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4041. Obsessive-compulsive disorder: When should I suspect obsessive-compulsive disorder?

) — suggested by recurrent pulling out of hair, resulting in hair loss. Excoriation (skin-picking) disorder — suggested by recurrent picking of skin, resulting in skin lesions. Substance-induced or medication-induced obsessive-compulsive disorder — suggested by OCD-type symptoms that are attributable to effects of medication or drug of abuse, and develop during or soon after substance intoxication or withdrawal or after exposure to substance. ICD-10 and DSM-5 criteria for the diagnosis of obsessive (...) that the point of the activity is lost, with absence of obsessions and compulsions, but may involve discomfort if things are sensed not to have been done completely. Body dysmorphic disorder (BDD) — suggested by obsessive preoccupation with a perceived defect in physical appearance. Somatic symptom disorder — suggested by excessive thoughts, feelings, or behaviours related to somatic symptoms or associated health concerns. Illness anxiety disorder (hypochondriasis) — suggested by a preoccupation with having

2017 NICE Clinical Knowledge Summaries

4042. Obesity: Scenario: Management

on the length of the follow-up period [ ]. Drug treatment plus lifestyle interventions can produce a small but statistically significant increase in weight loss, but long-term maintenance of the weight loss is also poor and adherence to treatment may be affected by possible adverse effects of the medication [ ]. Expert opinion in the European Guidelines for Obesity Management in Adults is that cognitive behavioural therapy directly addresses behaviours that require change for successful weight loss (...) . are the treatment of choice. Ensure weight management programmes include behaviour change strategies to increase people's physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person's diet, and reduce energy intake. Drug treatment and/or surgery may be required in some cases. Tailor the components of the planned weight management programme to the person's preferences, initial fitness, health status, and lifestyle. When deciding on treatment type (and intensity

2017 NICE Clinical Knowledge Summaries

4043. Obesity

are overweight or obese. The components of the planned weight management programme should be discussed and agreed with the person, and tailored to their preferences, initial fitness, health status, and lifestyle. Weight management programmes should include behaviour change strategies to increase people's physical activity levels or decrease inactivity, improve eating behaviour and the quality of the person's diet, and reduce energy intake. Drug treatment should be considered as an adjunct to lifestyle (...) Obesity Obesity | Topics A to Z | CKS | NICE Search CKS… Menu Obesity Obesity Last revised in December 2017 The terms 'overweight' and 'obesity' are used to describe excess body fat. Diagnosis Management Prescribing information Background information Obesity: Summary The terms 'overweight' and 'obesity' are used to describe excess body fat. Obesity results from an imbalance between energy intake and energy expenditure. Many factors can influence this, including lifestyle, genetics, medical

2019 NICE Clinical Knowledge Summaries

4044. Osteoarthritis: Scenario: Management

expert consensus document on pain management [ ], and are also pragmatic, based on what CKS considers to be good medical practice. The EULAR task force systematic literature review cited very low- to moderate-quality studies which found positive effects on pain from psychological interventions (such as cognitive behavioural therapy, mindfulness programmes, and stress management). Advice on pain management The recommendations on pain management are largely based on the NICE guideline [ ], the OARSI (...) , based on what CKS considers to be good medical practice. Arranging referral to psychological services The recommendation on provision of psychological support is based on the EULAR expert consensus document on pain management [ ], and is also pragmatic, based on what CKS considers to be good medical practice. Psychological and social interventions showed a uniform positive effect on pain for cognitive behavioural therapy (CBT) on general osteoarthritis, and relaxation interventions in osteoarthritis

2019 NICE Clinical Knowledge Summaries

4045. Opioid dependence: When should I suspect a person has a problem with opioid dependency?

Opioid dependence: When should I suspect a person has a problem with opioid dependency? Suspecting opioid dependency | Diagnosis | Opioid dependence | CKS | NICE Search CKS… Menu Suspecting opioid dependency Opioid dependence: When should I suspect a person has a problem with opioid dependency? July 2019 When should I suspect a person has a problem with opioid dependency? Drug misuse may become apparent while a person is consulting with another medical problem (that may or may not be drug (...) . Social history — family problems, unemployment, accommodation issues, financial problems. On physical examination, there may be evidence of poor nutrition, dental caries, other signs of neglect, needle tracks, skin abscess, and signs of drug intoxication or withdrawal. On mental health assessment, there may be indications of abnormal general behaviour, disorders of mood (particularly anxiety or low mood), delusions or hallucinations, confusion. Basis for recommendation These recommendations are based

