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4021. COVID-19 pandemic personal protective equipment (PPE): Guidance for intensive care

Gloves** for direct contact with the patient or their environment Gloves** for direct contact with the patient or their environment Gloves for direct contact with the patient or their environment Plastic apron** Patient location Side room (if possible but prioritise for COVID-19 patients undergoing AGP) Use side room Designated areas in ICU with physical barrier Enhanced Environmental Cleaning * Gowns should be water repellent or protected with a plastic apron if there is a risk of splashing of body (...) and patients *Use of Side rooms for AGPs Enhanced environmental cleaning *Local decisions around placement in non COVID-19 areas will have been made by senior medical staff in conjunction with local guidance, and take into account the risk/benefit balance based on clinical presentation, COVID-19 contact history, imaging results, COVID-19 prevalence and the nature and number of negative PCR samples. Routine use of side rooms for AGP in patients considered low risk is likely to be impractical in most units

2020 ICM Anaesthesia COVID-19

4022. Airway guidance for the endemic phase of COVID-19?

Airway guidance for the endemic phase of COVID-19? Airway guidance for the endemic phase of COVID-19 Contributors Tim Cook, Barry McGuire, Mary Mushambi, Upma Misra, Chris Carey, Nuala Lucas, Ellen O’Sullivan, Will Harrop-Griffiths Consensus airway guidelines from the Difficult Airway Society (DAS), Association of Anaesthetists, Intensive Care Society, Faculty of Intensive Care Medicine and Royal College of Anaesthetists (RCoA) were published on the Anaesthesia-Intensive Care Medicine hub (...) involved with the intubation of patients with or suspected to have COVID-19 subsequently developed symptoms consistent with SAR-CoV-2 infection or a positive antigen test, despite the vast majority of involved staff wearing airborne protection PPE. However, whether performing these procedures and subsequent evidence of infection is an association or is linked causally remains uncertain. The Association of Anaesthetists and the RCoA via the Anaesthesia-Intensive Care Medicine hub website have provided

2020 ICM Anaesthesia COVID-19

4023. Cow's milk allergy in children: How should I assess a child with suspected cow's milk allergy?

history of other food allergies. See the CKS topics on , , , and for more information. Any family history of food allergy or atopic conditions, particularly in parents and siblings. Any symptom response to dietary restrictions or reintroduction of cow's milk, and/or medications tried, such as oral antihistamines. Examine the child for: Nutritional status and growth, including weight, length/height, and calculation of body mass index (BMI). Any of a clinical reaction. Any signs of comorbid conditions (...) be a dose-dependent threshold for reactivity. It may also highlight incorrectly identified food triggers [ ; ]. The information on the typical age of presentation is based on the BSACI guideline. The recommendation to ask about family history of atopy affecting first-degree relatives is based on the NICE clinical guideline and expert opinion in a review article [ ]. Performing a physical examination The recommendations on physical examination are based on the NICE clinical guideline [ ], the EAACI

2018 NICE Clinical Knowledge Summaries

4024. Corticosteroids - oral: Scenario: Corticosteroids

of the properties and general therapeutic indications of different oral corticosteroids, see Table 2. Table 2. Properties and therapeutic indications of oral corticosteroids, relative to hydrocortisone. Drug Glucocorticoid properties Mineralocorticoid properties Duration of action after oral dose* General therapeutic indication Hydrocortisone 1 1 Short Drug of choice for corticosteroid replacement therapy. Cortisone 0.8 0.8 Short Similar to hydrocortisone, not used as an anti-inflammatory because (...) These recommendations are based on expert opinion in narrative reviews A practical guide to the monitoring and management of the complications of systemic corticosteroid therapy [ ] and Prevention and management of glucocorticoid-induced side effects: a comprehensive review: gastrointestinal and endocrinologic side effects [ ], expert opinion in a textbook Meyler's side effects of endocrine and metabolic drugs [ ], the manufacturer's Summary of Product Characteristics for prednisolone tablets [ ], a drug reference

2018 NICE Clinical Knowledge Summaries

4025. Contraception - emergency: Scenario: Emergency contraception

of Sexual and Reproductive Healthcare (FSRH) clinical guideline Emergency contraception [ ; ], the FSRH clinical guideline Intrauterine contraception [ ], the FSRH clinical guideline UK Medical Eligibility Criteria for contraceptive use [ ], guidance issued by the Medicines and Healthcare Products Regulatory Agency (MHRA) [ ], and the manufacturers' Summaries of Product Characteristics [ ; ]. A systematic review concluded that the risk of ectopic pregnancy when emergency contraceptive fails, does (...) or barrier failure occurs during, or in the 28 days following the use of potent liver enzyme-inducing drugs (such as rifampicin, phenytoin, carbamazepine). Combined oral contraceptive (COC) pill (except Qlaira®) — offer emergency contraception: If 2–7 pills have been missed (72 hours or more since the last pill in the current pack was taken) in week 1 after the hormone-free interval (HFI) and there has been UPSI or barrier failure during the HFI or week 1. If it has been 9 completed days or more since

