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3981. Pancreatitis - chronic: Scenario: Management of confirmed chronic pancreatitis

includes: Endoscopic therapy to remove obstructing pancreatic stones or to dilate strictures. Surgery or other interventions (for example endoscopic retrograde cholangiopancreatography [ERCP] and stenting) to relieve pain from large-duct (obstructive) chronic alcohol-related pancreatitis, or to deal with complications, such as pancreatic pseudocyst or gastric outlet obstruction. Adjuvant drugs such as amitriptyline, gabapentin, or pregabalin. Coeliac axis block, splanchnicectomy, or surgery (...) or a nonsteroidal anti-inflammatory drug (NSAID), for example ibuprofen, first-line. Consider the addition of a weak opioid, such as codeine phosphate, if first-line analgesia alone is inadequate. For more prescribing information, see the CKS topics on and . If the person has uncontrolled pain, refer the person to secondary care (gastroenterology, pancreatico-biliary surgery, a specialist pancreatic centre, or pain clinic) for a multidisciplinary assessment. Treatment options for pain relief in secondary care

2019 NICE Clinical Knowledge Summaries

3982. Palliative care - oral: History

Palliative care - oral: History History | Diagnosis | Palliative care - oral | CKS | NICE Search CKS… Menu History Palliative care - oral: History Last revised in October 2018 History Enquiry into symptoms and problems with the oral cavity should be part of a full history and examination that includes physical, psychological, social, and spiritual issues: Enquire about dry mouth, oral pain, halitosis, alteration in taste, excessive salivation, bad breath, difficulty chewing, difficulty (...) speaking, dysphagia and bleeding. Be particularly alert if the person has any for oral problems or is using medication that may cause a (for more information, see Table 1). Basis for recommendation This recommendation is based on expert opinion in a textbook [ ]. © .

2019 NICE Clinical Knowledge Summaries

3983. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper: Plant-based Milks

of Southern California, Los Angeles, CA, the y Harvard Medical School, Boston Children’s Hospital, Boston, MA, the z Division of Pediatric Gastroenterology, Hepatology & Nutrition, University of Miami Miller School of Medicine, Miami, FL, the § Division of Pediatric Gastroenterology, Hepatology and Nutrition, Depart- ment of Pediatrics, The Medical University of South Carolina, Charleston, SC, the jj Ann and Robert H Lurie Children’s Hospital of Chicago, Chicago, IL, the NASPGHAN Nutrition Committee (...) , Pediatric Nutrition Support and Pediatric Gastrointestinal Endoscopy, Section of Pediatric Gastroenterology, Hepatology and Nutrition Support, University of Chicago Medicine and Biological Sciences, Chicago, IL, the # Pediatric Gastroenterology Hepatology and Nutrition, Florida Intestinal Rehabilitation, Support and Treatment Program, Salah Foundation Children Hospital at Broward Health Medical Center, Fort Lauderdale, FL, the NOVA Southeastern University, Fort Lauderdale, FL, the yy University

2020 North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

3984. Management of Bleeding in Patients on Oral Anticoagulants

of on-therapy or aboveon-therapylevelsofdabigatran.However,anormal aPTT does not exclude the presence of on-therapy levels, especially when a relatively insensitive aPTT reagent is used (18–20). The preferred test for quantitation of apixaban, edox- aban, and rivaroxaban is a chromogenic anti-FXa assay calibrated with the drug of interest (see Table 2)(19,20). Anti-FXa assays may also be useful for quantitation of betrixaban, but modi?cation of current methods is necessary to achieve suitable sensitivity (...) (21). When an anti-FXa assay is calibrated with a low-molecular-weight heparin or unfractionated heparin standard, it can be useful for excluding clinically important levels of drug, but not for quantitation (see Table 3). If an anti-FXa assay is not available, the PT may be useful for qualitative assessment of betrixaban, edoxaban, and rivaroxaban. A prolonged PT suggests on-therapy or above on-therapy levels for these agents. However, depending on the sensitivityofthePTreagent

2020 American College of Cardiology

3985. Mitral Regurgitation Management

decision pathway; EF¼ ejection fraction; FDA¼ Food and Drug Administration; GDMT¼ guideline-directed management and therapy; HF¼ heart failure; LV¼ left ventricle; LVAD¼ left ventricular assist device; MDT¼ multidisciplinary team; MITRA-FR¼ Percutaneous Repair with the MitraClip Device for Severe Functional/Secondary Mitral Regurgitation; MR¼ mitral regurgitation; MV¼ mitral valve; RCT¼ randomized controlled trial; TTE¼ transthoracic echocardiography. JACC VOL. 75,NO. 17,2020 Bonow et al. MAY 5, 2020 (...) and palpitations. Incorporation into the medical record of a patient ques- tionnaire on health status is encouraged. The STS/ACC Transcatheter Valve Therapy (TVT) Registry (NCT01737528) includes an entry for the Kansas City Cardiomyopathy Questionnaire (14,15). The Patient Re- ported Outcomes Measurement Information System (PROMIS) is an alternative assessment tool (16). If the patient is asymptomatic, exercise testing may be performed safely and may elicit symptoms or demon- strate reduced exercise capacity

