Pamela Ann Lipsett, M.D.

• Program Director, Surgical Critical Care
• Professor of Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0003404/pamela-lipsett

Approximately 8-9 patients out of 10 will develop an adverse effect to cannabinoid therapy and attractive tradeoff hiv infection stomach pain generic medex 1mg with mastercard. But would you feel the same way if the patient was using 6 grams of ibuprofen per dayfi Or if the patient insisted that the ibuprofen was improving their blood sugar controlfi However acute hiv infection symptoms pictures buy medex 5mg overnight delivery, despite the relative lack of quality evidence antiviral y retroviral buy medex american express, patients often have strong beliefs about the value of each drug class hiv infection rates south africa cheap generic medex uk. Opioids can cause constipation;25 cannabinoids can cause psychiatric there are better choices! Non-pharmacological approaches to fi Addiction risk: With prescription opioids, estimated to be 5. Entourage effect: an unproven hypothesis that efficacy of cannabinoids is increased (or adverse effects decreased) when they are used in combination and/or in particular ratios and/or with flavonoids, terpenoids. In 9% of adults who use cannabis non-medically may develop addiction (& up to 17% if started in adolescence). Symptoms of Cannabis Withdrawal (onset 1-2 days, peak 2-6 days) [Note: Pharmacologic tx. Anger, aggression, appetite change, weight loss, anxiety, irritability, naltrexone, appears ineffective] Possible taper to prevent withdrawal: v by 25% q1week. Choosing Between Products note: currently Canada has a "two-stream" cannabis system: medically authorized cannabis, and cannabis through retail sale. Medical document must be re-authorized at Guidance monitoring, boundaries, or Saskatchewan). Note: despite prescriber attempts to guide product and dosing, patients may supplement with 6. No set daily limit; max possession is lesser of retail cannabis against medical advice. Average price still uncertain (Ranges from $8-20/gram) Calculatorfor the production of a limited amount of cannabis for medical purposes:health. Confident estimation of the benefits or harms is challenging due to the quality of available literature and varying clinical and patient experiences. A large portion of the cannabinoid/cannabis evidence base is observational which has inherent limitations, such as: o recall bias. And some patients, regardless of available science, will consume (or continue to consume cannabis) due to perceived medical benefit or desire for other effects. All provinces including Saskatchewan have raised this to 19 years of age with the exception of Alberta and Quebec. Vulnerability factors are not currently clear but may include factors such as childhood trauma and genetics. In those young adults who have developed psychosis, continued cannabis use worsens long-term symptom and functional outcomes. For example, 69% of Colorado cannabis dispensaries (medical and/or retail) recommended cannabis products to treat morning sickness. Note: exit strategy more difficult now that cannabis may be accessed through retail sale. If benefit obtained, but intolerable adverse effect, patients may decrease dose by 50% or return to previous titration step. Watch for additive side effects such as sedation, dizziness, hypotension or even falls when cannabinoids or medical cannabis is used in conjunction with other medications. Meta-analysis of 2 prospective observational studies including 5,520 participants without bipolar disorder at baseline demonstrated lifetime cannabis use. Cannabis (especially regular use) is also associated with increased symptoms of mania and hypomania. Reduced time to onset of angina has been demonstrated with smoked cannabis compared to placebo or nicotine cigarettes. A systematic review of observational studies found a positive association in 8/12 studies reporting a ~2-4-fold increased risk of lung cancer. Lastly, while most studies included smoked cannabis, the risk of vaporized cannabis and lung cancer has not been systematically studied. For example, in Colorado, where recreational marijuana was legalized in 2014, the number of drivers involved in fatal crashes increased from 627 in 2013 to 880 in 2016 and the number of drivers who tested positive for marijuana use increased from 47 in 2013 to 115 in 2016. The risk with long-term use is relatively unknown, and there may be prolonged impairment even after cessations based on limited data. A systematic review of 38 observational studies evaluated neurocognitive outcomes in patients abstinent from cannabis for at least 14 days. Prior cannabis use compared to nonuse was statistically associated with impaired attention, motor function, executive functioning, and learning/memory abilities, and structural differences. Cannabis use onset prior to 18 years of age was associated with greater neurocognitive impairment and imaging differences compared to those with onset after 18 years. The findings are limited by high statistical and clinical heterogeneity including variable cannabis exposure. This study will likely provide further insight on cannabis use and effects on cognitive development during adolescence. Incidence of acute psychosis or dissociation was 5% in those receiving cannabinoids compared to 0% in placebo. Although consistently greater numerically, there was not a statistically significantly difference with cannabinoid use compared to placebo. Cannabis use is consistently associated with greater risk of new-onset psychosis in a dose-related fashion. A prospective observational study of 2021 participants aged 14-24 years (mean age 18 years at baseline) were followed for 10 years. Tapering is advised for most patients who undergo a therapeutic trial of cannabis. Withdrawal symptoms upon cessation have been reported when cannabis is used daily for a few weeks to months in some individuals (note: severity is proportional to amount and duration of use). Withdrawal symptoms may include: anxiety/nervousness, decreased appetite/weight loss, restlessness, sleep disturbances. Generally, symptom onset is 1-2 days, peak 2-6 days, and return to baseline 1-2 weeks after cannabis discontinuation. Available data is encouraging, but majority is based on survey data or epidemiology level data. A survey conducted in Israel of patients at cannabis treatment initiation (2736 participants) and after 6 months (901 participants) reported 143 patients reduced opioid dose or discontinued opioid therapy and 32 patients increased opioid dose or initiated opioid therapy after the initiation of cannabis. In Australia, there was no statistical evidence that cannabis use reduced prescribed opioid dose or increased the rates of opioid discontinuation based on patient interviews/questionnaires at baseline and yearly for 4 years. Based on Veterans Affairs Canada data, the number of veterans with opioid prescriptions has reduced in 2017-2018 (10,130) compared to 2012-2013 (14,732) while the number of veterans with authorization for cannabis has increased in 2017-2018 (7,298) compared to 2012-2013 (68). Systematic review of systematic reviews for medical cannabinoids: Pain, nausea and vomiting, spasticity, and harms. Associations Between Marijuana Use and Cardiovascular Risk Factors and Outcomes: A Systematic Review. Dynamic mapping of human cortical development during childhood through early adulthood.