2019 NICE Clinical Knowledge Summaries

4046. Opioid dependence: Scenario: Management

for psychosocial interventions. Checking medication is being taken correctly (for example sublingual buprenorphine). A change of substitution therapy. Referral to a more specialized service. Harm-reduction advice about alcohol and other drug use (for example, cocaine, benzodiazepines). If the person is taking: Heroin — review treatment and consider increasing rather than decreasing the intensity of the treatment programme if the person is failing to benefit from treatment. Alcohol or benzodiazepines — review (...) Addiction services prescribing guidelines for medication assisted recovery with opioid replacement therapy [ ], a report from an expert panel Safe methadone induction and stabilization: report of an expert panel [ ], a personal communication [ ], and what CKS considers good clinical practice. Offering take-home naloxone [ ] Naloxone is a potentially life-saving medicine when used in settings associated with opiate misuse and overdose. Systematic reviews conclude that pre-provision of naloxone to heroin

2019 NICE Clinical Knowledge Summaries

4047. Neck pain - whiplash injury: Scenario: Whiplash injury

depends on the severity of pain, personal preferences, tolerability, and risk of adverse effects. For prescribing information on nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and codeine, see the CKS topics on and . Consider referral to physiotherapy for a multimodal treatment strategy, which may include range of motion exercises, strengthening and stretching exercises, and some form of manual therapy. Consider referral to a psychologist, for people : Considered to have a poor (...) , and are not recommended include : Anticonvulsants. Antidepressants. Muscle relaxants. Basis for recommendation These recommendations are based on an Australian guideline Guidelines for the management of acute whiplash-associated disorders for health professionals [ ], a Canadian guideline Management of neck pain and associated disorders [ ], the American Physical Therapy Association (APTA) guideline Neck Pain: Clinical Practice Guidelines Revision 2017 [ ], and the Scientific monograph of the Quebec Task Force

2016 NICE Clinical Knowledge Summaries

4048. Neck pain - whiplash injury: How should I assess someone with suspected whiplash injury?

Neck pain - whiplash injury: How should I assess someone with suspected whiplash injury? Assessment | Diagnosis | Neck pain - whiplash injury | CKS | NICE Search CKS… Menu Assessment Neck pain - whiplash injury: How should I assess someone with suspected whiplash injury? Last revised in October 2018 How should I assess someone with suspected whiplash injury? In people with neck pain following sudden extension, flexion or rotation of the neck: Take a detailed medical history, ask about (...) : The circumstances of the injury (type of collision). The symptoms: localisation, time and profile of onset, intensity of pain (ideally assessed using the Visual Analogue Scale [VAS]). Occupational history. Medical history, including previous injury or infection. Symptoms of anxiety or depression. History of cancer. Presence of fever. Do not examine neck movements until which may indicate a serious injury have been excluded. If a serious neck or head injury is suspected, urgently refer to Accident and Emergency

2018 NICE Clinical Knowledge Summaries

4049. Neck pain - non-specific: Scenario: Management

) if the person has failed to respond to treatment. Basis for recommendation These recommendations are based on the American Physical Therapy Association (APTA) guideline Neck Pain: Clinical Practice Guidelines Revision 2017 [ ], a Danish guideline National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy [ ], a Canadian guideline Management of neck pain and associated disorders [ ], expert opinion in a chapter on neck pain in the Oxford textbook (...) of primary medical care primary care [ ], narrative reviews The diagnosis and treatment of nonspecific neck pain and whiplash [ ], The diagnosis and treatment of nonspecific neck pain and whiplash [ ], Advances in the diagnosis and management of neck pain [ ], and what CKS considers good clinical practice. Analgesics Few clinical trials have evaluated drugs for neck pain, so treatment is often based on generalization from studies performed for back pain [ ]. Two moderately sized placebo controlled trials

2018 NICE Clinical Knowledge Summaries

4050. Neck pain - non-specific: How should I assess someone with non-specific neck pain?

a physical examination to distinguish neuropathic pain from mechanical neck pain. Ask about: . Occupational history. Medical history. Symptoms of anxiety or depression. Previous injury or infection. History of cancer — in these people, aetiology of pain should be assumed to be cancer, until it is excluded. Presence of fever — in these people, neck pain should be assumed to be secondary to an infection until proven otherwise. Assess the appearance of the neck and the range of motion. Palpate the neck (...) Neck pain - non-specific: How should I assess someone with non-specific neck pain? Assessment | Diagnosis | Neck pain - non-specific | CKS | NICE Search CKS… Menu Assessment Neck pain - non-specific: How should I assess someone with non-specific neck pain? Last revised in October 2018 How should I assess someone with non-specific neck pain? The diagnosis of non-specific neck pain is clinical — further investigation is not normally required. Take a detailed medical history and conduct

