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Coma Exam

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441. Cervical Spine Collar Clearance in the Obtunded Adult Blunt Trauma Patient

reassessment, cervical collar complication (e.g., pressure ulcer), and time to cervical collar clearance. The term obtunded required an operationalized definition using the terms Glasgow Coma Scale , altered , intoxicated , intubated , unconscious , and/or u nreliable exam . Unstable injuries were identified primarily using the system delineated by White and Punjabi and the three-column model of Denis. [9–11] C-spine instability required either a fracture or fractures involving contiguous columns or levels (...) Eligibility Our PICO question and protocol were registered with the PROSPERO international prospective register of systematic reviews [7][8] on August 23, 2013 (Registration Number: CRD42013005461) and last revised on June 18, 2014. Inclusion criteria consisted of adult blunt trauma patients 16 years or older, who underwent C-spine CT with axial thickness of less than 3 mm and who were obtunded with any author-specified definition of this term (Glasgow Coma Scale [GCS] score < 15, unconscious, intubated

2015 Eastern Association for the Surgery of Trauma

442. Heart Failure Management in Skilled Nursing Facilities Full Text available with Trip Pro

begins with accurate identification of residents diagnosed with HF. The clinical diagnosis of HF may largely rely on data from care before SNF admission. Residents without an HF diagnosis who develop pulmonary congestion or volume overload should have a physical examination, chest radiograph, and blood chemistry tests to confirm congestion and volume overload within the SNF setting if possible. Results from laboratory tests may take 24 hours or longer to return in SNFs; thus, appropriate clinical (...) for potential adverse effects (including drug-drug and drug-disease interactions). On Medicare-reimbursed units, the SNF bears medication costs, which adds further incentive for an appropriate pharmacological regimen. HF With Reduced Ejection Fraction Numerous randomized controlled trials have examined a wide range of pharmacological agents for the treatment of HF with reduced ejection fraction (HF r EF), usually defined as an ejection fraction <45%. A detailed review of agents shown to be effective

2015 American Heart Association

443. A Practice Guideline from the American College of Medical Genetics and Genomics and the National Society of Genetic Counselors: Referral Indications for Cancer Predisposition Assessment

the ACMG nor the NSGC “approve” or “endorse” any specific methods, practices, or sources of information. Volume 17 | Number 1 | January 2015 | GeNetiCS in MediCiNe71 A practice guideline for cancer genetics referral | HAMPEL et al ACMG PrACtiCe Guidelines risk assessment or diagnosis, which typically includes personal and family history, genetic and other laboratory results, results from procedures and imaging studies, and physical examination findings. Genetic counseling is an important component (...) , trichodis- comas or angiofibromas, and acrochordons), bilateral and multifocal renal tumors (chromophobe clear cell renal car- cinoma, renal oncocytoma, oncocytic hybrid tumor, and less often, clear cell renal carcinoma), and multiple bilateral lung cysts often associated with spontaneous pneumothorax. 15 GeNetiCS in MediCiNe | Volume 17 | Number 1 | January 201572 HAMPEL et al | A practice guideline for cancer genetics referral ACMG PrACtiCe Guidelines table 1 Common benign and malignant tumors

2015 American College of Medical Genetics and Genomics

444. Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence Full Text available with Trip Pro

diabetes mellitus is needed to elucidate the role of physical activity and weight loss in reducing clinical CVD end points. Another study examining the role of intensive lifestyle management on CVD risk factors was the Italian Diabetes and Exercise Study (IDES). The IDES was an RCT designed to examine the effects of an intensive exercise intervention strategy on modifiable CVD risk factors in 606 sedentary subjects with type 2 diabetes mellitus enrolled in 22 outpatient diabetes mellitus clinics across (...) to reduce the risk of stroke. Trials examining the effect of aspirin for primary prevention in patients with diabetes mellitus are summarized: 6 trials were conducted in the general population that also included patients with diabetes mellitus, and 3 other trials specifically examined patients with diabetes mellitus. Trials ranged from 3 to 10 years in duration and have examined a wide range of aspirin doses. Participants were mainly late middle-aged adults; 3 trials , , included only men. The range

2015 American Heart Association

445. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

of patients with ICH is crucial, because early deterioration is common in the first few hours after ICH onset. More than 20% of patients will experience a decrease in the Glasgow Coma Scale (GCS) of 2 or more points between the prehospital emergency medical services (EMS) assessment and the initial evaluation in the emergency department (ED). 6 Furthermore, another 15% to 23% of patients demonstrate continued deterioration within the first hours after hospital arrival. 7,8 The risk for early neurological (...) - tory, physical examination, and diagnostic studies that should be obtained in the ED. A routine part of the evaluation should include a stan- dardized severity score, because such scales can help stream- line assessment and communication between providers. The National Institutes of Health Stroke Scale (NIHSS) score, commonly used for ischemic stroke, may also be useful in ICH. 24,25 However, ICH patients more often have depressed consciousness on initial presentation, and this may diminish

