Analysis of Clinical Guidelines
Gersende Georg, Centre des Cordeliers, UMRS 872 Eq. 20, Paris, France
Study of References using Tropes
The surface of the disease sphere is proportional to the number of words it contains. The graph shows the Relations between the References. The References on the left of the central Reference are its predecessors, those on the right its successors. The associated references for disease are: treatment, therapy, patient, diagnosis, indication.
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The associated references for treatment are: disease, patient, therapy, indication, dose, and drug.
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We first studied the frequency of deontic verbs for the set of clinical guidelines collected (composed of 44 892 word occurrences).
Verb |
Number of Occurrences |
Verb |
Number of Occurrences |
Shall |
709 |
Recommend |
277 |
Use |
163 |
Have |
151 |
Consider |
142 |
Can |
113 |
Include |
104 |
Receive |
67 |
Assess |
62 |
May |
56 |
Perform |
55 |
Provide |
52 |
Indicate |
46 |
Treat |
45 |
Require |
45 |
Refer |
40 |
Determine |
36 |
Associate |
36 |
Administer |
35 |
Improve |
35 |
Reduce |
34 |
Occur |
34 |
Suggest |
31 |
Support |
31 |
Obtain |
28 |
Evaluate |
27 |
Prevent |
22 |
Initiate |
18 |
Must |
17 |
Dose |
16 |
Suspect |
15 |
Achieve |
15 |
Confirm |
15 |
Establish |
15 |
Avoid |
15 |
Cause |
14 |
Fail |
14 |
Appear |
14 |
Tolerate |
14 |
Appropriate |
14 |
Diagnose |
14 |
Limit |
13 |
Advise |
13 |
Inform |
12 |
Begin |
12 |
Prefer |
12 |
Complete |
12 |
Exclude |
11 |
Discuss |
11 |
Prescribe |
11 |
Detect |
11 |
Lead |
10 |
Choose |
10 |
Manage |
10 |
Contraindicate |
10 |
Involve |
9 |
Advocate |
9 |
Allow |
9 |
Combine |
8 |
Contribute |
7 |
Apply |
7 |
Change |
7 |
Affect |
7 |
Facilitate |
6 |
Permit |
6 |
Modify |
3 |
We used the statistical text analysis software TropesTM [1] to analyze these documents, particularly words occurrences and lemmatized verbs. We considered to recommend as the reference verb of the deontic modality in clinical guidelines due to the fact that in medical texts it always expresses recommendations.
The Star graph displays the Relations between References, or between a Word category and a Reference. The figures shown on the graphs give the number of Relations (co-occurrence frequency) existing between the various References. The graphs show the Relations between the References. They are oriented: the References on the left of the central Reference are its predecessors, those on the right its successors.
Co-occurrences of the verb to recommend are: therapy, indication, practitioner, information, patient, treatment, disease.
We studied the lexical context of each verb of the corpus and identified these which are similar to the reference verb. Co-occurrences of the verb shall are: disease, practitioner, patient, therapy, treatment, examination, assessment, dose, information.
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Co-occurrences of the verb to use are: practitioner, decision, drug, disease, therapy, substance, patient, treatment, combination.
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Co-occurrences of the verb to consider are: disease, therapy, practitioner, treatment, patient, examination, drug, diagnosis, agent.
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We have a set of deontic verbs specific to clinical guidelines such as to recommend, shall, must, can, may. We also identified a set of associated deontic verbs such as to use, to consider to include to receive, to assess, to perform, to indicate, to treat, to associate, to associate, to reduce, to improve, to avoid, to begin, to prefer, to prescribe, to contraindicate.
We then studied the context of each deontic verb with the Simple Concordance Program[2] to determine patterns.
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Examples of recommendations recognized by G-DEE[3]
Nurses
embrace the following values and beliefs: respect; human dignity; clients are
experts for their own lives; clients as leaders; clients' goals coordinate care
of the healthcare team; continuity and consistency of care and caregiver;
timeliness; responsiveness and universal access to care (1).
These values and beliefs must be incorporated
into, and demonstrated throughout , every aspect of client care and services (2).
The principles of client centred care should be included in
the basic education of nurses in their core curriculum , be available as
continuing education, be provided in orientation programs and be sustained
through professional development opportunities in the organization (3). Organizations
should engage all members of the healthcare team in this ongoing
education process (4).
To foster client centred care consistently
throughout an organization , healthcare services must be organized and
administered in ways that ensure that all caregivers , regardless of their
personal attributes , enact this practice successfully (5).
EEG should
be used to support the
classification of epileptic seizures and epilepsy syndromes when there is
clinical doubt (6).
All infants born to mothers taking AEDs should be given vitamin
K1 1 mg intramuscularly at birth (7).
For sustained control in other patients or if
seizures continue, within 30 minutes (8).
Give fosphenytoin in a dose of 18 mg/kg phenytoin
equivalent (PE) IV, up to 150 mg/min with electrocardiography (ECG) monitoring;
or phenytoin 18 mg/kg IV, 50 mg/min with ECG monitoring or phenobarbital 15
mg/kg IV, 100 mg/min (9).
Rates of infusion may need to be reduced if hypotension or arrhythmia occur or in elderly or renal/ hepatic
impairment (10).
Educate nurses, families, policy-makers, and the
public to respond to expected or unexpected life events within the family (11).
Identify resources and supports to assist families
address the life event, whether this is expected or unexpected (12). Resources should be identified within
the following three categories (13).
Intrafamilial Interfamilial Extrafamilial (14).
Assess family in the context of the event(s) to
identify whether assistance is required by the nurse to strengthen and support
the family (15).
Surgeries performed with the intent to limit
the venous outflow of the penis are not
recommended (16).
Only vacuum constriction devices containing a
vacuum limiter should be used whether purchased over-the-counter or procured with
a prescription (17).
Arterial reconstructive surgery is a treatment option
only in healthy individuals with recently acquired erectile dysfunction
secondary to a focal arterial occlusion and in the absence of any evidence of
generalized vascular disease (18).
If CIN is identified at the margins of a
diagnostic excisional procedure or in a postprocedure endocervical sampling ,
it is preferred that the 4- to 6-month follow-up visit include a
colposcopic examination and an endocervical sampling (19).
Excisional modalities are preferred for
patients who have recurrent biopsy-confirmed CIN-1 after undergoing previous
ablative therapy (20).
Podophyllin or podophyllin-related products are
unacceptable for use in the vagina or on the cervix (21).
Colony-stimulating factors are not recommended for
routine use to treat febrile or afebrile neutropenic patients (22).
Trimethoprim-sulfamethoxazole (TMP-SMZ)
therapy is recommended at risk for Pneumocystis carinii pneumonitis ,
regardless of whether they have neutropenia (23).
If the patient becomes afebrile but remains
neutropenic, the proper antibiotic course is less well defined (24). Some
specialists recommend continuation of antibiotics , given intravenously or
orally , until neutropenia is resolved (25).
Allergy to metronidazole is uncommon (26). Use 2% clindamycin
cream for metronidazole allergic women (27).
The results of further randomised controlled trials
of screening and treating all pregnant women are awaited, but there are
insufficient data to make such a recommendation at present (28). In
conclusion , symptomatic pregnant women should
be treated in the usual way (29).
Management (30).
General Advice (31).
Ideally , treatment should be effective (microbiological
cure rate >95%) , easy to take (not more than twice daily) , with a low side
effect profile , and cause minimal interference with daily lifestyle (32).
If a speculum examination is not possible then
urine samples can be utilized (33).
Fire hoses are sometimes found in hallways and
stairwells of older facilities (34).
Water from hoses is not sterile (35).
The water can
also create an electric shock
hazard (36). In addition
, the water stream itself can deliver sufficient force to cause injury or
mechanical damage and can make the hose difficult to hold onto (37). The
guideline developers do not recommend the uses of fire hoses to extinguish surgical fires (38).
Fire Drills (39).
Fire drills not only allow staff to practice
for a fire but also help troubleshoot any difficulties that might occur (40).
