Professionals working in primary healthcare settings are likely to come into contact with older adults suffering with anxiety disorders.
In a new window Figure 1. This model of coagulation oversimplifies the process of in vivo coagulation but is useful for the correlation of coagulation assay ie, activated partial thromboplastin time [aPTT], prothrombin time [PT] abnormalities with specific pathways and, hence, coagulation factors.
Excessive bruising, epistaxis, bleeding after dental extraction, and menorrhagia are symptoms suggestive of quantitative or qualitative platelet disorders. Quantitative platelet abnormalities in adults are most often acquired; autoimmune ie, idiopathic thrombocytopenic purpura [ITP] and drug-induced thrombocytopenia account for the vast majority of cases of isolated thrombocytopenia.
Congenital or inherited thrombocytopenias are usually diagnosed during childhood, but diagnosis could be delayed into adulthood, especially in individuals who do not regularly obtain health care.
Numerous inherited thrombocytopenias exist; individual conditions may be identified based on platelet size, coexisting physical or laboratory abnormalities, and the presence of defective platelet function as well as an abnormal platelet count. Conversely, documentation of previously normal platelet counts would exclude congenital thrombocytopenia.
In a new window Table 2. Differential Diagnosis and Diagnostic Features of Quantitative Platelet Disorders Qualitative platelet disorders presenting in adults can be caused by medication eg, aspirin and nonsteroidal anti-inflammatory drugs [NSAIDs]uremia, cirrhosis, and myeloproliferative disorders.
In patients with a relevant history eg, significant mucocutaneous bleeding, family historyinitial hematologic laboratory evaluation should include specific testing for VWD VWF antigen, VWF ristocetin cofactor activity, and factor VIII activity assays ; other screening tests such as activated partial thromboplastin time aPTT and bleeding time or a platelet function analyzer PFA; Siemens Health care Diagnostics Inc.
Consequently, in patients with mucocutaneous bleeding who do not have thrombocytopenia or VWD, platelet aggregometry should be considered as an initial test for assessing platelet function, 3 in addition to evaluation of a peripheral blood smear for abnormalities in platelet morphology that are specific to certain conditions eg, gray platelet syndrome.
In contrast to the superficial bleeding associated with platelet defects, coagulation factor defects result in delayed, deep bleeding, for example, into muscles or joints, as well as deep soft-tissue and mucocutaneous bleeding.
Patients with milder congenital deficiencies or those with certain specific congenital deficiencies eg, factor XI deficiency are more likely to bleed after hemostatic challenge.
Menorrhagia is a common bleeding symptom in women, both those with and without bleeding disorders. Menorrhagia is the most common bleeding symptom in women with inherited bleeding disorders, 24 particularly menorrhagia that begins at menarche and persists into adulthood. Samples may also be drawn for storage for future testing, 25 especially if administration of transfusional therapies eg, fresh frozen plasma [FFP] is anticipated.
Hematologic Laboratory Abnormalities Once a significant bleeding history is identified, an initial laboratory evaluation is generally undertaken to determine the underlying cause. Alternatively, an adult with an undiagnosed bleeding disorder may present with abnormal hematologic laboratory studies obtained as part of an evaluation for surgery or for some other reason.
Increased sensitivity of the reagents used in coagulation assays, most notably PT and aPTT, has led to an increased incidence in abnormal results for these tests.
Abnormal Coagulation Assays Prolongation of the aPTT or PT may indicate an acquired or congenital clotting factor deficiency or an inhibitor of one or more coagulation factors. Potential inhibitors include medication namely anticoagulantsantibodies directed against specific coagulation factors, and nonspecific inhibitors eg, lupus anticoagulants.
A mixing study can be used to differentiate a deficiency from an inhibitor. In a mixing study, equal volumes of normal and patient plasma are combined, and then the coagulation study is repeated. In cases of coagulation factor deficiency, the presence of normal plasma replaces the missing factor sthereby normalizing the abnormal coagulation study.
In contrast, when an inhibitor is present the abnormality persists after the addition of normal plasma. For example, lupus anticoagulant is more likely to be associated with thrombosis than with bleeding, except in rare cases of associated antiprothrombin antibodies, which lead to bleeding symptoms and a prolonged PT in addition to prolonged aPTT.
When asked to evaluate an asymptomatic patient who has a markedly prolonged aPTT, testing for lupus anticoagulant should be considered first when the mixing study fails to correct and for FXII deficiency when the aPTT corrects in the mixing study.
In a new window Figure 2. Once the coagulation laboratory study abnormality has been identified, the differential diagnosis may be further narrowed down based on the specific coagulation study abnormalities activated partial thromboplastin time [aPTT], prothrombin time [PT], or both ; the presence or absence of bleeding symptoms; and the results of the mixing study.
Note that prolonged incubation may be required for accurate mixing study results. Acquired deficiencies of single coagulation factors may occur in the setting of systemic diseases such as amyloidosis FX and myeloproliferative disease FV and must be differentiated from congenital deficiencies.
Potential inhibitors that may present with prolonged aPTT and PT include heparin, direct thrombin inhibitors, potent lupus anticoagulants, and other nonspecific inhibitors such as those associated with lymphoproliferative disorders or monoclonal protein disorders.
Acquired coagulation factor inhibitors or autoantibodiesmost commonly directed against FVIII a condition referred to as acquired hemophiliadeserve special mention because they may be associated with serious bleeding in adults with no history of bleeding.
Acquired hemophilia is a rare condition incidence of 1 to 4 per million per year 33 that predominately affects older adults.
Acquired hemophilia should be suspected in an adult with new- or recent-onset bleeding who has no personal or family history of bleeding and presents with an isolated prolonged aPTT that does not correct in a mixing study.
Because acquired hemophilia requires specialized treatment, prompt diagnosis is important, particularly when an invasive procedure is necessary.
In asymptomatic patients, artifactual thrombocytopenia as a result of platelet clumping may first be excluded by examining the peripheral blood smear.
Immune thrombocytopenias, either idiopathic primary or secondary to an autoimmune disease, may present with asymptomatic, isolated thrombocytopenia. Bleeding propensity in thrombocytopenic conditions usually depends on the platelet count.
This test also was used to screen for certain bleeding disorders, including VWD.The overarching goal of PCSS is to provide the most effective evidenced-based clinical practices in the prevention of OUD through proper opioid prescribing practices, identifying patients with OUD, and the treatment of opioid use disorder.
Read chapter 9 Barriers to Effective Treatment and Intervention: Every year, about 30, people die by suicide in the U.S., and some , receive emer. Medication-Assisted Treatment (MAT) is the use of medications, in combination with counseling and behavioral therapies, to provide a “whole-patient” approach to the treatment of substance use disorders.
Research shows that a combination of medication and therapy can successfully treat these disorders, and for some people struggling . ACT programs aim to provide mentally ill patients with treatment, rehabilitative, and support services in order to improve their ability to live independently.
ACT services include medication delivery, individual therapy, crisis and hospital services, substance abuse therapy, rehabilitative services, supported housing and transportation, and skill teaching to family members. Properly identify and assess drug-induced movement disorders such as tardive dyskinesia, pseudoparkinsonism, and akathisia.
Recognize medication-related movement disorders early, allowing for more effective treatment. Improve outcomes and patient adherence to medication regimens with early treatment and intervention.
treatment of dissociative identity disorder (DID) and those forms of disso- ciative disorder not otherwise speciﬁed (DDNOS) that are similar to DID. It is intended as a practical guide to the management of adult patients.