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High Altitude Edema

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141. Testosterone Therapy in Men with Hypogonadism (Full text)

with breast or prostate cancer, a palpable prostate nodule or induration, a prostate-specific antigen level > 4 ng/mL, a prostate-specific antigen level > 3 ng/mL combined with a high risk of prostate cancer (without further urological evaluation), elevated hematocrit, untreated severe obstructive sleep apnea, severe lower urinary tract symptoms, uncontrolled heart failure, myocardial infarction or stroke within the last 6 months, or thrombophilia. (1∣⊕⊕OO) 2.3 In hypogonadal men 55 to 69 years old, who (...) . The task force also used consistent language and graphical descriptions of both the strength of a recommendation and the quality of evidence. In terms of the strength of a recommendation, strong recommendations use the phrase “we recommend” and the number 1, and conditional recommendations use the phrase “we suggest” and the number 2. Cross-filled circles indicate the quality of the evidence, such that ⊕OOO denotes very low-quality evidence; ⊕⊕OO, low quality; ⊕⊕⊕O, moderate quality; and ⊕⊕⊕⊕, high

2018 The Endocrine Society PubMed

142. Evaluation and Management of Testosterone Deficiency

350,000 men) of which were used to support guideline statements. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low) for support of Strong, Moderate, or Conditional Recommendations. In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions. Approved by the AUA Board of Directors February 2018 Authors’ disclosure of po- tential conflicts (...) Level: Grade C) Adjunctive Testing 6. In patients with low testosterone, clinicians should measure serum luteinizing hormone levels. (Strong Recommendation; Evidence Level: Grade A) 7. Serum prolactin levels should be measured in patients with low testosterone levels combined with low or low/ normal luteinizing hormone levels. (Strong Recommendation; Evidence Level: Grade A) 8. Patients with persistently high prolactin levels of unknown etiology should undergo evaluation for endocrine disorders

2018 American Urological Association

143. CRACKCast E139 – Frostbite

Coagulation in microcirculation Damage tissue releases toxic mediators Tissues become ischemic as the coagulation system is activated Tissue edema for 48-72 hrs as tissue is thawed Necrosis appears as the edema resolves Dry gangrene appears [2] What are the major types of cold injuries? Freezing and NON-freezing! These injuries can occur together, especially in climates that hover around 0 degrees. [3] Describe the clinical differentiation between frostnip, frostbite, trenchfoot, and perino: [1] Frostnip (...) Unable to move the skin over bony tissues Rapid warming usually causes hyperemia – even in severe cases of frostbite Post rewarming: Good prognosis = Normal sensation, warmth and colour Concerning prognosis: Bleb formation Residual violaceous hue Hemorrhagic vesicles Lack of edema formation Eschar and mummification There are at least three different tissue classification models Superficial vs deep injury (based on whether tissue is lost) 1st through 4th degree (not recommended because

2017 CandiEM

144. CRACKCast E124 – Acid-Base Disorders

by hypoxia High altitude Severe anemia Ventilation-perfusion mismatch Central hyperventilation Voluntary or psychogenic Cerebrovascular accident Increased intracranial pressure (tumor, hemorrhage, trauma) Toxic or pharmacologic Salicylates** Caffeine, nicotine Catecholamines Thyroxine Pulmonary Pulmonary embolism Pneumonia Pulmonary edema Asthma Mechanical hyperventilation (iatrogenic) Endocrine Pregnancy Paco2 between 31 and 35 mm Hg, serum pH between 7.46 and 7.50, and serum bicarbonate concentration (...) Acidosis Acute Airway obstruction Pulmonary disease (pneumonia, asthma, pulmonary edema, aspiration pneumonitis) CNS depression (recreational drugs, intracranial catastrophe, neuromuscular disorders, thoracic trauma) Chronic Lung disease (COPD, IPF) Neuromuscular disorders (ALS, muscular dystrophy, obesity hypoventilation) After 3-5 days… an appropriate metabolic compensation for respiratory acidosis is an increase of approximately 3.5 mEq/L in the serum HCO3− concentration for every increase of 10 mm