2020 American College of Cardiology

3986. Interstage Home Monitoring for Infants With Single Ventricle Heart Disease: Education and Management Full Text available with Trip Pro

afford the IHM team an opportunity to validate weight trends and oxygen saturations using clinic equipment, review data trends recorded by caregivers, confirm medication dosages, review red flags and how to reach IHM team, observe enteral feeding, perform a comprehensive physical assessment, obtain diagnostic imaging if warranted, and assess the emotional and social state of caregivers. Other services that may be provided include speech, occupational, and physical therapy to assess and address (...) ) [ ] Therapies (physical, speech, and occupational) [ ] Neurodevelopmental clinic follow‐up (referral to local early intervention programs) [ ] Cardiac catheterization date (if known) [ ] Monthly palvizumab (RSV season only) [ ] Any follow‐up outpatient diagnostic or laboratory tests Emergency plan [ ] Identify the closest, equipped emergency department with guidelines on oxygenation and hydration, and urgent contact with IHM team and primary cardiologists Caregiver/family resources and support groups

2020 American Heart Association

3987. AGA Institute Rapid Review and Recommendations on the Role of Pre-Procedure SARS-CoV2 Testing and Endoscopy

Affiliations: 1. Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis VA Healthcare System, Minneapolis, Minnesota 2. Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania 3. Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri 4. Department of Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island. 5. Division of Gastroenterology (...) , Northeast Ohio Veterans Affairs Healthcare System, Case Western Reserve University School of Medicine, Cleveland, Ohio 6. Division of Gastroenterology and Center for Inflammatory Bowel Diseases, Beth Israel Deaconess Medical Center, Boston, Massachusetts 7. Mayo Clinic College of Medicine, Division of Gastroenterology and Hepatology, Jacksonville, FL, USA. 8. Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah 9. Yale Liver Center and Section of Digestive

2020 American Gastroenterological Association Institute

3988. Cardiorespiratory Fitness in Youth: An Important Marker of Health: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

, Carissa Baker-Smith , Nicholas Pietris , Nicholas M. Edwards , Originally published 20 Jul 2020 Circulation. 2020;142:e101–e118 Abstract Cardiorespiratory fitness (CRF) refers to the capacity of the circulatory and respiratory systems to supply oxygen to skeletal muscle mitochondria for energy production needed during physical activity. CRF is an important marker of physical and mental health and academic achievement in youth. However, only 40% of US youth are currently believed to have healthy CRF (...) those at increased risk. Cardiorespiratory fitness (CRF) refers to the capacity of the circulatory and respiratory systems to supply oxygen to skeletal muscle mitochondria for energy production needed during physical activity. , Low or unhealthy CRF is a strong, independent predictor of cardiovascular disease (CVD) and all-cause mortality in adults. In youth, CRF is a predictor of a number of health indicators, including cardiometabolic health, , premature CVD, academic achievement, and mental

2020 American Heart Association

3989. Hypothyroidism: Scenario: Overt hypothyroidism (non-pregnant)

if needed, to see if they have improved or whether management for dyslipidaemia is needed. See the CKS topics on and for more information. If TFTs remain abnormal or the person has persistent symptoms despite adequate or escalating LT4 doses: Assess for any possible causes and manage appropriately. These include: Non-compliance with prescribed LT4 treatment. Drug interactions of LT4 treatment with other medication that may reduce LT4 absorption or increase LT4 requirements, including multivitamins (...) and other over-the-counter medication. Advise the person to leave an interval of four hours between taking LT4 and the potentially interfering drug, if possible. See the section on in for more information on potential drug interactions. Gastrointestinal conditions causing malabsorption such as coeliac disease, Helicobacter pylori gastritis, atrophic gastritis/pernicious anaemia, giardiasis, and inflammatory bowel disease, which may reduce absorption of LT4 in the gut. Simultaneous intake of LT4

2020 NICE Clinical Knowledge Summaries

3990. Hiccups: Scenario: Management of hiccups

manoeuvre (a forced expiration against a closed glottis). Breathing into a paper bag. Pulling on the tongue. Sneezing. Swallowing a teaspoon of granulated sugar. Tasting vinegar or biting a lemon. Sipping iced water. Compressing the diaphragm by pulling the knees up to the chest. Swallowing water while closing the nose. For people with hiccups that have persisted for longer than 48 hours, or recurrent bouts of hiccups that persist for longer than an hour: If history, physical examination (...) techniques to interrupt of the hiccup reflex arc, such as stimulation of the nasopharynx with a finger, rubber catheter, or cotton-tipped applicator, lifting the uvula, or inducing a gasp by smelling salts or other noxious agents. Consider specialist referral so that pharmacotherapy can be initiated. Drug treatments include: Chlorpromazine. This is the recommended treatment. It is initially given intravenously and if it proves successful, can be continued orally for 7 to 10 days. Metoclopramide (off

