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ERROR: type should be string, got "https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly93d3cubWVkc2NhcGUuY29tL2Fuc3dlcnMvMjAxNzIyLTkwMTg4LzIwODY5Ny1vdmVydmlldw==\nDrugs & Diseases > Hematology > Platelet Disorders Q&A\nWhat causes thrombotic thrombocytopenic purpura (TTP)?\nAuthor: Perumal Thiagarajan, MD; Chief Editor: Srikanth Nagalla, MBBS, MS, FACP more...\nEvidence indicates that TTP results from the abnormal presence of unusually large multimers of von Willebrand protein. [11] These ultralarge precursors, normally synthesized in the endothelial cells, are hyperactive towards platelets. These large multimers are processed by a plasma enzyme to normal-sized multimers. This enzyme is identified as ADAMTS13, a metalloproteinase synthesized in the liver. [11]\nThe sporadic forms of TTP are caused by an antibody or toxin inhibiting the activity of ADAMTS13. The chronic, recurrent form of TTP may result from a congenital deficiency of the enzyme.\nThe ultralarge multimers are thought to induce the aggregation of platelets, causing platelet consumption. Occlusion of microvasculature by the platelets in the brain, kidney, and other organs leads to myriad symptoms. A TTP-like syndrome has been associated with lupus, pregnancy, HIV infection, and certain drugs (eg, quinine, ticlopidine, clopidogrel, cyclosporine, chemotherapeutic agents).\nPatients with TTP often report an episode of flulike illness 2-3 weeks before presentation. Most patients with TTP do not have the classic pentad. The most common presentation is petechiae and neurologic symptoms. The neurologic symptoms can range from headache and confusion to seizures and coma. Fever is present in slightly more than 50% of the patients.\nFor more information, see the Thrombotic Thrombocytopenic Purpura.\n[Guideline] Neunert C, Lim W, Crowther M, Cohen A, Solberg L Jr, Crowther MA. The American Society of Hematology 2011 evidence-based practice guideline for immune thrombocytopenia. Blood. 2011 Apr 21. 117(16):4190-207. [Medline]. [Full Text].\nMcMillan R. Classical management of refractory adult immune (idiopathic) thrombocytopenic purpura. Blood Rev. 2002 Mar. 16(1):51-5. [Medline].\nCooper N. State of the art - how I manage immune thrombocytopenia. Br J Haematol. 2017 Apr. 177 (1):39-54. [Medline]. [Full Text].\nWang X, Xu Y, Luo W, Feng H, Luo Y, Wang Y, et al. Thrombocytopenia in pregnancy with different diagnoses: Differential clinical features, treatments, and outcomes. Medicine (Baltimore). 2017 Jul. 96 (29):e7561. [Medline]. [Full Text].\nTarantino MD. Treatment options for chronic immune (idiopathic) thrombocytopenia purpura in children. Semin Hematol. 2000 Jan. 37(1 suppl 1):35-41. [Medline].\nD'Orazio JA, Neely J, Farhoudi N. ITP in children: pathophysiology and current treatment approaches. J Pediatr Hematol Oncol. 2013 Jan. 35 (1):1-13. [Medline].\nGrainger JD, Bolton-Maggs PH, Godeau B, Bussel J, Donato H, Elalfy M, et al. Diagnosis and management of chronic ITP: comments from an ICIS expert group. Ann Hematol. 2010 Jul. 89 Suppl 1:11-7. [Medline].\nMenis M, Forshee RA, Anderson SA, McKean S, Gondalia R, Warnock R, et al. Posttransfusion purpura occurrence and potential risk factors among the inpatient US elderly, as recorded in large Medicare databases during 2011 through 2012. Transfusion. 2014 Jul 28. [Medline].\nPeterson JA, McFarland JG, Curtis BR, Aster RH. Neonatal alloimmune thrombocytopenia: pathogenesis, diagnosis and management. Br J Haematol. 2013 Apr. 161 (1):3-14. [Medline].\nCurtis BR. Drug-induced immune thrombocytopenia: incidence, clinical features, laboratory testing, and pathogenic mechanisms. Immunohematology. 2014. 30 (2):55-65. [Medline].\nArepally GM. Heparin-induced thrombocytopenia. Blood. 2017 May 25. 129 (21):2864-2872. [Medline].\nTrachtman H. HUS and TTP in Children. Pediatr Clin North Am. 2013 Dec. 60 (6):1513-26. [Medline]. [Full Text].