperative cardiac complications remains unproven.
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Two years after being diagnosed with ulcerative colitis, a 57-year-old man taking oral mesalamine experienced severe respiratory distress due to left lung pleuropneumonitis. Eight months later, severe respiratory distress recurred due to right lung pneumonitis. Extraintestinal manifestations of inflammatory bowel disease or mesalamine-induced pulmonary injury were considered in the differential diagnosis, which was complicated by a history of aseptic meningitis and evidence of an ongoing autoimmune response. The implications of the case are discussed.
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The obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common disorder, estimated to occur in 4% of males and 2% of females in the workforce. This incidence increases with age. Obstructive sleep apnea-hypopnea is responsible for acute and chronic heart disease, but is a readily treatable disorder that is both underdiagnosed and underappreciated in health care. Because the cardiac consequences of untreated sleep apnea are so profound and the treatment relatively simple, the disorder needs to be recognized more frequently.