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121. Computed tomography to rule out suspected appendicitis in adults and reduce the negative appendectomy rate

Computed tomography to rule out suspected appendicitis in adults and reduce the negative appendectomy rate Health Policy Advisory Committee on Technology Technology Brief Computed tomography to rule out suspected appendicitis in adults and reduce the negative appendectomy rate (NAR) August 2016 © State of Queensland (Queensland Department of Health) 2016 This work is licensed under a Creative Commons Attribution Non-Commercial No Derivatives 3.0 Australia licence. In essence, you are free (...) associated with CT. One systematic review found CT in adults to be justified if radiation exposure is considered in the clinical decision pathway. Two of the non-randomised comparative studies supported a shift away from routine CT to diagnose appendicitis via the routine use of MRI or laparoscopy. This was, in part, owing to a reduction in the risks associated with abdominal and pelvic radiation (particularly in children and women of childbearing age). It is important to note that Choosing Wisely

2016 COAG Health Council - Horizon Scanning Technology Briefs

122. SureFire® Precision Chemoembolization Infusion System

SureFire® Precision Chemoembolization Infusion System Health Policy Advisory Committee on Technology Technology Brief Surefire Infusion System August 2016 © State of Queensland (Queensland Department of Health) 2016 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, as long as you attribute the authors and abide by the licence (...) . Figure 1 The Surefire Precision Infusion System with tip non-deployed and deployed 3 The novel feature common to all of Surefire Systems is the patented, expandable tip. The SIS is known as an anti-reflux catheter because it prevents the backward flow of injected agents to other parts of the liver or other organs. Liver tumours contain regions of high pressure that limit blood flow and make it difficult to deliver therapeutic agents. The tip of the SIS expands to the vessel wall, effectively stopping

2016 COAG Health Council - Horizon Scanning Technology Briefs

123. Reveal LINQ insertable cardiac monitor to detect atrial fibrillation after cryptogenic stroke

to be diagnosed as having AF. Some clinicians diagnose and treat an AF episode of any length of time; others will only consider treatment if an AF episode has exceed a threshold varying from 30 seconds to 6 hours. The most common threshold used in NHS care pathways is 2 minutes. This variation means that the number of false positives (people diagnosed with AF who do not actually have the condition) and the number of false negatives (people who do have AF, but is it 'missed' by the monitoring device) varies (...) Reveal LINQ insertable cardiac monitor to detect atrial fibrillation after cryptogenic stroke Re Rev veal LINQ insertable cardiac monitor to detect eal LINQ insertable cardiac monitor to detect atrial fibrillation after cryptogenic strok atrial fibrillation after cryptogenic stroke e Medtech innovation briefing Published: 16 February 2018 nice.org.uk/guidance/mib141 pathways Summary Summary The technology technology described in this briefing is Reveal LINQ insertable cardiac monitor (ICM

2018 National Institute for Health and Clinical Excellence - Advice

124. Management of Toxicities from Immunotherapy: ESMO Clinical Practice Guidelines

treatment As for Grade 1 Dermatology review Punch biopsy Clinical photography Symptom Grade Management escalation pathway Assessment and Investigations Figure 3. ICPi-related toxicity: management of skin rash/toxicity. Recognised skin AEs include: (i) most common: erythema, maculopapular and pustulopapular rash; (ii) rare: toxic epidermal necrolysis, Steven-Johnson syndrome and DRESS; (iii) vasculitis may also be present with purpuric rash. AE, adverse event; bd, twice daily; BSA, body surface area (...) single drug studies, is 16%-37% for anti-PD-1 and 12%-24% for anti-PD-L1 [5]. Only in a minority of patients fatigue can be attributed to hypothyroidism. High-grade toxic- ities from anti-PD-1 (either nivolumab or pembrolizumab) are less common than for the CTLA4 blocking agent ipilimumab. For nivolumab, any treatment-related AE was documented in 74%–85% of patients, with 12%–20% being grade 3 and 4 [2, 6, 7] for metastatic melanoma patients, 58% and 7%, respect- ively, for advanced cisplatin

2017 European Society for Medical Oncology

125. CRACKCast E044 – Neck Trauma

from minor wounds to severe hemorrhage, neurologic injury, to airway compromise Apparently stable patients can harbour life threatening injuries Three mechanisms of neck trauma: Blunt Penetrating Strangulation / near hanging Four anatomic injury areas: Laryngotracheal – airway Pharynx oesophageal – digestive tract Vascular system Neurologic system Principles of Disease Penetrating trauma : Aetiologies: GSW’s: High velocity: rifles > 2000 ft/s Have very predictable direct pathways through tissue (...) : produce a large blast effect Can produce a cavitation effect (if >1100 ft/s) Cavitation: an immediate release of kinetic energy as the bullet enters the tissue- creating extensive soft tissue damage. Low velocity: handguns and air rifles: Bone penetration occurs at 300 ft/s These produce erratic pathways : with no direct relationship between entrance and exit wounds stab wounds, impalement, shrapnel Low energy injuries produce much less severe mechanisms of injury Many of these do not need surgical

