{"version":"1.0.0","segments":[{"startTime":1.486,"endTime":3.396,"body":"♪ (music) ♪"},{"startTime":3.396,"endTime":5.597,"body":"(Cathy) Hi, welcome to \u003ci\u003eHarrison's Podclass\u003c/i\u003e"},{"startTime":5.597,"endTime":8.344,"body":"where we discuss important concepts"},{"startTime":5.597,"endTime":8.344,"body":"in internal medicine."},{"startTime":8.344,"endTime":9.585,"body":"I'm Cathy Handy."},{"startTime":9.585,"endTime":11.868,"body":"(Charlie) And I'm Charlie Wiener,"},{"startTime":9.585,"endTime":11.868,"body":"and we're coming to you"},{"startTime":11.868,"endTime":14.125,"body":"from the Johns Hopkins School of Medicine."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":17.524,"endTime":20.638,"body":"A 44 Year Old"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":17.524,"endTime":20.638,"body":"with Altered Mental Status and Fever."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":20.638,"endTime":22.29,"body":"(Charlie) Here's the opening."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":22.29,"endTime":25.846,"body":"A 44-year-old obese woman"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":22.29,"endTime":25.846,"body":"undergoes elective cholecystectomy"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":25.846,"endTime":27.406,"body":"for cholelithiasis."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":27.406,"endTime":30.229,"body":"She takes an antidepressant"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":27.406,"endTime":30.229,"body":"but is otherwise healthy."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":30.229,"endTime":32.106,"body":"(Cathy) So far that doesn't sound"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":30.229,"endTime":32.106,"body":"too abnormal."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":32.106,"endTime":34.485,"body":"Women get gallstones"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":32.106,"endTime":34.485,"body":"more commonly than men,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":34.485,"endTime":38.457,"body":"and obesity is one of the risk factors"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":34.485,"endTime":38.457,"body":"for the development of gallstones."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":38.457,"endTime":39.992,"body":"(Charlie) Okay, then let's move on."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":39.992,"endTime":44.515,"body":"Post-operatively she does well and is"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":39.992,"endTime":44.515,"body":"discharged to home after three days."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":44.515,"endTime":47.634,"body":"However, two days after discharge,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":44.515,"endTime":47.634,"body":"she develops altered mental status"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":47.634,"endTime":50.952,"body":"and fever and is brought to the"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":47.634,"endTime":50.952,"body":"emergency department by her family."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":50.952,"endTime":54.683,"body":"In the emergency department,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":50.952,"endTime":54.683,"body":"her temperature is 103 degrees Fahrenheit."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":54.683,"endTime":56.541,"body":"Pulse is 127 per minute."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":56.541,"endTime":60.675,"body":"Blood pressure's 110 over 78,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":56.541,"endTime":60.675,"body":"and she has a normal respiratory rate"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":60.675,"endTime":62.394,"body":"and oxygen saturation."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":62.394,"endTime":65.187,"body":"Physical examination is"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":62.394,"endTime":65.187,"body":"notable for confusion"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":65.187,"endTime":67.958,"body":"and a well-healed surgical incision."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":67.958,"endTime":70.97,"body":"Routine chemistries are drawn"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":67.958,"endTime":70.97,"body":"and show normal electrolytes"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":70.97,"endTime":74.25,"body":"with the exception of a BUN"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":70.97,"endTime":74.25,"body":"of 80 milligrams per deciliter"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":74.25,"endTime":76.096,"body":"and a creatinine of 2.5."