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Acute thrombotic thrombocytopenic purpura (TTP) is a life-threatening emergency and plasma exchange (PEX) is the initial treatment shown to reduce acute mortality.To compare current practice in the United Kingdom (UK) against the standards set out in the 2012 British Society of Haematology guideline, and to better understand the issues affecting prompt initiation of PEX.The trainee research network HaemSTAR conducted a retrospective nationwide review of adults presenting to UK hospitals with a first episode of acute TTP.Data on 148 patients treated at 80 UK hospitals between 2014 and 2019 demonstrated that 64.8% of patients received PEX within 24 h. Diagnostic uncertainty was the most commonly cited reason for delayed treatment. Conversely, a shorter time to PEX occurred in patients who had red cell fragments or severe thrombocytopenia identified on their first complete blood count. Availability of on-site PEX was associated with a greater proportion of patients receiving PEX within 8 h compared to patients transferred, but by 24 h there was no difference between the two groups and two-thirds of all patients had received their first PEX. The mortality rate for patients that received PEX was 9.2%, with 27.8% of deaths linked to delayed treatment initiation.This is the first multi-center evaluation of treatment delays in acute TTP and it will inform targeted pathways to improve prompt access to life-saving intervention.

myeloma. The role of surgery in addition to radiotherapy for the management of MSCC continues to be debated [2,3]. The most persuasive evidence for the benefit of surgery in addition to radiotherapy for the management of MSCC came in 2005 from a randomised trial of 101 patients that showed improved functional outcomes and survival for MSCC managed by decompressive surgery followed by radiotherapy compared with radiotherapy alone [4]. However, this study was limited to highly selected patients recruited over 10 years and has been criticised on several methodological grounds [2]. Importantly in the context of myeloma, the trial excluded patients with haematological malignancies. Rades et al. [3] carried out a retrospective review of the outcome of 521 patients with less than three vertebral metastases with MSCC managed with radiotherapy alone. This series included 63 patients with myeloma/lymphoma (grouped together for analysis); 76% of the myeloma/ lymphoma patients experienced an improvement in motor function, 2% deteriorated and local control (defined as the absence of recurrence or progression of motor defects) was achievedin98%at1year.Onmultivariateanalysis,myeloma/ lymphoma was a highly significant factor predicting a favourable functional outcome. The authors highlighted myeloma/lymphoma patients as a group that should be managed with radiotherapy alone. These results are supported by a subsequent retrospective matched pair analysis of 324 patients with MSCC [2]; in this series the outcomes (motor function, ambulatory status, regaining ambulation, local control and survival) after radiotherapy alone were similar to those after surgery and radiotherapy. In the 48 patients in the series with myeloma/lymphoma, motor function improved in 63% and deteriorated in 2% of patients, with a high local control rate of 95% at 1 year of follow-up. The optimal radiotherapy dose fractionation schedule is uncertain in MSCC. In a retrospective multinational study of 172 myeloma patients with MSCC, a functional improvement after radiotherapy alone was observed in 52% of patients and 47% of non-ambulatory patients regained the ability to walk at 4 months [5]. A functional improvement was more common after long-course than short-course radiotherapy (76 versus 40% at 12 months, P¼0.003). The authors concluded that a schedule of 30 Gy in 10 fractions over 2 weeks was appropriate for myeloma MSCC. In summary, we believe that the current evidence does not support the use of surgical decompression in myeloma patients with MSCC; these patients are adequately managed with radiotherapy. Exceptions include patients with spinal instabilityand/orbonycompression(uncommoninmyeloma). Vertebroplasty and kyphoplasty remain useful options after radiotherapy if pain control has not been achieved.