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Dyspepsia in Pregnancy

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181. Atrial fibrillation

Excellence (NICE) guideline: Atrial fibrillation: the management of atrial fibrillation [ ]. This CKS topic covers the management of people with atrial fibrillation (AF), including people with paroxysmal AF, and covers management issues such as rate control, anticoagulation treatment, and when to admit or refer to a cardiologist. This CKS topic does not cover the management of AF in children, AF during pregnancy, AF causing haemodynamic instability, postoperative AF, or atrial flutter. This guideline

2019 NICE Clinical Knowledge Summaries

182. Glaucoma

prostaglandin analogues and prostamides? Use prostaglandin analogues and prostamides with caution in people with aphakia, pseudophakia with torn posterior lens capsule or anterior chamber lenses, and in people with known risk factors for cystoid macular oedema, iritis, uveitis, or a history of significant ocular viral infections. Also, use with care in people with COPD, asthma, or compromised respiratory function. For pregnant women , the manufacturers advise: To avoid bimatoprost, tafluprost

2019 NICE Clinical Knowledge Summaries

185. Pelvic inflammatory disease

of pelvic inflammatory disease From age 13 years onwards (Female). Managing suspected PID How should I manage a woman with suspected pelvic inflammatory disease? Admit urgently if: Ectopic pregnancy cannot be ruled out, or the woman is pregnant. Symptoms and signs are severe (such as nausea, vomiting, and a fever greater than 38°C). There are signs of pelvic peritonitis. A surgical emergency (such as acute appendicitis) cannot be ruled out. A tubo-ovarian abscess is suspected. The woman is unwell (...) is limited. Previous trials have reported significant rates of treatment failure. The addition of ceftriaxone improves treatment outcome. Risk of a very early pregnancy (too early for a pregnancy test to be positive) Although PID in pregnancy is uncommon, it is associated with an increase in both maternal and fetal morbidity. BASHH advises that in very early pregnancy (prior to a pregnancy test becoming positive), the use of the same antibiotic regimens recommended for non pregnant women is justified

2019 NICE Clinical Knowledge Summaries

186. Anticoagulation - oral

are taking any other anticoagulants, except when switching to or from warfarin treatment. People with history of thrombosis diagnosed with antiphospholipid syndrome, in particular, triple positive patients, where use of DOACs could be associated with increased rates of recurrent thrombotic events. People who are taking strong inhibitors of cytochrome P3A4 enzyme and P-glycoprotein, such as ketoconazole, or HIV protease inhibitors such as ritonavir. For more information, see . Women who are pregnant (...) or breastfeeding. The safety of apixaban has not been established in pregnant or breastfeeding women. Basis for recommendation Basis for recommendation These recommendations are based on the manufacturer's Summary of Product Characteristics [ ], the British National Formulary [ ], and a Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update [ ]. Risk of serious haemorrhage A Drug Safety Update clarified that contraindications for dabigatran, where the person is at significant risk

2019 NICE Clinical Knowledge Summaries

187. Chronic kidney disease

. If the eGFR is less than 60 mL/min/1.73 m 2 , repeat the test within two weeks (unless the eGFR is stable). If the eGFR remains less than 60 mL/min/1.73 m 2 on repeat, with no evidence of sudden deterioration in renal function suggesting acute kidney injury, repeat the eGFR within 3 months. Note: interpret the eGFR result with caution if the person has extremes of muscle mass, is pregnant, has oedema, is malnourished or uses protein supplements, or is Asian or Chinese in origin. See the CKS topic (...) [ ]. The recommendation to avoid eating meat prior to eGFR testing is based on the fact that the cooking process converts creatine in meat to creatinine, which is subsequently absorbed into the bloodstream. Ingestion of cooked meat causes a significant increase in serum creatinine concentration, causing a potential underestimation of GFR [ ]. The recommendation to interpret the eGFR result with caution in people who are pregnant or have oedema is based on the NICE clinical guideline, which notes that serum creatinine

