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Alcohol Tremor

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141. Depression: Adult and Adolescent

of depression • Women with a history of domestic violence • Individuals with chronic health conditions (e.g., diabetes, heart disease, asthma, COPD, cancer, arthritis, chronic pain, terminal illness, or neurological disorders such as stroke or Parkinson’s disease) • Individuals with a history of drug or alcohol misuse • Individuals who identify as lesbian, gay, bisexual, or transgender (LGBT) • Adolescents who have been subjected to bullying Common presentations of depression include: • Feeling down (...) health and substance use concerns by integrating behavioral health into primary care clinics. The goal of BHI is to create a welcoming environment for patients to address common problems— alcohol and substance use disorders as well as depression— with their primary care teams. A major element of BHI is transitioning primary care social workers to a new role—that of integrated behavioral health specialist—in which they will work as provider extenders to address patient needs without disrupting patient

2017 Kaiser Permanente Clinical Guidelines

142. CRACKCast E147 – General Approach to the Poisoned Patient

of the parasympathetic system. Muscarinic effects: Diarrhea, diaphoresis Urination Miosis Bradycardia Bronchorrhea Emesis Lacrimation Lethargic Salivation Nicotinic effects: Mydriasis Tachycardia Weakness Tremors Fasciculations Seizures Somnolent Organophosphate and carbamate insecticides, nerve agents, nicotine, pilocarpine, physostigmine, edrophonium, bethanechol, urecholine, Liquids from e-cigarettes (muscarinic effects are less prominent) Antidotes: Atropine 2-pam aka Pralidoxime (2-pyridine aldoxime methyl (...) chloride) Benzos Supportive Sedative/hypnotic Sedation Vs. Hallucinogenic Depression of brain activity and muscular metabolism Altered mental status Pupils not changed clinically Benzodiazepines, barbiturates, carisoprodol, meprobamate, glutethimide, alcohols, zolpidem ( USA) Supportive Rule out traumatic injuries Opiate Sedation, diminished respiratory drive – responsive to naloxone Miosis, hypothermia, respiratory depression, apnea, Bradycardia, hyporeflexia, pulmonary edema Opioids (eg, heroin

2018 CandiEM

143. Management of menopausal symptoms in women with a history of breast cancer

. Caution should be taken for patients with conditions such as congenital Management of menopausal symptoms in women with a history of breast cancer page 79 of 181Generic name (brand names) Indications Contraindications Common side effects (occurring in =1% of patients) Drug interactions Precautions / Comments Headache Insomnia Somnolence Tremor *for side effects occurring in between 1% and 10% of patients please see specific PI efficacy long QT syndrome; acquired long QT syndrome; a family history (...) symptoms in women with a history of breast cancer page 80 of 181Generic name (brand names) Indications Contraindications Common side effects (occurring in =1% of patients) Drug interactions Precautions / Comments Gabapentin Epilepsy Neuropathic pain Hypersensitivity to gabapentin Side effects occurring in >5% of participants* Fatigue Nausea Vomiting Somnolence Dizziness Ataxia Nystagmus Headache Tremor Diplopia Asthenia Cimetidine Antacids may reduce gabapentin bioavailability Antiepileptic drugs

2017 Cancer Australia

144. CRACKCast E151 – Antidepressants

criteria for Serotonin Syndrome? Hunter criteria Exposure to a known serotonergic agent; AND Any of the following: Spontaneous clonus Inducible clonus and agitation or Diaphoresis Ocular clonus and agitation or Diaphoresis Tremor and hyperreflexia Hypertonic w/ Temp > 38 o C and ocular clonus or inducible clonus “The descending ladder of hyper-reflexia” As the hyper-reflexia gets less and less impressive, the additional criteria become more pronounced [5] How can you discern between NMS and Serotonin (...) Syndrome? Both look the same = FARM Fever Autonomic instability Rigidity / rhabdo Mental status changes However, the major differentiating features: NMS = parkinsonian type lead pipe rigidity; slower onset; similar presentation to the unwell septic patient SS = spastic rigidity – agitation / tremor / CLONUS / increased motor activity; rapid onset Onset: SS relatively rapid within hours NMS over days potentially Course: NMS may wax and wane. SS peaks then declines Obviously hyper-reflexia is the most