\nClemetson KJ, Clemetson JM. Molecular abnormalities in Glanzmann's thrombasthenia, Bernard-Soulier syndrome, and platelet-type von Willebrand's disease. Curr Opin Hematol. 1994 Sep. 1(5):388-93. [Medline].\nJames AH, Konkle BA, Kouides P, Ragni MV, Thames B, Gupta S, et al. Postpartum von Willebrand factor levels in women with and without von Willebrand disease and implications for prophylaxis. Haemophilia. 2014 Oct 21. [Medline].\nAndrews RK, Berndt MC. Bernard-Soulier syndrome: an update. Semin Thromb Hemost. 2013 Sep. 39 (6):656-62. [Medline].\nBalduini CL, Melazzini F, Pecci A. Inherited thrombocytopenias-recent advances in clinical and molecular aspects. Platelets. 2017 Jan. 28 (1):3-13. [Medline].\nGresele P, Orsini S, Noris P, Falcinelli E, Christine Alessi M, Bury L, et al. Validation of the ISTH/SSC bleeding assessment tool for inherited platelet disorders: a communication from the Platelet Physiology SSC. J Thromb Haemost. 2019 Nov 21. [Medline].\nAdler M, Kaufmann J, Alberio L, Nagler M. Diagnostic utility of the ISTH bleeding assessment tool in patients with suspected platelet function disorders. J Thromb Haemost. 2019 Jul. 17 (7):1104-1112. [Medline]. [Full Text].\nPerez Botero J, Warad DM, He R, Uhl CB, Tian S, Otteson GE, et al. Comprehensive Platelet Phenotypic Laboratory Testing and Bleeding History Scoring for Diagnosis of Suspected Hereditary Platelet Disorders: A Single-Institution Experience. Am J Clin Pathol. 2017 Jul 1. 148 (1):23-32. [Medline]. [Full Text].\nKühne T, Blanchette V, Buchanan GR, Ramenghi U, Donato H, Tamminga RY, et al. Splenectomy in children with idiopathic thrombocytopenic purpura: A prospective study of 134 children from the Intercontinental Childhood ITP Study Group. Pediatr Blood Cancer. 2007 Nov. 49 (6):829-34. [Medline].\nShim YJ, Kim UH, Suh JK, Lee KS. Natural course of childhood chronic immune thrombocytopenia using the revised terminology and definitions of the international working group: a single center experience. Blood Res. 2014 Sep. 49(3):187-91. [Medline]. [Full Text].\nKojouri K, Vesely SK, Terrell DR, George JN. Splenectomy for adult patients with idiopathic thrombocytopenic purpura: a systematic review to assess long-term platelet count responses, prediction of response, and surgical complications. Blood. 2004 Nov 1. 104(9):2623-34. [Medline]. [Full Text].\nVesely SK, Perdue JJ, Rizvi MA, Terrell DR, George JN. Management of adult patients with persistent idiopathic thrombocytopenic purpura following splenectomy: a systematic review. Ann Intern Med. 2004 Jan 20. 140(2):112-20. [Medline].\nWei Y, Ji XB, Wang YW, Wang JX, Yang EQ, Wang ZC, et al. High-dose dexamethasone vs prednisone for treatment of adult immune thrombocytopenia: a prospective multicenter randomized trial. Blood. 2016 Jan 21. 127 (3):296-302; quiz 370. [Medline].\nBlanchette V, Imbach P, Andrew M, et al. Randomised trial of intravenous immunoglobulin G, intravenous anti-D, and oral prednisone in childhood acute immune thrombocytopenic purpura. Lancet. 1994 Sep 10. 344(8924):703-7. [Medline].\nTaylor A, Westwood JP, Laskou F, McGuckin S, Scully M. Thrombopoetin receptor agonist therapy in thrombocytopenia: ITP and beyond. Br J Haematol. 2017 May. 177 (3):475-480. [Medline].\nKuter DJ, Bussel JB, Lyons RM, et al. Efficacy of romiplostim in patients with chronic immune thrombocytopenic purpura: a double-blind randomised controlled trial. Lancet. 2008 Feb 2. 371(9610):395-403. [Medline].\nAuger S, Duny Y, Rossi JF, Quittet P. Rituximab before splenectomy in adults with primary idiopathic thrombocytopenic purpura: a meta-analysis. Br J Haematol. 2012 Aug. 158(3):386-98. [Medline].\nJackson S, Beck PL, Pineo GF, Poon MC. Helicobacter pylori eradication: novel therapy for immune thrombocytopenic purpura? A review of the literature. Am J Hematol. 2005 Feb. 78(2):142-50. [Medline]. [Full Text].