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142. CRACKCast E186 – Substance Abuse

with the finding Think: Vitals – all of them! Head to toe exam, specifically: Mental status Skin Pupils Needle track marks See Table 140.1 in Rosens 9 th Edition Chapter 140 for: Physical Examination findings of substance abuse, the agents predominantly involved, and the proposed mechanism. Wisecracks [1] What is the CRAFFT to screen for substance abuse among adolescents? This is a huge problem! With massive amounts of morbidity and mortality. By the time adolescents become adults in the United States, almost (...) CRACKCast E186 – Substance Abuse CRACKCast E186 - Substance Abuse - CanadiEM CRACKCast E186 – Substance Abuse In , by Chris Lipp June 14, 2018 This episode of CRACKCast covers Rosen’s Chapter 140 (9th Edition), Substance Abuse. This chapter gives a brief overview regarding the burden of substance abuse from adolescent to elderly patients. An important consideration in the emergency department is self-awareness and advocacy for these patients that often are challenging to interact with and can

2018 CandiEM

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

Pruritus is a common symptom in patients with various hepa- tobiliary disorders, including cholestasis of pregnancy. 138–140 The skin in hepatic pruritus is often generally hyperpigmented and excoriated. 141 The hands and feet are often the worst- affected areas. 139 Pruritus in association with fatigue at presen- tation may be a marker for more aggressive disease, for exam- ple primary biliary cholangitis. 142 There is a poor correlation between pruritus and bile acid levels, suggesting that other (...) 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. Hoarseness (Dysphonia)

from work absenteeism. Dysphonia is often caused by benign or self-limited conditions, but it may also be the presenting symptom of a more serious or progressive condition requiring prompt diagnosis and management. This clinical practice guideline (CPG) is as an update of, and replacement for, a guideline published in 2009 by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF). An update was necessitated by new primary studies and systematic reviews that suggest (...) adults required proxy input for approximately 25% of the geriatric population. While many self-report measures for dysphonia are available, patients may be unable to complete them. - In these cases, proxy judgments by significant others about QOL are a good alternative. STATEMENT 2. IDENTIFYING UNDERLYING CAUSE OF DYSPHONIA: Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management . Recommendation

2018 American Academy of Otolaryngology - Head and Neck Surgery

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

be performed annually for those with a CD4 cell count >500 cells/mm 3 (2C): ? HIV viral load; ? CD4; ? FBC, renal/liver profile; ? Random lipids, only if smoker and/or BMI >30 or aged >40 years. If normal, repeat after 2 years; ? Screen for gonorrhoea and chlamydia all exposed sites if partner change since the last test (self-taken swabs if asymptomatic); ? Syphilis serology if partner change since the last test; ? Hepatitis B (for infection or immunity) and C screening (in at-risk patients). Also every 3

2019 British HIV Association

146. Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries

policy change NR; % by age group: 0.05 for pre-post change in both groups 36 First Author, Year ROB Intervention Comparison Study Design N Sites N Participants Breastfeeding Initiation Outcome Results Senarat h, 2007 75 High G1: Obstetric staff training on essential newborn care G2: Usual care Cluster RCT 5 hospitals 892 women Exclusive BF at discharge (mothers self-report), % (N): G1 pre: 97.8 (233) G1 post 97.3 (233) G2 pre: 99.6 (233) G2 post: 98.7 (223) Difference in pre-post change between

2018 Effective Health Care Program (AHRQ)

147. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology (Full text)

specimen-based approach, and includes bloodstream and cardiovascular system infections, central nervous system infections, ocular infections, soft tissue infections of the head and neck, upper and lower respiratory infections, infections of the gastrointestinal tract, intra-abdominal infections, bone and joint infections, urinary tract infections, genital infections, and other skin and soft tissue infections; or into etiologic agent groups, including arthropod-borne infections, viral syndromes (...) . Ocular Infections IV. Soft Tissue Infections of the Head and Neck V. Upper Respiratory Tract Bacterial and Fungal Infections VI. Lower Respiratory Tract Infections VII. Infections of the Gastrointestinal Tract VIII. Intra-abdominal Infections IX. Bone and Joint Infections X. Urinary Tract Infections XI. Genital Infections XII. Skin and Soft Tissue Infections XIII. Arthropod-Borne Infections XIV. Viral Syndromes XV. Blood and Tissue Parasite Infections Contents Introduction and Executive Summary I

2018 Infectious Diseases Society of America PubMed

148. End-of-Life Care for People Experiencing Homelessness

, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper, et al., 2010, p.82). Health Care for the Homeless Clinicians’ Network ADAPTING YOUR PRACTICE Recommendations for End-of-life Care for People Experiencing Homelessness 16 upper extremities, skin, lymph nodes, and neurologic system should be examined to assess the extent of disease. If a genital exam is indicated, assess if the patient has (...) care and end-of-life care. Patient Assessment and Evaluation 1. Focus primarily on assessing the social, emotional, mental, and environmental needs that affect the delivery of care for the terminally ill patient experiencing homelessness. 2. Focus the initial physical exam on the patient’s area of concern or areas most likely to be affected given the diagnosis or chief complaint. Perform serial focused exams as tolerated (if needed). Attempt to evaluate the stage of the patient’s condition. Look

