Lisa Angeline Cooper, M.D., M.P.H.
- Bloomberg Distinguished Professor, Equity in Health and Healthcare
- Professor of Medicine
https://www.hopkinsmedicine.org/profiles/results/directory/profile/0416615/lisa-cooper
Surgical procedures should be performed only in centers with adequate blood bank pain treatment centers of alabama buy 10 mg rizact free shipping, coagulation laboratory xiphoid pain treatment discount 5 mg rizact overnight delivery, and hematology consultation services unifour pain treatment center hickory nc cheap 5mg rizact fast delivery. Adjuncts to factor replacement include desmopressin acetate pain treatment center in morehead ky buy rizact 10 mg fast delivery, antifibrinolytic agents such as aminocaproic acid and tranexamic acid, and topical hemostatic agents such as fibrin glue and fibrillar collagen preparations applied directly to local areas of mucosal bleeding, such as epistaxis. On the other hand, use of desmopressin may completely eliminate the need for blood products in mild bleeding episodes or during minor dental or surgical procedures and may decrease the amount of blood products required for major bleeds or surgical procedures. Abnormal coagulation tests may result from a deficiency of one of the contact factors or from the presence of antiphospholipid antibodies (lupus anticoagulant), neither of which causes bleeding but may be associated with thrombosis. Mild coagulation factor deficiencies may be associated with normal or minimally prolonged clotting times and may result in bleeding only if major vascular injury occurs. If the response to desmopressin is unknown and a patient is actively bleeding, factor replacement with blood products is preferable. Desmopressin also stimulates release of tissue plasminogen activator, so antifibrinolytic therapy is often administered simultaneously. Aminocaproic acid and tranexamic acid are two commercially available antifibrinolytic agents that may be useful for managing bleeding in patients with a wide variety of bleeding disorders. The optimal level of factor activity, the precise interval between doses, and the duration of therapy are somewhat arbitrary and for most of the rare disorders reflect a lack of clinical experience. Genetic heterogeneity contributes further to the lack of firm data to support current recommendations. Because of the risks of bleeding, infections, and other transfusion-related complications, elective surgery should be avoided when possible. There is a body of literature demonstrating the success of surgery in hemophiliacs and others with inherited coagulation defects, but clearly, surgery in such patients poses significant risks and increases the demand for scarce resources, including blood products. Current screening for infectious diseases and processing of factor concentrates to eliminate many (but not all) infectious agents has significantly decreased the risk of transmission of infectious diseases from plasma-derived products. All patients with hemophilia and related coagulation disorders should be vaccinated against hepatitis B. However, recombinant factors are two to three times more expensive than plasma-derived factors, are not always available owing to limited production capacity, and may be associated with a higher rate of inhibitor development compared with plasma concentrates. Optimal management of inhibitors remains a challenge in management of severe hemophilia. Results from preliminary trials are promising, but this approach remains experimental. Clinical situation leading to decreased production or increased destruction of coagulation factors or presence of an anticoagulant. General Considerations Acquired coagulation disorders result from four basic mechanisms: vitamin K deficiency, liver disease, consumption of factors, or inhibition of factor activity or fibrin polymerization. Hemostatic abnormalities exacerbate bleeding from these sites and contribute to epistaxis, ecchymoses, and increased bleeding with invasive procedures. In general, the presence of a coagulopathy is a sign of advanced liver disease, although passive congestion of the liver owing to right-sided heart failure may be associated with coagulation disturbances without irreversible liver dysfunction. Consumption of coagulation factors and platelets is accompanied by secondarily accelerated fibrinolysis and results in a generalized bleeding tendency associated with mucosal bleeding, ecchymoses, and oozing from sites of vascular trauma, including venipuncture and surgical sites. As a result of widespread arterial and venous thrombosis, patients with purpura fulminans may have skin necrosis and gangrene of the distal extremities and digits. In this situation, depletion of coagulation factors and platelets may be accompanied by elevated circulating fibrin degradation products and may result in a serious bleeding tendency, but it is not associated with microvascular thrombus formation. Primary systemic fibrinolysis is extremely rare and results in rapid destruction of fibrin clots, destruction of circulating fibrinogen, and consumption of plasminogen and its inactivators. Inhibitors of Coagulation-Infrequently, inhibitors of coagulation develop and may result in a serious bleeding diathesis. In addition, many of the clinical symptoms and signs result from the underlying disease process; the coagulopathy is just one of many processes contributing to the overall clinical picture.