Some elements to consider in planning a fire drill
are (41). The proper
response of each surgical team member and the operating suite staff (42). How the
patient can easily and safely be moved to another OR How the spread of smoke should be
prevented (for example , through the use of smoke doors and air duct dampers) (43). The location and
operation of fire extinguishers, fire alarm pull stations, and exits (44). What the
response of additional fire-fighting personnel (such as the fire response team
and local fire department) should be (45).
If Evacuation is Necessary (46).
In some very rare cases , extreme smoke and
fire conditions may force the evacuation of the OR where the fire occurs
(47). In such
cases , the acronym RACE defines the actions that should take place
(48).
In primary care and specialty medical settings
, ACIP recommends implementation of standing orders to identify adults
recommended for hepatitis B vaccination and administer vaccination as part of
routine services (49).
To ensure vaccination of adults at risk for
HBV infection who have not completed the vaccine series , ACIP recommends the
following implementation strategies (50).
Provide information to all adults regarding
the health benefits of hepatitis B vaccination , including risk factors for HBV
infection and persons for whom vaccination is
recommended (51).
Help all adults assess their need for vaccination by
obtaining a history that emphasizes risks for sexual transmission and
percutaneous or mucosal exposure to blood (52).
Vaccinate all adults who report risks for HBV
infection (53). Vaccinate all
adults requesting protection from HBV infection, without requiring them to
acknowledge a specific risk factor (54).
Public health programs and primary care
providers should adopt strategies appropriate for the practice setting to
ensure that all adults at risk for HBV infection are offered hepatitis B
vaccine (55).
Hepatitis
B vaccination is recommended for all unvaccinated adults at risk for HBV
infection and for all adults requesting protection from HBV infection (see Box
below titled "Adults Recommended to Receive Hepatitis B Vaccination")
(1). Acknowledgment
of a specific risk factor should not be a requirement for vaccination (2).
A standing anteroposterior (AP) and a lateral
view should be taken initially (3).
A tangential view of the patella-femoral joint
("sunrise" view) and a standing posteroanterior (PA) view taken in 40
degrees of flexion can be useful (4).
Radiographic feature of OA include: narrowing of the
cartilage space, marginal osteophytes, subchondral sclerosis, and beaking of
the tibial spines (5).
Viscosupplementation may have a role
in the treatment of knee pain due to osteoarthritis during the initial 12 weeks
in the hands of physicians technically proficient in arthrocentesis (6).
Liver transplantation for metastatic
neuroendocrine tumors should be confined to highly selected patients who are not candidates
for surgical resection in whom symptoms have persisted despite optimal medical
therapy (7).
Children with tyrosinemia who develop
hepatocellular carcinoma (HCC) and meet the criteria for liver transplantation
for HCC should be high-priority candidates (8).
Liver transplantation is the only effective treatment
for infants with severe neonatal hemochromatosis (9).
Urgent evaluation at a transplant center is recommended (10).
Recommendations for Diagnosis of Patients with an
Intermediate Likelihood of Coronary Artery Disease (CAD) Exercise myocardial
perfusion SPECT to assess the functional significance of intermediate (25 to
75%) coronary lesions (11).
Adenosine or dipyridamole myocardial perfusion SPECT
after initial perfusion imaging in patients whose symptoms have changed to
redefine the risk for cardiac event (12).
Identification of hemodynamic significance of
coronary stenosis after coronary arteriography (13).
Stress MPI (14).
Patients 6 years of age or older should be referred to
an emergency department if they have ingested at least 10 g or 200 mg/kg (whichever is lower) or when the amount ingested is unknown (15).
Patients less than 6 years of age should be referred to
an emergency department if the estimated acute ingestion amount is unknown
or is 200 mg/kg or more (16).
Patients can
be observed at home if the dose
ingested is less than 200 mg/kg (17).
Activated charcoal can be considered if
local poison center policies support its prehospital use , a toxic dose
of acetaminophen has been taken , and fewer than 2 hours have elapsed since the
ingestion (18). Women at Average
Risk (19). Begin mammography
at age 40 (20).
For women in their 20s and 30s , it is recommended that
clinical breast examination (CBE) be part of a periodic health examination ,
preferably at least every three years (21).
Asymptomatic women aged 40 and over should continue to receive a clinical breast examination as part of a periodic health examination
, preferably annually (22).
Beginning in their 20s , women should be told
about the benefits and limitations of breast self-examination (BSE) (23).
Narcotic use must be carefully titrated and
supervised (24).
Antibiotic prophylaxis is effective in reducing wound
infection after hip fracture surgery (25).
Routine use of temporary leg traction appears to be
unnecessary (26).
Analgesia/symptomatic treatment (27).
Recognize that a number of morbidities
commonly seen in homeless patients , including untreated dental problems ,
hepatitis , and traumatic injuries , can
result in chronic pain (28). It is
important to remember that some drugs , such as methadone and other narcotics ,
can increase or decrease the effects of pain medications (29). Work with the
patient to understand the underlying cause of pain (30).
Prescribe appropriate pain medication and document
why you prescribed it (31).
To avoid overmedicating or contributing to
drug-seeking behavior, specify the plan of care in a written contract with the
patient, designating a single provider for pain prescription refills (32). Consider providing
a cough suppressant or analgesia for a children acute ear infection, if not
detrimental, to allow the child to sleep (33).
A crying child will disrupt other shelter
residents , which could place the family at risk for eviction (34).
If so, consult the Association of Occupational and
Environmental Clinics for referrals and assistance (35).
A written action plan can give the
patient and/or parent a sense of control (36).
Most important is to clarify the plan of care
in language they can understand (37).
For those who are comfortable with written
information , summarize key points on a pocket card that can be carried with
them (38). Ask if
there is another person who can help the patient or family cope with illness (39).
Drug treatment with peginterferon alfa-2a or
adefovir dipivoxil should be initiated only by an appropriately qualified healthcare
professional with expertise in the management of viral hepatitis (40). Continuation of
therapy under shared-care arrangements with a general practitioner is
appropriate (41).
Adefovir dipivoxil should not normally be given before treatment with lamivudine (42). It may be used either alone or in combination with lamivudine when
treatment with lamivudine has resulted in viral resistance , or lamivudine
resistance is likely to occur rapidly (for example , in the presence of highly
replicative hepatitis B disease) , and development of lamivudine resistance is
likely to have an adverse outcome (for example , if a flare of the infection
is likely to precipitate decompensated liver disease) (43).
Peginterferon alfa-2a is recommended as
an option for the initial treatment of adults with chronic hepatitis B
(HBeAg-positive or HBeAg-negative) , within its licensed indications (44).
When assessing adherence , clinicians should use precise
language that the patient can understand (45).
In addition , clinicians should verify that
patients are taking the medications as prescribed , specifically , correct
medications , correct number of pills per dose , and correct number of doses
per day (46).
Clinicians should
reassess potential barriers to
adherence at least every 3 to 4 months and whenever adherence problems are
identified (47).
Clinicians should
assess potential interactions
between HAART and methadone before and during therapy by inquiring about
oversedation and opioid withdrawal symptoms (48).
If withdrawal symptoms are present ,
the primary care clinician should conduct a detailed history and facilitate a dose increase by
educating the patient and communicating with the methadone provider (49). The stage of
ovarian cancer is an important prognostic factor that influences survival and
the choice of therapy (50).
The quality of the surgical staging is a key
determinant of treatment recommendations (51).
Women who have not undergone optimal surgical
staging can be offered two options (52).
The first option is that they undergo reoperation to
optimally define the tumour stage and then be offered adjuvant therapy based on
the findings (53).
The other option is that they be offered
platinum-based chemotherapy to decrease the risk of recurrence and improve
survival (54).
There is insufficient evidence to make a
recommendation on the role of adjuvant pelvic radiation, whole abdominal-pelvic
radiotherapy, or intraperitoneal radioactive chromic phosphate (55).
There is insufficient evidence to reliably inform the
use of intracavitary radiotherapy either alone or in combination with external
beam radiotherapy (56).
Regardless of surgical staging, adjuvant external
beam radiotherapy is recommended for patients at high risk of recurrence is not
recommended in patients at low risk of recurrence is a reasonable treatment
option for patients at intermediate risk of recurrence Two randomized trials
detected that adjuvant external beam radiotherapy improved pelvic control, but
not survival, when compared to no further treatment (57).