\nTreepongkaruna S, Sirachainan N, Kanjanapongkul S, et al. Absence of platelet recovery following Helicobacter pylori eradication in childhood chronic idiopathic thrombocytopenic purpura: a multi-center randomized controlled trial. Pediatr Blood Cancer. 2009 Jul. 53(1):72-7. [Medline].\nCoppo P, Froissart A, French Reference Center for Thrombotic Microangiopathies. Treatment of thrombotic thrombocytopenic purpura beyond therapeutic plasma exchange. Hematology Am Soc Hematol Educ Program. 2015 Dec 5. 2015 (1):637-43. [Medline].\nCabanillas G, Popescu-Martinez A. N-Acetylcysteine for Relapsing Thrombotic Thrombocytopenic Purpura: More Evidence of a Promising Drug. Am J Ther. 2015 Dec 29. [Medline].\nPatel PP, Becker J, Freyer C, Griffiths E, Thompson JE, Wang ES. Rituximab-refractory thrombotic thrombocytopenic purpura responsive to intravenous but not subcutaneous bortezomib. Transfusion. 2016 Jan 18. [Medline].\nGill JC, Castaman G, Windyga J, Kouides P, Ragni M, Leebeek FW, et al. Hemostatic efficacy, safety, and pharmacokinetics of a recombinant von Willebrand factor in severe von Willebrand disease. Blood. 2015 Oct 22. 126 (17):2038-46. [Medline].\nNormal hemostasis.\nPurpuric spots.\nSpurious thrombocytopenia. Peripheral smear of a patient reported to have platelet counts of 10,000-150,000/μL on various occasions. The smear shows clumping of the platelets and satellitism involving neutrophils and platelets.\nExamination of peripheral smears in immune thrombocytopenia often shows giant platelets. These platelets reflect the increased megakaryocytic mass in the marrow.\nPeripheral smear of a patient with Bernard-Soulier syndrome showing giant platelets. These platelets are not counted as platelets in most particle counters.\nExamination of the peripheral smear shows red blood cell fragments, basophilic cells, in addition to thrombocytopenia in thrombotic thrombocytopenic purpura.\nBone marrow in immune thrombocytopenia. Bone marrow examination reveals an increased number of megakaryocytes.\nVasculitis in childhood.\nSchistocytes (thrombotic thrombocytopenic purpura).\nPerumal Thiagarajan, MD Professor, Department of Pathology and Medicine, Baylor College of Medicine; Director, Transfusion Medicine and Hematology Laboratory, Michael E DeBakey Veterans Affairs Medical Center\nPerumal Thiagarajan, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Society for Biochemistry and Molecular Biology, American Society for Clinical Investigation, American Society of Hematology, Association of American Physicians, Royal College of Physicians\nRonald A Sacher, MBBCh, FRCPC, DTM&H Professor of Internal Medicine and Pathology, Director, Hoxworth Blood Center, University of Cincinnati Academic Health Center\nRonald A Sacher, MBBCh, FRCPC, DTM&H is a member of the following medical societies: American Association for the Advancement of Science, American Association of Blood Banks, American Clinical and Climatological Association, American Society for Clinical Pathology, American Society of Hematology, College of American Pathologists, International Society of Blood Transfusion, International Society on Thrombosis and Haemostasis, Royal College of Physicians and Surgeons of Canada\nSrikanth Nagalla, MBBS, MS, FACP Associate Professor of Medicine, Division of Hematology and Oncology, UT Southwestern Medical Center\nSrikanth Nagalla, MBBS, MS, FACP is a member of the following medical societies: American Society of Hematology, Association of Specialty Professors\nDisclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Alexion; Alnylam.\nKaren Seiter, MD Professor, Department of Internal Medicine, Division of Oncology/Hematology, New York Medical College\nKaren Seiter, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Society of Hematology\nDisclosure: Received honoraria from Novartis for speaking and teaching; Received consulting fee from Novartis for speaking and teaching; Received honoraria from Celgene for speaking and teaching."