2016 CandiEM

126. New drugs for deep vein thrombosis may offer a safe alternative to warfarin

that can be used by clinicians and commissioners weighing up the benefits and costs of potential changes to current treatment pathways (see Bibliography below for links). Share your views on the research. Why was this study needed? Deep vein thrombosis (DVT) describes a blood clot that has formed in the deep veins of the legs or pelvis, that is, not the ones you can see near the surface of the skin. It is relatively common and affects about one in a 1,000 people in the UK each year. There is a risk (...) : National Institute for Health and Care Excellence; 2012. NICE. TA170. London: National Institute for Health and Care Excellence; 2013. Why was this study needed? Deep vein thrombosis (DVT) describes a blood clot that has formed in the deep veins of the legs or pelvis, that is, not the ones you can see near the surface of the skin. It is relatively common and affects about one in a 1,000 people in the UK each year. There is a risk the clot could move and travel to one of the lung arteries causing a life

2018 NIHR Dissemination Centre

127. 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

2018 NIHR Dissemination Centre

128. Laser treatment is the preferred treatment for troublesome varicose veins

% probability), then surgery (5% probability). Foam had the most complications at six months, of which the most common were lumpiness, skin staining and tenderness. This treatment gave the smallest quality of life improvement and was least likely to close the vein. What does current guidance say on this issue? Where there is damage to leg vein valves and impaired blood flow, or troublesome symptoms such as aching legs, 2013 NICE guidance recommends treatment using minimally invasive procedures. The first (...) , Elders A, et al. . Health Technol Assess. 2015;19(27):1-342. This project was funded by the National Institute for Health Research HTA Programme (project number 06/45/02). Bibliography Brittenden J, Cotton SC, Elders A, et al. . NEJM. 2014;371:1218-27. Knott, L. . Leeds: EMIS Group; 2013 NICE. . IPG52. London: National Institute for Health and Care Excellence; 2004. NICE. . IPG440. London: National Institute for Health and Care Excellence; 2013. NICE. . NICE Pathway. London: National Institute

2018 NIHR Dissemination Centre

129. CRACKCast E041 – Head Injury

CRACKCast E041 – Head Injury CRACKCast E041 - Head Injury - CanadiEM CRACKCast E041 – Head Injury In , by Chris Lipp September 19, 2016 This episode of CRACKCast covers Rosen’s Chapter 041, Head Injury. This episode covers a spectrum of head injuries seen in the emergency department along with appropriate management. Shownotes – Rosen’s in Perspective Most common causes of head injury: falls, MVC’s Leading cause of death for people < 25 yrs old There may be no external indicators on someone (...) Cranial vault can take up to 1900 ml of space Brain takes up 80% of the cranial vault And is covered by (outside to inside): Meningeal dura Arachnoid layer Pia ….then brain Brain Divisions Cerebrum, cerebellum, brainstem CSF surrounds and protects the brain with buffering and cushioning. Produced by the choroid plexus (in the lateral ventricles) Pathway: ventricles → subarachnoid space → brain and spinal cord CSF functions Delivers brain substances, eliminates wastes, transports hormones, Normal

2016 CandiEM

130. CIRSE Guidelines on Percutaneous Ablation of Small Renal Cell Carcinoma

were both updated in 2013 by the International Society of Urological Pathology (ISUP) Vancouver Classi?cation [9]. The updated RCC histopathology classi?cation is shown in Table 1. The 5-year survival rate for kidney cancer is 91.8% for localized disease and 12.1% for advanced disease, with the most important prognostic factors being the tumour grade, the local extent and the presence of nodal or distal metastases at presentation [1]. The most common sites of metastasis include the lungs, bone (...) , the number and the pathway of the probes, the risk of adjacent organ injury and the necessity of ancillary procedures need to be de?ned from pre-proce- dural imaging [45, 46]. Ultrasound (US) is the least sensitive modality for the detection of T1a RCCs [47]. The use of micro-bubble contrast may increase the diagnostic accuracy of US: however, the relationship with the adjacent organs and the needle pathway cannot be con?dently de?ned in all cases and imaging with contrast-enhanced CT or MRI is neces

2016 Cardiovascular and Interventional Radiological Society of Europe

131. SCAI/CCAS/SPA Expert Consensus Statement for Anesthesia and Sedation Practice: Recommendations for Patients Undergoing Diagnostic and Therapeutic Procedures in the Pediatric and Congenital Cardiac Catheterization Laboratory