Diseases

• Christian syndrome
• Microcephaly, primary autosomal recessive
• Pulmonary veins stenosis
• Angiomyomatous hamartoma
• Landouzy Dejerine muscular dystrophy
• Fryns Smeets Thiry syndrome
• Pulmonary valves agenesis

It is a dreaded complication which occurs due to sudden and large posterior capsular rupture natural factors antiviral buy 1 mg medex with visa. The case must be referred to a vitreoretinal surgeon without making any attempts to fish out the nucleus hiv infection from dried blood proven medex 1 mg. It is a potentially serious complication because it may result in galucoma antiviral plot buy medex australia, chronic the Lens 235 uveitis antiretroviral used for hiv generic 5 mg medex mastercard, retinal detachment and chronic cystoid macular oedema. The patient should be referred to a vitreoretinal surgeon after controlling any uveitis or raised intraocular pressure. There is bleeding into suprachoroidal space which may result in extrusion of intraocular contents (expulsive haemorrhage). Although the exact cause is not known, contributing factors include advanced age, glaucoma, systemic cardiovascular disease and vitreous loss. In this test, a drop of fluorescein is instilled in the lower fornix and the patient is asked to blink. Preoperative treatment of pre-existing infection such as blepharitis, conjunctivitis, dacryocystitis etc. Povidone-iodine is instilled preoperatively as follows: Two drops of 5% betadine solution are instilled into the conjunctival sac several minutes prior to surgery. Meticulous draping technique that ensures that the lashes and lid margins are isolated d. Postoperative injection of anterior sub-tenon antibiotics is commonly performed f. It may occur when an organism of low virulence becomes trapped within the capsular bag. Intraoperatively, phacoemulsification allows excellent control of each phase of the operation for cataract removal. Aspiration of the cortex also occurs within a closed anterior chamber, with low risks of damaging the endothelium, iris and posterior chamber. Phacoemulsification and small incision surgery are compatible with small size implants, i. The main advantage of this technique is that it is an astigmatism free cataract surgery. Laser procedures 238 Basic Ophthalmology In diagnostic procedures these agents create a required working space, lubricate the instruments as in gonioscopy, three-mirror examination or even in performing laser procedures for glaucoma, after cataract and on the retina. For creating and maintaining surgical space as during insertion of intraocular lens during catract surgery. Protecting the endothelium from damage due to handling in keratoplasty and phacoemulsi fication. The common viscoelastic substances are 1%, 2% hydroxy propyl methyl cellulose, 1% chondroitin sulphate, 1% sodium hyaluronate (Healon) and combinations of these like Viscoat (3% Sodium hyaluronate and 4% chondroitin sulphate). Contact Lens Advantage There is minimum retinal image magnification therefore it is specially useful in case of unilateral aphakia. Biometry Removal of the crystalline lens substracts approximately 20D from the refracting system of the eye. Biometry offers calculation of the lens power likely to result in emmetropia or a desired postoperative refraction. The intraocular lens optic may be monofocal, toric or multifocal, but monofocal lenses with a separate pair of glasses for close work are most widely used. Advantages There is minimum retinal image magnification and early return of binocular vision. Treatment of unilateral cataract is often difficult and unsatisfactory when the vision is good in the fellow eye. Postoperative correction with spectacles causes intolerable diplopia due to difference in the size of retinal image (eyes can tolerate dioptric difference of 2 to 3 D). Raised tension is controlled medically before cataract surgery as it may result in expulsive haemorrhage during surgery due to increased pressure gradient. Iridectomy (peripheral buttonhole) alone may be done in case of narrow angle glaucoma. Precaution Following trabeculectomy, care is taken to make the corneo-scleral incision, i. In both these operations, the posterior capsule and part of anterior capsule remains in situ. Uniocular diplopia may be present in cases of partial dislocation (subluxated lens). The edge of lens and zonule are visible in subluxation of lens by the ophthalmoscope and slit-lamp examination. Dislocated lens is visible by naked eye or slit-lamp if it is in the anterior chamber. Secondary glaucoma may occur in cases of dislocation into the anterior chamber due to the angle closure. Posterior chamber dislocations may result in pupillary block or phacolytic glaucoma.