In patients with no adjuvant therapy , salvage
radiotherapy may be effective upon vaginal recurrence (58).
When considering adjuvant radiotherapy, the potential
improvement in pelvic control needs to be weighed against the toxicity of
radiotherapy (59).
Radiotherapy was associated with a low incidence of
severe acute and late adverse effects; however, many patients experienced mild
(grade 1 or 2) side effects (60).
The long-term effects of radiotherapy are unknown at
this time (61).
With the potential for substantial grade
changes upon pathology review , which may
influence decisions regarding
adjuvant radiotherapy , it may be important for each jurisdiction to establish a level
of quality assurance with specific indications for pathology review (62). However ,
the extent to which quality assurance can be
determined is outside of the scope
of this report (63).
Specialized nutrition support (SNS) should be used in
patients who cannot meet their nutrient requirements by oral intake (64).
When SNS is required , enteral
nutrition (EN) should generally be used in preference to parenteral nutrition (PN) (65). Help ensure that
all adolescents have knowledge of and access to contraception including barrier
methods and emergency contraception supplies (66).
Be aware of options and resources for adolescents and
advocate for comprehensive medical and psychosocial support for all pregnant
adolescents in the community (67).
Assess the adolescent mother's abilities to care for
her children and have resources available for referral and assistance before
neonatal discharge (68).
Nurses working with individuals with asthma must have the
appropriate knowledge and skills to (69).
Identify the level of asthma control,Provide basic
asthma education,Conduct appropriate referrals to physician and community
resources (70).
Education should
include as a minimum , the
following (71). Basic facts about
asthma,Roles/rationale for medications,Device
technique(s),Self-monitoring,Action plans (72).
Clients with poorly controlled asthma should be referred to
their physician (73).
In choosing the components for a clinically
relevant vaccine , the physician should be familiar with local and regional aerobiology and
indoor and outdoor allergens , paying special attention to potential allergens
in the patient's own environment (74).
Summary Statement 55 (75).
In older adults , medications and co-morbid
medical conditions may increase the risk from immunotherapy (76).
Therefore , special consideration must be given to
the benefits and risks of immunotherapy in older adults (77).
The maintenance concentrate and serial
dilutions , whether a single vaccine or a mixture of vaccines , should be prepared and
labeled for each patient (78).
There is evidence from one randomized controlled
trial demonstrating that continuous hyperfractionated accelerated radiation
therapy (CHART) improves survival over standard radiotherapy of 60 Gy in 30
fractions, in patients with locally advanced, unresectable stage III non-small
cell lung cancer (NSCLC) (79).
Selected patients (with Eastern Cooperative
Oncology Group [ECOG] performance status > 1 who do not fit the criteria for
induction chemotherapy and radiotherapy or patients who prefer radiotherapy
only) may be considered for continuous hyperfractionated accelerated
radiation therapy (80).
GH treatment is indicated in children with
documented GHD for correction of hypoglycemia and for induction of normal
statural growth (81).
GH treatment is indicated for girls with
Turner syndrome (82).
GH therapy is best accomplished under the direct
supervision of a clinical endocrinologist (83).
Short-term GH treatment is safe in both children and
adults (84). Continued
monitoring of side effects and long-term treatment results is needed (85).
Numerous observations are compatible with androgen
therapy yielding improved bone-related factors, particularly in doses that
exceed the normal range (86).
Adverse effects may occur with
androgen replacement therapy at supraphysiologic levels (87).
Acne, hirsutism, and a significant reduction in
high-density lipoprotein (HDL) cholesterol levels have been described (88).
Each patient should be appropriately monitored with
use of dual-energy x-ray absorptiometry as well as known clinical factors of
fracture risk to determine the adequacy of an administered dose of estrogen (89).
Similar results have been noted in the treatment of
cardiac and peripheral vascular ischemic disease (90).
Saw Palmetto (91).
Only two strong studies support the use of saw
palmetto extract in patients with benign prostatic hypertrophy (92).
Clinical toxicities related to the use of this
product seem to be minimal (93).
Therefore , with conclusive level 2 data
available , saw palmetto extract may be recommended
for patients with benign prostatic
hypertrophy who refuse conventional therapy or in whom conventional therapy
fails (94).
Glutamine (95).
Glutamine is a nontoxic, physiologically important
agent that is beneficial in critical illness (96).
Cervical cancer screening should begin approximately
three years after the onset of vaginal intercourse (97).
Screening should
begin no later than 21 years of age
(98).
Screening with vaginal cytology tests
following total hysterectomy (with removal of the cervix) for benign
gynecologic disease is not indicated (99). Efforts should be made to confirm and/or document via physical exam and review of the pathology report
(when available) that the hysterectomy was performed for benign reasons (the
presence of cervical intraepithelial neoplasia (CIN) 2/3 is not considered
benign) and that the cervix was completely removed (100).
A selective estrogen receptor modulator (SERM) has
been approved by the FDA for the prevention and treatment of osteoporosis in
menopausal women (101).
A bone disease specialist should participate in
the decision to choose a SERM in patients with GI diseases (102).
There is insufficient evidence to support a role for
IV bisphosphonates as an adjunctive therapy to radiation therapy in women with
pain caused by metastatic bone disease when systemic chemotherapy and/or
hormonal therapy is not being used (103).
The role of bisphosphonates vis-a-vis radiation
therapy as the sole therapy in this setting has not been determined (104). In women already
being treated with local radiotherapy who have persistent or recurrent pain,
bisphosphonates are an attractive but little-studied salvage therapy (105).
The Panel suggests that, once initiated, IV
bisphosphonates be continued until evidence of substantial decline in a
patient's general performance status (106).
The Panel stresses that clinical judgment must guide what
is a substantial decline (107).
There is no evidence addressing the consequences of
stopping bisphosphonates after one or more adverse skeletal-related events
(SREs) (108).
Starting bisphosphonates in women without
evidence of bone metastases , even in the presence of other extraskeletal
metastases , is not recommended (109). This
clinical situation has not been studied using IV bisphosphonates and should be the
focus of new clinical trials (110).
Regular gynecologic follow-up is recommended for
all women (111).
Patients who receive tamoxifen therapy are at
increased risk for developing endometrial cancer and should be advised to
report any vaginal bleeding to their physicians (112).
Longer follow-up intervals may be appropriate
for women who have had a total hysterectomy and oophorectomy (113).
[18F]fluorodeoxyglucose-positron emission
tomography (FDG-PET) scanning is not
recommended for routine breast
cancer surveillance (114).
Computed Tomography (CT) (115).
Recommendation (116).
CT is not
recommended for routine breast
cancer surveillance (117).
Bilateral orchiectomy or medical castration
with luteinizing hormone releasing hormone (LHRH) agonists are the recommended initial
treatments for metastatic prostate cancer (118).
A full discussion between practitioner and
patient should occur to determine which is best for the patient (119).
A discussion should occur between the
patient and his practitioner (120).
The patient needs to appreciate that there is
a small potential gain in overall survival (OS) with the addition of a
nonsteroidal antiandrogen to medical or surgical castration and that increased
side effects may occur as a result (121).
Until data from studies using modern medical
diagnostic and biochemical tests and standardized follow-up schedules become
available , no specific recommendations can
be issued by the Panel regarding
the question of early versus deferred ADT using LHRH agonists or orchiectomy (122). A
discussion about the pros and cons of early versus deferred therapy should occur between
patient and practitioner (123).
Antiandrogen monotherapy is not recommended (124).
Patients should
be followed clinically and started
on ADT once symptoms of locally progressive or metastatic disease present (125).
Staging Distant Metastatic Disease (126). Adrenal (127). The finding of an
isolated adrenal mass on ultrasonography, CT scan, or FDG-PET scan requires
biopsy to rule out metastatic disease if the patient is otherwise considered to
be potentially resectable (128).
Treatment (129).
Radiotherapy (130).
Local- and Distant-Site Palliative Effects of
External-Beam Radiation (131).