IN THE PCCCL Studies concerning anesthesia-related morbidity and mortality in recent decades have demonstrated that pe- diatric patients and especially patients with CHD are at increased risk for adverse events and cardiac arrest during surgery [1–3]. Common complications in chil- dren undergoing sedation or general anesthesia include airway events (laryngospasm, bronchospasm, apnea and aspiration), cardiovascular events (hypotension, arrhythmias and cardiac arrest) and postoperative issues such as nausea (...) and vomiting, emergence agitation, hypoxemia and apnea. In a prospective quality assur- ance audit of 24,165 anesthetics in children undergoing surgery, Murat et al. showed that respiratory issues comprised 53% and cardiac issues 12.5% of intraopera- tive adverse events [4]. Respiratory events were more common in infants under one year of age, intubated patients and those who were American Society of Anesthesiologists Physical Status (ASA PS) 3 or 4. Cardiac events were also most common in those with ASA

2016 Society for Cardiovascular Angiography and Interventions

132. Drugs That May Cause or Exacerbate Heart Failure

of Care and Outcomes Research Originally published 11 Jul 2016 Circulation. 2016;134:e32–e69 You are viewing the most recent version of this article. Previous versions: Abstract Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity (...) conditions. Using the National Health and Nutrition Examination Survey, Wong et al found that the proportion of patients with ≥5 comorbidities increased from 42.1% in the period of 1988 to 1994 to 58% in the period of 2003 to 2008. From this analysis, osteoarthritis (62%), obesity (46.8%), chronic kidney disease (45.9%), and diabetes mellitus (38.3%) were the most common noncardiovascular comorbidities. In an analysis of noncardiac comorbidity in 122 630 Medicare beneficiaries, Braunstein et al found

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2016 American Heart Association

133. Prevention of Stroke in Patients With Silent Cerebrovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Radiology and Intervention; Council on Functional Genomics and Translational Biology; and Council on Hypertension Originally published 15 Dec 2016 Stroke. 2016;48:e44–e71 You are viewing the most recent version of this article. Previous versions: Abstract Two decades of epidemiological research shows that silent cerebrovascular disease is common and is associated with future risk for stroke and dementia. It is the most common incidental finding on brain scans. To summarize evidence on the diagnosis (...) committee found strong evidence that silent cerebrovascular disease is a common problem of aging and that silent brain infarcts and white matter hyperintensities are associated with future symptomatic stroke risk independently of other vascular risk factors. In patients with cerebral microbleeds, there was evidence of a modestly increased risk of symptomatic intracranial hemorrhage in patients treated with thrombolysis for acute ischemic stroke but little prospective evidence on the risk of symptomatic

2016 American Heart Association

134. Acute Myocardial Infarction in Women

characteristics of women to produce differences in plaque characteristics (rupture versus erosion) and prevalence of CAS and SCAD. Plaque Rupture and Erosion Autopsy studies from past decades have established that there are predominantly 3 major vascular events underlying thrombotic coronary occlusions responsible for AMI: plaque rupture, plaque erosion, and calcific nodule. Plaque rupture is by far the most common cause, responsible for 76% of men and 55% of women with fatal MI. Originally described 3 (...) thrombosis in STEMI might originate from calcific nodules, seen more frequently in the right coronary artery. Although plaque rupture was responsible for 76% of fatal AMI events among men in a worldwide survey, only 55% of these events in women were found to be due to plaque rupture. Autopsy studies have shown an increased prevalence of plaque erosion in women compared with men, particularly in younger women. This is of significant interest given that MI without obstructive CAD is more common at younger

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2016 American Heart Association

135. Initial Diagnostic Workup of Acute Leukemia

of mixed-phenotype acute leukemia (MPAL), and included provisional entities of AML that were based on gene mutation studies. Since 2008, many other mutations have been described in all types of AL, and epigenetic changes, including protein and microRNA (miRNA) ex- pression and global and gene-speci?c methylation, have been reported to be common and prognostically relevant in AL. 6,7 The 2016 WHO classi?cation 8 of AL continued to de?ne some disease entities by a combination of morpho- logic (...) , and/or marrow clots, in conjunction with the bone marrow aspirates. Strong recommendation Note.—If bone marrow aspirate material is inadequate or if there is compelling clinical reason to avoid bone marrow examination, peripheral blood may be used for diagnosis and ancillary studies if sufficient numbers of blasts are present. If a bone marrow aspirate is unobtainable, touch imprint preparations of a core biopsy should be prepared and evaluated, and an additional core biopsy may be submitted unfixed

