Thrombocytopenia: Evaluation and Management

Thrombocytopenia is a platelet count of less than 150 × 103 per μL and can occur from decreased platelet production, increased destruction, splenic sequestration, or dilution or clumping. Patients with a platelet count greater than 50 × 103 per μL are generally asymptomatic. Patients with platelet counts between 20 and 50 × 103 per μL may have mild skin manifestations such as petechiae, purpura, or ecchymosis. Patients with platelet counts of less than 10 × 103 per μL have a high risk of serious bleeding. Although thrombocytopenia is classically associated with bleeding, there are conditions in which bleeding and thrombosis can occur, such as antiphospholipid syndrome, heparin-induced thrombocytopenia, and thrombotic microangiopathies. Patients with isolated thrombocytopenia in the absence of systemic illness most likely have immune thrombocytopenia or drug-induced thrombocytopenia. In stable patients being evaluated as outpatients, the first step is to exclude pseudothrombocytopenia by collecting blood in a tube containing heparin or sodium citrate and repeating the platelet count. If thrombocytopenia is confirmed, the next step is to distinguish acute from chronic thrombocytopenia by obtaining or reviewing previous platelet counts. Patients with acute thrombocytopenia may require hospitalization. Common causes that require emergency hospitalization are heparin-induced thrombocytopenia, thrombotic microangiopathies, and the hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. Common nonemergency causes of thrombocytopenia include drug-induced thrombocytopenia, immune thrombocytopenia, and hepatic disease. Transfusion of platelets is recommended when patients have active hemorrhage or when platelet counts are less than 10 × 103 per μL, in addition to treatment (when possible) of underlying causative conditions. It is important to ensure adequate platelet counts to decrease bleeding risk before invasive procedures;this may also require a platelet transfusion. Patients with platelet counts of less than 50 × 103 per μL should adhere to activity restrictions to avoid trauma-associated bleeding. (Am Fam Physician. 2022;106(3):288–298. Copyright © 2022 American Academy of Family Physicians.)

P. micra and F. necrophorum: Hepatic Abscesses in a Healthy Soldier.

Parvimonas micra (P. micra) and Fusobacterium necrophorum (F. necrophorum) are two pathogens known to cause odontogenic and oropharyngeal infections. It is exceedingly rare for these bacteria to cause coinfection and even systemic infection. There is limited literature on liver abscesses and bacteremia involving P. micra. Most cases are found in elderly patients with associated gastrointestinal malignancy (24%) or laryngeal pharynx malignancy (28%). However, a substantial portion of described cases were unable to identify a source (36%). A 36-year-old, otherwise healthy male presented for fevers and chills for 2 weeks. After testing negative for initial infectious workup, including COVID-19 multiple times, he was found to have multiple liver abscesses which grew P. micra and F. necrophorum. This case highlights a rare coinfection of hepatic abscesses in an otherwise healthy young immunocompetent adult with a solitary dental caries, resulting in septic shock.

Evaluating child maltreatment and family violence risk during the COVID-19 Pandemic: Using a telehealth home visiting program as a conduit to families.

The COVID-19 pandemic has affected many child maltreatment risk factors and may have affected maltreatment among vulnerable families. We surveyed 258 certified providers of an evidence-based home visiting program, SafeCare, about their perception of the impact of the pandemic on the families they serve. We examined if the providers perceived an overall change in child maltreatment and family violence risk among the families with young children they served and factors that may have contributed to changes. Regressions estimated the relationship between providers' assessment of families' ability to social distance, emotional struggles, and access to public resources/services with providers' perception of child maltreatment and family violence risk in the home. Findings indicate that 87% of providers believed maltreatment risk had increased during the pandemic. Providers serving families who were unable to social distance due to employment were more likely to report increased supervisory neglect and material neglect among the families they serve. Providers reporting that families were struggling with elevated frustration levels also reported more family conflict and material neglect among the families they serve. Results from this research can inform strategic decision-making for policies and programs that address the challenges low-income families with young children face in emergency situations.

