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Valproic Acid Toxicity

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101. CRACKCast E091 – Pancreas

of GI bleeding Bowel obstruction correction Treatment of acute cholangitis / venous thrombosis Wisecracks Question 1) Specifically list 10 drug causes of pancreatitis. Cannabis Codeine Dapsone Enalapril Furosemide Isoniazid Metronidazole Pravastatin Procainamide Simvastatin Sulfamethoxazole Tetracycline Valproic acid These are some of the class Ia drugs – from Uptodate – where people have developed pancreatitis on a re-challenge of the drug and other causes of pancreatitis have been ruled out (e.g (...) pancreatitis? Causes Toxic-metabolic ETOH abuse Smoking Obstructive Genetic Autoimmune Post-necrotic acute pancreatitis Idiopathic Diagnosis: Clinical features, laboratory analysis, imaging tests – still the best rule of thumb However, lab tests are less helpful: Amylase and lipase may not rise to the same degree or may be normal Liver function tests may be elevated due to concurrent ETOH abuse / biliary obstruction due to cirrhosis Likely have chronic hypoalbuminemia, hypocalcemia, hyperglycemia X-rays

2017 CandiEM

102. Alcohol: Adult Unhealthy Drinking

, or a viable plan for self-management? – If no, consider linking patient with Social Work to help develop this plan. Emergent situations: unplanned, acute withdrawal Occasionally, patients may stop drinking on their own. Consider directing a patient to an emergency department for possible inpatient medical or psychiatric treatment if the patient presents with: • Acute toxicity (e.g., altered mental status) that cannot be safely managed in an outpatient setting. • A coexisting medical condition (...) Restless Miserable Problems with memory Tremor (shakes) Nausea Heart pounding Sleep disturbance Sweating 22 Determining whether medical management is necessary Most cases of mild alcohol withdrawal do not require medical intervention (Kattimani 2013). Unnecessary prophylaxis or treatment of may lead to unintentional consequences including excessive sedation, falls, respiratory depression, propylene glycol toxicity, and delirium. To determine whether medication management is needed: • Evaluate

2016 Kaiser Permanente Clinical Guidelines

105. Folic acid

eating normally more difficult. Also, bone marrow depression (inducing leukopenia and thrombocytopenia) and acute kidney and liver failure have been reported. , under the drug name , a form of folate (formyl-THF), can help "rescue" or reverse the toxic effects of methotrexate. Folinic acid is not the same as folic acid. Folic acid supplements have little established role in cancer chemotherapy. Cases of severe adverse effects of accidental substitution of folic acid for folinic acid have been (...) [ ] The risk of toxicity from folic acid is low, because folate is a water-soluble vitamin and is regularly removed from the body through urine. One potential issue associated with high doses of folic acid is that it has a masking effect on the diagnosis of due to vitamin B 12 deficiency. An additional concern raised was that low vitamin B 12 status in combination with high folic acid intake appeared to increase the risk of cognitive impairment. The IOM sets ULs for vitamins and minerals when evidence

2012 Wikipedia

106. Antenatal and postnatal mental health: clinical management and service guidance

, whether preterm or full term, which are physically traumatic (for example, instrumental or assisted deliveries or emergency caesarean sections, severe perineal tears, postpartum haemorrhage) and births that are experienced as traumatic, even when the delivery is obstetrically straightforward. V Valproate alproate Refers to 3 formulations of valproate available in the UK: sodium valproate and valproic acid (licensed for the treatment of epilepsy) and semi-sodium valproate (licensed for the treatment (...) of acute mania and continuation treatment in people whose mania responds to treatment). Both Antenatal and postnatal mental health: clinical management and service guidance (CG192) © NICE 2019. All rights reserved. Subject to Notice of rights ( conditions#notice-of-rights). Page 13 of 50semi-sodium and sodium valproate are metabolised to valproic acid (also known as valproate), which is the pharmacologically active component. Valproate must not be used in pregnancy

2014 National Institute for Health and Clinical Excellence - Clinical Guidelines

107. Bipolar disorder: assessment and management

] [2018] 1.6.6 Follow the recommendations on using antipsychotics in section 1.10 and be aware of the potential interactions between valproate [18] and fluoxetine, lamotrigine and olanzapine. [2018] [2018] 1.6.7 T ake into account toxicity in overdose when prescribing psychotropic medication during periods of high suicide risk. Assess the need to limit the quantity of medication supplied to reduce the risk to life if the person overdoses. Re Reviewing treatment for bipolar depression viewing treatment