2018 NICE Clinical Knowledge Summaries

4051. Neck pain - non-specific

to the arms — in most cases no specific cause can be found. Symptoms vary with physical activity and over time. The cause is usually multifactorial and includes poor posture, neck strain, sporting and occupational activities, anxiety, and depression. Assessment of people with neck pain should include: Taking a detailed medical history and conducting a physical examination to distinguish neuropathic pain from mechanical neck pain. Assessing for features of specific neck conditions, for example whiplash (...) nonsteroidal anti-inflammatory drug (NSAID). Encouraging activity and a return to a normal lifestyle. Considering prescribing muscle relaxants. Considering a referral to physiotherapy for a multimodal treatment strategy that includes stretching and strengthening exercise, and some form of manual therapy. Advising that a firm pillow may provide comfort at night. Considering referral to a psychologist if appropriate. Consider referral to occupational health for people with neck pain related to their work

2018 NICE Clinical Knowledge Summaries

4052. Neck pain - cervical radiculopathy: What else might it be?

, antipsychotic drugs, metoclopramide, amphetamines, cocaine). Arthritis of cervical spine. Cervical strain/fracture/dislocation/myelopathy. Malignancy. Neurological disorders leading to dystonia (for example stroke, encephalitis). Non-specific neck pain — neck pain that varies with different physical activities and with time, or is related to an awkward movement, poor posture, or overuse. For more information, see the CKS topic on . Psychogenic dystonia. See Table 1 for the differential diagnosis of cervical (...) , endocrinological, or neurological. For example: Acute disc prolapse — the most common cause of severe secondary torticollis. Acute torticollis — neck pain that is due to acute spasm with no obvious underlying cause. For more information, see the CKS topic on . Acute trauma (for example, whiplash type injury) — neck pain symptoms that follow a recent sudden or excessive hyperextension, flexion, or rotation of the neck. For more information, see the CKS topic on . Adverse drug reactions (for example

2018 NICE Clinical Knowledge Summaries

4053. Neck pain - cervical radiculopathy: Scenario: Management

despite 6 to 12 weeks of conservative treatments, or progressive motor weakness, and MRI that shows nerve root compression. Basis for recommendation These recommendations are based on the American Physical Therapy Association (APTA) guideline Neck Pain: Clinical Practice Guidelines Revision 2017 [ ], a Danish guideline National clinical guidelines for non-surgical treatment of patients with recent onset neck pain or cervical radiculopathy [ ], a Canadian guideline Management of neck pain (...) depends on the severity of pain, personal preferences, tolerability, and risk of adverse effects. For prescribing information on nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and codeine, see the CKS topic on . Consider offering amitriptyline, duloxetine, pregabalin or gabapentin. For more information, see the CKS topic on . Consider prescribing muscle relaxants. For information on prescribing diazepam, see the CKS topic on . Consider a referral for physiotherapy — this may include

2018 NICE Clinical Knowledge Summaries

4054. Neck pain - cervical radiculopathy: How should I assess someone with suspected cervical radiculopathy?

Neck pain - cervical radiculopathy: How should I assess someone with suspected cervical radiculopathy? Assessment | Diagnosis | Neck pain - cervical radiculopathy | CKS | NICE Search CKS… Menu Assessment Neck pain - cervical radiculopathy: How should I assess someone with suspected cervical radiculopathy? Last revised in September 2018 How should I assess someone with suspected cervical radiculopathy? Take a detailed medical history and conduct a physical examination to distinguish neuropathic (...) spondylosis and neck pain [ ], The diagnosis and treatment of nonspecific neck pain and whiplash [ ], a chapter on neck pain in the Oxford textbook of primary medical care [ ], and a systematic review Value of physical tests in diagnosing cervical radiculopathy [ ]. Physical examination tests for cervical radiculopathy There is limited evidence for accuracy of physical examination tests for the diagnosis of cervical radiculopathy. A systematic review of five studies which looked at the accuracy

2018 NICE Clinical Knowledge Summaries

4055. Opioid dependence: Scenario: Assessment

the need for substitute medication or other prescribing for dependence. Assess risk behaviours, including those associated with injecting. Comprehensive assessment may need to be conducted over several sessions and is then ongoing. It may be appropriate for concerned friends, relatives, carers or other professionals already involved to attend. Take a history and ask about: Degree of dependence (past and current) — types of psychoactive drugs used (including prescribed and over-the-counter medicines (...) ; knowledge of HIV and hepatitis A, B, and C; issues of transmission and safer sex. For drug-misusing parents or other adults with dependent children, obtain information on the children and any drug-related risks to which they may be exposed. Medical history — current or previous physical complications of drug use such as infection with blood-borne viruses or continuing related risky behaviours, liver disease, abscesses, overdoses, enduring severe physical disabilities and sexual health problems, last