2016 NICE Clinical Knowledge Summaries

3991. Hiccups: How should I assess a person with recurrent or protracted hiccups for an underlying cause?

of duration <1 hour with no obvious trigger and with additional signs and symptoms, or associated complications The advice to use clinical judgement to determine whether people in this group require detailed physical examination and baseline tests is pragmatic, based on what CKS considers to be good medical practice. © . (...) for less than an hour, ask about exposure to potential triggers such as: Sudden excitement and emotional stress. Sudden changes in ambient or gastrointestinal temperature (cold showers, or drinking hot or cold beverages). Drinking carbonated beverages. Excessive food or alcohol consumption. If no clear trigger is identified, and/or the person reports other symptoms or complications, use clinical judgement to determine whether a physical examination and baseline investigations are appropriate (see below

2016 NICE Clinical Knowledge Summaries

3992. Herpes simplex - oral: How should I assess a person with oral herpes simplex?

, such as embarrassment or emotional distress. Known trigger factors, such as ultraviolet light, physical or emotional stress, fatigue, fever, menstruation, immunosuppression, extremes in temperature, mouth or lip trauma to the area of primary infection, and dental or surgical procedures. Any associated . Any underlying medical conditions that may affect the of herpes simplex infection, such as immunosuppression or atopic eczema. Assess for any red flags that may suggest more serious underlying disease such as oral (...) immunosuppression, such as HIV infection, depending on clinical judgement. For more information, see the CKS topic on . Basis for recommendation Features of the initial assessment The recommendations on how to assess a person with suspected oral herpes simplex infection are largely based on expert opinion in a Cochrane systematic review protocol Interventions for treatment of herpes simplex labialis (cold sores on the lips) [ ], a British Medical Journal (BMJ) Clinical Evidence systematic review article

2016 NICE Clinical Knowledge Summaries

3993. Herpes simplex - ocular: How should I assess a person with suspected ocular herpes simplex infection?

. The degree and duration of such as eye pain and blurred vision. A history of previous episodes of ocular herpes simplex. A history of contact lens use. Known trigger factors for recurrent episodes, such as ultraviolet light, physical or emotional stress, fatigue, fever, menstruation, immunosuppression such as topical or systemic corticosteroids (including inappropriate or excessive use), extremes in temperature, eye trauma, or trigeminal nerve manipulation surgery. Any associated . Any underlying medical (...) management guideline [ ] and the American Academy of Ophthalmology treatment guideline [ ], and is pragmatic based on what CKS considers to be good medical practice, as a diagnosis of suspected ocular herpes simplex in primary care is usually made on clinical features alone. © .

2019 NICE Clinical Knowledge Summaries

3994. Hepatitis B: When should I test for hepatitis B?

areas with a high prevalence, injecting drug users, and sex workers). Have been sexually assaulted. Have sustained a needlestick injury. Are HIV-positive. People with clinical features that could be indicative of hepatitis B: For acute infection, these include: A prodromal illness that includes fever, arthralgia, or a rash (that may appear about 2 weeks before the onset of jaundice, then resolves in acute hepatitis B). Non-specific malaise, fatigue, fever, nausea, and poor appetite. Right upper (...) quadrant abdominal pain. Jaundice (with dark urine and/or pale stools if cholestasis). Extrahepatic manifestations such as glomerulonephritis, vasculitis, and polyarteritis. Note: Acute hepatitis B infection is asymptomatic in almost all infants and children, 10-50% of adults, and is especially likely in people with HIV. For chronic infection, there are often no physical signs. After many years of infection, depending on the severity and duration, there may be signs of chronic liver disease including

2019 NICE Clinical Knowledge Summaries

3995. End of life care in children

. It embraces physical, emotional, social, and spiritual elements, and focuses on enhancement of quality of life for the child/young person and support for the family. It includes the management of distressing symptoms, provision of short breaks and care through death and bereavement. The prevalence of life-limiting conditions in children in England is both rising and higher than previously estimated. In England in 2017, there were around 3,000 child deaths due to medical conditions, of which 2,351 (...) of these were due to a known life-limiting condition or a neonatal death. Prevalence is higher in males (35.2%) compared to females (29.2%) and it also varies with ethnicity, deprivation, and geographical location. All children with a life-limiting condition should be cared for by a defined multidisciplinary team, and have a named medical specialist who leads on and coordinates their care. An advanced care plan should be developed at an appropriate time for the current and future care of each child

