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321. CRACKCast E122 – Disorders of Hemostasis

of laboratory test results, a careful history and focused physical examination are often the key to the diagnosis of hematologic diseases. All patients with bleeding disorders of unknown cause or of a significant degree should be admitted to the hospital for further evaluation. The frequency of hemostatic disorders seen in the ED is unknown; however, they are likely to be more common than thought. Although classic diseases such as hemophilia and DIC are uncommon, the use of antiplatelet and anticoagulation (...) diagnostic studies are being performed. Platelet dysfunction is often equated with low platelet counts. Even though critical thrombocytopenia increases the risk of bleeding, particularly with trauma and surgery, dysfunction can occur at normal counts. For example, aspirin therapy and renal disease can alter platelet function without reducing blood counts. All evaluations of suggested ITP should include a complete blood count, peripheral smear, antinuclear antibody test, and bone marrow examination. TTP

2017 CandiEM

323. Management of Suspected Opioid Overdose with Naloxone by Emergency Medical Services Personnel

, response to naloxone (e.g., based on Glasgow Coma Scale score), other substances and drugs involved in overdose, or other factors. Studies should supplement use of medical examiner and hospital records to identify outcomes with formal followup assessments, and evaluate outcomes such as linkage to treatment for opioid use disorder and risk of future overdose episodes, in addition to serious adverse outcomes such as death. Conclusions Low-strength evidence suggests that IN naloxone at a dose of 2 mg (...) naloxone administration by EMS personnel, what are the benefits and harms of transporting patients to a health care facility versus nontransport? The analytic framework (Figure A) shows the target population, interventions, and health outcomes examined; the Key Questions are numbered and indicated in the framework. We ES-2 focused on use of IN, IM, and IV naloxone; these are the formulations of naloxone most commonly used for reversal of suspected opioid overdose in the field. Figure A. Analytic

2017 Effective Health Care Program (AHRQ)

324. Delirium in Adult Cancer Patients: ESMO Clinical Practice Guidelines

patients [9]. The majority of studies in oncological populations examine de- lirium in advanced cancer patients admitted to palliative care units (PCUs) or inpatient palliative care consultation services [4, 9, 12–17] and do not include cancer survivors (see Supplementary Table S1, available atAnnalsofOncology online). There is limited published in- formation regarding the frequency of delirium in outpatients with advanced cancer [2]. The authors’ literature review found one study in an outpatient (...) ](Supplementary Table S1, available at Annals of Oncology online, provides more detailed information on the prevalence and incidence of delirium in admitted patients with cancer, and frequency of different delirium subtypes when reported). Mortalityandmorbidity Outcomes of delirium in the general hospital population have been examined in systematic reviews; delirium is associated with increased post-discharge mortality [hazard ratio 2.0; 95% con?- dence interval (CI): 1.5–2.5] and institutionalisation [odds

2018 European Society for Medical Oncology

325. Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder

in the RTI-UNC Systematic Review. Its authors concluded that the research evidence was insufficient to determine treatment effect heterogeneity by many of the subgroups that were examined. Members of the current guideline development panel agreed that the randomized trials included in the review do not sufficiently address the important issue of which treatments are best for which patients and constitutes an important future research need. Generalizability (applicability) of systematic review findings (...) be assumed. Panel members agree however that examination of treatment effect heterogeneity with diverse samples should be prioritized for future research. Community members on the GDP shared what they considered to be important patient values and preferences for PTSD treatment. These included such things as having a psychotherapist who is aware of and knowledgeable about trauma, who offers information about treatment, teaches coping skills, works from a personalized approach, and is sensitive to cultural

2017 American Psychological Association

326. Bone sarcomas: ESMO?PaedCan?EURACAN: Clinical Practice Guidelines for diagnosis, treatment and follow-up

the periosteum, but they are often later signs. The differential diagnosis of a bone sar- coma includes osteomyelitis, benign tumours and bone metasta- ses, all of which outnumber primary bone sarcomas [10–12]. The diagnosis can be strongly oriented by patient age. For patients 60%. In general, ChT is administered before and after surgery, although a formal proof that giving ChT preoperatively improves survival is lacking. The extent of histological response to preoperative ChT predicts sur- vival [25–27 (...) in the ?nal pathological examination. If en bloc R0 resection is not feasible, the patient is inoperable or surgical sequelae are not accepted by the patient, de?nitive RT Annals of Oncology Clinical Practice Guidelines Volume 29 | Supplement 4 | October 2018 doi:10.1093/annonc/mdy310 | iv87 Downloaded from https://academic.oup.com/annonc/article-abstract/29/Supplement_4/iv79/5115250 by guest on 26 March 2019alone (without debulking) is an alternative [V, C]. Particle ther- apy (high-dose protons