Before using this policy chronic pain syndrome treatment guidelines order 5 mg rizact with visa, please check the member specific benefit plan document and any applicable federal or state mandates pain solutions treatment center reviews 5mg rizact with amex. This Medical Benefit Drug Policy may also be applied to Medicare Advantage plans in certain instances pain medication for dogs ibuprofen purchase rizact 5 mg on line. UnitedHealthcare may also use tools developed by third parties treatment for pain associated with shingles purchase rizact 5mg amex, such as the InterQual criteria, to assist us in administering health benefits. UnitedHealthcare Medical Benefit Drug Policies are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. Rheumatoid Arthritis and Giant Cell Arteritis Liver Enzyme Abnormalities [see Warnings and Precautions (5. The most common serious infections included pneumonia, urinary tract infection, cellulitis, herpes zoster, gastroenteritis, diverticulitis, sepsis and bacterial arthritis [see Adverse Reactions (6. Consultation with a 9 physician with expertise in the treatment of tuberculosis is recommended to aid in the decision whether initiating anti-tuberculosis therapy is appropriate for an individual patient. Closely monitor patients for the development of signs and symptoms of tuberculosis including patients who tested negative for latent tuberculosis infection prior to initiating therapy. No cases of Hepatitis B reactivation were observed in the trials; however patients who screened positive for hepatitis were excluded. Promptly evaluate patients presenting with new onset abdominal symptoms for early identification of gastrointestinal perforation [see Adverse Reactions (6. Monitor neutrophils 4 to 8 weeks after start of therapy and every 3 months thereafter [see Clinical Pharmacology (12. In patients who develop a platelet count less than 50,000 per mm3 treatment is not recommended. These elevations did not result in apparent permanent or clinically evident hepatic injury in clinical trials [see Adverse Reactions (6. Increased frequency and magnitude of these elevations was observed when potentially hepatotoxic drugs. When clinically indicated, other liver function tests such as bilirubin should be considered. For recommended modifications based on transaminases [see Dosage and Administration (2. All patients in these studies had moderately to severely active rheumatoid arthritis. The most commonly reported infections (5% to 8% of patients) were upper respiratory tract infections and nasopharyngitis. In the all-exposure population, the overall rate of serious infections remained consistent with rates in the controlled periods of the studies. Gastrointestinal Perforations During the 24 week, controlled clinical trials, the overall rate of gastrointestinal perforation was 0. In the all-exposure population, the overall rate of gastrointestinal perforation remained consistent with rates in the controlled periods of the studies. Appropriate medical treatment should be available for immediate use in the event of a serious hypersensitivity reaction [see Warnings and Precautions (5. In the all-exposure population, the pattern and incidence of decreases in neutrophil counts remained consistent with what was seen in the 24 week controlled clinical studies [see Warnings and Precautions (5. Thrombocytopenia In the 24 week, controlled clinical studies, decreases in platelet counts below 100,000 per mm3 occurred in 1. In the all-exposure population, the pattern and incidence of decreases in platelet counts remained consistent with what was seen in the 24 week controlled clinical studies [see Warnings and Precautions (5. These elevations were not associated with clinically relevant increases in direct bilirubin, nor were they associated with clinical evidence of hepatitis or hepatic insufficiency [see Warnings and Precautions (5. In the all-exposure population, the elevations in lipid parameters remained consistent with what was seen in the 24 week, controlled clinical trials. The detection of antibody formation is highly dependent on the sensitivity and specificity of the assay.
