The increasing prevalence of chronic illnesses in the United States requires a fundamental redesign of the primary care delivery system's structure and processes in order to meet the changing needs and expectations of patients. Population management, systems-based practice, and planned chronic illness care are 3 potential processes that can be integrated into primary care and are compatible with the Chronic Care Model. In 2003, Harvard Vanguard Medical Associates, a multispecialty ambulatory physician group practice based in Boston, Massachusetts, began implementing all 3 processes across its primary care practices. From 2004 to 2006, the overall diabetes composite quality measures improved from 51% to 58% for screening (HgA1c x 2, low-density lipoprotein, blood pressure in 12 months) and from 13% to 17% for intermediate outcomes (HgA1c
Relapsing thrombotic thrombocytopenic purpura (TTP) is a rare disorder with most individuals experiencing 1 to 5 relapses. We report a patient with 18 episodes of thrombotic thrombocytopenic purpura (TTP), the highest number of relapses thus far described. The last 11 episodes were treated with regimens containing cyclosporine. The patient's medical record was reviewed for pertinent clinical, laboratory, and treatment data. We summarized various parameters for each episode and compared characteristics of relapses treated with vs. without cyclosporine. The initial episode of TTP was unusual in that it failed to respond to plasmapheresis, glucocorticoids, and fresh frozen plasma (FFP). It remitted only following splenectomy. Episodes 2-7 responded to FFP plus prednisone. Episode 8 failed to respond to prednisone plus FFP but remitted promptly with cyclosporine plus prednisone. Subsequently, 2 relapses responded to cyclosporine alone, 2 to cyclosporine plus FFP, 4 to cyclosporine plus prednisone ± FFP, and 2 to cyclosporine, FFP, prednisone, and plasma exchange. There was no difference in remission duration, or in severity or duration of relapses treated with vs. without cyclosporine. Use of cyclosporine, however, significantly decreased the requirement for prednisone and the length of maintenance therapy; thus it is effective mainly as an adjunctive therapy for TTP. Am.
Relapsing thrombotic thrombocytopenic purpura (TTP) is a rare disorder with most individuals experiencing 1 to 5 relapses. We report a patient with 18 episodes of thrombotic thrombocytopenic purpura (TTP), the highest number of relapses thus far described. The last 11 episodes were treated with regimens containing cyclosporine. The patient's medical record was reviewed for pertinent clinical, laboratory, and treatment data. We summarized various parameters for each episode and compared characteristics of relapses treated with vs. without cyclosporine. The initial episode of TTP was unusual in that it failed to respond to plasmapheresis, glucocorticoids, and fresh frozen plasma (FFP). It remitted only following splenectomy. Episodes 2-7 responded to FFP plus prednisone. Episode 8 failed to respond to prednisone plus FFP but remitted promptly with cyclosporine plus prednisone. Subsequently, 2 relapses responded to cyclosporine alone, 2 to cyclosporine plus FFP, 4 to cyclosporine plus prednisone +/- FFP, and 2 to cyclosporine, FFP, prednisone, and plasma exchange. There was no difference in remission duration, or in severity or duration of relapses treated with vs. without cyclosporine. Use of cyclosporine, however, significantly decreased the requirement for prednisone and the length of maintenance therapy; thus it is effective mainly as an adjunctive therapy for TTP.
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