2018 CandiEM

145. CRACKCast E165 – Sedative Hypnotics

blocker. Endotracheal intubation to protect against emesis, aspiration pneumonitis, and hypoxia is often necessary for patients with significant CNS or respiratory depression from GHB overdose. Withdrawal from GHB or its precursors begins with anxiety, tremor, and insomnia, but it can progress to a severe syndrome characterized by delirium and autonomic instability. Management of this syndrome often requires high-dose benzodiazepine or barbiturate therapy (because they are GABA depleted). Rosens (...) for noncardiogenic pulmonary edema & aspiration pneumonitis ***Note: Barbiturate withdrawal syndrome includes: Tremors Hallucinations Seizures delirium (similar to the delirium tremens of ethanol withdrawal) [5] How are barbiturate overdoses managed? Investigations / Supportive care / Invasive ventilation as needed Labs: The therapeutic level of phenobarbital is 15 to 40 μg/mL (65 to 172 μmol/L) A serum level greater than 50 μg/mL can be associated with coma, especially in a patient who is not a chronic user

2018 CandiEM

146. Management of Acute Pancreatitis in the Pediatric Population: A Clinical Report From the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Pancreas Committee

management, nutrition, pain control, protease inhibitors, surgery (JPGN 2018;66: 159–176) A cute pancreatitis (AP) has been increasingly diagnosed in children in recent decades (1–3). A variety of etiologies can result in AP in children, including structural/anatomic, obstructive/ biliary, trauma, infections, toxins, metabolic, systemic illness, inborn errors of metabolism, and genetic predispositions. These are a more prevalent compared with adult AP, when biliary and alcoholic causes are well (...) , and tremors (105). A review of narcotics and sphincter of Oddi function by Thompson (106), documents that no studies to date directly compare the effects of meperidine and morphine on sphincter of Oddi manometry and no comparative studies exist in patients with AP. Furthermore, no studies or evidence exist to indicate morphine is contraindicated for use in AP. A Cochrane review from 2013 includes 5 studies with a total of 227 subjects to assess the efficacy and safety of several opioids. Medications

2018 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

147. Appropriate Use Criteria: Imaging of the Head & Neck

movement disorders, to exclude an underlying structural lesion ? Hemifacial spasm ? Huntington’s disease ? Multiple system atrophy (MSA) ? Parkinson’s disease with atypical features ? Progressive supranuclear palsy ? Secondary dystonia ? Other focal or lateralizing movement disorder, such as hemiballismus, athetosis or chorea Note: Imaging is generally not indicated for evaluation of typical Parkinson’s disease, essential tremor or primary dystonia. Multiple sclerosis and other white-matter diseases (...) | Copyright © 2018. AIM Specialty Health. All Rights Reserved. 15 headache. Cephalalgia. 2007;27(8):904-911. 65. Secretariat. MA. Neuroimaging for the Evaluation of Chronic Headaches: An Evidence-Based Analysis. Ont Health Technol Assess Ser. 2010; 10(26): 1–57. 66. Sharifi S, Nederveen AJ, Booij J et al. Neuroimaging essentials in essential tremor: a systematic review. Neuroimage Clin. 2014 May 9;5:217-31. 67. Silvestri GA, Gould MK, Margolis ML, et al. Noninvasive staging of non-small cell lung cancer

2018 AIM Specialty Health

148. Hoarseness (Dysphonia)

. In this group, failure to evaluate the larynx can delay cancer diagnosis, resulting in higher staging, need for more aggressive treatment, and reduced survival rates. Other conditions that cause dysphonia are neurologic (eg, vocal fold paralysis, spasmodic dysphonia [SD], essential tremor, Parkinson’s disease, amyotrophic lateral sclerosis, multiple sclerosis), gastrointestinal (eg, reflux, eosinophilic esophagitis), rheumatologic/autoimmune (eg, rheumatic arthritis, Sjögren’s syndrome, sarcoidosis (...) , habits (eg, smoking, alcohol use), concurrent medical conditions, and prior surgery ( and ). Careful evaluation allows the clinician to (1) categorize dysphonia severity, (2) develop a treatment plan, and (3) prioritize patients who may need escalated care. , Physical examination should include a full head and neck examination with particular attention to listening to the voice (perceptual evaluation), inspection and palpation of the neck for masses or lesions, and, if feasible, indirect mirror