Long term use of intravenous immune globulin in patients with primary immunodeficiency diseases: inadequacy of current dosage practices and approaches to the problem back pain treatment ucla purchase rizact 5 mg mastercard. Use of intravenous immunoglobulin and adjunctive therapies in the treatment of primary immunodeficiencies joint and pain treatment center fresno ca cheap 5 mg rizact otc. A working group report of and study by the Primary Immunodeficiency Committee of the American Academy of Allergy nerve pain treatment options cheap 10 mg rizact amex, Asthma & Immunology blue ridge pain treatment center harrisonburg va order rizact 5mg line. Increased risk of adverse events when changing intravenous immunoglobulin preparations. The use of intravenous immunoglobulin in the treatment of autoimmune neuromuscular diseases: evidence-based indications and safety profile. Acute thromboembolic events associated with intravenous immunoglobulin infusion in antibody-deficient patients. High-dose immunoglobulin replacement therapy by slow subcutaneous infusion during pregnancy. Slow subcutaneous immunoglobulin therapy in a patient with reactions to intramuscular immunoglobulin. Rapid subcutaneous IgG replacement therapy is effective and safe in children and adults with primary immunodeficiencies-a prospective, multi-national study. Efficacy and safety of home-based subcutaneous immunoglobulin replacement therapy in paediatric patients with primary immunodeficiencies. Efficacy and safety of Hizentra, a new 20% immunoglobulin preparation for subcutaneous administration, in pediatric patients with primary immunodeficiency. Efficacy and safety of a new 20% immunoglobulin preparation for subcutaneous administration, IgPro20, in patients with primary immunodeficiency. Pharmacokinetics and safety of subcutaneous immune globulin (human), 10% caprylate/chromatography purified in patients with primary immunodeficiency disease. Pharmacokinetics of subcutaneous IgPro20 in patients with primary immunodeficiency. Recombinant human hyaluronidase-facilitated subcutaneous infusion of human immunoglobulins for primary immunodeficiency. The comparison of the efficacy and safety of intravenous versus subcutaneous immunoglobulin replacement therapy. Subcutaneous immunoglobulin replacement in patients with primary antibody deficiencies. Safety and efficacy of subcutaneous human immunoglobulin in children with primary immunodeficiency. Subcutaneous immunoglobulin replacement in patients with primary antibody deficiencies: safety and costs. Rapid subcutaneous IgG replacement therapy at home for pregnant immunodeficient women. The life situations of patients with primary antibody deficiency untreated or treated with subcutaneous gammaglobulin infusions. Safety of rapid subcutaneous gammaglobulin infusions in patients with primary antibody deficiency. Safety and efficacy of home-based subcutaneous immunoglobulin G in elderly patients with primary immunodeficiency diseases. Induction of unresponsiveness against IgA in IgA-deficient patients on subcutaneous immunoglobulin infusion therapy. Safety and efficacy of self-administered subcutaneous immunoglobulin in patients with primary immunodeficiency diseases. Quality of life and health-care resource utilization among children with primary immunodeficiency receiving home treatment with subcutaneous human immunoglobulin. Immunoglobulin treatment for primary antibody deficiencies: advantages of the subcutaneous route. Pharmacokinetics of subcutaneous immunoglobulin and their use in dosing of replacement therapy in patients with primary immunodeficiencies. Safety and efficacy of Privigen, a novel 10% liquid immunoglobulin preparation for intravenous use, in patients with primary immunodeficiencies. Home therapy with subcutaneous immunoglobulin infusions in children with congenital immunodeficiencies. Self-infusion programmes for immunoglobulin replacement at home: feasibility, safety and efficacy. Children and adults with primary antibody deficiencies gain quality of life by subcutaneous IgG self-infusions at home.