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Meconium analysis provides a more accurate indication of exposure over a longer gesta tional period than does urine analysis antiviral agents buy medex toronto. Although newborn meconium screen ing also may yield false-negative test results hiv infection rates miami order medex 5mg amex, the likelihood is lower than with urinary screening antiviral vodlocker purchase medex 1 mg visa. Drug withdrawal should be scored using an appropriate scoring tool hiv infection rates in the world purchase 1mg medex overnight delivery, such as the modified Neonatal Abstinence Scoring System (Fig. Each nursery should have a written policy for implemen tation of a standard scoring system for neonatal withdrawal and appropriate treatment of the withdrawing infant. Initial treatment of the infants experiencing drug withdrawal should be primarily supportive, because pharmacologic therapy may prolong hospitalization and subject the infant to exposure to drugs that may not be indicated. Supportive care includes swad dling to decrease sensory stimulation; frequent small feedings of hypercaloric (24 cal/oz) formula to supply the additional caloric requirements; and obser vation of sleeping habits, temperature stability, weight gain or weight loss, or change in clinical status that might suggest another disease process. Vomiting, diarrhea, or both, associated with dehydration and poor weight gain, in the absence of other diagnoses, are relative indications for treatment, even in the absence of high total withdrawal scores. These effects also may result from environmental factors that place drug-exposed infants at high risk of physical, sexual, and emotional abuse, neglect, and developmental delay. In general, a coordinated multidisciplinary approach without criminal sanctions has the best chance of helping infants and families. Management of Acquired Opioid and Benzodiazepine Dependency One of the cornerstones in caring for critically ill infants is to provide adequate and safe analgesia, sedation, amnesia, and anxiolysis using both pharmacologic Neonatal Complications and Management of High-Risk Infants 343 and nonpharmacologic measures. Infants cared for in intensive care units who have developed tolerance to opioids and benzodiazepines due to an extended duration of treatment can be converted to an equivalent regimen of oral methadone and lorazepam. Respiratory Complications Oxygen Therapy the hazards associated with administration of supplemental oxygen to preterm infants have been recognized for many years. Supplemental oxygen can be delivered via endotracheal tube, mask, oxygen hood, nasal prongs, or cannula. Except in emergency situations, supplemental oxygen should be warmed and humidified, and the concentration or flow should be monitored and regulated. Orders should be written to adjust frac tion of inspired oxygen (Fio2) or flow within a stated range to maintain oxygen saturation within specific limits. An important development in the care of infants who require oxygen therapy is the ability to monitor oxygenation continuously with noninvasive techniques. Throughout most of the oxygen-hemoglobin dissociation curve, pulse oximetry will closely predict Pao2 when adjustments are made for the presence of fetal hemoglobin, and it is an excellent continuous monitor of oxygenation; however, at saturations greater than 96%, the Pao2 may be extremely high. This device has the potential advantage of monitoring for high Pao2; however, the heated membrane may cause burns, and the membrane may not read accurately because of poor perfusion or skin thickness, and it has been largely replaced by oximetry. Continuous measurement of pulse oximetry combined with periodic mea surement of Pao2 in samples from an umbilical or peripheral artery catheter is the most complete method of monitoring oxygen therapy. In infants whose con dition is stable, correlation with arterial blood gas samples may be performed when clinically indicated. In the absence of an indwelling arterial catheter, arterialized capillary sam pling provides reasonable estimates of arterial pH and PaCo2 if perfusion to the extremity is not compromised. The use of either pulse oximetry or transcutaneous oxygen measurement may shorten the time required to determine optimum inspired oxygen concen tration and ventilator settings in the acute care setting. Surfactant therapy has no effect on coexisting morbidities, such as necrotizing enterocolitis, nosocomial infection, patent ductus arteriosus, and intraven tricular hemorrhage. Antenatal corticosteroids and postnatal surfactant replacement have additive effects. Surfactant replacement has proved clearly efficacious for infants with respiratory distress associated with primary surfactant deficiency and should be administered to these infants as soon as possible after intubation. Surfactant replacement with