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":76.096,"endTime":80.588,"body":"Her CBC shows her"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":76.096,"endTime":80.588,"body":"white cell count is 17,300,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":80.588,"endTime":82.243,"body":"her hematocrit is 30%,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":82.243,"endTime":84.712,"body":"and her platelet count is 25,000."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":85.289,"endTime":88.341,"body":"Of note, at discharge her CBC was normal."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":88.341,"endTime":91.543,"body":"(Cathy) So, she has the acute onset"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":88.341,"endTime":91.543,"body":"of fever and neurologic symptoms"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":91.543,"endTime":93.321,"body":"after her elective surgery."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":93.321,"endTime":96.667,"body":"To summarize the labs, we heard"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":93.321,"endTime":96.667,"body":"that she has acute renal failure,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":96.667,"endTime":99.794,"body":"leukocytosis, anemia"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":96.667,"endTime":99.794,"body":"and thrombocytopenia."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":99.794,"endTime":102.944,"body":"Did she have any coagulation studies"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":99.794,"endTime":102.944,"body":"or a peripheral smear"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":102.944,"endTime":106.779,"body":"because one consideration is"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":102.944,"endTime":106.779,"body":"that she could have sepsis with DIC,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":106.779,"endTime":109.692,"body":"but it's reassuring"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":106.779,"endTime":109.692,"body":"that the surgical sight looks good."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":109.692,"endTime":113.531,"body":"Although, she could also have an infection"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":109.692,"endTime":113.531,"body":"in an intra-abdominal source."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":113.531,"endTime":116.778,"body":"(Charlie) So, her coagulation studies"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":113.531,"endTime":116.778,"body":"in the ED are normal."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":116.778,"endTime":119.44,"body":"A peripheral blood smear"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":116.778,"endTime":119.44,"body":"shows schistocytes"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":119.44,"endTime":121.904,"body":"and confirms low platelets"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":119.44,"endTime":121.904,"body":"without clumping."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":121.904,"endTime":125.841,"body":"(Cathy) So, the normal coagulation studies"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":121.904,"endTime":125.841,"body":"make DIC due to sepsis less likely,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":125.841,"endTime":128.957,"body":"but the presence of schistocytes"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":125.841,"endTime":128.957,"body":"on the peripheral smear suggests"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":128.957,"endTime":132.09,"body":"that she has a microangiopathic"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":128.957,"endTime":132.09,"body":"hemolytic anemia."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":132.09,"endTime":134.179,"body":"(Charlie) So, how does"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":132.09,"endTime":134.179,"body":"that change your thinking?"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":134.179,"endTime":137.537,"body":"(Cathy) A microangiopathic"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":134.179,"endTime":137.537,"body":"hemolytic anemia with thrombocytopenia,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":137.537,"endTime":140.987,"body":"fever and neurologic findings"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":137.537,"endTime":140.987,"body":"are consistent, if not classic"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":140.987,"endTime":145.785,"body":"for the diagnosis of TTP,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":140.987,"endTime":145.785,"body":"or thrombotic thrombocytopenic purpura."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":145.785,"endTime":149.415,"body":"So, that's the classic pentad"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":145.785,"endTime":149.415,"body":"and includes fever, neurologic findings,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":149.415,"endTime":152.839,"body":"renal failure, hemolytic anemia"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":149.415,"endTime":152.839,"body":"and thrombocytopenia."