2015 Congress of Neurological Surgeons

446. Guidelines for the management of spontaneous intracerebral hemorrhage Full Text available with Trip Pro

. More than 20% of patients will experience a decrease in the Glasgow Coma Scale (GCS) of 2 or more points between the prehospital emergency medical services (EMS) assessment and the initial evaluation in the emergency department (ED). Furthermore, another 15% to 23% of patients demonstrate continued deterioration within the first hours after hospital arrival. , The risk for early neurological deterioration and the high rate of poor long-term outcomes underscore the need for aggressive early (...) should be contacted as quickly as possible while the patient is in the ED, and the clinical evaluation should be performed efficiently, with physicians and nurses working in parallel. Consultation via telemedicine can be a valuable tool for hospitals without on-site presence of consultants. , describes the integral components of the history, physical examination, and diagnostic studies that should be obtained in the ED. Table 4. Integral Components of the History, Physical Examination, and Workup

2015 American Academy of Neurology

447. Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke

Population Prevalence of ischemic stroke Lower0.63–1.2/100 000 , 1.2/100 000 per year , Higher, doubles for each decade after 55 y of age , <64 y: 2.4/100 00065–74 y: 7.6/100 000>75 y: 11.2/100 000 Clinical presentation Seizures, coma, and hemiparesis also common in nonvascular origins Seizures or coma at onset is less common in adults Stroke mechanism: prothrombotic factors 1/3 of stroke in newborns and 50% of stroke in children Less common Plasminogen levels Reduced (neonates) Normal Response to tPA (...) of Chest Physicians; ESO, European Stroke Organisation; RCT, randomized, controlled trial; and tPA, tissue-type plasminogen activator. The initial diagnosis of stroke in children may be challenging considering the diverse presenting symptoms (eg, coma, seizures, and hemiparesis) common to nonvascular causes of stroke. All major randomized trials evaluating the benefits of intravenous alteplase have excluded stroke patients ≤18 years of age. , Stroke mechanisms in children differ from those in adults

2015 American Academy of Neurology

448. Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke Full Text available with Trip Pro

Population Adult Population Prevalence of ischemic stroke Lower0.63–1.2/100 000 , 1.2/100 000 per year , Higher, doubles for each decade after 55 y of age , <64 y: 2.4/100 00065–74 y: 7.6/100 000>75 y: 11.2/100 000 Clinical presentation Seizures, coma, and hemiparesis also common in nonvascular origins Seizures or coma at onset is less common in adults Stroke mechanism: prothrombotic factors 1/3 of stroke in newborns and 50% of stroke in children Less common Plasminogen levels Reduced (neonates) Normal (...) , American College of Chest Physicians; ESO, European Stroke Organisation; RCT, randomized, controlled trial; and tPA, tissue-type plasminogen activator. The initial diagnosis of stroke in children may be challenging considering the diverse presenting symptoms (eg, coma, seizures, and hemiparesis) common to nonvascular causes of stroke. All major randomized trials evaluating the benefits of intravenous alteplase have excluded stroke patients ≤18 years of age. , Stroke mechanisms in children differ from

2015 American Heart Association

449. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage Full Text available with Trip Pro

of patients with ICH is crucial, because early deterioration is common in the first few hours after ICH onset. More than 20% of patients will experience a decrease in the Glasgow Coma Scale (GCS) of 2 or more points between the prehospital emergency medical services (EMS) assessment and the initial evaluation in the emergency department (ED). 6 Furthermore, another 15% to 23% of patients demonstrate continued deterioration within the first hours after hospital arrival. 7,8 The risk for early neurological (...) - tory, physical examination, and diagnostic studies that should be obtained in the ED. A routine part of the evaluation should include a stan- dardized severity score, because such scales can help stream- line assessment and communication between providers. The National Institutes of Health Stroke Scale (NIHSS) score, commonly used for ischemic stroke, may also be useful in ICH. 24,25 However, ICH patients more often have depressed consciousness on initial presentation, and this may diminish

2015 American Heart Association

450. Clinical Practice Guideline on management of patients with diabetes and chronic kidney disease stage 3b or higher (eGFR <45 mL/min) Full Text available with Trip Pro

the inclusion criteria. Any discrepancies at this stage were resolved by consensus. In a second round, full texts of potentially relevant studies were retrieved and independently examined for eligibility and final inclusion in the data extraction step. Any discrepancies were resolved by consensus. If no consensus could be reached, the disagreement was settled by group arbitrage. The flow of the paper selection is presented for each question in Appendix 5. 6.6.3. Data extraction and critical appraisal

