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Pruritus in Pregnancy

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181. Dupilumab and Crisaborole for Atopic Dermatitis: Effectiveness and Value

not provide direct evidence on dupilumab therapy as compared with topical calcineurin inhibitor therapy in such patients, since we are uncertain how many patients in the trial had failed topical calcineurin inhibitors. Patient-reported Outcomes Dupilumab improved patient quality of life as measured by DLQI and improved patient symptoms including individual measures of pruritus, and scoring systems looking at broader patient outcomes, patient-reported outcomes, and measures of anxiety and depression (...) phi.adj[i,k,j] 0) for (j in 1:nc[i]-1) { # LOOP THROUGH CATEGORIES r[i,k,j] ~ dbin(q[i,k,j],n[i,k,j]) # binomial likelihood q[i,k,j] 5, phi(x)=1 phi.adj[i,k,j] 0 and =2 lesion partial clearance: 1) 48.0, 2) 8.0 Pruritus mean severity score (estimated from graph): 1) 0.6 Erythema: 1) 0.8 Lichenification: 1) 0.9 Excoriation: 1) 0.4 Exudation: 1) 0.1 Application-site reactions, % 1) 12, 2) 12 Pimecrolimus Eichenfield, 2002 39 Good Quality Publication RCT, multi-center, double-blind 6 weeks 1

2017 California Technology Assessment Forum

182. CRACKCast E062 – Venomous Animal Injuries

of 2 vials every 3 hours or 4-6 if progressing to very severe. Pit viper envenomation may require initial doses of up to 18 vials, with maintenance up to 10 vials every 6 hours. Pearls : Kids often require double the doses compared to adults! Don’t forget about antibiotics for gram negatives – especially with high-risk patients and wounds with large amounts of local destruction. Pregnancy is not a contraindication Don’t do local infiltration of antivenin Toxicity is rarely delayed by more than 8-12 (...) crampy pain in the bite, with spread to the rest of the body over the next hour. The abdomen may become board like with minimal tenderness. Pregnant women may go into premature labour. Other symptoms include dizziness, restlessness, ptosis, N/V, pruritus, dyspnea, and well… just about anything! ECG may indicate dig toxicity like changes. Management initially is cleaning with soap, water, and tetanus. Patients with symptoms should have lab work including: CBC, lytes, BUN, Creatinine, Coags, UA

2017 CandiEM

183. Buprenorphine Implant for the Treatment of Opioid Use Disorder

reported implant site adverse events such as pain, pruritus, and erythema were mild and resolved without treatment. There was no evidence of unscheduled or attempted implant removal and no cases of implant migration. All US health care providers must complete a live training program on insertion and removal procedures, and become certified in the restricted program called the Probuphine Risk Evaluation and Mitigation Strategy program (REMS), before prescribing Probuphine or performing insertions (...) and removals. Background Opioid use disorder (also known as opioid dependence), defined as a problematic pattern of opioid use leading to clinically significant impairment or distress, is a growing public health concern in Canada that is associated with significant morbidity and mortality. 1-3 Individuals with opioid use disorder are at greater risk for incarceration, blood-borne infections, and fatal overdose. 4 In addition, babies born to mothers who used opioids during pregnancy are at increased risk

2017 CADTH - Issues in Emerging Health Technologies

184. Alcohol: Adult Unhealthy Drinking

in a guideline does not imply coverage. A decision to adopt any particular recommendation must be made by the provider in light of the circumstances presented by the individual patient. 2 Summary of Changes as of October 2016 Added recommendations for screening and intervention for PREGNANT WOMEN: • Abstinence is recommended for pregnant women and for women planning pregnancy. • Pregnant women should be screened with the AUDIT-C at least once per trimester and at the 6- week postpartum visit. o The timeframe (...) for the questions should be the last 3 months rather than the last year. o The threshold for “binge drinking” in the third question is 4 or more drinks on one occasion. • Pregnant women should be screened for alcohol use disorder (AUD) using the Alcohol Symptom Checklist if: o They score a 3 or greater on the AUDIT-C, or o They are currently drinking at any level since learning of their pregnancy, regardless of their AUDIT-C score. • Pregnant women who are negative for AUD should receive brief behavioral