2018 National Health Care for the Homeless Council

149. Management of Surgical Site Infections

of recommendations 5 Medical Imaging 5 Cultures 5 C-Reactive Protein 5 Erythrocyte Sedimentation Rate 5 Clinical Exam for the Diagnosis of Surgical Site Infections 5 Strong Evidence of Factors Associated with Increased Risk of SSI 6 Moderate Evidence of Increased Associated Risk of SSI 6 Limited Evidence of Increased Associated SSI Risk 6 Antibiotic duration for management of surgical site infections 7 Rifampin use for management of surgical site infections 7 Development Group Roster 8 Voting Members 8 Non (...) Prior antibiotic exposure 20 C-Reactive Protein 22 Erythrocyte Sedimentation Rate 23 Clinical Exam for the Diagnosis of Surgical Site Infections 24 Strong Evidence of Factors Associated with Increased Risk of SSI 25 Moderate Evidence of Increased Associated Risk of SSI 29 Limited Evidence of Increased Associated SSI Risk 31 Antibiotic duration for management of surgical site infections 32 Rifampin use for management of surgical site infections 33 References 34 Guideline Development Group Disclosures

2018 American Academy of Orthopaedic Surgeons

151. CRACKCast E176 – Pediatric Musculoskeletal Disorders

in injury to the brachial plexus. Middle third fractures have been associated with neurovascular bundle injuries, pulmonary injury, and pneumothorax. Reasons to call ortho: (red = obvious; black – you may have to know) Open fracture Skin tenting Neurovascular injury Brachial plexus, artery Suspicion for a posterior clavicle displacement injury Fractures with > 100% displacement of the fracture fragment Pathologic fractures Displaced medial third and lateral third fractures Distal clavicular fractures (...) of the thigh near the lesser trochanter Adduct the hip Exert downward pressure on the thigh with the thumb and push it into the table See also this graphic form medcomic – See Rosen’s Box 175.1 for original table [9] List 3 physical exam findings consistent with DDH. Ranges from: subtle acetabular dysplasia to irreducible hip dislocations. Often despite screening, DDH can be missed until later infancy and childhood! Asymmetry of Leg length Galeazzi’s sign: Apparent inequality of femur length is manifested

2018 CandiEM

152. Using Clinical Laboratory Tests to Monitor Drug Therapy in Pain Management Patients

. Additional research studies are needed where the collection of other physician tool data (e.g., self-report, pill counts) are directly compared with biological testing data. Laboratory testing vs. other physician tools, prescription monitoring, and self-report EVIDENCE-BASED RECOMMENDATION #4: Laboratory testing is more effective than other physician tools for the detection of relevant over-the-counter, prescribed and non-prescribed drugs, and illicit substances in pain management patients and should (...) effective than self-reporting at revealing re- cent opioid use(10). Specimen types Urine is typically the preferred matrix for pain management drug testing, as it has a longer window of drug detection than blood, has an adequate specimen volume for drug screening and confirmation, and drug markers (either parent drug or metabo- lites) are present in high concentrations. It is also less invasive and doesn’t require a phlebotomist for collection. Disadvantages include a high risk of adulteration

2018 American Academy of Pain Medicine

154. Imaging Guidelines

for pneumothorax and hemothorax. 1 Extremity radiographs remain an important secondary adjunct for diagnosis of extremity orthopaedic injury. A best practice is interpretation of all radiographs concurrent with the trauma evaluation to facilitate timely treatment interventions. Computed Tomography Imaging Multi-detector computed tomographic (MDCT) imaging is now well established as the imaging modality of choice in hemodynamically stable patients following the secondary survey exam. Oral contrast (...) require sedation for safety while travelling to the CT scanner. MRI The length of exam, noise, and motion artifact all contribute to a usual requirement for sedation in the pediatric patient, particularly those less than 5-years of age. When feasible consider using the “feed and sleep” technique in infants. When available, use child- life specialists with young children to attempt imaging without sedation. Ensure that qualified personnel remain with the patient throughout the imaging study because

2018 American College of Surgeons

155. Continuous glucose monitoring (CGM real-time) and flash glucose monitoring (FGM) as personal, standalone systems in patients with diabetes mellitus treated with insulin

, medications and medical supplies such as injection devices and self-monitoring consumables, and long-term care. The costs of diabetes internationally range from 5% to 10% of the total healthcare spending [106]. A cost-of-illness study that covered 8 European countries estimated annual direct medical costs per patient of € 2834 and total costs of € 29 billion [83]. Continuous (real-time) and flash glucose monitoring as personal, standalone systems in patients with DM treated with insulin Version 1.4, 27 (...) and consistent management approach. They should cover these basic principles of diabetes management [16]: • Interventions to promote and support healthy lifestyles, including healthy diet, physical activity, avoidance of tobacco use, and harmful use of alcohol. • Medication for blood glucose control – insulin or oral hypo-glycaemic agents as required. • Medication to control cardiovascular disease risk. • Regular exams for early detection of complications: comprehensive eye examination, measurement of urine