2019 NICE Clinical Knowledge Summaries

188. Diarrhoea - prevention and advice for travellers

advice should be sought if antibiotic prophylaxis or 'stand-by' treatment is being considered. Advice should be given about managing travellers' diarrhoea while travelling: Most episodes are short-lived and self-limiting, lasting a few days. The person could consider purchasing sachets of oral rehydration salt before travelling. During an episode of diarrhoea, it is important to prevent dehydration — particularly for young children, pregnant women, elderly people, and those with pre-existing illness (...) update. Prescribing information updated with information regarding azithromycin interacting with colchicine. September 2017 — minor update. SPC update on quinolones to align all CKS topics prescribing advice. Prostatitis – chronic, Gonorrhoea, Pyelonephritis, Diarrhoea – prevention and advice for travellers, Dyspepsia – unidentified cause, Dyspepsia – proven functional, Dyspepsia – proven peptic ulcer, Diverticular disease, Gastroenteritis and Scrotal pain swellings. March 2013 — reviewed

2019 NICE Clinical Knowledge Summaries

189. Anaemia - B12 and folate deficiency

are pregnant predisposes to neural tube defects (such as spina bifida, anencephaly, and encephalocele) in the foetus. Incidence of neural tube defects increases with decreasing serum folate or vitamin B12 levels. For more information on folic acid supplementation in pregnancy, see the CKS topic on . Nutritional deficiency of vitamin B12 or folate may cause ineffective production of any types of blood cells derived from bone marrow. Vitamin B12 or folate deficiency may cause sterility. This is reversible (...) phenytoin concentrations and adjust the dose accordingly. Primidone — levels may be reduced if taken concurrently with folic acid. Monitor primidone concentrations and adjust the dose accordingly. Sulfasalazine — absorption of folic acid may be reduced. Monitor blood counts closely if folic acid is given concurrently with sulfasalazine. [ ; ] Pregnancy and breastfeeding Pregnancy and breastfeeding Pregnancy Folic acid is not known to be harmful if used in women who are pregnant. Breastfeeding Folic acid

2019 NICE Clinical Knowledge Summaries

190. Pyelonephritis - acute

interval. [ ; ; ; ] Pregnancy and breastfeeding Pregnancy and breastfeeding Pregnancy Ciprofloxacin should be avoided in women who are pregnant. Breastfeeding Ciprofloxacin is excreted in breastmilk in quantities too small to be harmful, however the manufacturer advises that it should be avoided due to the risk of articular damage. However, studies indicate there is little risk, and quinolones are generally accepted for use during breastfeeding. Avoiding breastfeeding for 3 to 4 hours after a dose (...) be increased if taken with trimethoprim. Monitor phenytoin levels and adjust dose accordingly [ ; ; ; ] Pregnancy and breastfeeding Pregnancy and breastfeeding Pregnancy There is a teratogenic risk in the first trimester of pregnancy. The manufacturer advises that it should not be used in women who are pregnant. In women with normal folate status, who are well nourished, use of trimethoprim for a short period is unlikely to induce folate deficiency, however, it should be avoided if folate deficiency

2019 NICE Clinical Knowledge Summaries

191. Cellulitis - acute

, maceration or fungal infection between the toes, or a concomitant skin disorder (such as atopic eczema). Other risk factors for cellulitis include [ ; ; ; ; ; ]: Lymphoedema. Leg oedema. Venous insufficiency and history of venous surgery. Obesity. Pregnancy [ ]. R isk factors for either rapid progression of cellulitis or delayed response to treatment include [ ; ; ; ; ] : Conditions that predispose to infection, including diabetes mellitus, chronic liver or renal disease, immunocompromise (...) for 5–7 days. Doxycycline 200 mg on the first day then 100 mg once daily, for a total of 5–7 days. Erythromycin (in pregnancy) 500 mg four times daily for 5–7 days. For adults with infection near the eyes or nose who do not require : Prescribe co-amoxiclav 500/125 mg three times a day for 7 days. If this is unsuitable, or the person has a penicillin allergy, prescribe: Clarithromycin 500 mg twice daily for 5–7 days with metronidazole 400 mg three times daily for 7 days. For adults with known