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":152.839,"endTime":155.817,"body":"It's rarely seen these days"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":152.839,"endTime":155.817,"body":"happening all together."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":155.817,"endTime":158.79,"body":"So, in the absence of the pentad,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":155.817,"endTime":158.79,"body":"you shouldn't be discouraged"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":158.79,"endTime":160.238,"body":"about thinking about TTP,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":160.238,"endTime":162.686,"body":"and it really should be"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":160.238,"endTime":162.686,"body":"on the differential for any patient"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":162.686,"endTime":165.146,"body":"who has a microangiopathic"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":162.686,"endTime":165.146,"body":"hemolytic anemia"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":165.146,"endTime":167.126,"body":"and thrombocytopenia."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":167.133,"endTime":170.163,"body":"(Charlie) What is the mechanism"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":167.133,"endTime":170.163,"body":"of TTP, and who gets it?"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":170.163,"endTime":173.946,"body":"(Cathy) So, typically high molecular"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":170.163,"endTime":173.946,"body":"weight multimers of von Willebrand factor"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":173.946,"endTime":177.529,"body":"are produced by the endothelial cells"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":173.946,"endTime":177.529,"body":"and are processed into smaller multimers"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":177.529,"endTime":181.581,"body":"by a plasma metalloprotease"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":177.529,"endTime":181.581,"body":"called ADAMTS13."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":181.581,"endTime":186.541,"body":"In TTP, the activity of ADAMTS13"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":181.581,"endTime":186.541,"body":"the protease is inhibited,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":186.541,"endTime":189.773,"body":"and the ultra high molecular"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":186.541,"endTime":189.773,"body":"weight multimers of von Willebrand factor"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":189.773,"endTime":192.118,"body":"initiate platelet aggregation,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":189.773,"endTime":192.118,"body":"and they form clots"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":192.118,"endTime":193.622,"body":"and shear erythrocytes."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":193.622,"endTime":196.997,"body":"So, this causes the hemolytic anemia"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":193.622,"endTime":196.997,"body":"and the microthrombi that cause"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":196.997,"endTime":199.765,"body":"the rest of the clinical findings"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":196.997,"endTime":199.765,"body":"that were mentioned above."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":199.765,"endTime":202.669,"body":"(Charlie) What typically precipitates TTP?"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":202.669,"endTime":205.195,"body":"(Cathy) Most cases are acquired"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":202.669,"endTime":205.195,"body":"and usually there is some trigger."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":205.195,"endTime":207.257,"body":"In this case, it's probably surgery."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":207.257,"endTime":210.696,"body":"It's obviously not a common complication"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":207.257,"endTime":210.696,"body":"of elective cholecystectomies,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":210.696,"endTime":212.846,"body":"but definitely can trigger TTP."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":212.846,"endTime":216.485,"body":"Infection, pancreatitis, pregnancy"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":212.846,"endTime":216.485,"body":"have also been associated,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":216.485,"endTime":219.205,"body":"and some drugs can cause TTP, too."