2020 NICE Clinical Knowledge Summaries

4026. Diarrhoea - antibiotic associated: Scenario: Diarrhoea - antibiotic associated

Symptoms of C. difficile infection can vary from mild diarrhoea to more severe symptoms indicative of pseudomembranous colitis, toxic megacolon, bowel perforation, and sepsis [ ; ; ]. Although C. difficile infection almost always causes diarrhoea, abdominal distension, and pain, other symptoms such as nausea, vomiting, and fever may not be present. Physical findings can be non-specific and depend on the severity and duration of illness [ ; ]. Suspect the possibility of C. difficile infection if risk (...) [ ]. Recurrence risk increases with increasing age and a small proportion of people have repeated relapses [ ; ]. Stool testing for C. difficile toxin C. difficile infection is difficult to diagnose on the basis of physical examination alone, and therefore the diagnosis should be based on clinical signs and symptoms and supported by laboratory tests, including stool studies [ ; ; ; ]. Check for reports of other cases C. difficile has been associated with outbreaks in hospitals and care facilities, especially

2019 NICE Clinical Knowledge Summaries

4027. Diarrhoea - adult's assessment: Scenario: Chronic diarrhoea ( 4weeks)

than functional disorder). Fever, tachycardia, hypotension, dehydration. Look for other features suggestive of an underlying , including: Travel abroad — consider an infective cause, especially Giardia . Laxative use (including for treatment of hepatic encephalopathy). Other drugs. For examples, see the section on . Recent use of an antibiotic or proton pump inhibitor is associated with Clostridium difficile infection. Chronic fatty diarrhoea — suggests fat maldigestion (for example pancreatic (...) as a differential diagnosis as it is the most common cause of chronic diarrhoea [ ]. For further information, see the CKS topic on . Performing a physical examination The recommendation on abdominal and digital rectal examination is based on review articles that state although physical examination is not usually able to provide a specific diagnosis, digital rectal examination is useful in the assessment of diarrhoea as it can allow evaluation of the stool and identify anal pathology (such as fistulae

2020 NICE Clinical Knowledge Summaries

4028. Diabetes - type 2: Sodium-glucose cotransporter 2 inhibitors (SGLT-2i)

) are canagliflozin, dapagliflozin, and empagliflozin. These medications reversibly inhibit sodium-glucose co-transporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce glucose reabsorption and increase urinary glucose excretion. [ ; ; ; ] Recommended doses Canagliflozin, dapagliflozin, and empagliflozin are licensed for use in type 2 diabetes as monotherapy (if metformin inappropriate), or in combination with insulin or other antidiabetic drugs (if existing treatment fails to achieve adequate (...) is 10 mg dapagliflozin once daily for monotherapy and add-on combination therapy with other glucose-lowering medicinal products including insulin. When dapagliflozin is used in combination with insulin or an insulin secretagogue, such as a sulfonylurea, a lower dose of insulin or insulin secretagogue may be considered to reduce the risk of hypoglycaemia. Empagliflozin The recommended starting dose is 10 mg empagliflozin once daily for monotherapy and add-on combination therapy with other medicinal

2019 NICE Clinical Knowledge Summaries

4029. Hypercholesterolaemia - familial: Scenario: Management of adults with heterozygous familial hypercholesterolaemia

treatment. If unexplained muscle symptoms (such as pain, tenderness, or weakness) develop: Check creatine kinase (CK) levels. Stop statin treatment immediately if muscle symptoms are intolerable or if CK is five or more times the upper limit of normal. If muscle pain develops but statin treatment was previously tolerated for more than 3 months, explore other possible causes of myalgia and raised CK, such as vigorous physical activity, hypothyroidism, infection, recent trauma, and drug or alcohol misuse (...) erythematosus, and other systemic inflammatory disorders; and serious mental health problems. For more information, see the CKS topics on , , , and . Perform to determine the suitability of treatment with a lipid-modifying drug. If appropriate, prescribe a . Provide written information on FH, for example: HEART UK ( ) has an for people with FH. Offer advice on support groups, for example: HEART UK ( , telephone 0845 450 5988) provides information and advice on preventing premature deaths caused by high