2019 NICE Clinical Knowledge Summaries

192. Diverticular disease

removed. September 2017 — minor update. SPC update on quinolones to align all CKS topics prescribing advice. Prostatitis – chronic, Gonorrhoea, Pyelonephritis, Diarrhoea – prevention and advice for travellers, Dyspepsia – unidentified cause, Dyspepsia – proven functional, Dyspepsia – proven peptic ulcer, Diverticular disease, Gastroenteritis and Scrotal pain and swellings. July 2017 — reviewed. A literature search was conducted in June 2017 to identify evidence-based guidelines, UK policy, systematic (...) , stabbing lower abdominal or pelvic pain with nausea and vomiting. Ectopic pregnancy — see the CKS topic on for more information. Urological Urinary tract infection, including pyelonephritis — see the CKS topics on , , and for more information. Urinary tract obstruction, including ureteric stone — see the CKS topic on for more information. Basis for recommendation Basis for recommendation The information on differential diagnosis of diverticular disease and diverticulitis is based on expert opinion

2019 NICE Clinical Knowledge Summaries

193. Gonorrhoea

to be quinolone sensitive, as there is a high prevalence of quinolone resistance worldwide [ ]. Pregnancy and breastfeeding What treatment should I prescribe for a woman who is pregnant, or breastfeeding? In the unusual event that confirmed or suspected uncomplicated anogenital gonorrhoea needs to be treated in primary care, prescribe: Ceftriaxone 1 g intramuscular (IM) injection as a single dose. Do not prescribe a fluoroquinolone for a woman who is pregnant or breastfeeding. Seek specialist advice (...) arthralgia, tenosynovitis, or septic arthritis. In men, if left untreated, complications include epididymitis, infertility and prostatitis. In women, complications include pelvic inflammatory disease (PID). Gonorrhoea in pregnancy is associated with spontaneous abortion and other complications. A diagnosis of gonorrhoea may be suspected on the basis of history, symptoms, and examination. In men, symptoms (such as urethral discharge and dysuria) usually develop 2–5 days after exposure. Examination

2019 NICE Clinical Knowledge Summaries

194. Gastroenteritis

of disabling and potentially long-lasting or irreversible side effects [ ]. January 2019 — minor update. Aortic aneurysm and dissection is now listed as an adverse effect of ciprofloxacin. October 2018 — minor update. Adverse effects updated within prescribing information - metronidazole. September 2017 — minor update. SPC update on quinolones to align all CKS topics prescribing advice. Prostatitis – chronic, Gonorrhoea, Pyelonephritis, Diarrhoea – prevention and advice for travellers, Dyspepsia (...) – unidentified cause, Dyspepsia – proven functional, Dyspepsia – proven peptic ulcer, Diverticular disease, Gastroenteritis and Scrotal pain and swellings. November 2016 — minor update. Adverse effects of loperamide have been updated to include information in a U.S. Food and Drug Administration (FDA) Drug safety communication, warning that exceeding the maxium dose can cause serious cardiac problems including QT interval prolongation, Torsades de Pointes or other ventricular arrhythmias, syncope, and cardiac

2019 NICE Clinical Knowledge Summaries

196. MI - secondary prevention

in: People with history of angioedema associated with previous exposure to an ACE inhibitor. People with hereditary or recurrent angioedema. People with diabetes mellitus, or with an eGFR <60 mL/minute/1.73m 2 , who are also taking aliskiren. Pregnant women and those planning a pregnancy — due to risks to the fetus. Treatment with an ACE inhibitor should ideally be stopped as soon as pregnancy is detected and, if appropriate, alternative treatment should be started. For more information, see the CKS (...) should not be used at any stage of pregnancy, and have also issued updated advice on interactions with statins. Issued in January 2008. September to December 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Updated to reflect the NICE guideline on secondary prevention for people who have had a myocardial infarction. The main change

