Treatment of immune thrombocytopenia in Australian adults: A multicenter retrospective observational study.

Background: In Australia, prescribing restrictions limit access to internationally recommended second-line therapies such as rituximab and thrombopoietin agonists (TPO-A) (eltrombopag and romiplostim). Subsequent lines of therapy include an array of immunosuppressive and immune-modulating agents directed by drug availability and physician and patient preference. Objectives: The objective of the study was to describe the use of first and subsequent lines of treatment for adult immune thrombocytopenia (ITP) in Australia and to assess their effectiveness and tolerability. Patients/Methods: A retrospective review of medical records was conducted of 322 patients treated for ITP at eight participating centers in Australia between 2013 and 2020. Data were analyzed by descriptive statistics and frequency distribution using pivot tables, and comparisons between centers were assessed using paired t tests. Results: Mean age at diagnosis of ITP was 48.8 years (standard deviation [SD], 22.6) and 58.3% were women. Primary ITP was observed in 72% and secondary ITP in 28% of the patients; 95% of patients received first-line treatment with prednisolone (76%), dexamethasone (15%), or intravenous immunoglobulin (48%) alone or in combination. Individuals with secondary ITP were less steroid dependent (72% vs. 76%) and required less treatment with a second-line agent (47% vs. 58%) in the study sample. Over half (56%) of the cohort received treatment with one or more second-line agents. The mean number of second-line agents used for each patient was 1.9 (SD, 1.2). The most used second-line therapy was rituximab, followed by etrombopag and splenectomy. These also generated the highest rates of complete response (60.3%, 72.1%, and 71.8% respectively). The most unfavorable side effect profiles were seen in long-term corticosteroids and splenectomy. Conclusion: A wide range of "second-line" agents were used across centers with variable response rates and side effect profiles. Findings suggest greater effectiveness of rituximab and TPO-A, supporting their use earlier in the treatment course of patients with ITP across Australia.

Microvascular narrowing and BP monitoring: A single centre observational study.

INTRODUCTION: Half of all hypertensive individuals have inadequately-controlled BP because monitoring methods are ineffective. This single centre study examined consecutive subjects undergoing 24 hour BP measurements for clinic and ambulatory BP levels, and for end-organ damage (retinal microvascular abnormalities and left ventricular hypertrophy, LVH, > 1.1 cm). Retinal images were graded for microvascular retinopathy (Wong and Mitchell classification), and vessel calibre using a semiautomated method. Features were compared using chi-squared, Fisher's exact or the student's t test. METHODS: One hundred and thirty-one individuals (59 male, 45.0%, mean age 61.7 ± 14.5 years) were studied. Ninety-nine (76.2%) had a clinic BP ≥ 140/90 mm Hg, 84 (64.6%) had a mean awake systolic BP ≥ 135 mm Hg, 100 (76.9%) had a mean sleeping systolic BP ≥ 120 mm Hg, and 100 (76.2%) had abnormal nocturnal BP dipping patterns. Sixty-nine individuals had undergone echocardiography and 23 (33.3%) had LVH. RESULTS: All participants had a mild (88.5%) or moderate (11.5%) microvascular retinopathy. Moderate microvascular retinopathy was found in 86.7% of those with a mean awake systolic BP ≥135 mm Hg (p = 0.058) but was not associated with other abnormal BP measurements, abnormal dipping patterns or LVH. However retinal arteriole calibre was reduced in subjects with a mean 24 hour awake systolic BP ≥ 135 mm Hg (p = 0.05). Retinal arteriole calibre was smaller in subjects with LVH (128.1 ± 13.5 µm compared with 137.6 ± 14.1 µm in normals, p = 0.014). Venular calibre was also less in subjects with LVH (185.4 ± 24.6 µm compared with 203.0 ± 27.2 µm in normals, p = 0.016). Arteriole narrowing predicted an increased risk of LVH (AUC 0.69, 95%CI 0.55 to 0.83) that was comparable with 24 hour systolic BP ≥130 mm Hg (AUC 0.68, 95%CI 0.53 to 0.82) and mean awake systolic BP ≥135 mm Hg (AUC 0.68, 95%CI 0.54 to 0.83). CONCLUSIONS: This study suggests that retinal arteriole narrowing may be equally accurate in predicting LVH as any clinic or ambulatory BP measurement. The convenience and accuracy of microvascular calibre measurement mean that it should be investigated further for a role in routine hypertension assessment and monitoring.

Co-morbidity of PTSD and immune system dysfunction: opportunities for treatment.

Posttraumatic stress disorder (PTSD) is defined as a psychiatric disorder; however, PTSD co-occurs with multiple somatic manifestations. People living with PTSD commonly manifest dysregulations in the systems that regulate the stress response, including the hypothalamic-pituitary-adrenal (HPA) axis, and development of a pro-inflammatory state. Additionally, somatic autoimmune and inflammatory diseases and disorders have a high rate of co-morbidity with PTSD. Recognition and understanding of the compounding effect that these disease states can have on each other, evidenced from poorer treatment outcomes and accelerated disease progression in patients suffering from co-morbid PTSD and/or other autoimmune and inflammatory diseases, has the potential to lead to additional treatment opportunities.