This document provides an overview of plasmapheresis in neurological disorders. It begins with definitions of related terms and procedures. It then discusses the principles, techniques, complications, indications, and guidelines for plasmapheresis. Key points include that plasmapheresis is recommended for certain neurological conditions like Guillain-Barré syndrome, CIDP, myasthenia gravis, and NMOSD. Optimal treatment regimens vary based on the condition but typically involve removing 1-1.5 total plasma volumes over multiple sessions. Albumin is commonly used as the replacement fluid.
references:
1-European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force—Second revision.
2-Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Its Variants By Kelly Gwathmey, MD
3-Patient Journey in CIDP: Burden, Symptoms, and Diagnosis Jeffrey A. Allen, MD; Richard A. Lewis, MD
references:
1-European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force—Second revision.
2-Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Its Variants By Kelly Gwathmey, MD
3-Patient Journey in CIDP: Burden, Symptoms, and Diagnosis Jeffrey A. Allen, MD; Richard A. Lewis, MD
This is a brief review of autoimmune epilepsies, especially autoimmune encephalitis, SREAT, NORSE, FIRES and Rasmussen's encephalitis. A brief overview of investigations and treatment is included.
A neuromuscular disorder that leads to weakness of skeletal muscles.
Symptoms
Causes
Prevention
Complications
Common tests & procedures
Neurological examination:
Repetitive nerve stimulation test:
Antibody test:
Pulmonary function tests (PFTs): To check any breathing difficulty.
CT scan: To rule out a presence of tumor in thymus.
Magnetic resonance imaging (MRI): MRI of the chest is performed to rule out a presence of tumor in thymus.
Edrophonium (Tensilon) test:
Medication
Procedures
Nutrition
A detailed discussion on a very much in demand topic. Covered all aspects of the procedure which are important for an Emergency, Medical and Intensive Care physician should know. Nurses can also benefit from the presentation as we have tried to keep it as simple and straight forward as possible.
This is a brief review of autoimmune epilepsies, especially autoimmune encephalitis, SREAT, NORSE, FIRES and Rasmussen's encephalitis. A brief overview of investigations and treatment is included.
A neuromuscular disorder that leads to weakness of skeletal muscles.
Symptoms
Causes
Prevention
Complications
Common tests & procedures
Neurological examination:
Repetitive nerve stimulation test:
Antibody test:
Pulmonary function tests (PFTs): To check any breathing difficulty.
CT scan: To rule out a presence of tumor in thymus.
Magnetic resonance imaging (MRI): MRI of the chest is performed to rule out a presence of tumor in thymus.
Edrophonium (Tensilon) test:
Medication
Procedures
Nutrition
A detailed discussion on a very much in demand topic. Covered all aspects of the procedure which are important for an Emergency, Medical and Intensive Care physician should know. Nurses can also benefit from the presentation as we have tried to keep it as simple and straight forward as possible.
New class of therapeutic agents called soluble guanylate cyclase (sGC) stimulators.
Impairment of NO synthesis and signaling through the NO-sGC–cGMP pathway is involved in the pathogenesis of pulmonary hypertension.
Dual mode of action,
Directly stimulating sGC independently of NO, and
Increasing the sensitivity of sGC to NO.
vasorelaxation , antiproliferative and antifibrotic effects
In this ppt tried to give info about from serum therapy to plasma therapy in treatment of covid-19 is explained in concised form by collecting from so many sources.This ppt consists of about plasma,plasma composition,serum therapy which is invented by scientist and nobel laureate von behring and vaccines of diphtheria and tetanus ,convalescent plasma(CP) therapy procedure , CP application in curing covid-19 disease,and WHO statement about usage of plasma therapy for covid disease are explained in detailed manner.
CONCEPT OF NODOPATHIES AND PARANODOPATHIES.pptxNeurologyKota
emergence of autoimmune neuropathies and role of nodal and paranodal regions in their pathophysiology.
Peripheral neuropathies are traditionally categorized into demyelinating or axonal.
dysfunction at nodal/paranodal region key for better understanding of patients with immune mediated neuropathies.
antibodies targeting node and paranode of myelinated nerves have been increasingly detected in patients with immune mediated neuropathies.
have clinical phenotype similar common inflammatory neuropathies like Guillain Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy
they respond poorly to conventional first line immunotherapies like IVIG
This presentation briefs out the approach of dementia assessment in line with consideration of recent advances. Now the pattern of assessment has evolved towards examining each individual domain rather than lobar assessment.