Diagnostic Evaluation of Patients with Advanced Lung
Cancer (132). Staging Locoregional
Disease (133). Negative FDG-PET
scanning does not preclude biopsy of radiographically enlarged mediastinal
lymph nodes (134).
The Task Force recommends the
following endpoints be considered for safety and risk assessment in future
studies (135). Appearance of or
change in hirsutism, acne, male pattern balding, clitoromegaly, and deepening
of the voice (136).
Cardiovascular and metabolic evaluation , with
and without estrogen replacement , should
include fasting lipid profiles ,
vascular reactivity , markers of insulin sensitivity , and markers of
inflammation (137).
Effects on the breast , with or without
estrogen replacement , should be measured (138). Breast
biopsy studies with in vitro markers of cell proliferation and apoptosis should be considered (139).
Alterations in the endometrium with and without
estrogen coadministration Alterations in mood using validated instruments (140).
The Task Force recommends further
study of physiologic targets of androgen action such as (141).
Sexual dysfunction Cognition Mood Bone Cardiovascular
function Body composition Muscle strength and function (142).
The Task Force recommends additional
research in the following human model systems to define the clinical syndrome
of androgen deficiency and to study the benefits and risks of androgen therapy (143). Surgical
menopause is a condition in which the ovarian, but not adrenal androgen
precursors are removed abruptly independent of age (144).
Hypopituitarism , although uncommon , can be used to
study the physiological replacement of both ovarian androgens and adrenal
androgen precursors (145).
Anorexia nervosa may be used as a
model of androgen deficiency secondary to dysfunction of the
hypothalamic-pituitary and adrenal axes (146).
Primary adrenal insufficiency allows for the
investigation of the loss of adrenal androgen precursors in the presence of
intact ovarian androgen function (147).
Ablation-replacement models in normal women using
GnRH analogs to eliminate ovarian androgens, with or without suppression of
adrenal androgen precursors, offer another way to assess the effects of
androgen withdrawal and replacement (148).
Subjects with complete androgen insensitivity
syndrome offer a way to investigate target tissue effects which are dependent
on the androgen receptor but are independent of aromatization (149).
In patients whose cough resolves after the
cessation of therapy with ACE inhibitors , and for whom there is a compelling
reason to treat with these agents , a repeat trial of ACE inhibitor therapy may be attempted (150).
In patients for whom the cessation of ACE
inhibitor therapy is not an option , pharmacologic therapy , including that
with sodium cromoglycate , theophylline , sulindac , indomethacin , amlodipine
, nifedipine , ferrous sulfate , and picotamide that is aimed at suppressing
cough should be attempted (151).
The optimal treatment-delivery interval for
administration of antenatal corticosteroids is more than 24 hours but fewer
than seven days after the start of treatment (152).
Obstetricians should consider enrolling
their patients in randomised controlled trials if repeat corticosteroid
therapy is contemplated (153).
In patients with stroke associated with aortic
atherosclerotic lesions , the guideline developers recommend antiplatelet
therapy over no therapy (154).
For patients with cryptogenic stroke associated with
mobile aortic arch thrombi, the guideline developers suggest either oral
anticoagulation or antiplatelet agents (155).
For acute stroke patients with restricted
mobility , the guideline developers recommend
prophylactic low-dose subcutaneous
heparin or low molecular weight heparins or heparinoids (156).
For patients with AF and prosthetic heart valves
, the guideline developers recommend anticoagulation with an oral VKA , such as warfarin (157).
For AF occurring shortly after open-heart surgery and
lasting >48 hours, the guideline developers suggest anticoagulation with an
oral VKA, such as warfarin, if bleeding risks are acceptable (Grade 2C) (158).
In patients with persistent AF or PAF , age 65
to 75 years , in the absence of other risk factors , the guideline developers recommend antithrombotic
therapy (159).
For patients undergoing CABG who have no other
indication for vitamin K antagonists (VKAs), the guideline developers suggest
clinicians not administer VKAs (160).
For all patients undergoing IMA bypass grafting who
have no other indication for VKAs, the guideline developers suggest clinicians
not use VKAs (161).
For all patients with coronary artery disease
who undergo internal mammary artery (IMA) bypass grafting , the guideline
developers recommend aspirin , 75 to 162 mg/day , indefinitely (162).
Treatments for Different Types of Anxiety Disorders (163). Cognitive
behaviour therapy (CBT) is the psychotherapy of choice for panic disorder (164). Possible
treatment components for panic disorder, with or without agoraphobia, are
Psychoeducation (165).
Exposure to symptoms or situations Cognitive
restructuring Breathing retraining Continuous panic monitoring (166).
Treatment Settings for Anxiety Disorders (167). Psychiatric
evaluation and treatment is appropriate when (168).
There is serious risk of suicide (169). There are
psychotic symptoms (170).
Cooccurring drug/alcohol problems exist (171). Symptoms are
severe/complex (172).
If symptoms fail to improve on initial treatment and
follow-up (173).
Psychosocial Interventions for Anxiety Disorders (174). Psychological
therapy should be routinely considered as a treatment option when assessing mental
health problems , including anxiety disorder (175).
Parents should
be advised that home
cardiorespiratory monitoring has not been proven to prevent sudden unexpected
deaths in infants (176).
Home cardiorespiratory monitoring may be warranted
for premature infants who are at high risk of recurrent episodes of apnea ,
bradycardia , and hypoxemia after hospital discharge (177).
The use of home cardiorespiratory monitoring
in this population should be limited to approximately 43 weeks postmenstrual age or after
the cessation of extreme episodes , whichever comes last (178).
Home cardiorespiratory monitoring should not be prescribed to prevent sudden infant death syndrome (SIDS) (179).
None of the three markers TS , DPD , or TP are recommended for use to determine the prognosis of colorectal carcinoma (180).
Surveillance colonoscopy with multiple biopsy
specimens should be performed every 1 to 2 years beginning after 8 to 10 years of
disease (181).
Genetic testing along with counseling is recommended for
individuals with hereditary forms of CRC , including familial adenomatous
polyposis (FAP) and hereditary nonpolyposis colon cancer (HNPCC) (182).
Alternative methods for CRC screening in average-risk
patients include yearly fecal occult blood testing (A), flexible sigmoidoscopy
every 5 years, combined yearly fecal occult blood testing (FOBT) and flexible
sigmoidoscopy every 5 years (183).
Although an increased cancer risk has not been
established in patients with Barrett's esophagus and low-grade dysplasia ,
endoscopy at 6 months and yearly thereafter should
be considered (184).
Postgastric Surgery (185).
There are insufficient data to support routine
endoscopic surveillance for patients with previous partial gastrectomy for
peptic ulcer disease (186).
Polypoid defects of any size detected
radiographically should be evaluated endoscopically , with biopsy and/or removal of the
lesions (187).
Substance users who wish to stop using drugs should be referred to
substance abuse treatment when indicated (188).
The drug regimen of choice is currently unknown
because no randomized comparative trials have been conducted in this patient
population (189).
Options include tenofovir , emtricitabine ,
interferon alfa-2b , lamivudine , or adefovir; there are insufficient data to recommend combinations
of drugs at this time (190).
If lamivudine is given for treatment of
hepatitis B , it should never be used alone but in combination with other HIV-active
antiretroviral agents as a component of highly active antiretroviral therapy
(HAART) (191).
Clinicians should
inform and advise HIV-infected
substance users chronically infected with hepatitis B (or co-infected with
hepatitis B and C) that sharing injection equipment and engaging in unprotected
sex place their partners at risk for transmission of both HIV and viral
hepatitis (192).
Foot Ulcer Assessment (193).
Describe and document the ulcer characteristics (194).
Practice Recommendations (195).
Patient Empowerment and Education (196). Education is
based on identified individual needs, risk factors, ulcer status, available
resources, and ability to heal (197).
Management (198).
Provide pressure redistribution (199).
Practice settings need a policy with respect to providing and requesting
advance notice when transferring or admitting clients between practice settings
when special resources (e.g., surfaces) are required.
Reassess ulcers at least weekly to determine the
adequacy of the treatment plan (200).