ERROR: type should be string, got "https://www.nist.gov/baldrige/illinois-municipal-retirement-fund\nHow Baldrige Works\nExpand or Collapse\nAbout Baldrige\nBaldrige Impacts\nMalcolm Baldrige Biography\nBaldrige Process Integrity\nBaldrige FAQs\nBaldrige Director\nBaldrige Community\nExaminer Resources\nJudges Panel\nBaldrige Foundation\nState & Local Baldrige-Based Programs\nBaldrige Ambassadors\nCommunities of Excellence 2026\nInternational Award Programs\nSelf-Assessing\nBaldrige Key Terms\nImprovement Tools\nAre We Making Progress?\nAre We Making Progress as Leaders?\neasyInsight: Take a First Step Toward a Baldrige Self-Assessment\nAre You a Role-Model Leader?\nIntegrating Baldrige with Other Tools\nBaldrige by Sector\nNonprofit/Government\nBaldrige Cybersecurity Initiative\nBaldrige Excellence Framework\nBaldrige Excellence Builder\nBaldrige Executive Fellows Program\nBaldrige Collaborative Assessment\nBaldrige Connect\nBecome a Baldrige Examiner\nBaldrige Examiner Training Experience\nShop Baldrige Gear\nBusiness/Nonprofit\nBaldrige Excellence Framework Graphics\nBaldrige Case Study\nBlogrige\nInsights on the Road to Performance Excellence\nQuest for Excellence Conference\nBaldrige Fall Conference\nBaldrige Exhibit Schedule\nCurrent Baldrige Recipients\nName & Trademark Guidelines\nBaldrige Award\nAward Cycle Overview\nIs Your Organization Eligible?\nAward Process Fees\nThe Feedback Report\nFlickrGovDeliveryTwitterYoutube\nIllinois Municipal Retirement Fund\n2019 Award Recipient, Nonprofit\nCredit: Illinois Municipal Retirement Fund\nHighest-Ranking Official*\nPublic Affairs Contact\n*At time of award\n2211 York Road, Suite 500\nhttps://www.imrf.org\nBaldrige Application\nkgoerdt [at] imrf.org (subject: IMRF%E2%80%99s%20Baldrige%20Application) (Kathy Goerdt)\nOrganizational Excellence Officer\nMedia Inquiries & Speaking Opportunities\njkrupa [at] imrf.org (subject: Media%20Inquiries%20%26%20Speaking%20Opportunities) (John Krupa)\nWith a current workforce of 210, the Illinois Municipal Retirement Fund (IMRF) is a public-defined benefit pension plan providing services to the employees of units of local government and school districts throughout the state of Illinois (except for the City of Chicago and Cook County). The main product of IMRF is money payments to members in response to an event, such as separation from employment, disability, death, or retirement. IMRF serves 3,010 employers and has $42.7 billion in assets. IMRF has 176,517 active members (working in an IMRF-qualified position and making contributions), 119,939 inactive members (no longer actively contributing but have contributions on deposit for a future benefit), and 133,261 benefit recipients. It has main and satellite offices, respectively, in Oak Brook and Springfield, IL, as well as eight Illinois regional home offices for field representatives.\nIMRF has received a Standard & Poor’s “strong” rating since 2017 and is 90% funded; only 16 of the 100 largest U.S. public pension plans are funded at this level.\nIMRF’s 10-year performance of 9.47% gross annualized rate of return for the period ending in 2018 outperforms the actuarial assumption of 7.5% and a total portfolio benchmark of 8.78%.\nMember satisfaction with transactions was 97% in 2018. Employer satisfaction with transactions was 96%.\nIMRF contributes to societal well-being and the Illinois economy through the benefits paid to retired members. The $1.8 billion in benefits paid in 2018 added $2.7 billion in total economic activity in Illinois, and it supported the creation of 18,329 jobs.\nThe Board of Trustees supports responsible governance, assures accountability, and supports IMRF’s performance excellence journey. It sets high levels of accountability through the deployment and active monitoring of comparative indicators. IMRF has achieved 100% in measures of regulatory and legal compliance such as board fiduciary training and compliance with the Open Meetings Act, and zero adverse findings for public sector statutes and complaints to the Illinois public access counselor.