This presentation contains information about Dementia in Young onset. Also it describes the etiologies, clinical feature of common YOD & their management.
Entrapment Syndromes of Lower Limb.pptxNeurologyKota
This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
CDSCO and Phamacovigilance {Regulatory body in India}NEHA GUPTA
The Central Drugs Standard Control Organization (CDSCO) is India's national regulatory body for pharmaceuticals and medical devices. Operating under the Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India, the CDSCO is responsible for approving new drugs, conducting clinical trials, setting standards for drugs, controlling the quality of imported drugs, and coordinating the activities of State Drug Control Organizations by providing expert advice.
Pharmacovigilance, on the other hand, is the science and activities related to the detection, assessment, understanding, and prevention of adverse effects or any other drug-related problems. The primary aim of pharmacovigilance is to ensure the safety and efficacy of medicines, thereby protecting public health.
In India, pharmacovigilance activities are monitored by the Pharmacovigilance Programme of India (PvPI), which works closely with CDSCO to collect, analyze, and act upon data regarding adverse drug reactions (ADRs). Together, they play a critical role in ensuring that the benefits of drugs outweigh their risks, maintaining high standards of patient safety, and promoting the rational use of medicines.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
The Gram stain is a fundamental technique in microbiology used to classify bacteria based on their cell wall structure. It provides a quick and simple method to distinguish between Gram-positive and Gram-negative bacteria, which have different susceptibilities to antibiotics
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. Outline
– Introduction
– Principles and Procedure
– Complications
– Indications
– Contraindications
– Guidelines and recommendations
– Conclusion
3. Terminology
– Apheresis (Greek aphairesis–withdrawal)- An
umbrella term for "taking away" a blood
component.
– Plasmapheresis : Automated, selective
removal of plasma by centrifugation.
– Plasma exchange [TPE]- Removal of patient
plasma and replacement with another fluid (eg,
donor plasma, colloid, crystalloid).
4. Terminology…
– Hemapheresis (also called cytapheresis) –
Selective removal of abnormal blood cells or
excessive numbers of cells.
– Dialysis – A diffusion-based treatment best suited
for the removal of fluid or small molecules (eg,
uremic toxins, some drugs) from the blood using
a filter.
– Plasma filtration – A technique that separates
plasma from cellular components with a highly
permeable filter (plasma filter) using a dialysis or
hemofiltration machine.
5. Principles and Procedure
– The aim of plasma exchange is to significantly reduce
circulating pathologic substances (antibodies) from the
plasma.
– Substance to be removed must have a sufficiently long
half life.
– Substance to be removed must acutly toxic and
resistent to conventional therapy.
10. Centrifugal devices
– There is no upper limit to
the molecular weight of
proteins removed by this
method.
– Circuits are single use and
disposable.
– Platelet can decrease by as
much as 50%.
Membrane plasma filtration
– All immunoglobulins will
cross the membrane
however, some large
immune complexes and
cryoglobulins may not be
adequately cleared.
– Reuse of plasma ilters is not
advised, but performance
data do not indicate a
major loss of function
during routine plasma
exchange.
– There is no loss of platelets
11. – Estimate plasma volume (in liters) = 0.07 x
weight (kg) x (1 - hematocrit) .
– Usually 1-1.5 TPV or 30-40 ml/Kg of plasma is
removed/ cycle and replacement with plasma
expanders like albumin or FFP.
– 3-5 alt. day cycle.
12. Choice of Replacement
solution-Albumin
Advantage:
1. No risk of hepatitis/HIV
2. Stored at room
temperature
3. Allergic reaction are rare
4. No concern about ABO
blood group
5. Depletes inflammation
mediators
Disadvantage:
1. Expensive
2. No coagulation
factors
3. No
immunoglobulin's
14. – There is no consensus on the ideal replacement
solution during PE.
– The use of albumin and cross matching plasma
have been recommended*.
– Colloid replacement can be achieved with the
use of fresh-frozen plasma, albumin, albumin
and saline, or albumin and plasma expander
solutions.*
Korach JM, Berger P, Giraud C, Le Perff-Desman C, Chillet P. Role of replacement fluids in the immediate complications of plasma exchange. French Registry
Cooperative Group. Intensive Care Med 1998;24:452-8.