2018 European Society for Medical Oncology

327. Practical Management of Hyperglycaemic Hyperosmolar State (HHS) in children

) in children 2 Version 2, July 2017 Review 2020 Authors: SM Ng, JA Edge, AE Timmis ssociation of Children’s Diabetes Clinicians Clinicians Patient group This guideline is intended for use in managing Hyperglycaemic Hyperosmolar State (HHS) for all children and young people up to the age of 18 years with diabetes mellitus. 1. Introduction Hyperglycaemic Hyperosmolar State (HHS), previously known as Hyperosmolar Hyperglycaemic Non-Ketotic Coma (HONK), is a triad of severe hyperglycaemia, significant increase (...) in serum osmolality and severe dehydration without marked ketoacidosis. It is a life threatening complication of some forms of uncontrolled diabetes mellitus with significant mortality and morbidity. It is important that HHS is distinguished from Diabetic Ketoacidosis (DKA), which presents with hyperglycaemia, ketosis and acidosis, as the management is significantly different. Both disorders present with dehydration, hyperglycaemia and may show altered levels of mental status or coma. The prevalence

2018 British Society for Paediatric Endocrinology and Diabetes

328. Contemporary Management of Cardiogenic Shock: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

; SBP, systolic blood pressure; and SHOCK, Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock. * In setting of MI complicated by predominantly LV dysfunction. † In setting of acute MI. Historical Perspectives Before the routine use of early revascularization, MI-associated CS had an in-hospital mortality exceeding 80%. A registry trial of 250 patients with acute MI described the association between bedside physical examination (Killip classification) for the assessment

2017 American Heart Association

329. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition Full Text available with Trip Pro

. For information regarding this article, E-mail: This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition (ASPEN) and the Society of Critical Care Medicine (SCCM), to describe best practices in nutrition therapy in critically ill children. Guideline Limitations. These SCCM-ASPEN Clinical Guidelines are based on general consensus among a group of professionals who, in developing such guidelines , have examined the available literature (...) by at least two reviewers to examine eligibility for inclusion in guideline development. After careful review, 16 RCTs and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. These studies were then reviewed, and the relevant data were abstracted by the authors using a standardized form. After review of the abstracted data, evidence tables were generated for each question. Based on the evidence tables, the authors used an iterative process to develop

2017 Society of Critical Care Medicine

330. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU

and inclusion. | GRADE Process for Grading the Evidence GRADE assigns the strength of a recommendation based on the priority of a problem; balance of benefits and harms; certainty of the evidence of effect; values and preferences; equity; acceptability; and feasibility ( ). Two or three investigators examined and summarized the literature relevant to each PICO question. To avoid intellectual conflict, guidelines writing group members who had authored a study of interest did not perform the GRADE analysis (...) of the summary of recommendations for future research can be found in Appendix 1 . Note that this list is not exhaustive in nature. | Family Presence With Patients in the ICU. PICO question 1.1. In the critical care environment, does open family presence at the bedside (also called “open visiting”) affect family satisfaction? Evidence Summary : The majority of literature examining the effect of open family presence at the bedside (defined as no or minimal restrictions on presence at the bedside

2017 Society of Critical Care Medicine

331. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient Full Text available with Trip Pro

. Each citation was reviewed by at least 2 reviewers to examine eligibility for inclusion in guideline development. After careful review, 16 RCTs and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We then reviewed these studies and abstracted the relevant data with a standardized form. After review of the abstracted data, evidence tables were generated for each question. Given the evidence tables, we used an iterative process to develop practical (...) of malnutrition showing independent impact on duration of MV. Limitations: single‐center study; methodologic issues with sample size calculation. Delgado et al Retrospective, observational; single center To evaluate the incidence of malnutrition in the first 72 hr after PICU admission. Examine differences in IL‐6, CRP, LOS, sepsis, and mortality between the malnourished and well‐nourished groups. n = 1077 Malnutrition based on weight‐for‐age z score: moderate, −1 to −2; severe, <−2 Median age: malnourished