2018 American Academy of Otolaryngology - Head and Neck Surgery

149. Cannabis

, their use is almost three times higher than that of adults. ? The rate of daily cannabis use among the Canadian general population remains steady. Effects of Cannabis Use Short-term: Cannabis produces euphoria and relaxation, changes in perception, time distortion and deficits in attention span. It also negatively impacts the ability to divide attention and results in deficits in memory, body tremors and impaired motor functioning. Cannabis also impairs coordination and balance. Other physical effects (...) and municipal levels. 10 Driving while impaired by a drug, including cannabis, is an offence under the Criminal Code of Canada. Drivers who are impaired by drugs are subject to the same penalties as those impaired by alcohol. The government tabled Bill C-46 in April 2017 to strengthen the enforcement of impaired driving laws and also plans to enact this legislation in conjunction with the Cannabis Control Act. Currently, Canadians can legally access cannabis for medical purposes. Under the Marihuana

2018 Canadian Centre on Substance Abuse

150. Improving Quality of Life: Substance Use and Aging

. Eglit and Dilip V. Jeste Epidemiology of Psychoactive Substance Use Among Older Adults Scott B. Patten The Aging Brain and Substance Use Tarek Rajji and Simon Davies Consequences of Alcohol and Drug Use in Older Adults Jonathan Bertram and David K. Conn Considerations for Co-occurring Health Conditions Karolina Kozak and Tony George Detection, Screening and Assessment David K. Conn Substance Use Treatment for Older Adults Frederic C. Blow A Call to Action Franco J. Vaccarino, Elysia Vaccarino (...) use, as we do in this report, is key to developing new and more tailored strategies for reducing the harms of alcohol and drugs on older adults. Since 2005, the series now known as Substance Use in Canada has highlighted alcohol- and drug-related issues that are in need of greater attention. For this seventh edition, we began with two questions: How can we help people age in a healthy way? and How can we ensure they have the supports they need to sustain a good quality of life in their later years

2018 Canadian Centre on Substance Abuse

151. Clearing the Smoke on Cannabis: Maternal Cannabis Use during Pregnancy ? An Update

neurodevelopment leading to adverse effects on cognition and academic achievement. • There are also effects on behaviour in children and young adults, including attention deficits, increased hyperactivity and impulsivity, and increased likelihood of substance use. • Information on the effects of cannabis use during pregnancy is essential to help healthcare providers advise patients about the impact of cannabis use and improve the health and well-being of patients and their children. Background After alcohol (...) , cannabis (also referred to as marijuana) is the most widely used psychoactive substance in Canada. According to the 2015 Canadian Tobacco, Alcohol and Drugs Survey (CTADS), 12.3% of Canadians aged 15 years and older reported using cannabis at least once in 2015 (Statistics Canada, 2016a), an increase from 10.6% in 2013. The use of cannabis is generally more prevalent among young people, with 20.6% of youth aged 15 to 19 and 29.7% of young adults aged 20 to 24 reporting past-year use in 2015

2018 Canadian Centre on Substance Abuse

152. Gastroesophageal Reflux Disease (GERD) - Guidelines for Prescribing H2RAs and PPIs

; lifestyle changes are unlikely to be very effective in severe GERD but are still recommended as they contribute to general good health. Avoid foods / beverages that worsen or trigger symptoms (e.g. caffeine, chocolate, onions, peppermint, tomatoes, high-fat foods, over-indulgence in alcohol) Eat small meals and chew food well Don’t lie down for 2 -3 hours after eating Avoid tight clothing Encourage smoking cessation Elevate head of bed frame (i.e. not extra pillows) Achieve ideal body weight Over (...) or longer) can rarely cause hypomagnesemia. If a patient has taken a PPI daily for more than 1 year and is experiencing muscle cramps, palpitations, tremor, and/or dizziness, consider recommending rmagnesium levels be checked Other possible long-term safety issues of PPIs include pneumonia, osteoporosis, Clostridium difficile, and vitamin B12 malabsorption, but risk is very low Detailed information on contraindications, cautions, adverse effects and interactions is available in individual drug