\nSenior leaders and supervisors regularly engage with employees and chat about the REAACH (Respect, Empathy, Accountability, Accuracy, Courage, Honesty) values, with 94% of IMRF employees saying that they identify well with IMRF’s values, compared with 85% of respondents to a third-party employee engagement survey.\nIMRF has received a Standard & Poor’s “strong” rating since 2017 and is 90% funded; only 16 of the 100 largest U.S. public pension plans are funded at this level. The plan’s funded status far exceeds the U.S. average of 73.7% for 124 U.S. public pension funds. Since 2014, IMRF’s funding level has been more than double the levels of five Illinois state-funded plans and eight Chicago-funded plans.\nIMRF has grown its assets from $5,000 in 1941 to $42.7 billion in 2019, and it is the second-largest pension fund by assets in the state of Illinois. It is the largest in the state by number of members, with over 429,000.\nProduct and Service Results\nIMRF’s 10-year performance of 9.47% gross annualized rate of return for the period ending in 2018 outperforms the actuarial assumption (an estimate of an uncertain variable input into a financial model, normally for the purposes of calculating premiums or benefits) of 7.5% and a total portfolio benchmark of 8.78%. Despite the 2008 financial crisis and the resulting recession, IMRF’s 15-year performance of 7.12% is just below its 7.50% actuarial assumption. Investments in eight asset classes exceeded benchmarks in 13 of 24 measured periods of 3, 5, and 10 years.\nIMRF participates in a global benchmarking study that provides detailed comparisons for leading pension systems worldwide, including 44 in IMRF’s peer group. IMRF ranks ninth in its peer group for total service score, which measures the performance of its products and services. IMRF’s score increased from 86 in 2014 to 89 in 2019, well above the peer average of 77 and approaching the peer max of 94. IMRF is the industry leader, with a service score of 100, for written pension estimates.\nCustomer Processes with Results\nA voice-of-the-customer (VOC) survey process keeps the organization focused on its members and employers. To ensure timely and actionable feedback, tablet surveys for member walk-ins and toll-free lines are utilized to collect real-time data. Member satisfaction with transactions was 97% in 2018, with 85% of members indicating that they were very satisfied. Employer satisfaction with transactions was 96%, with 67% very satisfied.\nIMRF’s net promotor score (measuring how likely someone is to promote IMRF) for member transactions in 2018 was 87.1, and its score for employer transactions was 80.7 (an above-70 net promoter score is considered “world class”). IMRF’s workshop ratings were even higher: 92.9 for members and 93.2 for employers. IMRF outperforms the government industry benchmark (73.2), the finance industry benchmark (77.6), and the business support industry benchmark (57.2).\nIMRF is an industry leader in performance in a third-party survey that measures customer satisfaction using the American Customer Satisfaction Index (ASCI). IMRF’s ASCI score of 94 is better than the other funds that participate. It outperforms the benchmark for industries such as Pension Benefit Guaranty Corporation (89), banks (81), health insurance (73), and social security (70).\nPeople Processes with Results\nThe six-step Performance Management System reinforces high performance and leverages compensation, reward, recognition, and incentive practices. Feedback from employee mid-year and year-end performance reviews is aligned with the Leadership Scorecard and action plan performance measures. Recognition is provided through “Kudos” awards, as well as town hall meetings, service anniversary celebrations, staff emails, and newsletters.