Clark WF, Rock GA, Buskard N, Shumak KH, LeBlond P, Anderson D, et al. Therapeutic plasma exchange: An update from the Canadian Apheresis Group.
15. Immunoadsorption technique
– In addition to PE, the immunoadsorption technique
represents a newer approach that allows a more
selective removal of circulating antibodies.
– By binding to a ligand, removal of immunoglobulin
fractions can be achieved.
– After adsorption, the cellular blood components and
plasma are combined and reinfused.
Weinstein R. Therapeutic apheresis in neurological disorders. J Clin Apher 2000;15:74-128.
20. AAN Level of
Recommendations
A = Established as effective, ineffective or harmful.
B = Probably effective, ineffective or harmful.
C = Possibly effective, ineffective or harmful.
U = Data inadequate or conflicting; given current
knowledge, treatment (test, predictor) is unproven.
– Note that recommendations can be positive or
negative.
21. Methods
– MEDLINE, Cochrane Library, Web of Science,
and EMBASE
– 1995 to September 2009
– A secondary bibliography search of all full-text
articles
– Relevant, fully published, peer-reviewed articles
– Search terms
– “plasmapheresis”
– “neurologic disease (exploded)”
– key text words and index words for
plasmapheresis, plasma exchange,
immunoadsorption, and double filtration
plasmapheresis
22. Methods...
– At least two authors reviewed each article for
inclusion.
– Strength of practice recommendations were linked
directly to levels of evidence (Levels A, B, C, and
U).
– Conflicts of interest were disclosed.
23. Literature Review
2263 abstracts
and 59 articles
Inclusion criteria:
- Articles reporting results from
controlled clinical trials in humans
- Abstracts available in English
Exclusion criteria:
- Articles that were not controlled
clinical trials
- Abstracts in languages other than
English
24. Clinical Questions
1. What is the efficacy of plasmapheresis in the
treatment of AIDP, also known as GBS?
2. What is the efficacy of plasmapheresis in the
treatment of CIDP?
2. What is the efficacy of plasmapheresis in the
treatment of dysimmune neuropathies?
3. What is the efficacy of plasmapheresis in the
treatment of MG?
25. Clinical Questions…
5. What is the efficacy of plasmapheresis in the
treatment of CNS demyelinating disease?
6. What is the efficacy of plasmapheresis in the
treatment of PANDAS?
7. What is the efficacy of plasmapheresis in the
treatment of Sydenham chorea?
36. AIDP/GBS
– Primary treatment TPE- Category I
– TPE After IVIG –category III
– In GBS – There are autoantibodies against
various gangliosides including GM1, GD1a,
GalNAc-GD1a, GD1b, GQ1b, GD3, and GT1a,
particularly in AMAN and Miller Fisher
syndrome subtypes.
37. AIDP/GBS…
– The Cochrane Neuromuscular Disease Group review
of TPE in AIDP (2012)- found that TPE is most
effective when initiated within 7 days of disease onset.
– Evidence-based guidelines of the AAN –TPE=IVIG in
the treatment of GBS (Winters, 2011).
– Volume treated: 1–1.5 TPV, Frequency: Every other
day, Replacement fluid: Albumin
– Exchange 200–250 mL of plasma /kg body weight
over 10–14 days.
38. CIDP
– Recommendation Category-I
– Volume treated: 1–1.5 TPV
– Frequency: 2–3/week until improvement, then
taper as tolerated
– Replacement fluid: Albumin
– TPE provides short-term benefit but rapid
deterioration may occur afterwards
– The frequency of maintenance TPE may range
from weekly to monthly .
39. HASHIMOTO’S
ENCEPHALOPATHY; SREAT
– High dose steroid is first line Rx.
– Recommendation Category-II
– Volume treated: 1–1.5 TPV
– Frequency: Daily to every other day
– Replacement fluid: Albumin
– 3–9 procedures, mostly commonly 5.
40. MULTIPLE SCLEROSIS
– Acute CNS inflammatory demyelinating –Cat. II
– Chronic progressive MS , TPE – Cat. III
– Standard treatment for MS exacerbation – High
dose IV MPS.
