Clinics in laboratory medicine
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Much has been learned about thrombotic thrombocytopenic purpura (TTP) and heparin-induced thrombocytopenia (HIT) and much remains a diagnostic and management challenge. While the pentad of thrombocytopenia, microangiopathic hemolytic anemia, fever, and renal and neurologic abnormalities characterize the clinical presentation of TTP, few patients present with all signs and symptoms. ⋯ HIT is another systemic disorder presenting with thrombocytopenia and/or thrombosis with potential devastating consequences whose diagnosis is difficult and management is still evolving. Highlights of the conditions and clinical and laboratory hints that allow physicians to diagnose TTP and HIT efficiently and offer patients the best available therapeutic interventions are presented.
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In managing pain, clinicians working with the more than 80 million people in the United States who suffer annually from serious pain face decisions about choosing the most appropriate pharmacologic agent, to contemplating nonpharmacologic modalities. This article focuses on opioid use for pain management, their risks of toxicity and addiction, adverse reactions, undertreatment for fear of addiction, and integration of novel diagnostics, such as the pharmacogenetic biomarkers CYP2D6 and OPRM1 as holding promise for assessing a patient's risk of adverse events or likelihood of efficacy. Incorporation of such biomarkers is emerging on the forefront of personalized medicine, and has the potential to dramatically improve the utility and efficacy of both current and future pain management strategies.
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Genetic research heralds a new therapeutic approach to pain management. Increasing literature demonstrates individual genetic vulnerabilities to specific pain types and mechanisms, partially explaining differing responses to similar pain stimuli. ⋯ Family history and genotyping promise to play an important role in future pain therapies. As advances continue in the genetics of pain and analgesia, pharmacotherapy will depend more on an individualized, targeted approach and less on empiricism.
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Many of the complexities of human drug response are sufficiently well understood to transform the field of pharmacogenetics from a descriptive science to a predictive science. Clinical application of these markers is currently limited by lack of knowledge about the effects of modifying genes, about their prevalence and risk contribution in different ethnogeographic populations, and by fragmentary information about how genetic factors interact with physiologic or pathologic and other environmental factors. Nevertheless, progress has been notable, as exemplified in the identification of genetic markers predictive of pharmacokinetic variation, and in markers predictive of outcome and therapeutic benefit in the treatment of cancer.
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Carbon monoxide is an insidious poison that accounts for thousands of deaths each year in North America. Clinical effects maybe diverse and include headache, dizziness, nausea, vomiting,syn-cope, seizures, coma, dysrhythmias, and cardiac ischemia. Children, pregnant women, and patients who have underlying cardiovascular disease are particularly at risk for adverse out-comes. Treatment consists of oxygen therapy, supportive care, and, in selected cases, hyperbaric oxygen therapy.