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Common Clotting Pathway

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61. Sirens to Scrubs: Acute Coronary Syndrome – Beyond Door-to-Balloon

to Scrubs was created with the goal of helping to bridge the disconnect between pre-hospital and in-hospital care of emergency patients. The series offers in-hospital providers a glimpse into the challenges and scope of practice of out-of-hospital care while providing pre-hospital providers with an opportunity to learn about the diagnostic pathways and ED management of common (or not-so-common) clinical presentations. By opening this dialogue, we hope that these new perspectives will be translated (...) (the inner lining) of coronary arteries, resulting in physiological derangements causing increased clotting and impaired vasodilation. With the damage to the endothelium, inflammatory cells, including macrophages, are able to migrate into the artery wall in the area just below the endothelium called the subendothelium. Amongst other mechanisms beyond the scope of a short review, these macrophages consume and digest low-density lipoproteins (LDL), transforming into foam cells and contributing

2018 CandiEM

62. Management of Pregnancy

and well-being by guiding health care providers who are taking care of pregnant women along the management pathways that are supported by evidence. The expected outcome of successful implementation of this guideline is to: • Assess the condition of the mother and baby and determine the best management method in collaboration with the mother and, when possible and desired, other family and caregivers • Optimize the mother and baby’s health outcomes and improve quality of life • Minimize preventable (...) the past 25 years, maternal pregnancy-related mortality and morbidity have been increasing. Common complications that can occur during pregnancy include maternal obesity or excessive weight gain, mental health conditions (e.g., depression, anxiety, posttraumatic stress disorder [PTSD]), hyperemesis gravidarum, anemia, gestational diabetes mellitus (GDM), and hypertensive disorders of pregnancy (e.g., gestational hypertension, preeclampsia, eclampsia).[ ] 9 Pregnancy-related deaths (approximately 600

2018 VA/DoD Clinical Practice Guidelines

63. AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and Institutional Recommendations and Requirements for Transcatheter Aortic Valve Replacement

in the last decade. Training for TAVR should occur by 1 of 2 pathways: 1) a formal training program incorporated into cardiology fellowship or cardiovascular surgical residency or 2) formal proctorship wherein an established interventional cardiologist or cardiac surgeon participates in an established TAVR program under the tutelage of an experienced team. Ongoing education courses with didactics focused on new concepts of TAVR, hands-on experience with device-specific equipment; simulation, viewing live (...) and cardiopulmonary bypass machine f. Minimum room size of 800 square feet (74.3 m 2 ) to accommodate the standard equipment required in a cardiac catheterization laboratory (e.g., high-definition displays and monitors, ultrasound machine for access, O 2 analyzer and supply, defibrillator/resuscitation cart, suction, compressed air, CO-oximeter, activated clot- ting time analyzer) as well as echocardiographic equipment, sonographers, anesthesia equipment, emergency CT surgical team and cardiopulmonary bypass

2018 Society for Cardiovascular Angiography and Interventions

64. The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridium difficile infection and other potential indications

and factors influencing the gut microbiota (box 1) (GRADE of evidence: low; strength of recommenda- tion: strong). 2.2.3.4. Laboratory screening of potential donors Blood and stool screening of donors is mandatory (boxes 2 and 3) (GRADE of evidence: low; strength of recommendation: strong). 2.2.3.5. Repeat donor checks, and donation pathway i. In centres using frozen FMT, before FMT may be used clin- ically, we recommend that donors should have successful- ly completed a donor health questionnaire (...) of chronic pain syndromes, including chronic fatigue syndrome and fibromyalgia. 12. History of any malignancy. 13. Taking particular regular medications, or such medications within the past 3 months—that is, antimicrobials, proton pump inhibitors, immunosuppression, chemotherapy. 14. History of receiving growth hormone, insulin from cows or clotting factor concentrates. 15. History of receiving an experimental medicine or vaccine within the past 6 months. 16. History of travel to tropical countries

2018 British Society of Gastroenterology

65. An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome

in the ACS population, as has been demonstrated in patients with stable ischemic heart disease. Healthcare Costs The impact of TRA and related patient care pathways on healthcare costs is an evolving topic and the focus of active investigation but is also limited in data specific to the management of patients with ACS. Current data suggest that cost savings related to TRA are derived primarily from lower vascular and bleeding complication rates, shorter average intensive care unit and hospital lengths (...) of active chest discomfort at rest during PCI for ACS. Analgesia Alleviating discomfort and anxiety is an important factor that helps prevent stimulation of central neural pathways and arterial vasoconstriction. , Administration of a low dose of a combination of fentanyl and midazolam has been shown to reduce patient discomfort, the incidence of RA spasm (2.6% versus 8.3%; P <0.001), and access site crossover (9.9% versus 15.0%; P =0.001) compared with control. Administration of topical lidocaine may