2017 American Society for Parenteral and Enteral Nutrition

332. Soft tissue and visceral sarcomas: ESMO-EURACAN Clinical Practice Guidelines for diagnosis, treatment and follow-up

?cans, and in retroperitoneal tumours, where the performance is identical to MRI. Ultrasound may be the ?rst exam, but it should be followed by CT or MRI. Following appropriate imaging assessment, the standard approach to diagnosis consists of multiple core needle biopsies, possibly by using 14–16 G needles. However, an excisional biopsy may be the most practical option for 5cm lesions [II, B] [11–13]. RT is not given in the case of a currently unusual, truly compartmental resection of a tumour

2018 European Society for Medical Oncology

333. Heart Disease and Stroke Statistics 2017 Update: A Report From the American Heart Association Full Text available with Trip Pro

the National Health and Nutrition Examination Survey (NHANES) 1999 to 2000 to NHANES 2011 to 2012 show that the use of cho- lesterol-lowering treatment has increased substan- tially among adults, from 8% in 1999 to 2000 to 18% in 2011 to 2012. During this period, the use of statins increased from 7% to 17%. • From 1988 to 1994 to 2013 to 2014, mean serum total cholesterol for adolescents 12 to 19 years of age has decreased across all subgroups of race and sex. High Blood Pressure (Chapter 9) • The age (...) adults Disease Prevalence Prevalence is an estimate of how many people have a condition at a given point or period in time. The NCHS/ CDC conducts health examination and health interview surveys that provide estimates of the prevalence of dis- eases and risk factors. In this Update, the health inter- view part of the NHANES is used for the prevalence of CVDs. NHANES is used more than the NHIS because in NHANES, AP is based on the Rose Questionnaire; esti- mates are made regularly for HF; hypertension

2017 American Heart Association

334. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease

and Evidence Review? ? ? ? ? ? ? ? ? e728 1?2? Organization of the Writing Committee ? ? ? ? ? ? e730 1?3? Document Review and Approval ? ? ? ? ? ? ? ? ? ? ? e730 1?4? Scope of Guideline ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? e731 2? Clinical Assessment for PAD ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? e733 2?1? History and Physical Examination: Recommendations ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? e733 3? Diagnostic Testing for the Patient With Suspected Lower Extremity PAD (Claudication or CLI (...) of vertebral artery steal), no further imaging or intervention is warranted. Recommendations for History and Physical Examination (Continued) COR LOE Recommendations Table 4. Patients at Increased Risk of PAD Age =65 y Age 50–64 y, with risk factors for atherosclerosis (eg, diabetes mellitus, history of smoking, hyperlipidemia, hypertension) or family history of PAD 63 Age 1.40). 27,67–69,72 See Online Data Supplement 4. Standardized reporting improves communication among healthcare providers. Calculated

2017 American Heart Association

335. 2015 Revised Utstein-Style Recommended Guidelines for Uniform Reporting of Data From Drowning-Related Resuscitation: An ILCOR Advisory Statement Full Text available with Trip Pro

or ECG Ventricular fibrillationVentricular tachycardiaPulseless electrical activityAsystoleOther Vital signs Supplementary Devices are necessary to measure vital signs Heart rateBlood pressureTemperatureSp o 2 Pulmonary status Supplementary Assess severity of lung injury Normal lung examination; patient is coughing; unilateral rales; bilateral rales Type of water/liquid (eg, salt/fresh/chemical/other ) Supplementary In what type of liquid did the drowning occur? Fresh water, salt water, water (...) , was resuscitation attempted before arrival of EMS? was EMS called? was an EMS vehicle dispatched? was cyanosis present? These elements have either been replaced with updated elements or are considered unreliable (eg, cyanosis could be a result of hypoxia or submersion in cold water). ABC indicates alert, blunted, coma; AVPU, alert, responds to verbal stimuli, responds to painful stimuli, unresponsive; CPR, cardiopulmonary resuscitation; EMS, emergency medical services; GCS, Glasgow Coma Scale; and Y/N/U, yes