2016 Kaiser Permanente Clinical Guidelines

185. Guideline for the Evaluation of Cholestatic Jaundice in Infants: Joint Recommendations of NASPGHAN and ESPGHAN

–associated cholestasis (PNAC) (82). This is a major confounder in the evaluation of the cholestatic infant, and it is often worthwhile for caregivers to note the timing and initiation of PN in relation to serial measurements of fractionated bilirubin levels, especially if direct hyperbilirubinemia precedes the initiation of PN. Details in the family history including previous and current pregnancy such as miscarriages, pruritus, or overt liver dysfunction in maternal history should be noted; history (...) hyperbilirubinemia Prenatal history Prenatal ultrasonography ?ndings Presence of choledochal cyst, cholelithiasis, bowel anomalies or concern for syndrome Cholestasis of pregnancy May be seen in heterozygotes for PFIC gene mutations; mitochondrial disorder Acute fatty liver of pregnancy Neonatal long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) de?ciency Maternal infections TORCH infections Infant history Gestational age Prematurity as a risk factor for neonatal hepatitis SGA Increased risk of neonatal

2017 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

186. Evaluation of Abnormal Liver Chemistries

, primary sclerosing cholangitis; ULN, upper limit of normal. Kwo et al. The American Journal of GASTROENTEROLOGY VOLUME 112 | JANUARY 2017 20 meal due to increased levels of intestinal alkaline phosphatase ( 8 ). Alkaline phosphatase may be elevated during pregnancy due to placental synthesis of alkaline phosphatase. Typically, alkaline phosphatase elevates with obstruction of the bile ducts, which is due to increased canalicular synthesis of alkaline phosphatase with subsequent (...) ), formerly known as primary biliary cirrhosis, is an uncommon chronic liver disease primarily aff ecting intralobular bile ducts at the microscopic level ( 63 ). Although it is a rare cause of elevated liver tests, it is among the most common chronic cholestatic liver disorders and is seen more commonly in women than men. Patients may present with pri- mary complaints of fatigue and pruritus. Lab testing reveals bio- chemical evidence of cholestasis (elevated alkaline phosphatase with or without

2017 American College of Gastroenterology

188. Hemorrhoids - Guidelines for Prescribing Rectal Hydrocortisone Combination Products

movement. Create a permanent bulge at the anus. This stage is quite painful. Fourth-degree hemorrhoids are at risk of thrombosis and gangrene. External hemorrhoids originate and are located below the dentate line and can be painful. Mixed hemorrhoids - combination of internal and external hemorrhoids Contributing Causes: Chronic constipation Straining Diarrhea (due to frequent bowel movements) Pregnancy Old age Certain physical exertion (lifting heavy objects with poor technique) Prolonged sitting (...) of fullness and incomplete evacuation after defecation Protruding hemorrhoids present as a mass with more prominent bleeding If 4th degree internal hemorrhoid, increased risk of strangulation and/or thrombosis with acute pain Individuals often have fecal soiling --> pruritus and irritation Hemorrhoids are diagnosed based on the presence of the typical signs and symptoms listed above. Rule out the following conditions that may present with similar signs and symptoms: Colorectal Cancer - Symptoms: Large

2017 medSask

189. Atopic Dermatitis - Guidelines for Prescribing Topical Corticosteroids

after 2-week course of topical corticosteroids. Patient's self-diagnosis not consistent with atopic dermatitis and /or self-care is not appropriate. Goals of Treatment Relieve dry skin and pruritus Reduce inflammation Reduce risk of secondary infection Reduce flare-ups Non-pharmacological general measures Avoid agents that may cause irritation: Environmental allergens: harsh soaps, detergents, shampoos, alcohol based products, astringents, poor home ventilation, dry grass and leaves. Diet: Food (...) suppression, growth suppression, and other steroid side effects. Always prescribe the lowest potency steroid for the shortest duration which controls the patient’s symptoms. More caution is warranted if treating a large area, thin skin such as on the face, or skin folds. Pregnancy: If use of lubrication skin emollients does not control symptoms, topical corticosteroids are the main treatment option throughout pregnancy since systemic absorption is very low and poses no known risk to the baby. Recommend