2014 National Institute for Health and Clinical Excellence - Clinical Guidelines

108. CRACKCast E018 – Seizures

desaturates → intubate avoid long term neuromuscular blockade if possible (rare case where sux. could be used – consider checking K+ on a blood glass) consider EEG for monitoring of epileptiform brain activity Second-line agents: All agents are consensus based: all need to be given over 10 mins or so!!! Phenytoin – 20 mg/kg IV infusion Fosphenytoin (prodrug) – 20 mg/kg IV infusion  Less tendency to cause hypotension and dysrhythmias Phenobarbital – 20-30 mg/kg IV infusion Valproic Acid – 20-40 mg/kg (...) -of-hyponatremia-or-elevated-icp-with-bicarb-ampules/ 3) 3) What are the most common causes of status epilepticus? As per table 18-1: antiepileptic drug associated – withdrawal or under dose ~ 25% ETOH related – 15-25% drug toxicity / post-stroke / CVA / metabolic (lytes) / hypoxia / post-arrest – 35% others: infection, cerebral tumour, trauma, idiopathic – 15% This post was edited and uploaded by Rob Carey (@_Robcarey) (Visited 4,100 times, 1 visits today) Adam Thomas CRACKCast Co-founder and newly minted

2016 CandiEM

109. Drugs That May Cause or Exacerbate Heart Failure

of Care and Outcomes Research Originally published 11 Jul 2016 Circulation. 2016;134:e32–e69 You are viewing the most recent version of this article. Previous versions: Abstract Heart failure is a common, costly, and debilitating syndrome that is associated with a highly complex drug regimen, a large number of comorbidities, and a large and often disparate number of healthcare providers. All of these factors conspire to increase the risk of heart failure exacerbation by direct myocardial toxicity (...) . Hospitalization for HF is the largest segment of those costs. It is likely that the prevention of drug-drug interactions and direct myocardial toxicity would reduce hospital admissions, thus both reducing costs and improving quality of life. Patients with HF often have a high medication burden consisting of multiple medications and complex dosing regimens. On average, HF patients take 6.8 prescription medications per day, resulting in 10.1 doses a day. This estimate does not include over-the-counter (OTC

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2016 American Heart Association

110. Urinary tract infection (lower) - women

resistance. Sample containers with boric acid preservative should be filled to the marked line. If urine dipstick is negative for nitrite and positive for leukocyte, UTI is equally likely to other diagnosis. Send urine for culture to confirm diagnosis. If urine dipstick is negative for all nitrite, leukocyte and RBC, UTI is less likely. No need to send sample for urine culture — consider other diagnoses. A sample should be sent for urine culture in all women with suspected lower UTI who: Are pregnant (...) or leukocytes and blood are positive [ ]. Use of symptoms and dipsticks to diagnose UTI is not completely reliable — severity of symptoms must be considered in each specific case and appropriate safety-netting put in place [ ]. Urine samples in universal containers should be cultured within 4 hours of collection, refrigerated, or sent in a container with boric acid preservative [ ]. Boric acid can affect urine dipstick tests and cause false negative culture if urine is not filled to correct mark on specimen

2019 NICE Clinical Knowledge Summaries

114. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders

in fact be decreased [99,100]. Careful monitoring for evidence of self-harming or suicidal thoughts or behaviors is impor- tant inboth adult and pediatric patients. SSRIs and SNRIs are generally better tolerated and safer than TCAs and MAOIs, having less anticholinergic effects, toxicity, lethality, and psychomotor or cognitive impairment [85,101]. MAOIs are generally reserved for second- or third-line treatment because of side effects, drug interactions, and dietary restrictions [32]. Anxiolytics (...) therapies (see Sec- tions 3–9 for evidence and references). Anticonvulsants: Anticonvulsants are associated with gastrointestinal side effects, somnolence, weight gain, tremor, as well as dermatologic and hematologic side effects [111,118]. In addition, several anticonvulsants have a potential risk of serious rash, erythema multi- forme, Stevens-Johnson syndrome, or toxic epidermal necrolysis [111]. Regular monitoring of serum medica- tion levels and liver function is required for patients on divalproex