2015 European Renal Best Practice

451. Management of Traumatic Brain Injury

Management of Traumatic Brain Injury ACS TQIP BEST PRACTICES IN THE MANAGEMENT OF TRAUMATIC BRAIN INJURYTable of Contents Introduction 3 Using the Glasgow Coma Scale 3 Triage and Transport 5 Goals of Treatment 5 Intracranial Pressure Monitoring 6 Management of Intracranial Hypertension 9 Advanced Neuromonitoring 12 Surgical Management 13 Nutritional Support 14 Tracheostomy 15 Timing of Secondary Procedures 15 Timing of Pharmacologic Venous Thromboembolism Prophylaxis 17 Management (...) been compiled, but the paucity of high-quality studies limits the strength and scope of their counsel. The TQIP Best Practice Guidelines for the Management of Traumatic Brain Injury present recommendations regarding care of the TBI patients based on the best available evidence or, if evidence is lacking, based upon the consensus opinion of the expert panel. USING THE GLASGOW COMA SCALE Key messages: z The Glasgow Coma Scale (GCS) provides a reliable tool for assessing disturbances of consciousness

2015 American College of Surgeons

452. Quality Improvement Guidelines for Adult Diagnostic Cervicocerebral Angiography: Update Cooperative Study between the Society of Interventional Radiology (SIR), American Society of Neuroradiology (ASNR), and Society of NeuroInterventional Surgery (SNIS)

objects placed in the hand, repeat, and producespeech. Theintubated patient should be asked to write. Patient in a coma (question 1a, 3) will arbitrarily score 3 on this item. The examiner must choose a score for the patient with a stupor or limited cooperation but a score of 3 should be used only if the patient is mute and follows no one-step commands. 0, No aphasia, normal; 1, mild to moderate aphasia; some obvious loss of ?uency or facility of comprehension, without signi?cant limitation on ideas (...) provides the capability to produce a much more sophisticated examination, including such tools as three-dimensional (3D) imaging, sophisticated roadmapping, and theabilitytochooseoptimalprojections.Asaresult,theconceptofthe “complete diagnostic cervicocerebral angiogram” has become out- dated. In evaluating success rates, the standard should not be whether a “complete” examination was performed, but rather whether the examination provided the information for which it was performed while minimizing

2015 Society of Interventional Radiology

453. Management of Orthopaedic Trauma

tissue damage within six hours of impaired perfusion.  Caution regarding the estimation of elapsed time is important, as the time of precise onset is often uncertain. z Compartment syndrome is a dynamic process and, in patients with high-risk injuries, an evaluation should occur every one to two hours for a 24 to 48 hour period.  Sequential physical examinations should be performed for individuals at risk for compartment syndrome, as a single exam at one point in time is unreliable. z The most (...) clinical exam may benefit from measurement of intracompartmental pressures. A gradient of 48 hours after admission are reviewed by the trauma PIPS or equivalent committee in the hospital, unless a specific contraindication is documented in the medical record. Geriatric Hip Fractures z All geriatric (=65 years of age) patients with hip fractures and multiple co-morbidities are evaluated by a multidisciplinary team, including, at minimum, personnel with expertise in the care of the geriatric patients. z

2015 American College of Surgeons

454. Society of Gynecologic Oncology statement on risk assessment for inherited gynecologic cancer predispositions

inthesestudies,the trueriskmaybehigherinwomenwithanintactuterus.Inadditionto endometrialcancerrisk,womenwithgermlinemutationsinthePTEN gene haveup to a 50% risk of breast cancerand 3–10% riskof thyroid cancer [28–31]. Women who carry germline mutations in the TP53 gene,associatedwithLiFraumenisyndrome,haveuptoa60%lifetime riskofbreastcancer,inadditiontoother“core”cancersthatincludesar- comas, brain, and adrenocortical carcinomas [32]. The less common Peutz–Jegherssyndrome,causedbymutationsinSTK11/LKB1gene (...) type, displays frequent inactivating germline and somatic mutations in SMARCA4. Nat Genet 2014;46(5):427–9. [45] Kriege M, et al. Ef?cacy of MRI and mammography for breast cancer screening in womenwithafamilialorgeneticpredisposition.NEnglJMed2004;351(5):427–37. [46] WarnerE, etal. Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA 2004;292(11):1317–25. [47] Jarvinen HJ, et al. Controlled 15-year trial