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2018 American Heart Association

66. Guideline Supplement: Primary postpartum haemorrhage

guideline development processes 7 Table 5. Levels of evidence and grades of recommendation 8 Table 6. Summary recommendations 9 Table 7. NSQHS Standard 1 11 Table 8. Clinical quality measures 11 Table 9. NSQHS/EQuIPNational Criteria 12 © State of Queensland (Queensland Health) 2018 This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free to copy and communicate the work in its current form for non-commercial purposes (...) ? Removed: o Emergency donor panel o Blood transfusion administration o PPH proforma ? Added: o Point of care blood clot analyser use o Fibrinogen concentrate o Tranexamic acid administration o Prophylactic misoprostol o Requirements and actions for low resource settings March 2018 MN18.1V7-R23 ? Amendment to flowchart Initial response to PPH o Added: Dose of carboprost if administered intramyometrial (500 micrograms) Queensland Clinical Guideline Supplement: Primary postpartum haemorrhage Refer

2018 Queensland Health

67. Anticoagulants in non-valvular atrial fibrillation

. Factor Xa inhibitors (FXaI) are direct inhibitors of factor Xa. They disrupt both the intrinsic and the extrinsic coagulation pathways, preventing the formation of thrombin and subsequent clotting. Because the NOACs’ effect is determined solely by plasma concentration rather than by inhibition of clotting factor synthesis, they have a rapid onset of action. Furthermore, NOACs have more stable pharmacokinetic and pharmacodynamic characteristics than VKAs, making haemostasis monitoring and repetitive (...) with its content. ? Subsequently, a (final) version was submitted to the validators. The validation of the report results from a consensus or a voting process between the validators. The validators did not co-author the scientific report and did not necessarily all three agree with its content. ? Finally, this report has been approved by common assent by the Executive Board. ? Only the KCE is responsible for errors or omissions that could persist. The policy recommendations are also under the full

2017 Belgian Health Care Knowledge Centre

68. Acute lymphoblastic leukemia

from the proliferation and expansion of lymphoid blasts in the blood, bone marrow and other organs (Bassan and Hoelzer 2011). ALL occurs with a bimodal distribution with an early peak in children 4 – 5 years old followed by a second peak at ~ 50 years of age (Fullmer, et al 2010) with the worldwide incidence being ~ 1 – 4.75/100,000 individuals with a male:female prevalence of roughly 1·3:1 (Bassan and Hoelzer 2011). It is the most common childhood acute leukemia accounting for ~ 80 (...) and inherited diseases with excessive chromosomal fragility such as Fanconi’s anemia, Bloom’s syndrome and ataxia-telangiectasia have a higher risk of developing ALL (Jabbour, et al 2005). However, in the majority of ALL patients no gross chromosomal alteration is noted suggesting that additional submicroscopic genetic alterations likely contribute to leukaemogenesis (Inaba, et al 2013). Genome-wide association studies of childhood ALL (Inaba, et al 2013) have noted common allelic variants in IKZF1, ARID5B

2016 CPG Infobase

69. British Association of Dermatologists guidelines for the management of pemphigus vulgaris

intraepithelial, mucocutaneous blistering. Desmoglein 3 is the major antigen, but 50–60% of patients have additional antibodies to desmoglein 1, the antigen targeted in pemphigus foliaceus (PF). 3–5 Although the pathogenesis of PV is complex, involving multiple pathways, 6 the underlying antibody pro?le is a major determinant of the clinical phenotype of PV. 5,7,8 The average mortality of PV was 75% before the introduc- tion of corticosteroids in the early 1950s. 9 This ?gure may be an underestimate due (...) and less likely to achieve remission off-treatment than purely mucosal PV. 13 6.1 Clinical presentation The diagnosis of PV should be suspected in any patient with mucocutaneous erosions or blisters. The oral mucosa is the ?rst site of involvement in the majority of cases, and PV may remain con?ned to the mucosal surfaces or extend to involve the skin (average lag period of 4 months). 14–16 Diagnostic delay is very common when PV is con?ned to the oral mucosa. 17 A minority of patients will present

2017 British Association of Dermatologists

70. Guidelines on the management of abnormal liver blood tests

the number of deaths from other common conditions is falling in the UK, those due to liver disease have been increasing dramatically, with a 400% increase in the standardised mortality rate over the period 1970–2010. 1 Notably, for those patients younger than 65, the rise in standardised mortality rate for liver disease is >500%, such that it now constitutes the fifth biggest cause of premature mortality 2 with 64 000 years of working life lost every year. 3 For morbidity, in England and Wales, 57 682 (...) hospital admissions and 10 948 deaths were due to liver disease in 20 12. 1 This rising burden of liver disease is mainly a reflec- tion of the three the most common causes: alcohol-related liver disease, non-alcoholic fatty liver disease and viral hepatitis, although autoimmune liver disease is also a significant contrib- utor. 4 The burden of liver disease in children differs from that in adults, as although non-alcoholic fatty liver disease (NAFLD) is seen in all ages, reflecting the rise