– If unresponsive, a second steroid pulse is given
after an interval of 10–14 days.
41. MULTIPLE SCLEROSIS…
– In acute, severe attacks of MS in patients who
fail initial treatment with high-dose steroids, TPE
may be beneficial (Gwathmey,2014).
– TPE has also been used for drug removal in MS
patients treated with Natalizumab who developed
PML.
42. MS…
– Volume treated: 1–1.5 TPV
– Frequency: Acute: 5–7 over 14 days
– Chronic progressive: weekly
– Replacement fluid: Albumin
– In acute MS relapse unresponsive to steroids,
5–7 TPE procedures have a response rate of
50%.
43. ADEM
– Recommendation Category-II
– Indication-Steroid refractory ADEM
– High-dose IV steroids ;IV MPS 20–30
mg/kg/day (maximum 1 g/day) for 3–5 days
first-line therapy.
– It may be followed by a prolonged oral
prednisolone taper over 3–6 weeks.
44. ADEM…
– In one study (Llufriu, 2009) early initiation of
TPE (within 15 days of disease onset) in acute
attacks of CNS demyelination (including seven
cases of ADEM) was identified as a predictor of
clinical improvement at 6 months.
– Volume treated: 1–1.5 TPV
– Frequency Every other day
– Replacement fluid: Albumin
Llufriu S, Castillo J, Blanco Y, Ramio-Torrenta L, Rıo J, Valle`s M, Lozano M, Castella MD, Calabia J, Horga A, Graus F, Montalban X,Saiz A. Plasma exchange
for acute attacks of CNS demyelination: predictors of improvement at 6 months. Neurology 2009;73:949–953.
45. ADEM…
– No clear recommendations for optimal regimen .
– In one of the largest ADEM case series (Keegan,
2002), TPE achieved moderate and marked
sustained improvement in 50% of the patients.
– In the majority of studies, clinical response was
noticeable within days, usually after 2–3
exchanges.
– In published studies, TPE therapy often consisted
of 3–6 treatments.
Keegan M, Pineda AA, McClelland RL, Darby CH, Rodrigues M, Weinshenker BG. Plasma exchange for severe attacks of CNS demyelination: predictors of
response. Neurology 2002;58:143–146.
46. NEUROMYELITIS OPTICA
SPECTRUM DISORDERS
– Recommendation Category-
– Acute -II
– Maintenance TPE –III
– Acute attacks are managed by high-dose
intravenous steroids (usually intravenous pulse
steroids (methylprednisone 1 g daily 3- 5 days
followed by oral steroid taper) and, if
symptoms fail to resolve, TPE is added.
47. NMOSD…
– Volume treated: 1–1.5 TPV
Frequency:
1. Acute: Daily or every other day;
2. Maintenance: Variable
– Replacement fluid: Albumin
48. NMOSD…
– The majority of studies performed five
procedures on average for acute exacerbation.
– In one case series, 5 out 7 patients who were on
maintenance TPE therapy (3 per week for 2
weeks, 2 per week for 2 weeks, then weekly for
3–5 weeks) showed varying degrees of
improvement and reduction in the number of
NMOSD exacerbation
49. MYASTHENIA GRAVIS
– Recommendation Category
– Moderate–severe TPE –Cat. I
– Pre-thymectomy TPE –Cat. I
– Myasthenic crisis is characterized by acute
respiratory failure requiring intubation,
prolonged intubation following thymectomy, or
bulbar weakness causing dysphasia and high risk
of aspiration.
50. MG…
Four major treatment approaches-
1. Cholinesterase inhibitors
2. Thymectomy
3. Immunosuppression,
4. TPE or IVIG.
51. MG…
– TPE is used to remove circulating
autoantibodies, particularly in-
1. Myasthenic crisis
2. Perioperatively for thymectomy,
3. As an adjunct to other therapies to maintain
optimal clinical status
52. MG…
– IVIG and TPE appear equivalent in the literature
– Typical induction regimen consists of processing
225 mL/kg of plasma over a period of up to two
weeks but smaller volumes process can also be
beneficial.
– Number and frequency of procedures depends upon
clinical scenario.
– Some patients may require long-term maintenance
TPE.
53. LEMS
– Recommendation category-II
– Autoimmune disorder of presynaptic neuromuscular
transmission- anti VGCC antibody.