either animal-derived (natural) or synthetic surfactant preparations has shown efficacy for respiratory distress due to surfac tant deficiency. First-generation synthetic surfactant preparations are less effective than animal-derived surfactants, in part because of their inabil ity to mimic the spreading and recycling functions of surfactant-associated pro teins. Clinical studies comparing animal-derived and second-generation synthetic surfactants are progressing. Neonatal Complications and Management of High-Risk Infants 347 Infants receiving surfactant replacement therapy often have associated multisystem organ dysfunction that requires specialized care. Newborns who have received surfactant should be transferred from such institu tions as soon as feasible to a center with appropriate facilities and trained staff to care for multisystem morbidity in sick newborns. Additionally, inotropic agents, intravascular volume expansion, and antibiotics may be indicated. Term and late preterm infants who fail to respond to conventional interven tions may benefit from rescue therapies targeting specific physiologic abnor malities that may accompany hypoxic respiratory failure, such as surfactant replacement for primary or secondary surfactant deficiency or inhaled nitric oxide for pulmonary hypertension. Response to inhaled nitric oxide is optimized when the lungs are adequately recruited; if conventional mechanical ventilation is not successful in this regard, high fre quency ventilation may be useful. The use of inhaled nitric oxide in preterm infants with acute hypoxic respiratory failure appears to be of little clinical benefit in the large randomized controlled trials thus far reported. Until new trials report signifi cant beneficial results, preterm infants should receive inhaled nitric oxide for acute hypoxic respiratory failure only within the context of clinical research protocols. Extracorporeal membrane oxygen ation refers to prolonged (days to weeks) cardiopulmonary bypass for infants with hypoxic respiratory or cardiac failure who are unresponsive to less invasive therapies. Extracorporeal membrane oxygenation is highly invasive and Neonatal Complications and Management of High-Risk Infants 349 accompanied by risks associated with systemic anticoagulation, mechanical complications, and the cannulation procedures. Bronchopulmonary dysplasia has been variably defined as the need for oxygen at 28 days postnatal age or at 36 weeks of postmenstrual age, with or without clinical and radiographic abnormalities. Parents should be fully informed about the known short-term risks and long-term risks and consent to treatment. None of these can be recommended at this time either because of safety issues (erythromycin) or unconfirmed efficacy (vitamin E supplementation beyond that required to prevent vitamin E deficiency is not beneficial); superoxide dismutase and other antioxidant medications have not been studied adequately. The optimal oxygen saturation range is unknown, but oxygen supplementation has been shown to improve growth and decrease the likelihood of progression to pulmonary hyperten sion. Prematurity; low birth weight; multiple gestation; severity of illness; prolonged ventilatory support (especially when accompanied by episodes of hypoxia and hypercapnia); and clinical conditions, including acidosis, shock, sepsis, apnea, anemia, chronic lung disease, intraventricular hemorrhage, patent ductus arteriosus, and vitamin E deficiency also have been associated with retinopathy of prematurity. To date, a safe level of Pao2 in relation to retinopathy of prematurity has not been established, perhaps because multiple other factors, such as those listed previously play a part in its pathogenesis. Data have demonstrated no additional progression of active prethreshold retinopathy of prematurity when supplemental oxygen was administered at pulse oximetry 354 Guidelines for Perinatal Care saturations between 96% and 99%. Sterile instru ments should be used to examine each infant in order to avoid possible cross contamination of infectious agents. Consideration also may be given to the use of nonpharmacologic pain management interventions, such as pacifiers and oral sucrose. This sched ule was designed to detect retinopathy of prematurity before it progresses to retinal detachment and to allow for earlier intervention, while minimizing the number of potentially traumatic examinations. One examination is sufficient only if it unequivocally shows the retina to be fully vascularized in each eye. However, the number of infants treated was small and there remain unanswered questions involving dosage, timing, safety, visual outcomes, and other long-term effects. Management of High-Risk Infants Nutritional Needs of Preterm Infants Optimal nutrition is critical in the management of preterm infants.

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