2016 NICE Clinical Knowledge Summaries

4030. Hypercholesterolaemia - familial: How should I assess a person with possible familial hypercholesterolaemia?

mellitus or obesity (although hypertriglyceridaemia alone is the more common presentation). See the CKS topics on , , and for more information. Pregnancy. Renal replacement therapy or end-stage chronic kidney disease. See the CKS topic on for more information. Monoclonal gammopathy. Excess alcohol consumption. See the CKS topic on for more information. HIV infection. See the CKS topic on for more information. The use of certain drugs, including thiazide diuretics, corticosteroids, retinoic acid (...) /L. Look for clinical signs of FH, such as , but be aware that the absence of clinical signs does not exclude a diagnosis of FH. Exclude . An underlying cause can usually be detected from the history and examination and by checking thyroid stimulating hormone, HbA1c, renal function, electrolytes, and liver function. An underlying condition or drug may be exacerbating primary FH, and serum lipids should be rechecked (if possible) after the condition has resolved or the drug has been stopped. Use

2019 NICE Clinical Knowledge Summaries

4031. Contraception - sterilization: Scenario: Tubal occlusion

the CKS topic on . To avoid rigorous physical activity for one week. To avoid sex for at least one week. When to seek medical help, including: Abdominal pain, especially if accompanied by temperature, loss of appetite, vomiting, and generally feeling unwell — this could indicate a bowel perforation. Abdominal pain associated with missed periods — possible ectopic pregnancy. A painful, red, swollen, warm calf, or difficult weight-bearing on the leg may indicate deep vein thrombosis. For more

2020 NICE Clinical Knowledge Summaries

4032. Contraception - natural family planning: Scenario: Fertility awareness methods

. Menstrual and cycle irregularities. Postpartum – in the first 4 weeks postpartum, there are unlikely to be any detectable fertility signs or hormonal changes. Recent use of hormonal contraception – the menstrual cycle may be altered. Drugs – antibiotics (such as tetracyclines), cold remedies and analgesics may affect fertility indicators. Women with medical conditions (such as Eisenmenger syndrome), or taking certain medicines (such as teratogenic drugs), which make pregnancy an unacceptable risk should (...) on the assessment of a woman who is planning to use a fertility awareness method of contraception, see the CKS topic on . What medical conditions may make fertility awareness methods of contraception less suitable? There are no medical conditions which become worse due to the use of fertility awareness methods (FAM) and generally, these methods can be used without concern. However, several conditions can make the use of the mucus (cervical secretion and cycle length) FAM and the device methods more complex

2020 NICE Clinical Knowledge Summaries

4033. Developmental rheumatology in children: Scenario: Flat feet in children

[ ], and expert opinion in review articles [ ; ; ; ]. Experts suggest that physical therapy, bracing, or a surgical procedure (rarely indicated — for example Achilles tendon lengthening, osteotomies, joint fusion) may be beneficial for children with painful flexible flatfoot, and orthotics can provide relief of pain and prevent shoe deformation. For painful or functionally limiting rigid flat feet, orthotics, osteotomies, or fusions may be beneficial [ ; ; ; ]. © .

2019 NICE Clinical Knowledge Summaries

4034. Dermatitis - contact

. Allergic contact dermatitis is a type IV (delayed) hypersensitivity reaction that occurs after sensitization and subsequent re-exposure to a specific allergen or allergens. Common allergens include personal care products (such as cosmetics, skin care products, nail varnish, fragrances, and hair dye), metals (such as nickel), topical medications (including antibiotics and corticosteroids) and certain plants (such as sunflower and primula). Irritant contact dermatitis is a non-immunological inflammatory (...) reaction caused by the direct physical or toxic effects of an irritating substance on the skin — prior sensitisation is not required. Common irritants include repeated exposure to water (‘wet work’), detergents, cleaning agents, acids and alkalis and certain plants such as ranunculus. Prognosis is variable and depends on the causative agent and the feasibility of avoiding exposure. Complications of contact dermatitis include reduced quality of life and functional impairment (which may threaten

2016 NICE Clinical Knowledge Summaries

4035. Depression

-intensity psychosocial interventions (such as individual guided self-help, computerized cognitive behavioural therapy (CCBT) or a structured group-based physical activity programme). Antidepressants should not be used routinely for mild-to-moderate depression, but may be used for people with a history of depression, persistent subthreshold symptoms, or a concomitant chronic physical health problem. People with moderate or severe depression should be offered a combination of an antidepressant and a high (...) Depression Depression | Topics A to Z | CKS | NICE Search CKS… Menu Depression Depression Last revised in March 2020 Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive, physical Diagnosis Management Prescribing information Background information Depression: Summary Depression is characterised by persistent low mood and/or loss of pleasure in most activities and a range of associated emotional, cognitive