Medical management may include initiating
a two-week trial of topical antibiotics for clean pressure ulcers that are not
healing or are continuing to produce exudate after two to four weeks of optimal
patient care (201).
The antibiotic should be effective against
gram-negative , gram-positive and anaerobic organisms (202).
Carers (203).
Older people who are carers of people with
intellectual or other disabilities should be
assessed for health and support
needs (204).
Assessors and Multidisciplinary Teams. (205). Assessors
of older people should be part of (or have ready access to) a wider multidisciplinary
team (MDT) to whom they can quickly refer the older person for more in-depth
assessment or for help in any particular domain (206).
Location of Assessment (207).
Proactive assessments of people should usually
take place within the older persons home , unless the older person is in an
emergency department (ED) (208).
Attendance at an ED should trigger a
comprehensive assessment prior to discharge (209).
Asthma should
be considered well controlled if (1)
asthma symptoms are twice a week or less; (2) rescue bronchodilator medication
is used twice a week or less; (3) there is no nocturnal or early morning
awaking; (4) there are no limitations of work , school , or exercise; (5)
the patient and physician consider their asthma well controlled; and (6) the
patient's peak expiratory flow (PEF) or forced expiratory volume in one second
(FEV1) is normal or his or her personal best (210).
A patient's asthma control for a specific
clinical encounter should be determined as well controlled or not well controlled (211). Asthma symptoms
do not always correlate with asthma severity (212).
There are limitations to classifying asthma severity
in patients already being treated (213).
Premature ejaculation can be treated effectively
with several serotonin reuptake inhibitors (SRIs) or with topical anesthetics (214). The
optimal treatment choice should be based on both physician judgment and patient preference (215).
The diagnosis of premature ejaculation (PE) is based
on sexual history alone (216).
A detailed sexual history should be obtained from
all patients with ejaculatory complaints (217).
The risks and benefits of all treatment
options should be discussed with the patient prior to any intervention (218). Patient and
partner satisfaction is the primary target outcome for the treatment of PE (219).
In women with pathological stage III tumours ,
bone scanning , liver ultrasonography , and chest radiography are recommended postoperatively
as part of baseline staging (220).
In women for whom treatment options are restricted to tamoxifen or hormone therapy , or for whom
no further treatment is indicated because
of age or other factors , routine bone scanning , liver ultrasonography , and
chest radiography are not indicated as part of baseline staging (221).
In women who have pathological stage II
tumours , a postoperative bone scan is
recommended as part of baseline
staging (222).
Routine liver ultrasonography and chest
radiography are not indicated in this group but could be considered for patients
with four or more positive lymph nodes (223).
Ambulance transportation is recommended for
patients who are referred to emergency departments because of the potential for
life-threatening complications of beta-blocker overdose (224).
Provide usual supportive care en route to the
hospital, including intravenous fluids for hypotension (225).
Asymptomatic patients who are referred to
healthcare facilities should be monitored for at least 6 hours after ingestion if they took an
immediate-release preparation other than sotalol , 8 hours if they took a
sustained-release preparation , and 12 hours if they took sotalol (226). Routine 24-hour
admission of an asymptomatic patient who has unintentionally ingested a
sustained-release preparation is not warranted (227).
Patients with stated or suspected self-harm or
who are the victims of a potentially malicious administration of beta-blocker should be referred to
an emergency department immediately (228).
This referral should be guided by
local poison center procedures (229).
In general , this should occur regardless
of the dose reported (230).
Women with early stage (stages I and II)
breast cancer who have undergone breast conservation surgery should be offered postoperative
breast irradiation (231).
The optimal fractionation schedule for breast
irradiation has not been established and the role of boost irradiation is
unclear (232). Outside of a
clinical trial, two commonly used fractionation schedules are suggested (233).
Women who have undergone breast conservation
surgery should receive local breast irradiation as soon as possible following
wound healing (234).
A safe interval between surgery and the start of
radiotherapy is unknown, but it is reasonable to start breast irradiation
within 12 weeks of definitive surgery (235).
Evaluation of education programs should be considered in
order to evaluate the effectiveness of prenatal breastfeeding classes (236).
Nurses with experience and expertise in
breastfeeding should provide support to mothers (237).
Such support should be established in the
antenatal period , continued into the
postpartum period and should involve face-to-face contact (238).
Key components of the prenatal assessment should include (239).
If docetaxel and capecitabine are used in combination , the recommended starting dose for most patients is 950 mg/m2 twice
daily of capecitabine (75% of full dose) on days 1 to 14 plus docetaxel 75
mg/m2 intravenously on day 1 of a 21-day cycle (240).
In patients with renal impairment ,
capecitabine therapy can increase systemic exposure to alpha-fluoro-beta-alanine
(FBAL) and 5-deoxy-5-fluorouridine (5- DFUR) (241).
All schools should
implement age-appropriate and
culturally sensitive curricula on changing students' patterns of dietary intake
, physical activity , and smoking behaviors (242).
All schools should
institute policies that they be
maintained as tobacco-free environments (243).
School policies should address all
foods and snacks consumed on- and off-premises during school hours (244).
Nurses will change all add-on devices a minimum of
every 72 hours (245).
Nurses will assess and evaluate vascular access
devices for occlusion in order to facilitate treatment and improve client
outcomes (246).
Health care organizations have access to infusion
therapy nursing expertise to support optimal vascular access outcomes (247).
Although the available evidence suggests a lower VAP
rate with passive humidification than with active humidification, other issues
related to the use of passive humidifiers (resistance, dead space volume,
airway occlusion risk) preclude a recommendation for the general use of these
devices (248). The
decision to use a passive humidifier should
not be based solely on infection
control considerations (249).
Evidence is lacking related to ventilator-associated
pneumonia (VAP) and issues of heated versus unheated circuits, type of heated
humidifier, method for filling the humidifier, and technique for clearing
condensate from the ventilator circuit (250).
It is prudent to avoid excessive accumulation of
condensate in the circuit (251).
Care should
be taken to avoid accidental
drainage of condensate into the patient airway and to avoid contamination of
caregivers during ventilator disconnection or during disposal of condensate (252). Care should be taken to
avoid breaking the ventilator circuit , whic
could contaminate the interior of the circuit (253).
Women with uncomplicated (extended or flexed
leg) breech presentation at term should be
offered a caesarean after full
discussion of the risks and benefits (254).
Women with uncomplicated breech at 37 to 40
weeks should be offered external cephalic version (ECV) to increase the
likelihood of cephalic presentation and vaginal birth (255).
Full and unbiased information on choosing VBAC
should be discussed on a case-by-case basis with the pregnant woman with
previous caesarean to enable her to make an informed decision about her birth choices
(256).
Clinicians should
consider patient variables in CE
decision making (257).
Clinicians should
also consider several radiologic
factors in decision making about CE (258).
Carotid endarterectomy (CE) is established as
effective for recently symptomatic (within previous 6 months) patients with 70
to 99% internal carotid artery (ICA) angiographic stenosis (259). CE should not be considered for symptomatic patients with less than 50% stenosis (260). CE may be considered for
patients with 50 to 69% symptomatic stenosis but the clinician should consider additional
clinical and angiographic variables (261).
It is recommended that the patient have at least a 5-year life expectancy (262).
The panel recommends
the following (263).
Formation of a federation of celiac disease
societies, celiac disease interest groups, individuals with celiac disease and
their families, physicians, dietitians, and other health care providers for the
advancement of education, research, and advocacy for individuals with celiac
disease (264).
To reduce the incidence and mortality rate of
cervix cancer , effective screening and preventive strategy must be actively pursued in addition to early detection of disease and effective therapy (265).
Ovarian conservation should be considered for
young patients (266).
The addition of post-operative treatment using a
combination of chemotherapy and radiotherapy has been shown to improve survival
outcome for patients with tumour involvement of pelvic lymph nodes, resection
margins, and/or parametrial tissue (267).
Combination platinum-based chemotherapy can be administered safely
and with acceptable and manageable toxicity profiles in patients with good PS
who have stage IV NSCLC (268).
