2. Research article in AJH, August 2015.
After recovery from an acute episode of
acquired TTP patients often describe
problems with memory, concentration and
endurance.
In this study, the frequency, severity and
clinical course of depression and cognitive
impairment is after recovery from TTP are
described.
3. Acquired autoimmune TTP is much more
prevalent in South Africa, especially in the HIV
positive population.
HIV in itself is associated with a decline in
mental function, depression, psychosis and
HIV encephalopathy.
Adding to it the burden of TTP, the incidence
of the depression and cognitive impairment
are much higher than what we can anticipate.
4. They evaluated health-related quality-
of-life, which documented significant
deficits involving both physical and
mental health domains.
They then evaluated neurocognitive
function , which documented significant
abnormalities in domains measuring
complex attention and concentration
skills, memorization and language
generation.
They also documented significantly
increased frequency of severe depression.
5. The Oklohoma TTP-HUS Registry has enrolled
all consecutive patients for whom the
Oklahoma Blood Instutite (OBI) was requested
to provide plasma exchange treatment for a
diagnosis of TTP, HUS or another thrombotic
microangiopathy (TMA) since Jan 1,1989.
There are no exclusion criteria, there is no
referral or selection bias.
6. ADAMTS13 measurments: Since Nov 1995,
serum samples have been collected
immediately before the first plasma
exchange. Severe deficiency : Levels <10%
Acquired autoimmune TTP was defined by the
presence of severe ADAMTS13 deficiency with
an ADAMTS13 activity inhibitor or by the
recovery of ADAMTS13 activity during
remission.
7. Included the following:
ADAMTS13 levels.
Screening evaluation for depression: Using the Beck
Depression Inventory (BDI)-II depressive symptoms were
acessed during six of the evaluations. (2004, 2006, 2009-
2011 & 2014)
Psychiatric interview and revised Hamilton rating scale for
depression. (In 2011)
Screening for cognitive impairment. (2006 - & 2014)
Statistical analysis: The 2014 BDI-II, RBANS, and MoCA
wore analysed as continuous variables for their scores.
These standarized scores provided a valid common metric
for the comparisons of individual patients across 8 years
from 2006-2014.
8. 77 patients
ADAMTS13<10%
1995-2014
64 survived
Initial episode
61 eligible for BD-II
2004-20I4
13 died
at initial
episode1313
3died
1998-2003
52 (85%) tested with BDI-
II
(1-6 x, median 4)
15 (29%)
severe
depression
>1 x
8 (15%)
moderate
depression
>1 x but
never
severe
8(15%) mild
depression
>1 x but
never
moderate or
severe
21 (41%)
minimal/no
depression
at all times
9. In 2014, 32 patients completed both the BDI-II
screening test for depression and the RBANS test for
cognitive function. The correlation between the
RBANS total scores and the BDI-II scores (p=0.0920,
r=0.31) did not support an asosiation between
cognitive impairment and depression for these
patients.
15 of the 32 patients have been evaluated by
extensive cognitive tests in 2006. The RBANS results
were significant worse than the 2006 results for the
overall score.
The domains which demonstrated decreased funtion
were immediate memory and delayed memory.
This is consistent with cognitive disorders associated
with cerebral small vessel disease.
10. The frequency of severe depression after
recovery of TTP is high, occurring in 29% of the
patients across 11 years.
These observations emphacise that regular
screening is an essential component of routine
patient care after acquired TTP to ensure that
depression is appropiatly diagnosed and
managed.
Depression is a dangerous disease. It erodes the
quality of life and personal productivity and is
assoaciated with nearly a two fold increased for
death. In 2002, depression ranked 4th in the
world as a cause of burden of disease.
11. The reason why the frequency of depression is
high among TTP survivors is uncertain.
Neither depression nor cognitive impairment was
significantly associated with the occurance of
previous relapses or with the occurance of severe
ADAMTS13 deficiency.
Patients with SLE also has a increased frequency
of depression and patients with TTP have an
increased risk for developting SLE.
SLE and TTP are common in young, black women.
Morbid obesity was significantly increased among
the patients at time of diagnosis of TTP.
These 3 factors have higher risk for depression.
12. Based on their experience, they suggest that
annual screening of patients who have
recovered form acquired TTP for depression
and cognitive function is appropiate.
Because acquired autoimmune TTP is an ucommon disorder, the authors had began regular meetings for survivors and there families in 1996 to help them understand their ilness. An unexpected outcome was that their patients helped them understand their long term outcomes. Although the patients had return to their normal activities and occupations, they and their families reported and incomplete return to their normal mental and physical function.
The OBI is the sole provider of plasma exchange services for all hospitals in 58/77 oklohama countries. Therefore the registry includes all consecutive patients within a defined geopgraphic region in whom the diagnosis of TTP/HUS/TMA was suspected and treated.
AdamsTS13 activity was measured in all samples by both quantitative immunoblotting and a flurogenic assay.
Beginning 2004 all pts who had recovered from acquired TTP have been asked to participate in annual evaluations.
2. The BDI-II is a 5-10 min self-reported screening questionnared with 21 statements related to the patient sx during the previous 2/52. The scores are interpreted as no/mininmal depression, mild depression or severe depression.
3 . Pt with BDI-II scores suggesting moderate or severe depression on at least one occasion were asked to take part in a psychiatric interview.
The diagnosis establish by psychiatric interview were as follows: MDD , No MDD but presence of depressive sx, and no MDD or depressive sx
4. Patients were screened with two tests the MOCA ( Montreal cognitive assesment ) and Repeatable battery for assesment of neurolopsychological status (RBANS).
From 1995-2013, 77 consecutive patients with acquired TTP have been enrolled at the time of their initial episode.
13 (17%) out of 77 patients died at their initial episode, 3 additional patients died before the annual evaluations begin in 2004.
52 (85%) out of 61 surviving eligble Oklahoma Registry patients who had recovered from TTP, documented by ADAMTS13 activity <10%, have had at least one (median four) evaluation for depression over 11 years using the BDI-II.
31 (59%) patients screened positive for depression at least once, in 15 (29 %) suggested severe depression at least once.
Psychiatric interview was conducted on 9 out of 11 patients.
The interview confirmed a MDD in 8 of the 9 pt.
From 1995-2013, 77 consecutive patients with acquired TTP have been enrolled at the time of their initial episode.
13 (17%) out of 77 patients died at their initial episode, 3 additional patients died before the annual evaluations begin in 2004.
52 (85%) out of 61 surviving eligble Oklahoma Registry patients who had recovered from TTP, documented by ADAMTS13 activity <10%, have had at least one (median four) evaluation for depression over 11 years using the BDI-II.
31 (59%) patients screened positive for depression at least once, in 15 (29 %) suggested severe depression at least once.
Psychiatric interview was conducted on 9 out of 11 patients.
The interview confirmed a MDD in 8 of the 9 pt.
The reason for the progressive impairment of cognitive function in TTP survivors is uncertain. It may be consistant with other indications of progressive organ impairment and increased mortality after recovery from TTP.