2014 CPG Infobase

115. Childhood Astrocytomas Treatment (PDQ®): Health Professional Version

at specific amino acids in histone genes, and together these account for approximately one-half of pediatric high-grade gliomas. The following pediatric high-grade glioma subgroups were identified on the basis of their DNA methylation patterns, and they show distinctive molecular and clinical characteristics:[ ] H3.3 ( H3F3A ) and H3.1 ( HIST1H3B and, rarely, HIST1H3C ) mutation at K27: The Histone K27–mutated cases occur predominantly in midchildhood (median age, approximately 10 years), are almost (...) that contour the radiation to the tumor and avoid normal brain tissue ( , , , and ) all appear effective and may potentially reduce the acute and long-term toxicities associated with these modalities.[ , ]; [ ][ ] Care must be taken in separating radiation-induced imaging changes from disease progression, which usually occurs during the first year after radiation, but may occur even after the first year, especially in patients with pilocytic astrocytomas

2018 PDQ - NCI's Comprehensive Cancer Database

116. Childhood Acute Lymphoblastic Leukemia Treatment (PDQ®): Health Professional Version

of hyperdiploid (51–65 chromosomes) precursor B-cell ALL. ARID5B is a gene that encodes a transcriptional factor important in embryonic development, cell type–specific gene expression, and cell growth regulation.[ , ] Other genes with polymorphisms associated with increased risk of ALL include GATA3 ,[ ] IKZF1 ,[ , , ] CDKN2A ,[ ] CDKN2B ,[ , ] CEBPE ,[ ] PIP4K2A ,[ , ] and TP63 .[ ] Rare germline variants with high penetrance. A germline variant in PAX5 that substitutes serine for glycine at amino acid 183 (...) % surviving at 5 years.[ - ] Despite the treatment advances in childhood ALL, numerous important biologic and therapeutic questions remain to be answered before the goal of curing every child with ALL with the least associated toxicity can be achieved. The systematic investigation of these issues requires large clinical trials, and the opportunity to participate in these trials is offered to most patients and families. Clinical trials for children and adolescents with ALL are generally designed to compare

2018 PDQ - NCI's Comprehensive Cancer Database

119. HPLC-DAD Quantification of Flucytosine (5-Fluorocytosine)

-methylcytosine) and a precipitating agent (trichloroacetic acid) are added and mixed successively into a plasma sample. The tubes are centrifuged, then a 10 µL aliquot is injected into the HPLC-DAD system in isocratic mode with detection at 266 nm. Threshold values are as follows: ? Ineffectiveness (and risk of secondary resistance): less than 25 ?g/mL ? Optimal therapeutic level: 30 to 80 ?g/mL ? Risk of toxicity: greater than 100 ?g/mL Other authors report different threshold values. 2.4 Licence (...) Tolbutamide X Tricyclic antidepressants X Valproic acid 499 µmol/L Warfarin X *HPLC-DAD method.

2015 Canadian Agency for Drugs and Technologies in Health - Rapid Review

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

Long-duration local anaesthetics 123 5.1.3 Local anaesthetic toxicity 126 5.2 Opioids 128 5.2.1 Neuraxial opioids 128 5.2.2 Peripheral opioids 131 Acute Pain Management: Scientific Evidence xiii CONTENTS 5.3 Adjuvant Drugs 133 5.3.1 Alpha-2 agonists 133 5.3.2 Adrenaline 134 5.3.3 Ketamine 135 5.3.4 Midazolam 136 5.3.5 Neostigmine 136 5.3.6 Magnesium 137 5.3.7 Botulinum toxin A 137 5.4 Anti-inflammatory drugs 138 5.4.1 Cortic osteroids 138 5.4.2 Non-steroidal anti-inflammatory drugs 139 References (...) 1.3 Proposed pathways of glucose-induced cellular toxicity 18 1.4 Acute pain management and rehabilitation 20 10.1 Faces Pain Scale — Revised 344SUMMARY Acute Pain Management: Scientific Evidence xix SUMMARY OF KEY MESSAGES A description of the levels of evidence and associated symbols can be found in the Introduction (see pages vi to vii). 1. PHYSIOLOGY AND PSYCHOLOGY OF ACUTE PAIN Psychological aspects of acute pain 1. Preoperative anxiety, catastrophising, neuroticism and depression

2015 National Health and Medical Research Council

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