2016 College of American Pathologists

136. Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: A Scientific Statement From the American Heart Association

or lower extremities, or in an intracavitary location, primarily within the abdomen or less commonly within the thorax. Frequency The frequency of VGI depends on the anatomic location of the graft. The infection rate is 1.5% to 2% for most extracavitary grafts and as high as 6% with vascular grafts in the groin. For intracavitary grafts, the infection rate is ≈1% to 5%. Graft infection is most common after emergency procedures and after reoperation. , Aortic graft erosion or fistulous communication (...) for at least two thirds of VGIs. , Infections caused by coagulase-negative staphylococci are more common than those caused by S aureus . Among S aureus infections, methicillin-resistant S aureus (MRSA) infections are increasing in frequency. Pseudomonas aeruginosa is now the most common cause of gram-negative infections and accounts for at least 10% of VGIs , ( ). Figure 1. Microbiology of prosthetic vascular graft infections. ICD indicates implantable cardioverter-defibrillator; and PPM, permanent

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2016 American Heart Association

137. HER2 Testing and Clinical Decision Making in Gastroesophageal Adenocarcinoma

. Authors’ disclosures of potential conflicts of interest and author contributions are found in the Appendix at the end of this article. Reprints: Angela N. Bartley, MD, Department of Pathology, St. JosephMercyHospital,5603EHuronRiverDr,AnnArbor,MI48108 (email: angelbart16@gmail.com). Arch Pathol Lab Med—Vol 140, December 2016 HER2 Testing in Gastroesophageal Adenocarcinoma—Bartley et al 1345 (stomach) most common cancers worldwide. 2 Gastroesoph- ageal adenocarcinoma is often diagnosed at an advanced (...) humanized monoclonal antibody trastuzumab (Herceptin; Genentech, San Francisco, California) statistically signi?cantly pro- longedoverallsurvival,comparedwithchemotherapyalone, inpatientswithHER2–positiveadvancedGEA. 3 ERBB2(also commonly known as HER2) is a proto-oncogene located on chromosome 17 that encodes a 185-kDa tyrosine kinase receptor belonging to the epidermal growth factor receptor family whose phosphorylation initiates signaling pathways that lead to cell division, proliferation

2016 College of American Pathologists

138. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients

more than 70% of the committee to be in support. Strong recommendations required at least an 80% majority following the previously validated RAND algorithm as shown in ( ). Guidelines are based on the notion that any bedside ultrasound information is complimentary to the physical examination and intensivist clinical judgment and therefore organized around most common suspected ICU diagnoses. Repeat examinations are predicated on significance of the change in patient condition or to follow (...) the distance distal to hepatic veins (1–2 cm) and the movement of point of measurement during lung inflation can be overlooked when using M-mode. Using cine-loop and manually measuring a fixed anatomical point may overcome this common mistake. RV function and RV to LV coupling are presumed to be normal. Patients should be ventilated in a flow-limited (volume-control) mode with 8 mL/kg ideal body weight tidal volume and not display ventilator dyssynchrony. Simultaneous assessment of LV end-diastolic

2016 Society of Critical Care Medicine

139. Laser treatment is the preferred treatment for troublesome varicose veins

% probability), then surgery (5% probability). Foam had the most complications at six months, of which the most common were lumpiness, skin staining and tenderness. This treatment gave the smallest quality of life improvement and was least likely to close the vein. What does current guidance say on this issue? Where there is damage to leg vein valves and impaired blood flow, or troublesome symptoms such as aching legs, 2013 NICE guidance recommends treatment using minimally invasive procedures. The first (...) , Elders A, et al. . Health Technol Assess. 2015;19(27):1-342. This project was funded by the National Institute for Health Research HTA Programme (project number 06/45/02). Bibliography Brittenden J, Cotton SC, Elders A, et al. . NEJM. 2014;371:1218-27. Knott, L. . Leeds: EMIS Group; 2013 NICE. . IPG52. London: National Institute for Health and Care Excellence; 2004. NICE. . IPG440. London: National Institute for Health and Care Excellence; 2013. NICE. . NICE Pathway. London: National Institute

2018 NIHR Dissemination Centre

140. New drugs for deep vein thrombosis may offer a safe alternative to warfarin

that can be used by clinicians and commissioners weighing up the benefits and costs of potential changes to current treatment pathways (see Bibliography below for links). Share your views on the research. Why was this study needed? Deep vein thrombosis (DVT) describes a blood clot that has formed in the deep veins of the legs or pelvis, that is, not the ones you can see near the surface of the skin. It is relatively common and affects about one in a 1,000 people in the UK each year. There is a risk (...) : National Institute for Health and Care Excellence; 2012. NICE. TA170. London: National Institute for Health and Care Excellence; 2013. Why was this study needed? Deep vein thrombosis (DVT) describes a blood clot that has formed in the deep veins of the legs or pelvis, that is, not the ones you can see near the surface of the skin. It is relatively common and affects about one in a 1,000 people in the UK each year. There is a risk the clot could move and travel to one of the lung arteries causing a life

2018 NIHR Dissemination Centre

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