2017 CandiEM

145. CRACKCast E071 – Ophthalmology Part A

keratitis? Radiation burns Ultraviolet keratitis (tanning booths, sunlamps, high altitude, welder’s arc) Latent period of 6-10 hrs then: Foreign body sensation, tearing, intense pain photophobia, blepharospasm Signs Decreased VA, conjunctival injection Treatment Cycloplegic Topical broad spectrum abx (weak evidence for this) PO analgesics Symptoms should resolve in 24 hrs 3) What is ophthalmia neonatorum? In which time-frame are each bacteria expected to be causative? What is the treatment? Ophthalmia (...) out abscess Eyelid swelling / redness Warmth of skin overlying orbit Tenderness over bone Palpebral injection/chemosis of the conjunctiva Fever Ill / Toxic appearance Blurred vision Proptosis Painful or limited extraocular movements Binocular diplopia Edema of optic disk Venous engorgement of the retina Further Work Up: Treatments: Measure IOP, if >20 may need surgery Blood cultures CT orbits to rule out: Foreign body Emphysema Hematoma Abscess Osteomyelitis Cavernous sinus thrombosis Consider

2017 CandiEM

146. Diagnosis and Management of Noncardiac Complications in Adults With Congenital Heart Disease: A Scientific Statement From the American Heart Association (Full text)

adult CHD (ACHD) admissions to an intensive care unit, abnormal thyroid, creatinine, and bilirubin tests were highly pre- dictive of both intensive care unit and hospital mortal- ity. 19 Furthermore, comorbidities can be costly. A recent study demonstrated renal insufficiency as a primary driver of high resource use for ACHD hospitalizations, which account for only 10% of the admissions but make up one third of the total hospital charges. 20 The impact of noncardiac comorbidities on both car- diac (...) be as high as 16% and carries clinical consequences such as increased incident thromboem- bolic complications. 52 In addition, cyanotic patients may develop secondary renal tubular acidosis with subse- quent normal anion gap metabolic acidosis. 53 Management Assessment of kidney function may be accomplished through standard methods of calculating GFR, relying on serum creatinine, age, sex, and race. Normal kidney function is defined as = 90 mL·min -1 ·1.73 m -2 . Because of the high prevalence of renal

2017 American Heart Association PubMed

147. Heart Disease and Stroke Statistics 2017 Update: A Report From the American Heart Association (Full text)

Behaviors 3. Smoking/Tobacco Use . . . . . . . . . . . . . . e183 4. Physical Inactivity . . . . . . . . . . . . . . . . e196 5. Nutrition . . . . . . . . . . . . . . . . . . . . . e214 6. Overweight and Obesity . . . . . . . . . . . . . e240 Health Factors and Other Risk Factors 7. Family History and Genetics . . . . . . . . . . . e263 8. High Blood Cholesterol and Other Lipids . . . . . e270 9. High Blood Pressure . . . . . . . . . . . . . . . e280 10. Diabetes Mellitus (...) in the percentage of current smokers. — The region with the highest rates is the Midwest (20.7%), and the state with the highest per- centage was West Virginia (26.7%). The lowest percentages regionally were observed in the West (13.1%), and by state in Utah (9.7%). • In 2015, e-cigarettes were the most commonly used tobacco product among middle school (5.3%) and high school (16.0%) students. The risks for nicotine dependence and for CVD associated with regular e-cigarette use are unknown. Use of cigaril- los

2017 American Heart Association PubMed

148. CRACKCast E016 – Depressed Consciousness and Coma

, digoxin, TCAs, acetaminophen, ASA, SSRI, anticonvulsants [2] Infection: Meningitis, encephalitis, Septic shock and sepsis [3] Metabolic (by organ system) Pancreas Hypoglycemia DKA, HONK Thyroid (hyper or hypothyroid) Kidneys (electrolyte derangements, kidney failure with uremic state) Liver (hepatic encephalopathy) [4] Environmental High altitude cerebral edema Heat stroke Hypothermia Dysbarism [5] Structural Intracranial Catastrophe ICH, Stroke, Epidural hematoma, Subdural hematoma, SAH Status (...) epilepticus, acute hydrocephalus Cardiac ACS, Aortic Dissection Cardiogenic / Hypovolemic / Obstructive / Distributive shock HTN crisis, malignant arrhythmia AEIOU TIPS Approach to Altered LOC Anaphylaxis or altitude illness or alcohol Epilepsy (pre, intra, or post ictal) or Environmental (hypo/hyperthermia or altitude) Infection Overdose of drugs (insulin, benzos, etc.) Underdose of drugs Trauma (TBI, hemorrhage) / Tumour Insulin Psychogenic / Poisons Stroke / Shock 2) List GCS / Pediatric GCS Need

