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Hepatotoxic Medication

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141. CRACKCast E186 – Substance Abuse

in patients with chronic pain syndromes. Chronic pain may not manifest the typical overt sympathetic changes or physical findings of acute pain. Patients may seek treatment because of perceived failure of their outpatient regimen, an acute flare up, or because of abuse or addiction. Therefore, emergency clinicians constantly walk a tightrope between undertreating legitimate pain and inappropriately rewarding substance abusers with controlled medications. [1] List 15 complications of drug abuse They can (...) half will have tried an illicit drug, and over 80 percent will have used alcohol. A large 2013 survey of teenagers in grades 9 to 12 found misuse and abuse of prescription medications to be the third most prevalent drug abuse behavior among teens, trailing only use of marijuana and alcohol. Abuse of over-the-counter (OTC) cough medications is on par with or higher than the abuse of illegal drugs, such as ecstasy and cocaine. A few common culprits include: Dextromethorphan abuse Ingesting

2018 CandiEM

142. CRACKCast E157 – Iron and Heavy Metals

Asymptomatic patients seeking ED care for an abnormal metal test need follow-up evaluation arranged with a medical toxicologist. Metal testing in the ED should only be ordered in consultation with a medical toxicologist or regional poison center. Acute ingestion of the salts of most metals causes rapid severe gastrointestinal pain and emesis. Any abnormal neurologic signs in a patient with any metal exposure warrants admission for further evaluation and chelation therapy. Acute iron poisoning can result (...) in gastrointestinal symptoms, metabolic acidosis, and hepatotoxicity. Serum iron levels at 3 and 6 hours after ingestion determine toxicity and need for therapy. The chelation agent of choice for severe iron poisoning is deferoxamine and is indicated for peak serum iron concentrations greater than 500 μg/dL (90 mmol/L) and patients with severe signs and symptoms regardless of the iron level. The most important intervention for lead poisoning is removal from the source of exposure. The gastrointestinal

2018 CandiEM

143. British Association of Dermatologists? guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis

Valley Medical Practice, 40–48 George Lane, London NR14 6QH, U.K. 6 Oncology Department, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, U.K. 9 Dermatology Department, St George’s Hospital, Blackshaw Road, London SW17 0QT, U.K. 10 Dermatology Department, Ninewells Hospital, Dundee DD1 9SY, U.K. 11 British Association of Dermatologists, Willan House, 4 Fitzroy Square, London W1T 5HQ, U.K. Correspondence George Millington. E-mail: george.millington@nnuh.nhs.uk; guidelines@bad.org.uk Accepted (...) Pharma, Novartis, La Roche-Posay and Proctor & Gamble to the Skin Health Alliance (nonspeci?c); and is the current Assistant Honorary Secretary of the BAD and member of the BAD Therapy & Guidelines subcommittee. N.J.L. has received travel subsistence from Novartis (nonspeci?c), has been the Clinical Vice-President of the BAD and President of the British Society for Medical Dermatology (nonspeci?c), and is the current National Specialty Lead (Dermatology) at the National Institute of Health Research

2018 British Association of Dermatologists

144. CRACKCast E158 – Hydrocarbons

and hepatotoxicity) Aromatic hydrocarbons (bone marrow suppression and leukemia) Metals (neurotoxicity) Pesticides (cholinergic crises, seizures, respiratory depression) [4] What is the risk of intentional GI ingestion? Who should be decontaminated by Gastric Lavage? Major risk is aspiration Lipoid pneumonia can also rarely develop after hydrocarbons coalesce in alveoli and become encapsulated by fibrous tissue reported in adults siphoning gasoline and from re-eating performances, also known as “fire-eater’s (...) and monitoring are the cornerstones of management Discharge criteria for hydrocarbon ingestion 6 hour asymptomatic period Non-lethal substance (Ie anything but CHAMP) Which hydrocarbons are potentially lethal = CHAMP Camphor (neurotoxicity and seizures) Halogenated hydrocarbons (dysrhythmias and hepatotoxicity) Aromatic hydrocarbons (bone marrow suppression and leukemia) Metals (neurotoxicity) Pesticides (cholinergic crises, seizures, respiratory depression) For the Disposition of Patients with known