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":219.205,"endTime":222.56,"body":"The drugs I typically think of"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":219.205,"endTime":222.56,"body":"as being associated tend to be"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":222.56,"endTime":224.854,"body":"the immunosuppressive agents,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":222.56,"endTime":224.854,"body":"some chemotherapies"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":224.854,"endTime":228.262,"body":"or antiplatelet drugs,"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":224.854,"endTime":228.262,"body":"but she isn't taking any of those."},{"speaker":"(Cathy) Welcome to Episode 20","startTime":228.262,"endTime":230.173,"body":"(Charlie) Okay, so let's get"},{"speaker":"(Cathy) Welcome to Episode 20","startTime":228.262,"endTime":230.173,"body":"to the question."},{"speaker":"The question asks","startTime":230.173,"endTime":233.517,"body":"\"Which"},{"speaker":"The question asks","startTime":230.173,"endTime":233.517,"body":"of the following statements"},{"speaker":"The question asks","startTime":233.517,"endTime":236.162,"body":"regarding her condition is true?\""},{"speaker":"The question asks","startTime":236.162,"endTime":242.352,"body":"Option A says, a low activity"},{"speaker":"The question asks","startTime":236.162,"endTime":242.352,"body":"of metalloprotease ADAMTS13"},{"speaker":"The question asks","startTime":242.352,"endTime":244.904,"body":"is likely present in her peripheral blood."},{"speaker":"The question asks","startTime":244.904,"endTime":249.293,"body":"Option B is, plasma exchange"},{"speaker":"The question asks","startTime":244.904,"endTime":249.293,"body":"is unlikely to be helpful."},{"speaker":"The question asks","startTime":249.293,"endTime":252.739,"body":"Option C says, her condition"},{"speaker":"The question asks","startTime":249.293,"endTime":252.739,"body":"was likely caused"},{"speaker":"by an occult E. coli O157","startTime":252.739,"endTime":257.75,"body":"H7 infection."},{"speaker":"by an occult E. coli O157","startTime":257.75,"endTime":261.783,"body":"Option D says, her condition is"},{"speaker":"by an occult E. coli O157","startTime":257.75,"endTime":261.783,"body":"more common in men than women."},{"speaker":"by an occult E. coli O157","startTime":261.783,"endTime":266.203,"body":"Option E says, untreated mortality"},{"speaker":"by an occult E. coli O157","startTime":261.783,"endTime":266.203,"body":"from this condition is low."},{"speaker":"by an occult E. coli O157","startTime":266.203,"endTime":268.638,"body":"(Cathy) As I alluded to before,"},{"speaker":"by an occult E. coli O157","startTime":266.203,"endTime":268.638,"body":"the answer is A."},{"speaker":"by an occult E. coli O157","startTime":268.638,"endTime":271.709,"body":"So, you can send"},{"speaker":"by an occult E. coli O157","startTime":268.638,"endTime":271.709,"body":"an ADAMTS13 activity level"},{"speaker":"by an occult E. coli O157","startTime":271.709,"endTime":273.474,"body":"which can take a while to come back."},{"speaker":"by an occult E. coli O157","startTime":273.474,"endTime":277.099,"body":"So, it's not something you can generally"},{"speaker":"by an occult E. coli O157","startTime":273.474,"endTime":277.099,"body":"use to make the diagnosis overnight,"},{"speaker":"by an occult E. coli O157","startTime":277.099,"endTime":280.461,"body":"but that activity level will be low"},{"speaker":"by an occult E. coli O157","startTime":277.099,"endTime":280.461,"body":"in patients who have TTP."},{"speaker":"by an occult E. coli O157","startTime":280.461,"endTime":282.803,"body":"(Charlie) What do you think"},{"speaker":"by an occult E. coli O157","startTime":280.461,"endTime":282.803,"body":"about the other answers though?"},{"speaker":"by an occult E. coli O157","startTime":282.803,"endTime":284.008,"body":"Why are they wrong?"},{"speaker":"by an occult E. coli O157","startTime":284.008,"endTime":286.244,"body":"(Cathy) Well, it's more common"},{"speaker":"by an occult E. coli O157","startTime":284.008,"endTime":286.244,"body":"in women compared to men,"},{"speaker":"by an occult E. coli O157","startTime":286.244,"endTime":287.855,"body":"so that excludes D."},{"speaker":"by an occult E. coli O157","startTime":287.855,"endTime":290.66,"body":"And B and E are also the opposite"},{"speaker":"by an occult E. coli O157","startTime":287.855,"endTime":290.66,"body":"of what is true."},{"speaker":"by an occult E. coli O157","startTime":290.66,"endTime":293.983,"body":"E. coli infection is associated"},{"speaker":"by an occult E. coli O157","startTime":290.66,"endTime":293.983,"body":"with the development of HUS,"},{"speaker":"by an occult E. coli O157","startTime":293.983,"endTime":297.899,"body":"or hemolytic uremic syndrome,"},{"speaker":"by an occult E. coli O157","startTime":293.983,"endTime":297.899,"body":"and it's seen predominantly in children."},{"speaker":"by an occult E. coli O157","startTime":297.899,"endTime":300.576,"body":"(Charlie) What's the role"},{"speaker":"by an occult E. coli O157","startTime":297.899,"endTime":300.576,"body":"of plasma exchange in TTP?"