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2017 medSask

190. Superficial Bacterial Skin Infections - Guidelines for Prescribing Topical Antibiotics for impetigo and folliculitis

dermatitis: Did the patient have any recent contact with an unknown plant, chemical, or topical medicine? Lesions would be limited to exposed area Distinguished by: Sudden onset of severe pruritus Asymmetric distribution Location Allergy history : An ulcerative, deeper form of impetigo usually found on the lower leg area following a trauma to the skin such as a scratch or cut. Punched out ulcers covered with a yellow crust; raised purple margins Commonly on buttocks, thighs, legs, ankles or feet Diabetes (...) to patient's primary care provider Pregnancy: Animal studies have not reported any safety issues but human data is limited. Only small amounts of mupirocin are absorbed after topical use and there are no reports of teratogenicity—risk appears minimal. However, consider avoiding unless benefit outweighs risk. Systemic agents [penicillins, cephalosporins, clindamycin and erythromycin (except estolate)] are indicated for impetigo and are safe in pregnancy, so may be an appropriate alternative Lactation

2017 medSask

191. Australian recommendations for the management of hepatitis C virus infection: a consensus statement

. The most commonly reported adverse effects are nausea, pruritus and insomnia; these are uncommon and mild in most people. Rises in serum alanine aminotransferase (ALT) levels have been rarely observed, particularly among women taking ethinyl estradiol-containing contraceptives, which should be stopped before treatment. Alternative contraceptive agents (eg, progestin-only contraception) or methods are recommended. Transient isolated hyperbilirubinaemia may be seen early (Weeks 1–2) but typically (...) during DAA therapy. Pregnancy, breastfeeding and children As there are no safety data for the use of any DAA regimen during pregnancy, treatment of pregnant women is not recommended. Ribavirin (classed as Category X) and pegIFN are contraindicated during pregnancy. Both women and men should be counselled about the risk of teratogenicity and the importance of avoiding pregnancy during and for 6 months after ribavirin treatment. As noted above, women treated with PrOD should avoid ethinyl estradiol

2016 MJA Clinical Guidelines

192. Hodgkin Lymphoma: ESMO Clinical Practice Guidelines

are characterised by the expression of CD20 and CD45 but lack CD15 and CD30. Stagingandriskassessment The diagnostic work-up is shown in Table 1. The medical history including the presence of B symptoms (fever, drenching night sweats, unexplained weight loss> 10% over 6 months) and other disease-related symptoms such as fatigue, pruritus and alcohol- induced pain as well as the results of a physical examination should be recorded [1]. Chest X-ray and a contrast-enhanced computed tomography (CT) scan of the neck (...) affection) Staging and risk strati?cation Medical history and physical examination X-ray of the chest Contrast-enhanced CT scan of the neck, chest and abdomen PET Full blood cell count and blood chemistry, ESR HBV, HCV and HIV screening Pretreatment examinations ECG Echocardiography Pulmonary function test Reproductive counselling (in patients of reproductive age) Serum pregnancy test (in female patients of reproductive age) Consultation of an ear, nose and throat specialist including a ?breoptic

2018 European Society for Medical Oncology

194. What guidance is there available on the use of vitamin K for the management of obstetric cholestasis?

2017 Background Obstetric cholestasis (OC) or intrahepatic cholestasis of pregnancy has been described as a multifactorial condition of pregnancy characterised by intense pruritus with the absence of a skin rash, with abnormal liver function tests, neither of which have an alternative cause and both of which resolve after birth(1). It is associated with a significantly increased risk of adverse perinatal outcomes, including stillbirth (2). The use of vitamin K as part of the management of OC (...) for the management of OC is a commonly asked question. In addition, there have been reports of neonatal toxicity following menadiol sodium diphosphate administration in late pregnancy or during delivery (4). Answer Menadiol sodium phosphate is a water-soluble synthetic vitamin K derivative that can be given orally for the prevention or treatment of vitamin K deficiency due to malabsorption, as it is absorbed without dependence on the presence of bile salts (3,4). Phytomenadione however, is the fat-soluble

2017 Specialist Pharmacy Services

195. British Association of Dermatologists and British Photodermatology Group guidelines for the safe and effective use of psoralen ultraviolet A (PUVA) therapy

photodermatosis. There was limited comparative data between the two forms of phototherapy to ascertain which form is more likely to provoke the eruption. Pooling the incidence of adverse events from the small number of PLE studies, the side-effects of rash provocation, erythema and pruritus were found to be common in both forms of pho- totherapy, although more common with UVB than with PUVA (Table 3). However, as the number of patients in each cohort was small and the severity of the adverse events (...) not directly comparable, the overall percentages should be regarded with caution. In the treatment of PLE, the side-effects of rash provocation, erythema and pruritus were found to be common in both PUVA better 1st Author Year Design NB-UVB PUVA Outcome Total n % more cleared with PUVA (95% CI) Westerhof 75 1997 controlled (alternate allocation), parallel group 2times a week 0.005% psoralen gel, 2 times a week any repigmentation by 4 months 106 –27% (–48% to –6%) Bhatnagar 77 2007 controlled ( randomly