2018 CandiEM

145. CRACKCast E154 – Hallucinogens

*** Clinical Pearl*** Isoxazole poisoning CAN RESEMBLE anticholinergic toxicity BUT THEY DON’T CONTAIN belladonna alkaloids Some people mistake the name = A. muscaria with that of muscarine, a cholinergic toxin. Atropine can worsen anticholinergic effect. Don’t use it But the most important not of this podcast is here: “It is important to differentiate isoxazole-containing Amanita mushrooms from the deadly hepatotoxic cyclopeptide- containing Amanita mushrooms, of which Amanita phalloides is a member (...) !!! Increasing reports of sudden cardiac death, likely from prolonged QTC and PMVT Tx torsades with Mg and possible overdrive pacing This post was copy-edited and uploaded by Andrew Guy (Visited 645 times, 1 visits today) Chris Lipp is one of the founding Fathers for CrackCast. He currently divides his time as an EM Physician in Calgary (SHC/FMC) and in Sports Medicine. His interests are in endurance sports, exercise as medicine, and wilderness medical education. When he isn’t outdoors with his family, he's

2018 CandiEM

146. Evaluation and Treatment of Hirsutism in Premenopausal Women

To update the “Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline,” published by the Endocrine Society in 2008. Participants The participants include an Endocrine Society–appointed task force of seven medical experts and a methodologist. Evidence This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence (...) . We suggest against testing for elevated androgen levels in eumenorrheic women with unwanted local hair growth ( i.e. , in the absence of an abnormal hirsutism score) because of the low likelihood of identifying a medical disorder that would change management or outcome. (2 |⊕⊕OO) 2.0 Treatment of hirsutism in premenopausal women 2.1. For most women with patient-important hirsutism despite cosmetic measures, we suggest starting with pharmacological therapy (2 |⊕OOO). For women who then desire

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2018 The Endocrine Society

147. Non-alcoholic Fatty Liver Disease, Diagnosis and Management

) Because this guidance document is lengthy, to make it easier for the reader, a list of all guidance statements and recommendations are pro- videdinatabularformasSupportingTableS1. De?nitions Forde?ningNAFLD,theremustbe(1)evidence of hepatic steatosis (HS), either by imaging or histology, and (2) lack of secondary causes of hepatic fat accumu- lation such as signi?cant alcohol consumption, long- term use of a steatogenic medication, or monogenic hereditary disorders (Table 1). In the majority (...) . For de?ning “advanced” ?brosis, this guidance document will be referring speci?cally to stages 3 or 4, that is, bridging ?brosisorcirrhosis. TABLE 1. Common Causes of Secondary HS Macrovesicular steatosis - Excessive alcohol consumption - Hepatitis C (genotype 3) -WD - Lipodystrophy - Starvation - Parenteral nutrition - Abetalipoproteinemia - Medications (e.g., mipomersen, lomitapide, amiodarone, methotrexate, tamoxifen, corticosteroids) Microvesicular steatosis - Reye’s syndrome - Medications

2018 American Association for the Study of Liver Diseases

148. Routine investigation and monitoring of adult HIV-1-positive individuals (2019 interim update)

documented in the last 2 years (90%) and blood pressure (BP) recorded in the last 15 months (90%). BHIVA guidelines on the routine investigation and monitoring of HIV-1-positive adults 6 3. Tables summarising the monitoring of patients at different stages of their HIV care 3.1 Baseline/initial assessment for all newly diagnosed HIV-positive patients History • General medical (including symptoms) • Psychosocial • Sexual and reproductive health • Past and current co-morbidities • Concomitant medications (...) months post-ART start • If VL not fully supressed at 6 months or any increase in VL at any time, see section 4.7.2 3.5 Monitoring of patients established on ART and with the viral load suppressed Cover all annual issues as outlined in Table 3.2: In addition: History at each visit: • Full medication history and recreational drug use • Understanding of dosing instructions • Adherence • Mood • Adverse effects • Patients’ concerns about medication Examination • According to any symptoms Investigations