2018 medSask

153. Ecstasy or Molly (MDMA) (Canadian Drug Summary)

memory deficits; 7,9,12,13 and attention deficits. 9 Effects of synthetic cathinones ? Short-term: The short-term effects of synthetic cathinones include euphoria; 14,15 increased energy; 15 increased heart rate and blood pressure; 16,17,18 sweating; 18 muscle tremors; 15,18 chest pains; 15,16,17 hallucinations; 15,16,17,18 paranoia; 15,16,17,18 agitation; 15,17,18 and aggressive behaviour. 15,18 ? Long-term: The long-term effects of synthetic cathinone use are not well known. 19,20,21 Legal Status (...) by half since 2008. 22,23,24,25,26,27 The most recent estimate, taken from the 2015 Canadian Tobacco, Alcohol and Drugs Survey (CTADS), indicates that 0.7% of Canadians aged 15 and older reported using ecstasy in the past year. 28 Students (grades 7–12): Findings from the 2014–2015 Canadian Student Tobacco, Alcohol and Drugs Survey indicate that 2.4% of Canadian students in grades 7–12 reported using ecstasy in the past 12 months. Students in grades 10–12 had a higher prevalence of past-year ecstasy

2017 Canadian Centre on Substance Abuse

154. Staff and Associate Specialist Grade Handbook (Third Edition)

• Long sleeves when inappropriate • Frequent toilet breaks • Nasal rubbing/itching or drowsiness after ‘top-up’ breaks • Nasal discharge, yawning, tears, pallor, sweating, piloerection and feeling cold if withdrawing • Alcohol on the breath • Poor anaesthetic charts – particularly altered or (deliberately) illegible entries. Similarly, uncharacteristically poor handwriting (alcohol withdrawal tremor) • Using techniques without narcotics, falsifying charts and diverting drugs for own use • Offering (...) disease [1], and is classified accordingly with other chronic illnesses. Unfortunately society’s attitude has not changed significantly and addiction is still a rather taboo subject. For the purpose of this chapter, the terms ‘addiction’ and ‘dependence’ are used interchangeably. Further and more detailed information on some aspects of addiction and its management can be found on the AAGBI website and in Drug and Alcohol Abuse amongst Anaesthetists. Out of each cohort at medical school, approximately

2017 Association of Anaesthetists of GB and Ireland

155. Pain Management

daily or non-steroidal anti-inflammatory drug (NSAID) (if not contraindicated - see section"Adjuvant therapies" below)) ± other adjuvant Consider reducing paracetamol dose to 500mg four times daily when poor nutritional status, low weight (< 50kg), hepatic impairment and/or chronic alcohol abuse (check local policy for paracetamol and NSAIDs if patient receiving chemotherapy). Inadequate pain relief Step 2: mild to moderate pain weak opioid Codeine 30 to 60mg four times daily or dihydrocodeine 30 (...) ) caution in cardiovascular disease. gabapentin (side effects: sedation, tremor, confusion; reduce dose if renal impairment). Corticosteroids : dexamethasone 16mg daily for raised intracranial pressure. 8mg daily for neuropathic pain; 4 to 8mg/day for liver capsule pain. Give in the morning; reduce to lowest effective dose. Consider PPI. Monitor blood glucose. TENS, nerve block, radiotherapy, surgery, bisphosphonates, (specialist use) and skeletal or smooth muscle relaxants. Opioid toxicity – seek

2016 Scottish Palliative Care Guidelines

156. CRACKCast E126 – Diabetes Mellitus and Disorders of Glucose Homeostasis

become unarousable. They may have a seizure or show focal neurologic signs, which resolve with glucose administration. For most other patients: signs and symptoms of hypoglycemia are caused by excessive secretion of epinephrine and CNS dysfunction; these include Sweating Nervousness/Tremor Tachycardia Hunger Neurologic symptoms, ranging from bizarre behavior and confusion to seizures and coma. [10] List 10 causes of hypoglycemia Causes of hypoglycemia in the non-diabetic can be thought about in terms (...) that can cause congenital hyperinsulinism Causes of hypoglycemia in the diabetic: Consider their own medications, such as with excess insulin or other oral hypoglycemic agents Use the “DIMES” approach (coupled with how UpToDate does it): Drugs: Insulin Insulin secretagogues: Alcohol Others – e.g. indomethacin, quinine Infection / illnesses: Sepsis Metabolic: Liver, renal failure Adrenal insufficiency Type 1 diabetic – without glucagon Environmental: Accidental, surreptitious, or malicious hypoglycemia