Some investigators believe this area represents a locus minoris resistentiae (a site of lower resistance or higher susceptibility to damage) because it is the site where Schwann cells are substituted by oligodendroglia in providing the myelin sheath pain treatment center memphis rizact 10mg online. A second pathophysiologic theory wrist pain treatment exercises rizact 5mg free shipping, admittedly more debatable pain medication for dogs 10 mg rizact amex, is that the damaged primary afferents in the area of focal demyelination become a source of ectopic generation of impulses pain treatment with methadone order 5mg rizact with visa. The author proposes that, because mitochondria and the energetic apparatus necessary to pump sodium off are physiologically concentrated at the level of the nodes of Ranvier, when the demyelinating process allows the passage of ions in and out of the axon, then the axons do not have enough energy to promptly reestablish the resting potential. Hence, the axons tend toward a depolarization level, which makes them hyperexcitable. Spontaneously, or because of a local direct mechanical stimulus such as the artery pulsation, ectopic activity is generated. More supported by evidence in animal models of focal demyelination of the trigeminal root is the concept of ephaptic transmission (cross talk) from close, healthy nerve fibers and the generation of highfrequency discharges. Hence surgery, being extremely efficacious in trigeminal neuralgia, should be proposed. Some patients cannot take either of the two choice drugs because of specific contraindications (most frequently cardiac conduction problems or severe arrhythmias). Indeed, patients on carbamazepine must undergo a complete blood count every 3 to 4 months. These central side effects, which are more frequent with carbamazepine than oxcarbazepine (Figure 3-7),17 may prevent patients from maintaining adequate doses. Hence, in this third group of patients, who are neither responders nor nonresponders, other drugs can be tried. In particular, analysis of the evidencebased trials led to the following suggestions: lamotrigine, baclofen, and pimozide. Although pimozide was found more efficacious than carbamazepine in a small head-to-head clinical trial, it was never tried again. Trigeminal Neuralgia Case 3-2 A 67-year-old woman with a history of hypertension presented with a 6-month history of right-sided facial pain. The pain was paroxysmal (she described it as similar to an electric shock), and it was evoked by typical trigger maneuvers for trigeminal neuralgia: light touch on the forehead and eyebrow, eyelid movement when looking upward, and combing her hair. She had previously been prescribed carbamazepine 600 mg/d, and her pain had disappeared. Her problems were twofold: first, the carbamazepine induced central nervous system side effects (eg, somnolence, dizziness, imbalance), which she found unbearable, and second, no investigation had yet occurred to ascertain the etiology. The patient returned for follow-up 3 weeks later, and she still had central nervous system depression, although to a far lower degree, which she felt was tolerable. The possibility of an endovascular intervention was discussed, but its efficacy was considered uncertain. One week later, the patient suddenly developed severe weakness and confusion and was seen in a local emergency department, where she was diagnosed with severe hyponatremia (120 mEq/L) and was begun on saline infusions. She was also seen by another neurologist, who quickly tapered and stopped oxcarbazepine, as well as an interventional neuroradiologist who, as soon as the electrolyte abnormality resolved, proceeded with endovascular intervention first with a coil in the aneurysm and then with a stent in the artery. Within 24 hours after the intervention, she had complete disappearance of the neuralgic pain attacks and continued to have no further symptoms when seen in follow-up 6 months later. Regarding medication side effects, although oxcarbazepine by no means requires the three to four checks per year of blood elements that are mandatory for the duration of therapy for patients on carbamazepine, monitoring of serum sodium is necessary at least once. Regarding the etiologic classification of this patient, although secondary trigeminal neuralgia is usually attributed to tumors or multiple sclerosis, other major neurologic diseases (eg, the rare trigeminal isolated sensory neuropathy or aneurysms) should be kept in mind when something in the history or symptoms suggests a secondary origin. In this case, the only unusual clinical factor was the location of her pain, which exclusively involved the ophthalmic division (this was long considered a Continued on page 411 410 ContinuumJournal. Regarding pathophysiology, it is well known that microvascular decompression relieves neuralgic pain far before a remyelinating process might take place. This case suggests the need for a pulsating stimulus on the demyelinated nerve fibers to induce the ectopic generation of high-frequency discharges. In microvascular decompression, the neurosurgeon leaves a tiny sponge to keep the artery and the nerve root separate.
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