2019 British HIV Association

149. Targeted Immunomodulators for the Treatment of Moderate-to-Severe Plaque Psoriasis: Effectiveness and Value

ii Final Evidence Report: Plaque Psoriasis Condition Update About ICER The Institute for Clinical and Economic Review (ICER) is an independent non-profit research organization that evaluates medical evidence and convenes public deliberative bodies to help stakeholders interpret and apply evidence to improve patient outcomes and control costs. The funding for this report comes from government grants and non-profit foundations, with the largest single funder being the Laura and John Arnold (...) with the input of all stakeholders. New England CEPAC seeks to help patients, clinicians, insurers, and policymakers interpret and use evidence to improve the quality and value of health care. The New England CEPAC is an independent committee of medical evidence experts from across New England, with a mix of practicing clinicians, methodologists, and leaders in patient engagement and advocacy. All Council members meet strict conflict of interest guidelines and are convened to discuss the evidence summarized

2018 California Technology Assessment Forum

150. Treatment of chronic lymphocytic leukaemia

) nomenclature was used to evaluate levels of evidence and to assess the strength of recommendations. The GRADE criteria can be found at . The guideline group was selected to be representative of UK medical experts and patients. Recommendations are based on a review of the literature using Medline/Pubmed searches under the heading, chronic lymphocytic leukaemia AND phase III AND (Ibrutinib OR Idelalisib OR Venetoclax OR Obinutuzumab OR Ofatumumab OR Bendamustine OR Rituximab OR Fludarabine (...) and continuous use of targeted agents has led to a growing cohort of patients who, while no longer subject to the volatility associated with intermittent cytoreductive agents, may experience complications of on‐going secondary immunodeficiency and treatment‐related side‐effects (see , and for the full lists of side‐effects and drug interactions for ibrutinib, idelalisib and venetoclax, respectively). Physicians must maintain good pharmacovigilance and encourage patients to discuss any new medication

2018 British Committee for Standards in Haematology

151. AASLD Guidelines for Treatment of Chronic Hepatitis B

Consortium, Anchorage, AK Division of Gastroenterology, Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania Perelman School of Medicine, Philadelphia, PA Department of General Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY Ochsner Medical Center, New Orleans, LA (...) Division of Clinical Decision Making, Tufts Medical Center, Tufts University School of Medicine, Boston, MA Corresponding Author E-mail address: Division of Gastroenterology/Hepatology, University of California San Francisco, San Francisco, CA ADDRESS CORRESPONDENCE AND REPRINT REQUESTS TO : Norah Terrault, M.D., M.P.H. Division of Gastroenterology/Hepatology, University of California San Francisco 513 Parnassus Avenue Room S‐357 San Francisco, CA 94143‐0358 E‐mail: Tel: +1‐415‐476‐2227 Division

2018 American Association for the Study of Liver Diseases

152. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Chronic Pain

and rescue medications to address adverse effects; and what constitutes a positive treatment response. The group was able to reach consensus on all questions. Evidence supports the use of ketamine for chronic pain, but the level of evidence varies by condition and dose range. Most studies evaluating the efficacy of ketamine were small and uncontrolled and were either unblinded or ineffectively blinded. Adverse effects were few and the rate of serious adverse effects was similar to placebo in most studies (...) , Johns Hopkins School of Medicine; and † Uniformed Services University of the Health Sciences, Bethesda, MD; ‡ Department of Anesthesiology, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada; § Department of Anesthesiology, Rush Medical College, Chicago, IL; ∥ Department of Anesthesiology, Jefferson Medical College, Philadelphia; and ** Departments of Anesthesiology and Psychiatry, University of Pittsburgh, Pittsburgh, PA; †† Departments of Anesthesiology and Public Health