2019 NICE Clinical Knowledge Summaries

4056. Opioid dependence

and antagonist activity at opioid receptors. Opioid dependence develops after a period of regular use of opioids, with the time required varying according to the quantity, frequency and route of administration, factors of individual vulnerability and the context in which drug use occurs. Physical and psychological dependence can develop within a relatively short period of continuous use (2–10 days). The key elements of opioid dependence include a strong desire or sense of compulsion to take opioids (...) be suspected in people who actively ask for help for dependency, and those with: A complication of illicit drug use. Clinical features of opioid intoxication, or withdrawal. A psychiatric, forensic, or social history which may be related to opioid dependency. Signs or symptoms of dependency, such as poor nutrition, needle tracks, or skin abscess. The need for opioid substitution therapy should be assessed and whether to opt for maintenance therapy or detoxification discussed. If substitution is being

2019 NICE Clinical Knowledge Summaries

4057. Neck pain - acute torticollis: Scenario: Management

appropriate. Basis for recommendation CKS could find no treatment guidelines or systematic reviews, or randomised placebo controlled trials which compared treatments for acute torticollis. These recommendations are extrapolated from the British Medical Journal (BMJ) best practice guide Acquired torticollis [ ], the American Physical Therapy Association (APTA) clinical practice guideline Neck Pain [ ], expert opinion in a medical textbook ABC of common soft tissue disorders [ ], a narrative review Advances (...) , personal preferences, tolerability, and risk of adverse effects. For prescribing information on nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol, and codeine, see the CKS topic on . Consider prescribing muscle relaxants. For information on prescribing diazepam, see the CKS topic on . Consider a referral for physiotherapy treatment. Provide useful . Advise people to return for further assessment if their symptoms do not improve, or if they deteriorate. Refer people with symptoms when

2019 NICE Clinical Knowledge Summaries

4058. Neck pain - acute torticollis: How should I assess someone with suspected acute torticollis?

investigations are not usually required. Take a detailed medical history and conduct a physical examination to distinguish neuropathic pain from mechanical neck pain. Ask about: of acute torticollis. Occupational history. Medical history (for example, rheumatoid arthritis, which can cause atlantoaxial rotatory subluxation). Symptoms of anxiety or depression. Previous injury or infection. History of cancer — in these people, aetiology of pain should be assumed to be cancer, until it is excluded. Presence (...) to exclude cervical radiculopathy. Consider looking for Kernig's sign (painful/resisted extension of leg bent at hip and knee) and Brudzinski's sign (reflective flexion of the knees when patient is on his/her back and the neck is bent forwards) to demonstrate nuchal rigidity if meningitis is suspected. Identify and urgently refer people with indicative of serious spinal pathology. Exclude of neck pain. Basis for recommendation These recommendations are extrapolated from the British Medical Journal (BMJ

2019 NICE Clinical Knowledge Summaries

4059. Neck pain - acute torticollis

. Acute torticollis (less than six weeks duration) is thought to be due to minor local musculoskeletal irritation causing pain and spasm in neck muscles. The cause of torticollis is often not known, but it may be due to issues with posture — for example, poor positioning at a computer screen, inappropriate seating, sleeping without adequate neck support, or carrying heavy unbalanced loads. Assessment of a person with acute torticollis should include: Taking a detailed medical history and conducting (...) a physical examination to distinguish neuropathic pain from mechanical neck pain. Excluding red flags suggestive of a serious spinal or other abnormality, including compression of the spinal cord (myelopathy), cancer, severe trauma or skeletal injury, and vascular insufficiency. Identifying typical features of acute torticollis such as a sudden onset of severe unilateral pain, with restricted and painful neck movements, and diffuse tenderness on the involved side with palpable spasm. Excluding other

2019 NICE Clinical Knowledge Summaries

4060. Endoscopic management of gastrointestinal motility disorders – part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

, Belgium ?9 Department of Hepatogastroenterology, Institutefor Clinical and Experimental Medicine, Prague, Czech Republic 10 Department of Medicine I, University Medical Center Mainz, Mainz, Germany 11 Department of Health Sciences, Beaujon Hospital, Clichy,Assistance Publique-Hôpitaux de Paris and University of Paris, Paris, France 12 Division of Gastroenterology, Montréal University Hospital (CHUM), Montréal, Canada 13 Department of Surgery, Oncology and Gastroenterology, DiSCOG, University of Padova (...) ; 52 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Bas L.A.M. Weusten, MD, PhD, Dept of Gastroenterology and Hepatology, University Medical Center Utrecht, Internal mail no F02.618, P.O. Box 85500, 3508 GA UTRECHT, The Netherlands b.l.a.weusten@umcutrecht.nl Appendix 1s – 3s Online content viewable at: https://doi.org/10.1055/a-1171-3174 MAIN RECOMMENDATIONS ESGE suggests flexible endoscopic treatment over open surgical treatment as first-line therapy

2020 European Society of Gastrointestinal Endoscopy

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