– Its classical clinical triad include:
1. Muscle weakness (most prominent in proximal
muscles of the lower extremities)
2. Hyporeflexia
3. Autonomic dysfunction (e.G., Dry mouth,
constipation, and male impotence).
54. LEMS
– In contrast to myasthenia gravis (MG), brain
stem symptoms such as diplopia and dysarthria
are uncommon.
– Associated with SCLC
– Other CA –lymphoma and malignant thymoma
– No controlled trials exist on the use of TPE in the
LEMS.
55. LEMS…
– In one series, 8 out 9 patients (Newsom-Davis,
1984) had increase in electromyographic muscle
action potential (P<0.01) while receiving TPE
and immunosuppression.
– 5 to 15 daily TPE over 5–19 days to 8–10 TPE
carried out at 5–7 day intervals.
– Improvement may not be seen for 2 weeks or
more after initiation of TPE.
56. LEMS…
– Treatment should continue until a clear clinical and
EMG response is obtained or at least until a 2–3
week course of TPE has been completed.
– Repeated courses -in case of neurological relapse,
– Effect may last only upto 6 weeks in the absence of
immunosuppressive therapy.
57. NMDA RECEPTOR ANTIBODY
ENCEPHALITIS
– Recommendation category-I
– An acute autoimmune neurological disorder first
described by dalmau(2007).
– It is characterized by IgG antibodies targeting the
synaptic GLuN1 (also known as NR1) subunit of
the NMDAR.
58. NMDA RECEPTOR
ANTIBODY ENCEPHALITIS
– 50% have an underlying neoplasm; usually
ovarian teratoma.
– Definitive diagnosis -by the detection of
NMDAR autoantibodies in the serum, and more
specifically in the CSF.
– Imaging, EEG, and brain biopsy are typically
nondiagnostic.
– Delay in diagnosis is common - often mistaken
for psychosis or viral encephalitis.
59. NMDA RECEPTOR
ANTIBODY ENCEPHALITIS
First-line immunotherapies-
1. IV MPS
2. IVIG, and/or TPE.
– Approximately 50% of patients respond to these
first-line immunotherapies
– Other 50% require second-line therapies-
rituximab or combination of rituximab and
cyclophosphamide
60. NMDA RECEPTOR
ANTIBODY ENCEPHALITIS
– 75–80% -recover or improve (50% within 4 weeks
of treatment)
– 20%- substantial deficits or death.
– Relapses -12–20%
– Disease activity appears to correlate with antibody
levels.
61. NMDA RECEPTOR
ANTIBODY ENCEPHALITIS
– Dalmau (2011) proposed a treatment plan consisting
of teratoma removal (if present), corticosteroids
and/or IVIG and/or TPE (alone or any combination)
as the first-line of treatment), and rituximab and
cyclophosphamide as the second-line of treatment
for non-responders.
– The exact order of the treatments (corticosteroids,
IVIG, and TPE) was not defined.
62. NMDA RECEPTOR
ANTIBODY ENCEPHALITIS
– Furthermore, systematic comparisons between
the three first-line modalities are unavailable
(Titulaer, 2013).
– Recent case series (Pham, 2011; DeSena, 2015)
suggest early initiation of TPE or TPE followed
by IVIG provide better outcomes
– 5–6 TPE procedures on alternate days.
63. Conclusion
– Removal of immunoglobulins
– Centrifugation and Plasma filtration
– Albumin MC used
– 5 cycles alt. days
– Good response in GBS,Myasthenia crisis,
Autoimmune encephalitis.
– Good for acute management
64.
65. References
– Joseph Schwartz et al; Guidelines on the Use of Therapeutic
Apheresis in Clinical Practice—Evidence-Based Approach from
the Writing Committee of the American Society for Apheresis:
The Seventh Special Issue ;.; Journal of Clinical Apheresis
31:149–338 (2016)
– Update: Plasmapheresis in Neurologic Disorders; Report of the
Therapeutics and Technology Assessment Subcommittee of the
American Academy of Neurology; Irene Cortese, MD et al; 2011.
– American Academy of Neurology (AAN) guideline update
(Neurology ® 2011;2011;76:294–300) regarding use of
plasmapheresis in treating neurologic disorders
– Neurology in clinical practice ;Bradley 7TH edition.