2016 NICE Clinical Knowledge Summaries

4036. Dementia

otherwise. Advance care planning. Assessment of, and appropriate intervention for, physical and mental health and functional disability. Assessment of carer needs and appropriate management of any mental and physical health problems as they arise. Drug treatment for cognitive symptoms of dementia — this is initiated by a specialist, but may be continued and monitored by a GP under a shared-care protocol. Prevention and management of BPSD, as far as possible, with non-pharmacological interventions (...) %) which often co-exists with vascular dementia. Vascular dementia (up to 20%). Dementia with Lewy bodies (10–15%). Frontotemporal dementia (2%). Modification of specific risk factors (in particular, cardiovascular risk factors such as smoking, diabetes and lack of physical activity) can delay or prevent the onset of dementia. Early diagnosis of dementia is important for treatment of reversible causes and advance planning while a person still has mental capacity. Dementia should be suspected if any

2019 NICE Clinical Knowledge Summaries

4037. Deep vein thrombosis

trauma or direct trauma to a vein (for example, intravenous catheter). Hormone treatment (for example hormone replacement therapy). Pregnancy and the postpartum period. Dehydration. The most serious complication is pulmonary embolism. The possibility of DVT should be considered if typical symptoms and signs are present, especially if the person has risk factors. Typical signs and symptoms are: Localised pain and swelling in one leg (occasionally both legs). Tenderness, skin changes including oedema (...) , redness, warmth. Vein distension. Other conditions that may present with similar signs and symptoms include: Physical trauma. Cardiovascular disorders, such as superficial thrombophlebitis and post-thrombotic syndrome. Other conditions such as ruptured Baker’s cyst, cellulitis, and dependent oedema. The two-level DVT Wells score should be used to assess the likelihood of DVT and inform further management. For people who are likely to have DVT (based on the results of the two-level DVT Wells score

2019 NICE Clinical Knowledge Summaries

4038. CVD risk assessment and management

advice about: Smoking cessation. Weight loss if overweight or obese. Eating a healthy diet. Keeping alcohol consumption within the recommended limits. Being physically active. Statin treatment should be offered for the primary prevention of CVD to people with an estimated 10 year CVD risk of 10% or more if lifestyle interventions have not proved effective. Atorvastatin 20 mg a day is the recommended statin if the person decides to take drug treatment after an informed discussion about benefits (...) , people of South Asian origin have an increased risk of CVD compared with people of European origin). Modifiable risk factors include smoking, high blood level of non-high density lipoprotein cholesterol, lack of physical activity, unhealthy diet, alcohol intake above recommended levels, overweight and obesity. Comorbidities that can increase the risk of developing CVD include: hypertension, diabetes mellitus, chronic kidney disease, dyslipidaemia, rheumatoid arthritis, influenza, serious mental

2019 NICE Clinical Knowledge Summaries

4039. Corticosteroids - inhaled: Scenario: Corticosteroids - inhaled

Intercollegiate Guidelines Network (SIGN) British guideline on the management of asthma [ ] , the National Institute for Health and Care Excellence (NICE) guideline Asthma: diagnosis, monitoring and chronic asthma management [ ], and the Medicines and Healthcare products Regulatory Agency (MHRA) advice High dose inhaled steroids: new advice on supply of steroid treatment cards [ ]. What delivery systems are available for inhaled corticosteroids? Pressurized metered-dose inhalers (pMDIs) In a pMDI, the drug (...) , physical barriers (for example, arthritis, muscle weakness), other medical conditions (for example, impaired vision), coordination, cognitive impairment, and inspiratory flow (a minimum inspiratory flow rate is required for use of dry powder inhalers [DPIs] or breath-actuated metered-dose inhalers [BA-MDIs]). For children aged under 3 years, the preferred device is a pressurized metered-dose inhaler (pMDI) with spacer and face mask. For children aged 3–5 years, the preferred device is pMDI with spacer

2018 NICE Clinical Knowledge Summaries

4040. Contraception - assessment: Scenario: Issues to discuss and consider

thromboembolism (VTE). Concurrent medication — liver enzyme-inducing drugs (such as medicines used to treat epilepsy, anti-retrovirals and St John’s Wort) can affect some forms of contraception. Avoid less effective methods of contraception (such as fertility awareness-based methods) if the woman is taking teratogenic drugs (for example lithium or warfarin). Age of the woman — approaching the menopause or under 18 years. Consider any relevant ethical and legal issues if the woman has a learning disability (...) (pill, transdermal patch, or vaginal ring). Progestogen-only pill. Progestogen-only injectable. If pregnancy cannot be excluded and the woman wishes to start hormonal contraception without delay, see the section on . Identify any relevant medical conditions or medication that could affect the choice of contraception. Check the to ensure that her preferred method is not contraindicated. If the woman is considering sterilization, or natural family planning, the should be checked as these issues

2020 NICE Clinical Knowledge Summaries

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