2016 CandiEM

149. Mitochondrial Function, Biology, and Role in Disease (Full text)

The incessant energy requirements of the heart are sustained by the consumption of a mass of ATP daily that surpasses cardiac weight itself by approximately 5 to 10 fold. This perpetual demand for energy reflects the continuous contractile functioning of the heart to sustain systemic circulation and nutrient supply. This high-energy flux translates into the cardiomyocyte having a mitochondrial volume between 23% and 32% of myocellular volume. Interestingly, cardiac mitochondrial density increases from human (...) pathology is not clear cut. In this section, we give a brief overview of metabolism and perturbations and their consequences on myocardial function. ETC Biology: Energetics and ROS The final common pathway for oxidative metabolism, which generates the bulk of cardiac ATP, is the sequential passage of electrons from high (NADH or FADH 2 ) to low (molecular oxygen) redox potentials down the ETC (complexes I through IV). This stepwise electron transfer results in the active pumping of hydrogen ions out

2016 American Heart Association PubMed

150. Lymphangioleiomyomatosis Diagnosis and Management Part I: An Official ATS/JRS Clinical Practice Guideline

confounding or bias. On the basis of these criteria, the quality of evidence was categorized as high,moderate, low, or very low. All panelists reviewed the evidence summary and the quality of evidence rating. Feedback was provided and revisions were made if deemed appropriate. Disagreements were resolved by discussion and consensus. Development of Recommendations The guideline development panel formulated recommendations on the basis of the evidence synthesis. Recommendations were based on the following (...) had adverse events, including mouth ulcers, hyperlipidemia, and peripheral edema. The results of these trials, combined with the preclinicaldataandtheneedforassessment of the bene?ts and risks of sirolimus with potential confounders minimized, provided the rationale for conducting a randomized controlled trial for LAM. The MILES (Multicenter International LAM Ef?cacy of Sirolimus) Trial was a double-blind, randomized, parallel group trial in which 89 patients with LAM and moderate lung impairment

2016 American Thoracic Society

151. Suspected Pulmonary Hypertension

(PVOD) and/or pulmonary capillary hemangiomatosis (PCH); Group 1 ?, persistent PH of the newborn; Group 2, PH due to left heart disease; Group 3, PH due to lung diseases and/or hypoxia; Group 4, CTEPH and other pulmonary artery obstructions; and Group 5, PH with unclear and/or multifactorial mechanisms [2] (see Appendix 1). The signs and symptoms of PH are nonspecific and may include fatigue, dyspnea, weakness, angina, peripheral edema, hepatomegaly, ascites, and syncope [10,11]. Because (...) requests to: publications@acr.org. ACR Appropriateness Criteria ® 3 Suspected Pulmonary Hypertension Additionally, Miniati et al [20] showed high sensitivity (96.9%) and specificity (99.1%) for detection of PH by CXR. However, CXR is known to be insensitive in the detection of mild PH. Thus, a normal CXR does not exclude PH and further imaging evaluation should be pursued if there are persistent unexplained symptoms such as dyspnea or risk factors for PH [2,14,21,22]. Findings of PH on CXR include

2016 American College of Radiology

152. Does This Patient Have Acute Mountain Sickness?: The Rational Clinical Examination Systematic Review. (Full text)

Does This Patient Have Acute Mountain Sickness?: The Rational Clinical Examination Systematic Review. Acute mountain sickness (AMS) affects more than 25% of individuals ascending to 3500 m (11 500 ft) and more than 50% of those above 6000 m (19 700 ft). AMS may progress from nonspecific symptoms to life-threatening high-altitude cerebral edema in less than 1% of patients. It is not clear how to best diagnose AMS.To systematically review studies assessing the accuracy of AMS diagnostic (...) at altitude, Acute Mountain Sickness-Cerebral, and clinical functional score perform similarly to the Lake Louise Questionnaire Score using a score of 5 or greater as a reference standard. In clinical and travel settings, the clinical functional score is the simplest instrument to use. Clinicians evaluating high-altitude travelers who report moderate to severe limitations in activities of daily living (clinical functional score ≥2) should use the Lake Louise Questionnaire Score to assess the severity