2015 Society of Gynecologic Oncology

455. Haematological malignancies and ITU

Medicine, Society of Critical Care Medicine, ). Over the last decade, as new data have emerged, it has become clear that this statement requires re‐examination: A large 2009 study across 178 ICUs in England, Wales and Northern Ireland showed, ICU mortality of 43·1% and in‐hospital mortality of 59·2% among patients with a HM; substantially lower than previous studies had suggested (Hampshire et al , ). This guideline aims to provide an up‐to‐date, evidence‐based review of the literature on outcome (...) consideration of ICU admission. A larger study (428 ICU admissions over an 11 year period) examined survival of cancer patients, of whom two‐thirds had HM, admitted to ICU with severe sepsis or septic shock, in the presence of neutropenia (Legrand et al , ). Older age and need for inotropic support predicted inferior survival on multivariate analysis. Improved survival was predicted by admission after 2003 (study period 1998–2008), use of combination antibiotics including an aminoglycoside, and early

2015 British Committee for Standards in Haematology

456. Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection

Solà, David Rigau Comas (Centre Cochrane Iberoamericà, Spain); Victoria Wakefield, Charlotta Karner (BMJ – Technology Assessment Group, London, UK); Emmanouil Tsochatzis (Royal Free Sheila Sherlock Liver Centre and UCL Institute for Liver and Digestive Health, UCL and Royal Free Hospital, UK). We appreciate the contribution from Grammati Sarri and Jill Parnham (National Clinical Guideline Centre [NCGC], Royal College of Physicians, UK) for providing technical presentations and sharing their network

2015 World Health Organisation Guidelines

457. Community management of opioid overdose

) with the ability to induce analgesia, euphoria and, in higher doses, stupor, coma and respiratory depression. The term opiate excludes synthetic opioids. See also: opioid. opioid A generic term applied to alkaloids from the opium poppy (Papaver somniferum), their synthetic analogues and compounds synthesized in the body, which interact with the same specific receptors in the brain, have the capacity to relieve pain and produce a sense of well-being (euphoria). The opium alkaloids and their synthetic analogues (...) also cause stupor, coma and respiratory depression in high doses. opioid maintenance treatment Also referred to as opioid agonist maintenance treatment or opioid substitution treatment. Examples of opioid maintenance therapies are methadone and buprenorphine maintenance treatment. Maintenance treatment can last from several months to more than 20 years, and is often accompanied by other treatment (such as psychosocial treatment). overdose The use of any drug in such an amount that acute adverse

2015 World Health Organisation Guidelines

458. Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada

).In this way, they provide a convenient summary of the evidence to facilitate clinicians in the task of “weighting” and incorporating ever increasing evidence into their daily clinical decision making. They also facilitate the ability of clinicians, healthcare planners, healthcare providers and society, in general, to critically examine anyrecommendationandarriveattheirownconclusionsregarding its appropriateness. Thus, these guidelines facilitate their own (...) scrutinybyothersaccordingtothesameprinciplesthattheyuseto scrutinize the literature. It is important to note that the system chosen for grading recommendations differs from the approach used in some other guideline documents, such as the one pertaining to the periodic health examination in Canada, in which harmful practices were assigned a grade of D (8). In this Canadian Diabetes Association guidelines document, recommendation to avoid any harmful practices would be graded in the same manner as all other recommendations.However

2013 CPG Infobase

459. Transthoracic Echocardiography in Adult Patients with Ischemic Stroke

and less well tolerated, more time-consuming and costly, and potentially less readily available. Both procedures are considered to have low diagnostic yields in identifying cardiac sources of emboli in patients with no other identifiable reason for stroke, but they do enable intervention in patients with positive findings. This report examines the clinical and cost effectiveness of using TTE with clinical evidence to identify cardiac sources of emboli in adult patients with ischemic stroke, alone (...) and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1. Table 1: Selection Criteria Population Adult patients that experienced an ischemic stroke (cerebral ischemia) Intervention Transthoracic echocardiography (TTE) Comparator Q1+Q3: Clinical evidence (medical history, abnormal examination, abnormal chest x-ray, abnormal electrocardiogram) Q2+Q4: Transesophageal echocardiography (TOE

2014 Canadian Agency for Drugs and Technologies in Health - Rapid Review

460. Kadcyla (trastuzumab emtansine (genetical recombination))

] In the meeting held on August 26, 2013, the Second Committee on New Drugs concluded that the product may be approved and that this result should be presented to the Pharmaceutical Affairs Department of the Pharmaceutical Affairs and Food Sanitation Council. The re-examination period is 8 years, the drug substance and the drug product are both classified as powerful drugs, and the product is classified as a biological product. *Japanese Accepted Name (modified INN) This English version of the Japanese review (...) .(2) Shelf life of drug substance and drug product The applicant had proposed a shelf life of 36 months for both drug substance and drug product, based on the data of the following long-term testing and examination thereof. However, the shelf life of the drug substance and the drug product should be based on long-term stability data on at least 3 batches. Therefore, PMDA requested the applicant to re-determine the shelf life based on the most updated long-term stability data. ? Results of long

2013 Pharmaceuticals and Medical Devices Agency, Japan

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