2017 CandiEM

157. CRACKCast E099 – Urological Disorders

options for uncomplicated and complicated pyelonephritis. Pyelonephritis = UTI involving the renal collecting system or parenchyma Fever, chills, flank pain, CVA tenderness, N/V, +/- cystitis In the elderly: altered mental status, lethargy, abdominal pain, generalized weakness Uncomplicated (same treatment as complicated UTI) Ciprofloxacin 500 mg bid 7 days GI disturbance, headache, dizziness, tremors, restlessness, confusion, rash, Candida infections Levofloxacin 750 mg once daily 5 days Same (...) Cough, abdominal pain, nausea, vomiting Ciprofloxacin 400 mg every 12 hours GI disturbance, headache, dizziness, tremors, restlessness, confusion, rash, Candida infections Levofloxacin 500 mg every 24 hours Same as for ciprofloxacin [6] What are safe antibiotic options for bacteriuria in pregnancy? How is pyelonephritis managed in pregnancy? A couple key points about the pregnant patient with a UTI: Bacteriuria in pregnancy – gets treated even if the patient is asymptomatic If the patient

2017 CandiEM

158. Clearing the Smoke on Cannabis: Cannabis Use and Driving ? An Update

Clearing the Smoke on Cannabis: Cannabis Use and Driving ? An Update Key Points • Among young drivers, driving after using cannabis is more prevalent than driving after drinking. • Cannabis impairs the cognitive and motor abilities necessary to operate a motor vehicle and doubles the risk of crash involvement. • After alcohol, cannabis is the most commonly detected substance among drivers who die in traffic crashes. • The police have the tools and authority required to detect and arrest drivers (...) who are impaired by cannabis. Background After alcohol, cannabis, also referred to as marijuana, is the most widely used psychoactive substance in Canada. According to the 2015 Canadian Tobacco, Alcohol and Drugs Survey (CTADS), 12.3% of Canadians aged 15 years and older reported using cannabis at least once in the past year (Statistics Canada, 2016), significantly higher than the 10.6 in 2013. The use of cannabis is generally more prevalent among youth, with 20.6% of youth aged 15 to 19 and 29.7

2017 Canadian Centre on Substance Abuse

159. Links between antipsychotics in pregnancy and harmful outcomes for baby may be influenced by mother’s lifestyle

child outcomes after poorer health and riskier lifestyles were taken into account. For pregnant women these were things like other medications, obesity, smoking, alcohol and taking illicit drugs. The study also provides further evidence against the use of valproate during pregnancy for epilepsy, bipolar disorder or schizophrenia because of the increased risk of poor outcomes for the child. The risk was double that of taking the alternatives, lamotrigine or carbamazapine during pregnancy. Mental (...) in nature. What did it find? Antipsychotic use during pregnancy did not increase the risk of caesarean section, prematurity or poor child outcomes after adjusting the results to take into account age, obesity, alcohol problems, smoking, illicit drug use and other psychotropic drug use. Anticonvulsant use during pregnancy compared to no use increased the risk of: Caesarean section from 18.3% to 21.4% (adjusted relative risk ratio [RRR] 1.14, 95% confidence interval [CI] 1.04 to 1.26). Major congenital

2019 NIHR Dissemination Centre

160. Parkinson's disease in adults.

inform the Driver and Vehicle Licensing Agency (DVLA) and their car insurer of their condition when PD is diagnosed. [2006] Diagnosing Parkinson's Disease Definition and Differential Diagnosis Suspect Parkinson's disease people presenting with tremor, stiffness, slowness, balance problems and/or gait disorders. [2006] If Parkinson's disease is suspected, refer people quickly and untreated to a specialist with expertise in the differential diagnosis of this condition. [2006, amended 2017] Clinical (...) with Parkinson's disease should be seen at regular intervals of 6 to 12 months to review their diagnosis.) [2006] Single Photon Emission Computed Tomography (SPECT) Consider 123 I-FP-CIT [(N-omega-fluoropropyl-2beta-carboxymethoxy-3beta-(4-iodophenyl)tropane)] SPECT for people with tremor if essential tremor cannot be clinically differentiated from parkinsonism. [2006, amended 2017] 123 I-FP-CIT SPECT should be available to specialists with expertise in its use and interpretation. [2006] Positron Emission

2017 National Guideline Clearinghouse (partial archive)

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