2016 British Association of Dermatologists

196. Practice Guidelines for Obstetric Anesthesia

delivery, and selected aspects of postpartum care and analgesia ( i.e. , neuraxial opioids for postpartum analgesia after neuraxial anesthesia for cesarean delivery). The intended patient population includes, but is not limited, to intrapartum and postpartum patients with uncomplicated pregnancies or with common obstetric problems. The guidelines do not apply to patients undergoing surgery during pregnancy, gynecological patients, or parturients with chronic medical disease ( e.g. , severe cardiac (...) , comparative studies are insufficient to directly evaluate the impact of these practices. Studies with observational findings suggest that certain patient or clinical characteristics ( e.g. , hypertensive disorders of pregnancy such as preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome, obesity, and diabetes mellitus) may be associated with obstetric complications ( Category B2/B3-H evidence ). Survey Findings: The consultants and ASA members both strongly agree (1

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2016 American Society of Anesthesiologists

198. Management of Vulvar Intraepithelial Neoplasia

program demonstrate that VIN incidence increased more than fourfold between 1973 and 2000 ( ). Although spontaneous regression has been reported, VIN should be considered a premalignant condition, as shown by a case series of 405 New Zealand women with VIN ( ). Sixty-three (16%) women received no treatment, 10 of whom experienced progression to invasive cancer (2). Although cancer regression has been reported, especially among women in whom cancer was diagnosed during pregnancy ( ), the risk (...) on immunosuppression after organ transplant may need biopsy of lesions when the level of suspicion is lower. Colposcopy, or other forms of magnification of the vulva, can be useful in determining the extent of disease if lesions are not visible or not clearly demarcated in women with persistent focal vulvar pruritus and pain with no gross lesions, and women who remain symptomatic despite appropriate treatment for presumed vulvo-vaginitis. It should be performed after applying 3–5% acetic acid to the vulva

2016 American College of Obstetricians and Gynecologists

199. Screening and Management of Lipids

sequestrants, protease inhibitors, retinoic acid, anabolic steroids, sirolimus, raloxifene, tamoxifen, beta blockers (not carvedilol), thiazides Diseases Biliary obstruction, nephrotic syndrome Nephrotic syndrome, chronic renal failure, lipodystrophies, Cushing's syndrome Disorders and altered states of metabolism Hypothyroidism, obesity, pregnancy* Diabetes (poorly controlled), hypothyroidism, obesity, inactivity; pregnancy* * Cholesterol and triglycerides rise progressively throughout pregnancy (...) ; treatment with statins, niacin, and ezetimibe are contraindicated during pregnancy and lactation. Adapted from 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol Table 2. 10-Year Risk Assessment for ASCVD Ten-year risk is defined as the risk of developing a first ASCVD event (nonfatal MI, CHD death, fatal or non fatal stroke) over a 10-year period among people free from ASCVD at the beginning of the period Pooled Cohort Equations estimate 10-year ASCVD risk in individuals age 40 to 79 years

2016 University of Michigan Health System

200. Management of scabies

during the first trimester. If an oral antihistamine is required to control pruritus during pregnancy, chlorpheniramine is the antihistamine of choice. Sexual partners ? Current sexual partners as well as members of the household and those that have hade close personal contact should be examined and treated at the same time 40 ? Contact tracing of partners from the previous one month should be undertaken 40 Follow-up ? No clear evidence exists as to optimal follow-up but is not generally required (...) is uncommon but can occur in those wearing heavily contaminated clothing or using a bed recently occupied by an infested person. 2 It is more likely to occur with crusted scabies due to the greater number of mites present 4,6,7 and because mites can survive longer for up to 7 days. 8 Clinical Manifestations Classical scabies The main clinical feature of scabies is intense generalised pruritus that is usually worse at night. The pruritus is due to a delayed type-IV hypersensitivity reaction to the mite

2016 British Association for Sexual Health and HIV

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