2019 NICE Clinical Knowledge Summaries

197. Lipid modification - CVD prevention

disease [ ], the British National Formulary (BNF) [ ], the manufacturer's Summary of Product Characteristics for atrovastatin [ ], and what CKS considers good clinical practice. First-line therapy Which first-line lipid modification therapy should I offer for primary prevention of CVD? Offer high intensity statin treatment unless this is (for example in pregnancy). Discuss the risks and benefits of statin treatment so that the person can make an informed choice about their treatment. Advise that: High (...) Characteristics for atorvastatin [ ], and what CKS considers good clinical practice. First-line therapy Which first-line lipid modification therapy is recommended for secondary prevention of CVD? Offer high intensity statin treatment unless this is (for example in pregnancy). If the person is already taking a different statin for secondary prevention of cardiovascular disease (CVD), see the section on . Discuss the risks and benefits of statin treatment so that the person can make an informed choice about

2019 NICE Clinical Knowledge Summaries

198. Leg ulcer - venous

, resulting in enlarged veins, oedema, and venous skin changes (hyperpigmentation, , , and ). As the condition of the skin and subcutaneous tissue worsens, it becomes increasingly vulnerable to ulceration. Risk factors for developing venous leg ulcers include [ ; ; ; ; ; ; ] : Increasing age. Obesity. Immobility. Limited range of ankle function. Previous ulcer. Personal or family history of varicose veins. Personal history of deep vein thrombosis. Female sex. Multiple pregnancies. Arteriovenous fistula

2019 NICE Clinical Knowledge Summaries

199. Dabigatran (Pradaxa)

<30mL/min, women who are pregnant or are breast-feeding, or in patients with active cancer. © 2015 Thrombosis Canada Page 2 of 4 MONITORING: Routine laboratory monitoring of the anticoagulant response is unnecessary. The prothrombin time/international normalized ratio (PT/INR) does not provide a reliable measure of its anticoagulant activity. The activated partial thromboplastin time (aPTT) is prolonged by dabigatran but the responsiveness of the test is reagent-dependent and the values plateau (...) with dyspepsia in up to 10% of users; the frequency of this complication can be reduced by having patients take the drug with meals. Dyspepsia usually resolves with time and may improve with the use of an anti-ulcer medication such as a proton pump inhibitor, but caution is advised as the absorption of dabigatran is decreased when co-administered with aluminum, magnesium or calcium containing antacids. PERI-PROCEDURAL MANAGEMENT: See Clinical Guide: New/Novel Oral Anticoagulants (NOAC): Peri-Operative

2015 Thrombosis Interest Group of Canada

200. Acute pain management: scientific evidence (3rd Edition)

359 10.7.1 Peripheral nerve blocks 359 10.7.2 Central neural blockade 361 10.8 Acute pain in children with cancer 365 10.8.1 Cancer-related pain 365 10.8.2 Procedure-related pain 365 10.8.3 Treatment-related pain 366 References 367 Acute Pain Management: Scientific Evidence xvii CONTENTS 11. OTHER SPECIFIC PATIENT GROUPS 385 11.1 The pregnant patient 385 11.1.1 Management of acute pain during pregnancy 385 11.1.2 Management of pain during delivery 390 11.1.3 Pain management during lactation 394 (...) and cultural groups 413 11.5 The patient with obstructive sleep apnoea 415 11.6 The patient with concurrent hepatic or renal disease 418 11.6.1 Patients with renal disease 418 11.6.2 Patients with hepatic disease 419 11.7 The opioid-tolerant patient 426 11.7.1 Definitions and clinical implications 426 11.7.2 Patient groups 427 11.7.3 Management of acute pain 427 11.8 The patient with an addiction disorder 431 11.8.1 Management of acute pain in pregnant patients with an addiction disorder .. 433 11.8.2 CNS

2015 National Health and Medical Research Council

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