2016 NICE Clinical Knowledge Summaries

3996. Eating disorders

, haematological and dental problems. Diagnosis of an eating disorder is based on the person's history, suggestive clinical features, and supported, where possible, by corroboration from a relative or friend. Clinicians should be aware that assessment may appear normal even in medically unstable people. Management of a suspected eating disorder in primary care involves: Considering the need for emergency admission if the person is at risk of serious physical or psychological complications such as: Severely (...) . While awaiting assessment by the eating disorder team: Arranging regular review to monitor level of physical and mental health risk. Seeking advice from an appropriate specialist for people with co-morbidities (such as diabetes) and pregnant women. Considering the impact of malnutrition and compensatory behaviour on medication effectiveness and risk of side effects. Management of a confirmed eating disorder in primary care involves: Ensuring there is a clear agreement between primary and secondary

2016 NICE Clinical Knowledge Summaries

3997. Domestic violence and abuse: Scenario: Managing domestic violence and abuse

(including any injuries) and do not need the person's permission to do this. Enter in the medical record any health complaints, symptoms, and signs, as you would for any other person, including a description of any injuries. It may be helpful to note the cause or suspected cause of these injuries or other conditions, including the person who caused the injury. Consider taking photographs of physical injuries as pictures will convey the severity of injuries more effectively than a verbal description (...) , such as: 'Has anyone ever hit you? Who was it? What happened? When? What help did you seek?' 'Are you afraid of your husband (or partner)?' 'Has your husband (or partner) or someone else at home ever threatened to hurt you or physically harm you in some way? If so, when has it happened?' 'Does your husband (or partner) or someone at home bully you or insult you?' 'Does your husband (or partner) try to control you, for example, not letting you have money or go out of the house?' 'Has your husband (or partner

2018 NICE Clinical Knowledge Summaries

3998. Domestic violence and abuse

; and pregnancy or childbirth. Domestic violence and abuse can adversely affect the physical and mental health of the person being abused and that of any children in their care. Signs of possible domestic violence and abuse include unexplained injuries, depression, fear, alcohol or drug misuse, and the presence of an intrusive ‘other person’ in consultations. Healthcare services should have a domestic violence and abuse policy and a designated person responsible for the response to domestic violence and abuse (...) or over who are, or have been, intimate partners or are family members regardless of gender or sexuality. It includes psychological, physical, sexual, emotional, and financial abuse, forced marriage, and 'honour'-based violence. At least 29.9% of women and 17% of men in England and Wales have experienced domestic abuse at some point in their lives. Risk factors for experiencing domestic violence and abuse include being female; having a long-term illness, disability, or mental health problem

2018 NICE Clinical Knowledge Summaries

3999. Falls - risk assessment: Scenario: Falls - risk assessment

, mobility, or balance) from a collapse (caused by an acute medical problem, for example, arrhythmias, transient ischaemic attack, or vertigo). Are at risk of falling because they: Have cognitive impairment. Have a visual impairment. Have a condition that affects mobility or balance, such as arthritis, diabetes, incontinence, stroke, or Parkinson's disease. For more information, see the CKS topics on , , , , , and . Are taking multiple drugs, psychoactive drugs (such as benzodiazepines), or drugs (...) that can cause postural hypotension (such as anti-hypertensive drugs). Have a fear of falling. Are physically frail — tools such as the (eFI) may be used to identify people aged 65 years and over who may be living with moderate or severe frailty. Have other for falling, such as alcohol misuse, depression, or environmental hazards. For more information, see the CKS topics on and . For people who have had one or more falls or are considered to be at risk of a fall, assess their gait and balance

2018 NICE Clinical Knowledge Summaries

4000. Erectile dysfunction: Scenario: Management of erectile dysfunction

of Product Characteristics [ ]. More frequent dosing regimens. In clinical trials, patients were allowed up to daily dosing whereas in clinical practice medication is often restricted. The European Society for Sexual Medicine (ESSM) suggests that daily dosing might salvage as many as 50% of non-responders to a first drug. One study reported that up to 57% of PDE5I failures could be salvaged with up to 12 weeks of tadalafil 10 mg daily.Tadalafil 5 mg daily is licensed for this indication but sildenafil (...) of PDE-5 inhibitors are partly dose-dependent, so increasing the dose may overcome lack of effect. There is anecdotal evidence that a man may respond to a different PDE-5 inhibitor; therefore, it is worth trialling a different drug before classing PDE-5 inhibitors as ineffective [ ; ; ]. More frequent dosing regimens. In clinical trials, patients were allowed up to daily dosing whereas in clinical practice medication is often restricted. The European Society for Sexual Medicine (ESSM) suggests

2018 NICE Clinical Knowledge Summaries

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