2018 EUnetHTA

156. Low Back Pain, Adult Acute and Subacute

Low Back Pain, Adult Acute and Subacute Health Care Guideline: Adult Acute and Subacute Low Back Pain Copyright © 2017 by Institute for Clinical Systems Improvement 1 Diagnosis Algorithm Text in blue in this algorithm indicates a linked corresponding annotation. Adult patient present with acute or subacute low back pain History and exam: • Pain characteristics • Sensory and strength changes • Prior treatment and response yes Complete assessment tools for pain and function (...) approach for patients at high risk of permanent disabling low back pain, but not for those at low to medium risk (Whitehurst, 2015). Exam The purpose of the exam is to identify and document neurologic deficits, muscle weakness and biomechanical dysfunction. Adult Acute and Subacute Low Back Pain Algorithm Annotations Sixteenth Edition/March 2018 Return to Table of ContentsInstitute for Clinical Systems Improvement 13 The exam should expand upon a patient’s history and pain drawing

2018 Institute for Clinical Systems Improvement

157. Adult Type 1 diabetes mellitus

their expertise and provide feedback during the external consultation process. Dr Kevin Moore Chair, Guideline Development Group, February 2018 3 | A National Clinical Guideline | Adult type 1 diabetes mellitusNational Clinical Guidelines Providing standardised clinical care to patients in healthcare is challenging. This is due to a number of factors, among them variations in environments of care and complex patient presentations. It is self- evident that safe, effective care and treatment are important (...) insulin regimens, as the insulin injection regimen of choice for all adults with type 1 diabetes. Provide the person with guidance on using multiple daily injection basal-bolus insulin regimens. Awareness and management of hypoglycaemia • Assess awareness of hypoglycaemia in adults with type 1 diabetes at each annual review. Care of adults with type 1 diabetes in hospital • Enable adults with type 1 diabetes who are hospital inpatients to self-administer subcutaneous insulin if they are willing

2018 National Clinical Guidelines (Ireland)

158. Care of Adults with Neurofibromatosis Type 1

to malignant neoplasms and cardiovascular causes. 3,4 Most adults with NF1 are clinically diagnosed in childhood, according to NIH consensus criteria 5 (Supplemental Table S1 online). The criteria are both highly specific and sensitive in adults with NF1. 6 In most cases, the diagnosis can be easily made based on a history, physical exam, and pedigree review and no additional imaging or NF1 genetic testing is needed. These issues and recommendations for the health supervision of children with NF1are (...) the skin. cNFs are histologically similar to PN but do not appear to undergo malignant transformation. 79 Although cNFs are not life-threatening, they can lead to significant morbidity. A population-based survey in Wales found cNFs in > 99% of adults with NF1, 80 making this the most common tumor manifestation in adults. This study described an increase in the number of cNFs with increasing age and revealed that 10 of 30 (33%) women underwent an increase in size and number of cNFs during pregnancy

2018 American College of Medical Genetics and Genomics

159. Paediatric Urology

. Tubularized incised plate hypospadias repair for distal hypospadias. J Pediatr Urol, 2010. 6: 408. 218. Schwentner, C., et al. Interim outcome of the single stage dorsal inlay skin graft for complex hypospadias reoperations. J Urol, 2006. 175: 1872. 219. Ahmed, M., et al. Is combined inner preputial inlay graft with tubularized incised plate in hypospadias repair worth doing? J Pediatr Urol, 2015. 11: 229 e1. 220. Pippi Salle, J.L., et al. Proximal hypospadias: A persistent challenge. Single institution (...) : 31. 234. Lam, P.N., et al. 2-stage repair in infancy for severe hypospadias with chordee: long-term results after puberty. J Urol, 2005. 174: 1567. 235. Mokhless, I.A., et al. The multistage use of buccal mucosa grafts for complex hypospadias: histological changes. J Urol, 2007. 177: 1496. 236. Stanasel, I., et al. Complications following Staged Hypospadias Repair Using Transposed Preputial Skin Flaps. J Urol, 2015. 194: 512. 237. Castagnetti, M., et al. Does Preputial Reconstruction Increase

2018 European Association of Urology

160. An Overview of Clinical Applications of Artificial Intelligence

to be approved without the need for resubmissions, an issue of particular concern with self-learning and self-adapting software. 22 The program is intended to go through pilot testing for products classified as software as a medical device in 2019. 23 Regulation of specialized AI applications may require additional considerations. For example, CAR recommends that AI tools with radiology applications must consider the principles of evidence-based medicine and should receive the same level of clinical (...) of imaging exams, AI tools may also help radiologists by coordinating and integrating information, identifying patients for screening examinations, prioritizing patients for immediate interpretation, and standardizing reporting. 33,34 While AI in radiology is currently concentrated in the research domain, 24 deep learning algorithms are anticipated to diffuse into widespread clinical use, 33,35 as is evident by the FDA’s recent approval of two AI-driven technologies. 36-38 As well, numerous manufacturers

2018 CADTH - Issues in Emerging Health Technologies

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