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Coma Exam

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481. 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

482. Haematological malignancies and ITU Full Text available with Trip Pro

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

483. Systematic review of needs for medical devices for ageing populations

health. The United Nations applies 60 years as the cut- off for older people, so the health conditions that are the subject of this project were identified by examining the top five causes of loss of DALYs in people aged 60–79 years in the Western Pacific Region. 1.4 AGEING AND DISEASE Damage at the cellular level that is attributed to the process of ageing has been linked to the pathology of certain diseases associated with the ageing population, such as atherosclerosis and cancers (13 (...) ; • supporting or sustaining life; • control of conception; • disinfection of medical devices; • providing information by means of in vitro examination of specimens derived from the human body and which does not achieve its primary intended action by pharmacological, immunological or metabolic means, in or on the human body, but which may be assisted in its intended function by such means (4,5). 2.3 INTERVENTION The intervention for this project is defined as “needed devices”. The devices were categorized

2015 Publication 80

484. Paediatric trauma protocols

radiation burden. ? An example of a suitable contrast and timings calculator is included (see the Camp Bastion contrast wheel, Appendix 2). ? A hand injection of contrast is appropriate in very small children and babies. ? There are no mechanisms of injury which mandate abdominal CT as an isolated factor. Decisions to perform abdominal CT should be made on the basis of the clinical history and examination. 29 ? Where there is an isolated head injury, a reduced Glasgow Coma Scale (GCS) score should (...) minutes of hospital presentation, and immediately if there is any reduction in conscious level. Adequate resuscitation, clinical examination and administration of analgesia should take place in the process of deciding whether to perform CT. Isolated head injuries are common in childhood and fulfilling the criteria for a cranial CT scan is not an indication on its own for a CT of the cervical spine or any other body part. Cranial CT should be performed before administration of intravenous contrast

2014 Royal College of Radiologists

485. Prediction rule: CT should not be relied on for cases of isolated vomiting in children with blunt head trauma Full Text available with Trip Pro

department (ED) after <24 h of trauma; Glasgow Coma Scale score of 14–15; and acute head CT. Clinicians completed a standardised patient history and physical examination before head CT. History of vomiting, the number of vomiting episodes, timing of onset and the time since last episode were recorded. Isolated vomiting was defined in two ways: extensive (based on an extensive list of variables) versus an age-specific list of prediction rule variables defined by the Pediatric Emergency Care Applied (...) Research Network (PECARN) on initial ED examination. Two categories of outcomes were defined: clinically-important TBI and TBI on CT. Outcomes were analysed in three groups: children with non-isolated vomiting; children with isolated vomiting (extensive definition); and children with isolated vomiting (PECARN definition). The rates of clinically-important TBI and TBI on CT were compared for children with and without isolated vomiting using the Newcombe-Wilson continuity-adjusted method. Findings Of 43

2015 Evidence-Based Medicine

486. Lenvatinib (Lenvima)

(Modified from the protocol for brevity) b. Efforts should be made to conduct study visits on the day scheduled (± 1 day). Clinical laboratory assessments may be conducted anytime within 72 hours prior to the scheduled visit, unless otherwise specified. d. pTNM staging g. A comprehensive physical examination (including a neurological examination) will be performed at the Screening or Baseline Visit, on Cycle 1/Day 15, on Day 1 of each subsequent cycle, and at the off-treatment assessment. A symptom (...) -directed physical examination will be performed on C1D1 and at any time during the study, as clinically indicated. h. Required if screening physical examination was performed > 7 days prior C1D1. i. Single 12-lead ECG. Subjects must be in the recumbent position for a period of 5 minutes prior to the ECG. j. Echocardiogram during screening, every 16 weeks, and at end of treatment visit, or sooner if clinically indicated. k. Clinical chemistry and hematology results must be reviewed prior

2014 FDA - Drug Approval Package

488. Guidelines for Transport of Critically Ill Patients

history and clinical examination findings of their patients. Documentation should include an ongoing record of physiological status, clinical procedures, and any subsequent interventions. A copy of this patient record should be provided to the receiving hospital along with the clinical record and investigations from the referring facility, where available. For intrahospital transport, this documentation may form part of the inpatient notes. 10. MONITORING Monitoring of certain physiological variables (...) , measurement of the arterial blood pressure and assessment of peripheral perfusion. 10.1.2 Respiration Respiratory rate should be assessed and recorded at frequent and clinically appropriate intervals. 10.1.3 Oxygenation The patient’s oxygenation should be assessed at frequent and clinically appropriate intervals by observation and use of pulse oximetry. 10.1.4 Level of consciousness by Glasgow Coma Scale and pupil reaction. 10.1.5 Pain score Patients’ pain should be monitored including regular assessment

2015 Australian and New Zealand College of Anaesthetists

489. 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

490. 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

491. 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

492. 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

493. 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

494. 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

495. 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

496. 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

498. Evolocumab (Repatha)

barrier prevents access to cholesterol carrying lipoproteins from the circulation. 7 This should allow the brain to remain largely independent from circulating levels of cholesterol. Nevertheless, to examine this potential cognitive safety issue more thoroughly, a search was done of neurocognitive-related adverse event terms that included deliria (including confusion), cognitive and attention disorders and disturbances, dementia and amnestic conditions, disturbances in thinking and perception

2014 FDA - Drug Approval Package

499. Does a normal CT scan within 6?h rule out subarachnoid haemorrhage?

(complete) Three Part Question In [patients presenting with a history of sudden onset headache] is a [CT scan within 6 h] sufficient to rule out [subarachnoid haemorrhage]. Clinical Scenario A normally fit and well 26-year-old man presents to the emergency department with a sudden onset headache. It came on 2 h ago, and is the worst he has ever had. He has taken paracetamol without success. The headache made him feel very unwell, but he has no neurological symptoms. His Glasgow Coma Scale (GCS) is 15 (...) and clinical examination is normal. You are concerned that he may have had a subarachnoid haemorrhage (SAH) and want to rule this out. He has a CT scan within 6 h of the onset of the headache. It is reported as normal. You wonder if this excludes a diagnosis of SAH. Search Strategy ( OR AND ( OR or exp Hemorrhage/) AND (6 OR six AND ( or exp Cerebrospinal Fluid/ OR lumbar or exp Spinal Puncture

2015 BestBETS

500. 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 HIV Guidelines

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