\nIn 2019, IMRF performed at the 89th percentile in an employee engagement survey; IMRF equals or outperforms the top 25% average for all 10 drivers of employee engagement, including empowerment, culture, customer focus, learning and development, rewards and recognition, co-worker relationships, department relationships, company potential, manager relationships, and senior manager relationships.\nThe 12-step Strategic Planning Process involves key internal and external stakeholders in the development of strategic objectives that are aligned with IMRF’s key result areas. Innovation and intelligent risk taking are evaluated throughout the strategic planning process. Action plans are developed and executed using a Single Point Accountable (SPA), who is assigned to take the lead role in the planning and deployment of action projects for each key strategy. The SPA annually identifies resource requirements and reviews them with a senior leader sponsor who ensures that the needed resources are included in the next year’s budget. Key Performance Indicators for each Key Result Area are reviewed 10 times per year with the entire leadership team.\nIn order to ensure information system security, IMRF incorporated comprehensive security policies into its Code of Conduct; created a centralized security function; built an integrated, multilevel security infrastructure; has security audited by external parties; uses data encryption; and implemented a five-step Cybersecurity Management Process. In addition, 100% of staff have completed cybersecurity training.\nIMRF ensures that data and information are shared with the workforce, employers, members, partners, and reciprocal systems, and that IT systems are reliable and user-friendly. Over 92% of Spectrum (IMRF’s proprietary mainframe computer software pension administration system) transactions since 2014 have been less than one second. A new web-centric customer service delivery model enables members and employers to access information and make transactions online. The number of employer transactions available online has tripled since 2005 and is now 99%.\nWork Process Effectiveness Results\nIMRF utilizes a four-step Continuous Improvement Process, IAPI (Identify-Analyze-Prioritize-Implement), for any staff member to identify and submit opportunities for improvement online in the COMPASS intranet site, which has an automated workflow for tracking the status of improvement efforts. IAPI is a driving force for operational improvements in cost control, automation, auditing, timeliness, the volume of transactions per employee, and reduction of errors and need for rework.\nThe Office Services Department error rate has decreased from 0.38% in 2016 to 0.21% in 2018, and the percentage of documents processed the same day is 100%. Call hold time has decreased from 139 seconds in 2014 to 72 seconds in 2018, outperforming the target of 105.\nCitizenship with Results\nIMRF contributes to societal well-being and the Illinois economy through the benefits paid to retired members; 86% of IMRF’s benefit recipients reside in Illinois. The $1.8 billion in benefits paid in 2018 added $2.7 billion in total economic activity in Illinois, and it supported the creation of 18,329 jobs.\nInvestment performance with minority and women-owned businesses exceeds the state’s goal of 20% and has earned IMRF the Pacesetter Award from the National Association of Security Professionals; $10.2 billion of IMRF’s assets are managed by minorities, women, and persons with a disability. In addition, $1 billion of its assets are managed by Illinois-based, minority investment management firms.\nSearch All Baldrige Award Recipients\nBaldrige Award Recipient FAQs\nAttend Quest for Excellence\nBaldrige Program Impacts\nPerformance excellence, Baldrige award, Baldrige examiners, Baldrige Framework and Criteria and Best practices\nBaldrige Customer Service\nbaldrige@nist.gov\nNIST/BPEP\n100 Bureau Drive, M/S 1020\nGaithersburg, MD 20899-1020\nCreated November 6, 2019, Updated November 20, 2019"