When selecting patients for systemic
chemotherapy , performance status (PS) at the time of diagnosis should be used because
it is a consistent prognostic factor for survival (269).
Patients with a PS of Eastern Cooperative
Oncology Group (ECOG) 0 or 1 should be
offered chemotherapy (270). Data are
not yet sufficient to routinely recommend chemotherapy to patients with a PS of ECOG level 2 (271). Patients
with a PS of ECOG level 3 or 4 should not
receive chemotherapy (272).
If survival is the main outcome of interest for a
patient, it is reasonable to offer chemotherapy to medically suitable patients
as an option for this condition with a full discussion of the benefits,
limitations, and toxicities (273).
If symptom control and/or quality of life
are the outcomes of interest for a patient , chemotherapy is a reasonable
option which may improve quality of life and reduce disease-related
symptoms (274).
Strong evidence including meta-analyses indicates
that there is a small survival benefit of cisplatin-based chemotherapy over
best supportive care in patients with non-small cell lung cancer and good
performance status (275).
Testing may
also be performed to reassure the
patient , parent , and physician of the absence of organic disease ,
particularly if the pain significantly diminishes the quality of life of the
patient (276).
Functional abdominal pain generally can be diagnosed correctly
by the primary care clinician in children 4 to 18 years of age with chronic
abdominal pain when there are no alarm symptoms or signs , the physical
examination is normal , and the stool sample tests are negative for occult
blood , without the requirement of additional diagnostic evaluation (277).
Education of the family is an important part of
treatment of the child with functional abdominal pain (278).
It is often helpful to summarize the child's symptoms
and explain in simple language that although the pain is real, there is most
likely no underlying serious or chronic disease (279).
It may be helpful to explain that chronic abdominal pain is a common symptom in
children and adolescents , yet few have a disease (280).
Functional abdominal pain can be likened to
a headache , a functional disorder experienced at some time by most adults ,
which very rarely is associated with serious disease (281).
In a patient with an acute respiratory
infection manifested predominantly by cough , with or without sputum production
, lasting no more than 3 weeks , a diagnosis of acute bronchitis should not be made unless
there is no clinical or radiographic evidence of pneumonia and the common cold
, acute asthma , or an exacerbation of chronic obstructive pulmonary disease
(COPD) have been ruled out as the cause of cough (282).
In a patient with chronic cough , asthma should always be considered as a potential etiology because asthma is a common
condition with which cough is commonly associated (283).
Patients with severe and/or refractory cough
due to asthma should receive a short course (1 to 2 weeks) of systemic (oral)
corticosteroids followed by inhaled corticosteroids (284).
For patients with asthmatic cough that is
refractory to treatment with inhaled corticosteroids and bronchodilators , in
whom poor compliance or another contributing condition has been excluded , an
leukotriene receptor antagonist (LTRA) may be
added to the therapeutic regimen
before the escalation of therapy to systemic corticosteroids (285).
In patients with cough secondary to
sarcoidosis , therapy with oral corticosteroids followed by inhaled
corticosteroids may improve symptoms (286).
In patients with cough secondary to
sarcoidosis , although therapy with oral corticosteroids may lead to
symptomatic improvement , as they have not been proven to have a durable
benefit and are associated with significant side effects , an individualized
analysis of the overall benefit and risk is necessary (287).
In patients with chronic cough , before
diagnosing interstitial lung disease (ILD) as the sole cause , common
etiologies such as upper airway cough syndrome (UACS) , which was previously
referred to as postnasal drip syndrome , asthma , and gastroesophageal reflux
disease (GERD) should be considered (288). As these
common causes may also share clinical features with specific ILDs , a diagnosis of ILD as the cause of cough should be considered a
diagnosis of exclusion (289).
For patients with more advanced NSCLC (stages
III and IV) , external beam radiation and/or chemotherapy should usually be offered (290).
For patients with cough and lung cancer , the
use of centrally acting cough suppressants such as dihydrocodeine and
hydrocodone is recommended (291).
In patients with a suspicion of airway involvement by a malignancy (e.g.,
smokers with hemoptysis), even when the chest radiograph findings are normal,
bronchoscopy is indicated.
In patients with chronic cough due to nonasthmatic eosinophilic
bronchitis, the possibility of an occupation-related cause needs to be
considered (292).
For patients with chronic cough due to nonasthmatic
eosinophilic bronchitis, the first-line treatment is inhaled corticosteroids
(except when a causal allergen or sensitizer is identified (293).
In patients with chronic cough with normal chest
radiograph findings, normal spirometry findings, and no evidence of variable
airflow obstruction or airway hyperresponsiveness, the diagnosis of
nonasthmatic eosinophilic bronchitis as the cause of the chronic cough is
confirmed by the presence of an airway eosinophilia, either by sputum induction
or bronchial wash fluid obtained by bronchoscopy, and an improvement in the
cough following corticosteroid therapy (294).
In patients with cough and incomplete or
irreversible airflow limitation , direct or indirect signs of small airways
disease seen on high resolution computed tomography (HRCT) scan , or purulent
secretions seen on bronchoscopy , nonbronchiectatic suppurative airways disease
(bronchiolitis) should be suspected as the primary cause (295).
In patients with cough in whom more common
causes have been excluded , because bacterial suppurative airways disease may be present
and clinically unsuspected , bronchoscopy is required before excluding it as a
cause (296).
In patients with DPB , prolonged treatment
(> 2 to 6 months) with erythromycin (or other 14-member ring macrolides such
as clarithromycin and roxithromycin) is
recommended (297).
In patients with chronic cough who live in
areas with a high prevalence of TB , this diagnosis should be considered ,
but not to the exclusion of the more common etiologies (298).
Sputum smears and cultures for acid fast
bacilli and a chest radiograph should be
obtained whenever possible (299).
In patients with unexplained chronic cough who
have resided in areas of endemic infection with fungi or parasites , a diagnostic
evaluation for these pathogens should be
undertaken when more common
causes of cough have been ruled out (300).
In areas where there is a high prevalence of
tuberculosis (TB) , chronic cough should be
defined as it is in the World
Health Organization Practical Approach to Lung Health (PAL) program as being 2
to 3 weeks in duration (301).
Serological screening for hepatitis B surface
(HBs) antigen and antibody (HBs Ag , anti-HBs IgG) should be done within
6 months pre-vaccination for all , except newborns (302).
Patients should
be told of the risks of
hepatocellular carcinoma (HCC) associated with chronic hepatitis B infection
and offered the option of hepatocellular carcinoma surveillance (303). For
patients who are agreeable to surveillance , ultrasonography and serum
alpha-fetoprotein should be done at regular intervals (304).
Ultrasonography should be done at
6- and 12-monthly intervals for cirrhotic and non-cirrhotic patients ,
respectively (305).
Patients' blood should be sampled for
alpha-fetoprotein every 3 to 6 months and 6 to 12 months for cirrhotic and
non-cirrhotic patients , respectively (306).
Patients with normal serum alanine
transaminase (ALT) levels should have 6-monthly outpatient follow-up visits with repeat
serum ALT done at each visit (307).
Patients with elevated serum ALT levels should have more
frequent follow-up visits , with repeat liver function tests carried out based
on the physician-in-charge's discretion (308).
In patients for whom a specific etiology of
chronic cough is not apparent , empiric therapy for UACS in the form of a first
generation A/D preparation should be
prescribed before beginning an
extensive diagnostic workup (309).
A patient suspected of having UACS induced
cough who does not respond to empiric antihistamine/decongestant (A/D) therapy
with a first-generation antihistamine should next undergo sinus imaging (310).
In patients in whom the cause of the
UACS-induced cough is apparent , specific therapy directed at this condition should be instituted
(311).
Confirm that the infant has a scheduled appointment
with a primary care provider or health worker within five to seven days after
birth (312). Schedule additional visits as needed until
a consistent weight gain pattern has been established (III).Identify
breastfeeding support resources within the community such as. International Board Certified Lactation Consultants
(IBCLCs) Community health workers and home visitors trained to provide
breastfeeding support Breastfeeding clinic staff Health department staff (313).