La pandemia del COVID-19 ha afectado muchos factores de riesgo de maltrato del niño y pudiera haber afectado el maltrato en familias vulnerables. Les preguntamos en una encuesta a 258 proveedores certificados de un programa de visitas a casa con base en la evidencia, SafeCare®, acerca de sus percepciones del impacto de la pandemia en las familias a quienes les ofrecían el servicio. Examinamos si los proveedores percibían un cambio general en el maltrato del niño y el riesgo de violencia familiar en familias con niños pequeños a las que les servían y los factores que pudieran haber contribuido a los cambios. Las regresiones calcularon la relación entre la evaluación de los proveedores acerca de la habilidad de la familia para mantener la distancia social física, los problemas emocionales, así como el acceso a recursos y servicios públicos, con la percepción de los proveedores acerca del maltrato infantil y el riesgo de violencia familiar en la casa. Los resultados indican que el 87 por ciento de los proveedores creía que el riesgo de maltrato había aumentado durante la pandemia. Aquellos proveedores que les servían a familias que no podían mantener la distancia social física debido al empleo, estuvieron más propensas a reportar el aumento en la negligencia de supervisión y la negación de material en las familias a quienes les servían. Los proveedores que reportaron que las familias estaban luchando con elevados niveles de frustración también reportaron más conflicto familiar y negación de material en las familias a las que les servían. Los resultados de esta investigación pueden apoyar la toma de decisiones estratégica para políticas y programas que se enfoquen en los retos que enfrentan las familias de bajos recursos con niños pequeños en situaciones de emergencia.

La pandémie du COVID-19 a affecté bien des facteurs de risque de la maltraitance de l'enfant et peut avoir affecté la maltraitance chez les familles vulnérables. Nous avons questionné 258 prestataires certifiés d'un programme de visite à domicile fondé sur des données probantes, SafeCare®, sur leur perception de l'impact de la pandémie sur les familles qu'ils servent. Nous avons examiné si les prestataires ont perçu un changement général de la maltraitance de l'enfant et dans le risque de violence familiale au sein des familles avec les jeunes enfants qu'ils servaient et les facteurs qui ont pu contribuer à ces changements. Des régressions ont estimé la relation entre l'évaluation qu'ont fait les prestataires de la capacité des familles à assurer la distanciation sociale, des difficutés émotionnelles et de l'accès aux resources/services publiques avec la perception des prestataires de la maltraitance de l'enfant et du risque de violence familiale à la maison. Les résultats indiquent que 87 pourcent des prestataires pensaient que le risque de maltraitance avait augmenté durant la pandémie. Les prestataires servant les familles qui ne pouvaient pas assurer la distanciation sociale à cause de leur emploi étaient plus à même de faire état d'une négligence acrue de la supervision et de négligence matérielle chez les familles qu'ils servent. Les prestataires indiquant que les familles faisaient face à des difficultés avec des niveaux de frustration élevés ont aussi fait état de plus de conflit familial et de néglicence matérielle chez les familles qu'ils servent. Les résultats de ces recherches peuvent aider les prises de décision stratégiques pour les politiques et les programmes qui répondent aux défis des familles défavorisées avec de jeunes enfants dans des situations d'urgence.

The Impact of COVID-19 on the Delivery of an Evidence-Based Child Maltreatment Prevention Program: Understanding the Perspectives of SafeCare® Providers.

Child maltreatment (CM) is a global public health problem. Evidence-based home visiting programs, such as SafeCare®, reduce CM risk, and enhance parent-child relationships and other protective factors. As the result of the COVID-19 pandemic and resulting restrictions, SafeCare Providers transitioned from home to virtual delivery for the SafeCare curriculum. The purpose of this study is to 1) examine active SafeCare Providers' opinions on the feasibility and effectiveness of SafeCare via remote delivery, and 2) better understand workforce concerns for human service professionals within the context of COVID-19 mitigation efforts. Data are from a cross-sectional survey of SafeCare Providers (N = 303) in the United States, Canada, and Australia. The majority of Providers reported they were actively delivering SafeCare virtually and were comfortable with the delivery format. Providers indicated that the majority of SafeCare families are making progress on target skills, and that engagement is high among many families. Some service delivery challenges were reported, ranging from family data plan limitations to difficulty with delivery of specific components of the SafeCare curriculum related to modeling and assessment. The impact of COVID-19 on Providers' daily routines, stress level, and work-life balance has been significant. Remote, virtual delivery of CM prevention programming offers the opportunity to continue serving vulnerable families in the midst of a pandemic. Barriers related to family technology and data access must be addressed to ensure reach and the effective delivery of prevention programming during the pandemic and beyond.