2017 American Heart Association

336. Palliative Care

support the family when providing care in accordance with the patient’s wishes. Bereavement support is invaluable after the patient dies, but that specialized support might not be available in many medical centers. Trauma care providers need to be able to ensure a reasonable degree of family comfort (physical and emotional). They need to be conversant with the process and help prepare the family for the next steps following death, including the possibility of medical examiner involvement. Referrals

2017 American College of Surgeons

337. Prevention, Diagnosis & Management of infective endocarditis

or fastidious microorganisms, and perform the appropriate microbiological tests (refer Table 3.2 and Figure 3a).16 • Histopathological examination (HPE) of cardiac tissue/vegetations obtained during surgery is of diagnostic value and is recommended. • A transthoracic echocardiogram (TTE) should be obtained without delay if the diagnosis of IE is suspected. • Echocardiogram findings should be interpreted in the context of the clinical scenario and repeated if the clinical suspicion of IE persists despite (...) a negative initial echocardiogram. • Transoesophageal echocardiogram (TOE/TEE) should be done if initial TTE examination is negative, in patients with strong clinical suspicion of IE, in those with prosthetic valves/cardiac material and in those with high-risk features (refer Figure 3b). • Echocardiography plays a crucial role in the diagnosis of IE, monitoring for complications and progression of valvular dysfunction, assessing the outcome of surgical repair and in the follow-up after completion

2017 Ministry of Health, Malaysia

338. Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support: A Scientific Statement From the American Heart Association

to understand the differences in the physical examination and in methods that can help rescuers determine if an unresponsive or mentally altered patient is, in fact, in cardiac arrest or circulatory collapse. Pulsatile-Flow LVADS Most early generations of LVADs had pulsatile pumps, which filled and emptied a volume-displacement chamber sequentially, generating pulsatile flow similar to the native heart. Given the advantages of continuous-flow devices, intracorporeal pulsatile devices are no longer available (...) when preload increases and pumping less quickly when preload decreases. The native heart continues to contract in patients with a continuous-flow device, but the filling and emptying of the device is not synchronous with the heart. Because the flow from pulsatile-flow LVADs mimics that of the native heart, these patients have a detectable pulse on physical examination that reflects forward cardiac output and perfusion. However, because a pulsatile-flow device fills and empties asynchronously

2017 American Heart Association

339. Poststroke Fatigue: Emerging Evidence and Approaches to Management: A Scientific Statement for Healthcare Professionals From the American Heart Association

absent in patients with continuous-flow LVADs, it is important to understand the differences in the physical examination and in methods that can help rescuers determine if an unresponsive or mentally altered patient is, in fact, in cardiac arrest or circulatory collapse. Pulsatile-Flow LVADS Most early generations of LVADs had pulsatile pumps, which filled and emptied a volume-displacement chamber sequentially, generating pulsatile flow similar to the native heart. Given the advantages of continuous (...) on the pump preload. The pumps maintain decompression of the LV by pumping more quickly when preload increases and pumping less quickly when preload decreases. The native heart continues to contract in patients with a continuous-flow device, but the filling and emptying of the device is not synchronous with the heart. Because the flow from pulsatile-flow LVADs mimics that of the native heart, these patients have a detectable pulse on physical examination that reflects forward cardiac output and perfusion

2017 American Heart Association

340. Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association Full Text available with Trip Pro

stroke unit. The recommended monitoring includes blood pressure measurement and neurological examination every 15 minutes for the first 2 hours after the alteplase infusion, then every 30 minutes for the next 6 hours, and then every hour for the next 16 hours. Because an excessively high blood pressure may increase hemorrhagic complications, a blood pressure goal of <180/105 mm Hg is recommended for 24 hours after the infusion. In addition, an emergent brain computed tomography (CT) is recommended (...) the risk of hematoma expansion against the risk of stroke recurrence. Timing of Postthrombolytic ICH In early large trials of thrombolysis for myocardial ischemia, sICH occurred within 12 hours after thrombolytic therapy in 65% of patients, within 12 to 24 hours in 17%, within 24 to 48 hours in 9%, and after 48 hours in 9%. In acute ischemic stroke, several studies have examined sICH timing but with variable time thresholds, thereby limiting comparability. , , , One recent review of stroke clinical

2017 American Heart Association

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