Comply with the International Code of Marketing of
Breast-milk Substitutes and subsequent World Health Assembly resolutions, and
avoid distribution of infant feeding product samples and advertisements for
such products (314).
Identify maternal and infant risk factors that
may impact
the mother's or infant's ability to breastfeed effectively and provide appropriate
assistance and follow-up (315).
Females aged between 1 and 2 years presenting
with fever without source should be
considered at risk for having a
urinary tract infection (316).
Obtain a urine culture in conjunction with other
urine studies when urinary tract infection is suspected in a child aged younger
than 2 years because a negative urine dipstick or urinalysis result in a
febrile child does not always exclude urinary tract infection (317).
Urethral catheterization or suprapubic aspiration are
the best methods for diagnosing urinary tract infection (318).
For patients receiving neuromuscular blocking
agents and corticosteroids , every effort should
be made to discontinue
neuromuscular blocking agents as soon as possible (319).
Institutions should perform an economic
analysis using their own data when choosing neuromuscular blocking agents
for use in an intensive care unit (320).
Drug holidays (i.e., stopping neuromuscular blocking agents daily until forced
to restart them based on the patients condition) may decrease the incidence of
acute quadriplegic myopathy syndrome (AQMS).
If blood pressure measurements are
persistently elevated with a systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg , the patient should be referred for
follow-up of possible hypertension and blood pressure management (321).
Initiating treatment for asymptomatic hypertension in
the ED is not necessary when patients have follow-up (322).
Patients with a single elevated blood pressure
reading may require further screening for hypertension in the outpatient
setting (323).
Pain response to therapy should not be used as
the sole diagnostic indicator of the underlying etiology of an acute headache (324).
Patients
presenting with acute sudden-onset headache should
be considered for an emergent* head
computed tomography scan (1).
Human immunodeficiency virus (HIV)-positive
patients with a new type of headache should
be considered for an urgent*
neuroimaging study (2).
Patients who are older than 50 years
presenting with new type of headache without abnormal findings in a neurologic
examination should be considered for an urgent neuroimaging study (3).
Adult patients with headache exhibiting signs
of increased intracranial pressure including papilledema , absent venous
pulsations on funduscopic examination , altered mental status , or focal
neurologic deficits should undergo a neuroimaging study before having an LP (4). In the
absence of findings suggestive of increased intracranial pressure , an LP can be performed without
obtaining a neuroimaging study (5).
Interpretation of Serum Human Chorionic Gonadotropin
(hCG) Levels: Arrange follow-up for patients with a nondiagnostic transvaginal
ultrasound and a serum hCG level above 2,000 mIU/mL because they have an
increased likelihood of ectopic pregnancy (6).
Methotrexate in Ectopic Pregnancy:Because the
symptoms associated with gastrointestinal side effects of methotrexate therapy may mimic an
acute ectopic rupture , rule out ectopic rupture resulting from treatment
failure before attributing gastrointestinal symptoms to methotrexate toxicity (7).
Interpretation of Serum Human Chorionic
Gonadotropin (hCG) Levels: Consider transvaginal ultrasound because it may detect ectopic
pregnancy when the serum hCG level is below 1,000 mIU/mL (8).
Recent food intake is not a contraindication
for administering procedural sedation and analgesia , but should be considered in
choosing the timing and target level of sedation (9).
Consider capnometry to provide additional information
regarding early identification of hypoventilation (10).
Physicians should
fully explain diagnosis , prognosis
, and all treatment options to each patient (11).
Discussions should
occur with the patient or legal
agent about life expectancy and quality of life (12).
For patients requiring dialysis , but who have
an uncertain prognosis or for whom a consensus cannot be reached about
providing dialysis , nephrologists should
consider offering a time-limited
trial of dialysis (13).
Modifying Factors: Clinicians should assess the
patient with diffuse AOE for factors that modify management (nonintact tympanic
membrane , tympanostomy tube , diabetes , immunocompromised state , prior
radiotherapy) (14).
Clinicians should
inform patients how to administer
topical drops (15).
When the ear canal is obstructed ,
delivery of topical preparations should be
enhanced by aural toilet ,
placement of a wick , or both (16).
Topical Therapy: The choice of topical
antimicrobial for initial therapy of diffuse AOE should be based upon
efficacy , low incidence of adverse events , likelihood of adherence to therapy
, and cost (17).
The time to normalization of base deficit, lactate,
and pHi is predictive of survival (18).
Measurements of tissue (subcutaneous or
muscle) oxygen and/or carbon dioxide levels may
identify patients who require
additional resuscitation and are at risk for multiple organ dysfunction
syndrome and death (19).
Persistently high base deficit or low pHi (or
worsening of these parameters) may be an early indicator of complications (eg , ongoing
hemorrhage or abdominal compartment syndrome) (20).
All adults and adolescents with chronic kidney
disease (CKD) should be evaluated for dyslipidemias (21).
Nonsteroidal anti-inflammatory drugs (NSAIDs)
or acetaminophen may be used as adjuncts to opioids in selected patients (22).
Propofol is
the preferred sedative when rapid
awakening (eg , for neurologic assessment or extubation) is important (23).
Fentanyl is
preferred for a rapid onset of analgesia
in acutely distressed patients (24).
Disseminated Infection (Extrapulmonary):
Nonmeningeal:Amphotericin B is recommended for alternative therapy , especially if lesions are
appearing to worsen rapidly and are in particularly critical locations , such
as the vertebral column (25).
Disseminated Infection (Extrapulmonary):
Nonmeningeal: Initial therapy is usually initiated with oral azole antifungal
agents, most commonly fluconazole or itraconazole (26).
Meningitis:Patients who respond to azole
therapy should continue this treatment indefinitely (27).
Clinicians should
refer patients who require
treatment with multiple psychotropic medications and/or are using illicit
substances for psychiatric consultation because of the risk of drug-drug
interactions and toxicity (28).
Clinicians should
refer patients with HAD who present
with accompanying depression , mania , psychosis , behavioral disturbance , or
substance use for psychiatric consultation to assist in psychopharmacologic
treatment and management (29).
Clinicians should
exclude other treatable , reversible causes of change in mental status before
a diagnosis of HIV-associated dementia (HAD) can
be made (30).
Offer screening with FOBT every year combined with
flexible sigmoidoscopy every 5 years (31).
When both tests are performed , the
FOBT should be done first (32).
Screening People at Increased Risk People with
a first-degree relative with colon cancer or adenomatous polyp diagnosed at age
>60 years or 2 second-degree relatives with colorectal cancer should be advised to
be screened as average risk persons , but beginning at age 40 years (33).
Surveillance with colonoscopy should be considered for
patients who are at increased risk because they have been treated for
colorectal cancer , have an adenomatous polyp diagnosed , or have a disease
that predisposes them to colorectal cancer , such as inflammatory bowel disease
(34).
Schools
should be considered appropriate sites for the availability of condoms , because they contain large adolescent populations
and may potentially provide a comprehensive array of related educational and
health care resources (1).
Research is encouraged to identify methods to
increase correct and consistent condom use by sexually active adolescents and
to evaluate effectiveness of strategies to promote condom use, including condom
education and availability programs in schools (2).
An intravenous bolus followed by continuous-infusion
proton-pump inhibitor is effective in decreasing rebleeding in patients who
have undergone successful endoscopic therapy (3).
The placement of clips is a promising endoscopic
hemostatic therapy for high-risk stigmata (4).
Clinical (nonendoscopic) stratification of patients
into low- and high-risk categories for rebleeding and mortality is important
for proper management (5).
Available prognostic scales may be used to
assist in decision-making (6).
Early stratification of patients into low- and
high-risk categories for rebleeding and mortality, based on clinical and endoscopic
criteria, is important for proper management (7).
Available prognostic scales may be used to
assist in decision making (8).
In patients with immune deficiency, the initial
diagnostic algorithm for patients with acute, subacute, and chronic cough is
the same as that for immunocompetent persons, taking into account an expanded
list of differential diagnoses that considers the type and severity of immune
defect and geographic factors (9).
In human immunodeficiency (HIV)-infected
patients , CD4+ lymphocyte counts should be
used in constructing the list of
differential diagnostic possibilities potentially causing cough (10).