2017 British Society of Gastroenterology

71. Administration of Blood Components

of whether or not the transfusion achieved the desired effect (e.g. post‐transfusion increment rates or improvement in patient's symptoms), The management and outcome of any transfusion reactions or adverse events, The provision of any post‐transfusion patient information or advice and General practitioner (GP) notification of transfusion. All transfusion‐related documentation should include the patient core identifiers. The use of specifically designed transfusion care pathways to record

2017 British Committee for Standards in Haematology

72. CRACKCast E122 – Disorders of Hemostasis

factors through blood flow, Alteration of platelet activity by endothelium-generated nitric oxide and prostacyclin Removal of activated coagulation components by the reticuloendothelial system Regulation of the clotting cascade by anti-thrombin III, protein C, protein S, and tissue factor pathway inhibitor Activation of the fibrinolytic system Clinical evaluation of a bleeding patient – see Box 114.5. When it comes to a differential diagnosis of platelet disorders (see box 114.6) it comes down (...) ) Treat based on the major component of DIC that is present: If bleeding: Platelets, FFP, cryoprecipitate If clotting: IV heparin Wisecracks [1] How do you differentiate coagulation disorders from platelet disorders? History alone can often discriminate between platelet factor abnormalities and coagulation factor abnormalities: PD Acquired >>>> congenital Petechiae Pupura (not palpable) Mucosal bleeding More common in women Capillary bleeding – ecchymosis, petechiae, epistaxis, menorrhagia, GI

2017 CandiEM

73. Wearable Artificial Kidneys for End-Stage Kidney Disease

vascular system and anticoagulant drug therapy to prevent blood clots, hemodialysis is more complex than peritoneal dialysis (discussion to follow). 6,9,23 Peritoneal dialysis Peritoneal dialysis uses the patient’s peritoneum (the membrane lining the inner wall of the abdominal cavity) to remove wastes. 9,23 Dialysate (a pre-packaged solution of purified water, glucose, and minerals) is placed in the abdominal cavity through a catheter. The dialysate remains inside the abdomen for a few hours, allowing (...) hemodialysis. 3,6 As well, after long-term exposure to glucose from the dialysate, the peritoneum may no longer function as well as previously for removing wastes. 3,6,9 Opportunities for technological advancement Dialysis, in any form, has a negative impact on quality of life. Individuals undergoing dialysis must avoid certain foods and limit their consumption of fluids. 19 Supplements and medications are needed to replace nutrients lost during treatment, and post-treatment fatigue is common. 12,26

2017 CADTH - Issues in Emerging Health Technologies

74. Rapid blood test helps exclude pulmonary embolism for low risk patients

at the accuracy of a simple blood test called a D-dimer added to the usual diagnostic pathway and a clinical prediction rule. The test is already used to indicate the likelihood of related blood clots in the legs. Findings from four studies suggest that a negative D-dimer result effectively rules out the diagnosis, particularly for patients with few risk factors. A positive result is less reliable and may pick up people without the condition, especially in over 65’s. People who test positive will still need (...) diagnostic imaging. Overall a change in the management pathway for suspected pulmonary embolism (PE) have potential to be cost saving and provide better care. Commissioners, will be interested in the overall pathway costs but unfortunately these were not researched here. Share your views on the research. Why was this study needed? In the UK, 47,734 cases of PE were reported between 2014 and 2015. Emergency admissions for PE increased by 30% between 2008 and 2012. A pulmonary embolism is a blockage

2019 NIHR Dissemination Centre

75. Rhythm control drugs after catheter ablation for atrial fibrillation give short-term but not long term benefits

ablation reduced the risk of abnormal heart rhythms in the three months after the procedure. They were of no benefit in preventing recurrence of atrial fibrillation in the longer term. Atrial fibrillation is a common abnormal heart rhythm that carries a high risk of stroke. Catheter ablation can be used to destroy the electrical pathways in the heart muscle that cause the abnormal rhythm, but recurrence is common. Several factors could influence the likelihood of abnormal rhythms returning after (...) catheter ablation. These include the duration and type of atrial fibrillation and associated medical conditions. Such things could influence practitioners’ decision to give further rhythm control treatment. In the absence of a standard approach further study may be needed to inform the best treatment strategy. Share your views on the research. Why was this study needed? Atrial fibrillation is a common abnormal heart rhythm that affects around 1 in 10 people over the age of 65. Around 800,000 people