},{"speaker":"by an occult E. coli O157","startTime":300.576,"endTime":304.569,"body":"(Cathy) The mortality of TTP untreated"},{"speaker":"by an occult E. coli O157","startTime":300.576,"endTime":304.569,"body":"is very high, close to 90%,"},{"speaker":"by an occult E. coli O157","startTime":304.569,"endTime":307.49,"body":"and that's primarily"},{"speaker":"by an occult E. coli O157","startTime":304.569,"endTime":307.49,"body":"from microvascular thrombosis,"},{"speaker":"by an occult E. coli O157","startTime":307.49,"endTime":309.061,"body":"and multi-organ failure."},{"speaker":"by an occult E. coli O157","startTime":309.061,"endTime":311.829,"body":"Plasma exchange is the mainstay"},{"speaker":"by an occult E. coli O157","startTime":309.061,"endTime":311.829,"body":"of treatment, and it's done"},{"speaker":"by an occult E. coli O157","startTime":311.829,"endTime":313.749,"body":"as soon as you make the diagnosis."},{"speaker":"by an occult E. coli O157","startTime":313.749,"endTime":317.749,"body":"Again, this is often before"},{"speaker":"by an occult E. coli O157","startTime":313.749,"endTime":317.749,"body":"even the ADAMTS13 result is back."},{"speaker":"by an occult E. coli O157","startTime":317.749,"endTime":320.707,"body":"And it's repeated"},{"speaker":"by an occult E. coli O157","startTime":317.749,"endTime":320.707,"body":"until the platelet count is normalized,"},{"speaker":"by an occult E. coli O157","startTime":320.707,"endTime":323.048,"body":"and the signs of hemolysis are resolved."},{"speaker":"by an occult E. coli O157","startTime":323.048,"endTime":326.672,"body":"(Charlie) Okay, so therefore, Option B,"},{"speaker":"by an occult E. coli O157","startTime":323.048,"endTime":326.672,"body":"which says plasma exchange"},{"speaker":"by an occult E. coli O157","startTime":326.672,"endTime":330.511,"body":"is unlikely to be helpful is actually,"},{"speaker":"by an occult E. coli O157","startTime":326.672,"endTime":330.511,"body":"again, the opposite of what is true."},{"speaker":"by an occult E. coli O157","startTime":330.511,"endTime":331.798,"body":"- Right?"},{"speaker":"by an occult E. coli O157","startTime":330.511,"endTime":331.798,"body":"- (Cathy) That's right."},{"speaker":"by an occult E. coli O157","startTime":331.798,"endTime":335.791,"body":"(Charlie) Okay, so the teaching point"},{"speaker":"by an occult E. coli O157","startTime":331.798,"endTime":335.791,"body":"here is that the classic pentad of TTP,"},{"speaker":"by an occult E. coli O157","startTime":335.791,"endTime":339.804,"body":"that being fever, neurologic symptoms,"},{"speaker":"by an occult E. coli O157","startTime":335.791,"endTime":339.804,"body":"renal failure, hemolytic anemia,"},{"speaker":"by an occult E. coli O157","startTime":339.804,"endTime":342.932,"body":"and thrombocytopenia is classic for TTP,"},{"speaker":"by an occult E. coli O157","startTime":342.932,"endTime":345.637,"body":"although is seldom seen"},{"speaker":"by an occult E. coli O157","startTime":342.932,"endTime":345.637,"body":"in any real patient."},{"speaker":"by an occult E. coli O157","startTime":345.637,"endTime":349.709,"body":"TTP can be precipitated"},{"speaker":"by an occult E. coli O157","startTime":345.637,"endTime":349.709,"body":"by surgery, or other drugs,"},{"speaker":"by an occult E. coli O157","startTime":349.709,"endTime":351.439,"body":"or other precipitating events."},{"speaker":"by an occult E. coli O157","startTime":351.439,"endTime":358.123,"body":"And the diagnostic test is measurement"},{"speaker":"by an occult E. coli O157","startTime":351.439,"endTime":358.123,"body":"of a low ADAMTS13 activity in the serum."},{"speaker":"by an occult E. coli O157","startTime":358.123,"endTime":361.239,"body":"Plasmapheresis is the treatment of choice"},{"speaker":"by an occult E. coli O157","startTime":358.123,"endTime":361.239,"body":"and should be initiated"},{"speaker":"by an occult E. coli O157","startTime":361.239,"endTime":363.641,"body":"as soon as you suspect the diagnosis."},{"speaker":"by an occult E. coli O157","startTime":363.641,"endTime":366.673,"body":"(Cathy) And you can read more about TTP"},{"speaker":"by an occult E. coli O157","startTime":363.641,"endTime":366.673,"body":"in \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"by an occult E. coli O157","startTime":366.673,"endTime":368.967,"body":"on Disorders of the Kidney"},{"speaker":"by an occult E. coli O157","startTime":366.673,"endTime":368.967,"body":"and Urinary Tract,"},{"speaker":"by an occult E. coli O157","startTime":368.967,"endTime":371.476,"body":"or in the section"},{"speaker":"by an occult E. coli O157","startTime":368.967,"endTime":371.476,"body":"on Hematopoietic Disorders"},{"speaker":"by an occult E. coli O157","startTime":371.476,"endTime":373.528,"body":"in Oncology and Hematology."},{"speaker":"by an occult E. coli O157","startTime":373.528,"endTime":375.273,"body":"♪ (music) ♪"}]}