2017 JAMA PubMed

153. Pediatric Pulmonary Hypertension (Full text)

known to be associated with PAH Referred to as HPAH with positive family or genetic evaluation PHVD Broad category that includes forms of PAH but includes subjects with elevated TPG (mPAP-left atrial pressure or PAWP >6 mm Hg) or high PVRI as observed in patients with cavopulmonary anastomoses without high mPAP HPAH indicates heritable pulmonary artery hypertension; IPAH, idiopathic pulmonary artery hypertension; mPAP, mean pulmonary artery pressure; PAH, pulmonary artery hypertension; PAWP (...) hernia (CDH) (Class I; Level of Evidence B). 2. High-frequency oscillatory ventilation is a reason- able alternative mode of ventilation for subjects with CDH when poor lung compliance, low vol- umes, and poor gas exchange complicate the clinical course (Class IIa; Level of Evidence A). 3. iNO therapy can be used to improve oxygenation in infants with CDH and severe PH but should be used cautiously in subjects with suspected LV dysfunc- tion (Class IIa; Level of Evidence B). 4. ECMO is recommended

2015 American Heart Association PubMed

154. Treatment of Hypertension in Patients With Coronary Artery Disease (Full text)

Receptor Blockers 1394 6.7.4. β-Blockers 1394 6.7.5. Nitrates and Hydralazine 1395 6.7.6. Aldosterone Receptor Antagonists 1395 6.8. Renal Denervation 1395 6.9. Goal BP 1395 6.10. Drugs to Avoid 1395 6.11. Recommendations 1396 This is an update of the American Heart Association (AHA) scientific statement “Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease: A Scientific Statement From the American Heart Association Council for High Blood Pressure Research (...) groups. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure uses the traditional definition of hypertension as an SBP of ≥140 mm Hg or a DBP of ≥90 mm Hg and/or the current use of antihypertensive medication. With this definition, an estimated 65 million adult Americans, or nearly one fourth of the adult population of the United States, have hypertension. Another quarter of the population have prehypertension, defined as an SBP

2015 American Heart Association PubMed

155. Pediatric Pulmonary Hypertension: ATS/AHA Clinical Practice Guidelines

but includes subjects with elevated TPG (mPAP-left atrial pressure or PAWP >6 mm Hg) or high PVRI as observed in patients with cavopulmonary anastomoses without high mPAP HPAH indicates heritable pulmonary artery hypertension; IPAH, idiopathic pulmonary artery hypertension; mPAP, mean pulmonary artery pressure; PAH, pulmonary artery hypertension; PAWP, pulmonary artery wedge pressure; PH, pulmonary hypertension; PHVD pulmonary hypertensive vascular disease; PVRI, pulmonary vascular resistance index (...) parenchymal lung disease, particularly if associated with prolonged rupture of membranes and oligohydramnios (Class IIa; Level of Evidence B). Congenital Diaphragmatic Hernia 1. Minimizing peak inspiratory pressure and avoid- ing large tidal volumes is recommended to reduce ventilator-associated acute lung injury in infants with congenital diaphragmatic hernia (CDH) (Class I; Level of Evidence B). 2. High-frequency oscillatory ventilation is a reason- able alternative mode of ventilation for subjects

2015 American Thoracic Society

156. Physical Activity and Exercise During Pregnancy and the Postpartum Period

of recreational activities is safe. Activities with high risk of abdominal trauma should be avoided (Box 3). Scuba diving should be avoided in pregnancy because of the inability of the fetal pulmonary circulation to filter bubble formation ( ). For lowlanders, physical activity up to 6,000 feet altitude is safe in pregnancy ( ). Special Populations Several reviews have determined that there is no credible evidence to prescribe bed rest in pregnancy, which is most commonly prescribed for the prevention (...) training in pregnancy has been shown to increase aerobic capacity in normal weight and overweight pregnant women ( ). Temperature regulation is highly dependent on hydration and environmental conditions. During exercise, pregnant women should stay well-hydrated, wear loose-fitting clothing, and avoid high heat and humidity to protect against heat stress, particularly during the first trimester ( ). Although exposure to heat from sources like hot tubs, saunas, or fever has been associated