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2018 American Society of Regional Anesthesia and Pain Medicine

153. Evaluation and Treatment of Hirsutism in Premenopausal Women

To update the “Evaluation and Treatment of Hirsutism in Premenopausal Women: An Endocrine Society Clinical Practice Guideline,” published by the Endocrine Society in 2008. Participants The participants include an Endocrine Society–appointed task force of seven medical experts and a methodologist. Evidence This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence (...) . We suggest against testing for elevated androgen levels in eumenorrheic women with unwanted local hair growth ( i.e. , in the absence of an abnormal hirsutism score) because of the low likelihood of identifying a medical disorder that would change management or outcome. (2 |⊕⊕OO) 2.0 Treatment of hirsutism in premenopausal women 2.1. For most women with patient-important hirsutism despite cosmetic measures, we suggest starting with pharmacological therapy (2 |⊕OOO). For women who then desire

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2018 The Endocrine Society

154. Castration-Resistant Prostate Cancer

Castration-Resistant Prostate Cancer Prostate Cancer: Castration Resistant Guideline - American Urological Association advertisement Toggle navigation About Us About the AUA Membership AUA Governance Industry Relations Education AUAUniversity Education Products & Resources Normal Histology and Important Histo-anatomic Structures Urinary Bladder Prostate Kidney Renovascular Diseases Andrenal Gland Testis Paratesticular Tumors Penis Retroperitoneum Cytology Online Learning For Medical Students (...) developed to provide a rational basis for treatment based on currently available published data. [pdf] [pdf] [pdf] Note to the Reader: On July 21, 2014, the FDA issued a recommendation that health care professionals should consider the alcohol content of docetaxel when prescribing or administering the drug to patients. On July 26, 2013, the FDA issued a safety announcement related to the use of ketoconazole in the form of oral tablets. Side effects can include hepatotoxicity, adrenal insufficiency

2018 American Urological Association

155. MASAC Document Regarding Risks of Gene Therapy Trials for Hemophilia

, in at least a subset of clinical trial participants. The mechanisms behind this toxicity are not fully understood, but include an immune response to vector capsid; possible direct cellular toxicity due to stress from catabolizing the AAV capsid; a cellular stress response due to high transgene protein synthesis burden; and/or hepatotoxicity resulting from interaction of vector and co-administered potentially hepatotoxic medications, e.g. efavirenz a component of a HAART regimen for HIV infection(11, 12 (...) ). While the mechanisms are not all understood, these adverse events support the need to counsel patients receiving gene therapy to avoid potentially hepatotoxic therapies such as within HAART, and support the need for more studies to determine the mechanisms of liver toxicity complicating gene therapy. The Medical and Scientific Advisory Council (MASAC) of NHF continues to emphasize the careful consideration of advances in gene therapy to quantify and mitigate the risks to patients and others

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2018 National Hemophilia Foundation

156. Withdrawal of, and alternatives to, valproate-containing medicines in girls and women of childbearing potential who have a psychiatric illness

and multiple Asian countries) suggest that between 14.1% and 35.2% of patients might be prescribed valproate-containing medicines, typically combined with antipsychotic medication. The following paragraphs mention particular medicines in particular indications though in some instances the named drug does not currently (December 2018) have a market authorisation (‘licence’) for that indication. Further guidance on steps to be taken when considering the prescription of a medicine outside the terms of its (...) of valproate-containing medicines, other than risks associated with pregnancy, including hepatotoxicity (family history of liver disease represents a contra- indication), hair loss and thrombocytopenia, and these and other potential problems also need to be considered and discussed with patients when making treatment decisions. 3. Switching patients from valproate-containing preparations to alternative medicines Psychiatrists should consider the possibility of a potential pregnancy when assessing

