Chong, Christina

Background: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening hematologic emergency caused by ADAMTS13 deficiency, leading to microvascular thrombosis, haemolytic anaemia, thrombocytopenia, and end-organ damage. Neurological symptoms occur in up to 90% of cases and are frequently misdiagnosed as stroke. Prompt recognition and treatment reduce the mortality rate from over 90% to 10–20%. Case presentation: A 70-year-old woman with no significant medical history presented with acute aphasia and right-sided facial and upper extremity numbness. Five days prior, she had experienced fatigue, headache, and bruising. On admission, she had stable vitals with mild aphasia and purpuric ecchymoses noted on examination. Laboratory findings revealed haemolytic anaemia (haemoglobin 7.8 g/dl, lactate dehydrogenase 875 U/l, total bilirubin 2.4 mg/dl), thrombocytopenia (35 ×109/l), and unremarkable coagulation studies (partial thromboplastin time 30 sec, prothrombin time-international normalized ratio 1, fibrinogen 370 mg/dl, D-dimer 2.15 ng/ml). Peripheral smear showed no schistocytes but noted 2+spherocytes. Stroke was ruled out with brain magnetic resonance imaging/magnetic resonance angiography. Given the bicytopenia with possible haemolysis along with new neurological symptoms, TTP was considered in the differential diagnosis. A PLASMIC score of 5 suggested a high probability of TTP. Plasma exchange and corticosteroids were initiated within 5 hours of presentation. ADAMTS13 activity <1% confirmed the diagnosis 4 days after presentation. After five plasma exchange sessions, the patient’s platelet count normalized and neurologic deficits resolved by discharge. Conclusion: This case underscores the importance of considering TTP in stroke mimics, even in the absence of schistocytes, if clinical suspicion is high. Early recognition and initiation of treatment significantly improve patient outcomes.

ABSTRACTBackgroundEfficient discharge planning is crucial for improving hospital capacity and patient care. Multidisciplinary rounds (MDRs) have been shown to enhance communication and coordination, yet their impact on resident teaching teams’ discharge efficiency is less studied.AimsTo examine how embedding dedicated case managers (CMs) and social workers (SWs) into internal medicine (IM) resident teams impacts discharge efficiency.MethodsWe conducted a retrospective cross‐sectional study at The Queen's Medical Center comparing two resident multidisciplinary teaching (MDT) teams that included dedicated CMs and SWs with two resident standard care teams over an 8‐month period (October 18 2023–June 25 2024). The outcomes assessed included length of stay (LOS), expected discharge date (EDD) accuracy, readmission rates and the rate of conditional discharge orders placed.ResultsA total of 1944 patients were included. The MDT teams showed significantly improved EDD accuracy (72.0% vs 66.7%, P = 0.0120) and more frequently placed conditional discharge orders (61.7% vs 43.8%, P < 0.0001) compared to standard care teams. No significant difference was observed in LOS or readmission rates.ConclusionEmbedding dedicated CMs and SWs within resident teams improved EDD accuracy and the rate of conditional discharge orders placed, suggesting an opportunity to integrate MDRs as a standard within IM residency training to enhance discharge planning efficiency.