2015 American College of Obstetricians and Gynecologists

157. Management of Hypertension (HTN) in Primary Care

blood pressure (SBP) >140 mmHg or a diastolic blood pressure (DBP) of >90 mmHg. Prehypertension is classified as SBP 120-139 or DBP 80-89. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) went on to further classify hypertension into stages [1] (Stage 1: SBP 140- 159 mmHg or DBP 90-99; Stage 2: SBP >160 mmHg or DBP >100 mmHg), though the use of these stages has begun to be phased out. Hypertension is usually (...) , sedentary lifestyle, and dietary choices, can lead to high blood pressure. [2] Secondary hypertension is high blood pressure that results from an underlying and identifiable cause. [3] Main causes of secondary hypertension include adverse effects of medications, tobacco products or illegal drugs, renal disease, obstructive sleep apnea, pheochromocytoma, aldosteronism, and aortic coarctation. Complications of hypertension include damage to the large arteries (macrovascular complications) that can lead

2014 VA/DoD Clinical Practice Guidelines

158. Pharmacologic Therapy for Pulmonary Arterial Hypertension in Adults

of childbearing age taking these medications. 76. When pregnancy does occur, we suggest care at a pulmonary hypertension center, using a multidisci- plinary approach including the pulmonary hyperten- sion, the high-risk obstetrical and cardiovascular anesthesiology services (Grade CB) . Altitude and Air Travel 77. In patients with P AH, we suggest that exposure to high altitude be avoided, and that supplemental oxygen be used as needed during altitude exposure or air travel to maintain oxygen saturations (...) , FCCP ; Rex Yung , MD, FCCP ; C. Gregory Elliott , MD, FCCP ; and David B. Badesch , MD, FCCP OBJECTIVE: Choices of pharmacologic therapies for pulmonary arterial hypertension (PAH) are ideally guided by high-level evidence. Th e objective of this guideline is to provide clinicians advice regarding pharmacologic therapy for adult patients with PAH as informed by available evidence. METHODS: Th is guideline was based on systematic reviews of English language evidence pub- lished between 1990

2014 American College of Chest Physicians

159. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

are home oxygen and high-frequency nasal cannula. There is emerging evidence for the role of home oxygen in reducing LOS or admission rate for infants with bronchiolitis, including 2 randomized trials. , Most of the studies have been performed in areas of higher altitude, where prolonged hypoxemia is a prime determinant of LOS in the hospital. , Readmission rates may be moderately higher in patients discharged with home oxygen; however, overall hospital use may be reduced, although not in all settings (...) in the discussion of prevention. This guideline will not address long-term sequelae of bronchiolitis, such as recurrent wheezing or risk of asthma, which is a field with a large and distinct literature. Bronchiolitis is a disorder commonly caused by viral lower respiratory tract infection in infants. Bronchiolitis is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, and increased mucus production. Signs and symptoms typically begin with rhinitis and cough, which

2014 American Academy of Pediatrics

160. Diabetes, Pre-Diabetes and Cardiovascular Diseases

Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes ALTITUDE Aliskiren Trial in Type 2 Diabetes Using Cardio- Renal Endpoints Apo apolipoprotein ARB angiotensin receptor blocker ARIC Atherosclerosis Risk In Communities ARISTOTLE Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation ASCOT Anglo-Scandinavian Cardiac Outcomes Trial ATLAS Assessment of Treatment with Lisinopril And Survival AVERROES Apixaban VERsus (...) for prevention of Vascular Events Aspirin ACTIVE W Atrial ?brillation Clopidogrel Trial with Irbesar- tan for prevention of Vascular Events Warfarin ADA American Diabetes Association ADDITION Anglo-Danish-Dutch Study of Intensive Treat- ment in People with Screen Detected Diabetes in Primary Care ADP adenosine diphosphate ADVANCE Action in Diabetes and Vascular Disease: Pre- terax and Diamicron Modi?ed Release Con- trolled Evaluation AF atrial ?brillation AGEs advanced glycation end-products AIM-HIGH

2013 European Society of Cardiology

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