2019 British Association for Psychopharmacology

157. Cannabis

for Addiction and Mental Health, T oronto, Ontario, Canada; 3 Acute Care Program, Centre for Addiction and Mental Health, T oronto, Ontario, Canada; 4 Departments of Family and Community Medicine, Pharmacology and T oxicology, Psychiatry, Institute of Medical Science, University of T oronto, T oronto, Ontario, Canada; 5 Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, T oronto, Ontario, Canada; 6 Institute for Mental Health Policy Research, Centre for Addiction (...) @ucalgary.ca Keywords: Cannabis; Hepatic disorders; Gastroenterological disorders; Position statement Medical cannabinoid products are widely used in Canada to treat medical symptoms of all kinds, and gastrointestinal (GI) symptoms are among the most commonly cited reasons for use (1). Cannabis is also widely used recreationally (2), and legal- ization of recreational use has occurred in Canada. Currently, cannabis is not an approved therapeutic product in Canada. However, health care practitioners may

2018 Canadian Association of Gastroenterology

158. European Society of Endocrinology Clinical Practice Guidelines for the management of aggressive pituitary tumours and carcinomas

Tumors, Hamburg, Germany 9 Medical Faculty, University Belgrade, Belgrade, Serbia 10 Centre de Pathologie et de Biologie Est, Groupement Hospitalier Est, Hospices Civils de Lyon, Bron, France 11 Departments of Internal Medicine (Section Endocrinology) & Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands 12 Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark Correspondence should be addressed to G Raverot; Email: gerald.raverot@chu-lyon.fr The European (...) Society of Endocrinology has initiated this guideline on the Management of Aggressive Pituitary DOI: Page(s): G1–G24 Volume/Issue: Article Type: Research Article Online Publication Date: Jan 2018 Copyright: © 2018 European Society of Endocrinology 2018 Free access Background Pituitary tumours are common and easily treated by surgery or medical treatment in most cases. However, a small subset of pituitary tumours does not respond to standard medical treatment and presents with multiple local

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2018 European Society of Endocrinology

159. European Society of Endocrinology Clinical Practice Guidelines on the management of adrenocortical carcinoma in adults

, Department of Internal Medicine I, University Hospital 2 Comprehensive Cancer Center Mainfranken, University of Würzburg, Würzburg, Germany 3 Department of Clinical Epidemiology 4 Department of Clinical Endocrinology and Metabolism, Leiden University Medical Centre, Leiden, the Netherlands 5 Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark 6 Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA (...) 7 Endocrine Oncology and Nuclear Medicine, Institut Gustave Roussy, Villejuif, France 8 INSERM UMR 1185, Faculté de Médecine, Le Kremlin-Bicêtre, Université Paris Sud, Paris, France 9 Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, Medical Oncology, University of Brescia at ASST Spedali Civili, Brescia, Italy 10 Department of Pathology, Erasmus MC University Medical Center, Rotterdam, the Netherlands 11 Department of Pathology, University Medical Center

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2018 European Society of Endocrinology

160. Alcoholic Liver Disease

and close monitoring Consider norepinephrine + albumin if progressive HRS-1 Volume expansion with albumin Renal insufficiency Pan-culture, Chest X-Ray Infection Perform doppler abdominal US and if indicated, MRI Rule out HCC/biliary obstruction/Budd-Chiari Mechanical obstruction Use of any potential hepatotoxic substance in the last 3 months Uncertain alcohol intake history Atypical presentation and/or laboratory tests(eg.AST or ALT>400) All negative Review detailed history of medication, supplements (...) ). Owing to various susceptibility factors, individuals with long-term heavy alcohol use remain at risk for advanced liver disease with alcoholic steatohepatitis (ASH), cirrhosis, and hepa- tocellular carcinoma (HCC) ( 3 ). Most patients with ALD present for medical care aft er they have developed jaundice or complica- tions of cirrhosis ( 4 ). Identifi cation of ALD in the primary-care setting at an early stage and subsequent behavioral interventions should thus be encouraged. Compared with the recent

2018 American College of Gastroenterology

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