2019 NIHR Dissemination Centre

76. Guidance on the reporting of thyroid cytology specimens

of existing national and international guidance were it exists, relevant literature and good practice identified by the authors. It has been graded using modified SIGN guidance. The bulk of the evidence is level B to D or meets the ‘Good practice point’ (GPP) criteria (see Appendix A). No major organisational changes or cost implications have been identified that would hinder the implementation of the tissue pathways. A formal revision cycle for all guidelines takes place on a five-year cycle. The College (...) of ‘incidental’ occult small thyroid cancer, identified at thyroidectomy for other reasons. 4 The original RCPath thyroid cytology document was intended to help produce consistent and reproducible reporting and classification of thyroid cytology specimens in the UK. The importance of thyroid cytology in the diagnosis of thyroid nodules is highlighted in several guidelines. 5 Rising investigation of thyroid problems and the common finding of multiple thyroid nodules on radiological investigation 6 have

2016 Royal College of Pathologists

77. Guidance on the reporting of thyroid cytology specimens

of existing national and international guidance were it exists, relevant literature and good practice identified by the authors. It has been graded using modified SIGN guidance. The bulk of the evidence is level B to D or meets the ‘Good practice point’ (GPP) criteria (see Appendix A). No major organisational changes or cost implications have been identified that would hinder the implementation of the tissue pathways. A formal revision cycle for all guidelines takes place on a five-year cycle. The College (...) of ‘incidental’ occult small thyroid cancer, identified at thyroidectomy for other reasons. 4 The original RCPath thyroid cytology document was intended to help produce consistent and reproducible reporting and classification of thyroid cytology specimens in the UK. The importance of thyroid cytology in the diagnosis of thyroid nodules is highlighted in several guidelines. 5 Rising investigation of thyroid problems and the common finding of multiple thyroid nodules on radiological investigation 6 have

2016 Royal College of Pathologists

78. National minimum retesting intervals in pathology: A final report detailing consensus recommendations for minimum retesting intervals for use in pathology

’. 5 The evidence or source for these recommendations has been taken from a number of authorities such as the National Institute for Health and Clinical Excellence (NICE), NHS Clinical Knowledge Summaries (CKS) (formerly PRODIGY) and the Scottish Intercollegiate Guidelines Network (SIGN). The CKS are a reliable source of evidence-based information and practical 'know how' about the common conditions managed in primary care that were identified following a literature search and expert opinion (...) to unfounded variation in the clinical laboratory. Ann Clin Biochem 2011;48:195–197. 2. Smellie WS, Association for Clinical Biochemistry’s Clinical Practice Section. Time to harmonise common laboratory test profiles. BMJ 2012;344:e11693. 3. Lang T. National Minimum Re-testing Interval Project: A final report detailing consensus recommendations for minimum retesting intervals for use in Clinical Biochemistry. London: Association of Clinical Biochemistry and Laboratory Medicine, 2013. 4. Smellie WS

2016 Royal College of Pathologists

79. Clinical practice guidelines for the care of girls and women with Turner syndrome: proceedings from the 2016 Cincinnati International Turner Syndrome Meeting

facial appearance, with neck webbing and lymphedema ( , ), we suggest that the clinical manifestations of TS should be broadened to include other features, such as linear growth failure, ovarian insufficiency (pubertal delay), early sensorineural hearing loss, distinctive congenital cardiovascular, skeletal, digital and renal anomalies, a particular neurodevelopmental profile, and a constellation of other disorders that are more common in TS, including hypothyroidism and celiac disease ( , , ). Table (...) ( ). In contrast, neurocognitive deficits typical of 45,X TS are common in girls with cytogenetically visible deletions of Xp22.3 ( ), although this may not be the case for girls with submicroscopic Xp22.3 deletions detected only by molecular cytogenetic or microarray studies. Females who have a deletion distal to Xq24 frequently have primary or secondary amenorrhea without short stature or other TS features and should be referred to as having premature ovarian failure (POF). Phenotypic males with 45,X/46,XY

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2016 European Society of Human Reproduction and Embryology

80. Care at the Scene: Research for ambulance services

on demand for ambulance services) were identified. This confirmed that consistent, year on year, increase in de- mand was common across many developed countries and was seen particularly in ambulance services. Some, but not all, of this could be explained by ageing pop- ulations. Other factors included health needs (chronic conditions, acute illness, drug and alcohol dependen- cy), socioeconomic factors (isolation and loneliness, lack of social support, deprivation), patient factors and supply of local (...) ). “The service over the years has developed excellent pathways for onward referral of patients to avoid hospital admissions. How- ever, we still struggle with patients expe- riencing mental health crises. Often we are the only service that can help and mostly out-of-hours and sadly our only option is emergency departments, which aren’t nec- essarily the right setting for them.” Robert Lankford, Emergency Care Assistant, South Central Ambulance Service Mental health is another challenging area

2016 NIHR Dissemination Centre - Themed Reviews

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