In patients with chronic bronchitis , agents
that have been shown to alter mucus characteristics are not recommended for
cough suppression (11).
In patients with acute cough due to the common
cold , preparations containing zinc are not
recommended (12).
In patients with cough due to URI , peripheral
cough suppressants have limited efficacy and are
not recommended for this use (13).
Follow-up:For patients at lower risk of
recurrence (stages I and Ia) or those with co-morbidities impairing future
surgery , only visits yearly or when symptoms occur are recommended (14).
Staging: CT or MRI of the pelvis should be done to assess mesorectal margin status (15).
Staging: If T and N category determinations
will drive decisions on the use of neoadjuvant therapy , transrectal
ultrasound or MRI with endorectal coil is
recommended (16).
Operator skill is more likely to influence the
accuracy of transrectal ultrasound versus MRI with endorectal coil (17). It is likely that
advances in technology will demonstrate similar staging accuracy for routine
MRI versus MRI with endorectal coil (18).
Review assessment data together with the woman and
identify the outcomes important to the woman and amenable to nursing
intervention (19).
Incorporate screening questions into a
self-assessment that is routinely collected during intake (20).
Ideally , all women should be screened for
CPPD on a routine basis (21).
Step 1: Is the patient dehydrated or does the
patient have a fluid/electrolyte imbalance? Consider seriously the presence of
a fluid/electrolyte imbalance whenever a patient experiences new symptoms or a
decline of an existing condition that cannot
be readily attributed to another
cause (22).
Step 6: Are the causes and consequences of the patient's dehydration or
fluid/electrolyte imbalance to be treated? If it is decided to treat the causes
of the patient's dehydration or fluid/electrolyte imbalance or to intervene to
correct or prevent a fluid deficit or electrolyte imbalance, proceed to Step
7.If the cause of the patient's dehydration is not clear, continue to look for
that cause while providing appropriate support and symptomatic management. If it is decided not to treat or intervene because the
patient has a terminal or end-stage condition or because the patient or family
has requested no intervention, or for any other valid clinical reason, document
the reasons for this decision in the patient's medical record (23).
Step
2 Is the patient at risk for dehydration or fluid/electrolyte imbalance? If the
patient is not currently dehydrated and has either no fluid/electrolyte
imbalance or a mild fluid/electrolyte imbalance , it is important to identify the risk for development or progression of these
conditions (1).
The recommended interval between oral health
reviews should be determined specifically for each patient and tailored to meet
his or her needs , on the basis of an assessment of disease levels and risk of
or from dental disease (2).
This assessment should integrate
the evidence presented in this guideline with the clinical judgement and
expertise of the dental team , and should be discussed with
the patient (3).
The longest interval between oral health
reviews for patients younger than 18 years should
be 12 months (4).
Provide or refer for psychotherapy (5).
Conduct a comprehensive assessment of the social
factors specific to spinal cord injury (6).
Use established diagnostic criteria to diagnose
depression (7).
Recommendation:As the child's clinical course
improves, continuous measurement of SpO2 is not routinely needed (8).
Recommendation: Hand decontamination is the most
important step in preventing nosocomial spread of respiratory syncytial virus
(RSV) (9). Hands should be decontaminated
before and after direct contact with patients , after contact with inanimate
objects in the direct vicinity of the patient , and after removing gloves (10).
Recommendation: Alcohol-based rubs are preferred for
hand decontamination (11).
An alternative is hand-washing with antimicrobial
soap (12).
Healthcare professionals should have an
increased awareness of the possibility of the presence of otitis media with
effusion in asymptomatic children (13).
Parents of children with otitis media with
effusion should be advised to refrain from smoking (14).
Children with otitis media with effusion should not be treated with antibiotics (15).
Daily calcium supplementation has not been
shown to prevent preeclampsia and , therefore , is not recommended (16).
Antihypertensive therapy (with either
hydralazine or labetalol) should be used for treatment of diastolic blood pressure levels of
105/110 mm Hg or higher (17).
If analgesia/anesthesia is required ,
regional or neuraxial analgesia/anesthesia should
be used because it is efficacious
and safe for intrapartum management of women with severe preeclampsia in the
absence of coagulopathy (18).
Stage Ib1 should
be distinguished from stage Ib2
carcinoma of the cervix because the distinction predicts nodal involvement and
overall survival and m may therefore , affect treatment and outcome (19).
Treatment for pregnant patients with invasive
carcinoma of the cervix should be individualized on the basis of evaluation of
maternal and fetal risks (20).
Conization of the cervix is considered a clinical
examination (21).
Patients with infected wounds require early and careful
follow-up observation to ensure that the selected medical and surgical
treatment regimens have been appropriate and effective (22).
Aerobic gram-positive cocci (especially Staphylococcus
aureus) are the predominant pathogens in diabetic foot infections (23).
Studies have not adequately defined the role
of most adjunctive therapies for diabetic foot infections , but systematic
reviews suggest that granulocyte colony-stimulating factors and systemic
hyperbaric oxygen therapy may help prevent amputations (24).
These treatments may be useful for
severe infections or for those that have not adequately responded to therapy ,
despite correcting for all amenable local and systemic adverse factors (25).
Diagnosis of Primary TumorIn patients with a central
lesion who present with or without hemoptysis, sputum cytology (at least three
specimens) is a reasonable first step (in centers with a formal program
directed at the acquisition, handling, and interpretation of sputum samples) in
the diagnostic workup (26).
Diagnosis of Primary Tumor Therefore, a nonspecific
result on bronchoscopy of a peripheral lesion that is suspicious for lung
cancer requires further testing to definitively rule out cancer (27).
Clinicians should
repeat CD4 or viral load results
that are inconsistent with the clinical presentation before management
decisions are made (28).
Clinicians should
maintain a high level of suspicion
for acute HIV infection in all patients presenting with a compatible clinical
syndrome (29). When acute
retroviral syndrome is suspected , a plasma HIV RNA assay should be used in
conjunction with HIV-1 antibody test to diagnose acute or primary HIV infection
(30).
An individual who tests negative 3 months
after exposure but continues to engage in risky behavior should receive counseling
to reduce his/her personal risk and the potential transmission to others (31). Such an
individual should be offered repeat testing no more than every 3 months as long
as risky behavior continues (32).
Because much of the risk of developing type 2
diabetes is attributable to obesity , maintenance of a healthy body weight is strongly recommended as a means of preventing this disease (33).
The relationship between glycemic index and glycemic
load and the development of type 2 diabetes remains unclear at this time (34).
Low-carbohydrate diets are not recommended in
the management of diabetes (35).
Although dietary carbohydrate is the major
contributor to postprandial glucose concentration, it is an important source of
energy, water-soluble vitamins and minerals, and fiber (36).
Thus, in agreement with the National Academy of
Sciences-Food and Nutrition Board, a recommended range of carbohydrate intake
is 45-65% of total calories (37).
In addition, because the brain and central nervous system have an absolute
requirement for glucose as an energy source, restricting total carbohydrate to
<130 grams/day is not recommended.
Regulation of blood glucose to achieve near-normal
levels is a primary goal in the management of diabetes, and, thus, dietary
techniques that limit hyperglycemia following a meal are likely important in
limiting the complications of diabetes (38).
The Discharge Planning Process: Discuss symptom
management (39).
The Discharge Planning Process: Clarify activity
level and ability, with a focus on safety and mobility (40).
Surveillance interventions (potential areas to
address): Ensure adequate functional status before discharge or refer for
appropriate home care needs (41).
Prompt investigation of the scene at which the infant
was found lifeless or unresponsive and careful interviews of household members
by knowledgeable individuals with the legal authority and mandate to conduct
such investigations (42).
Accurate history taking by emergency responders and
medical personnel at the time of death and immediate transmission of this
historical information to the medical examiner or coroner (43).
Appropriate consultations with available medical
specialists (eg, pediatrician, pediatric pathologist, pediatric radiologist,
and/or pediatric neuropathologist) by medical examiners and coroners (44).
Women should
be advised that pregnancies have
been reported in COC users taking non-liver enzyme-inducing antibiotics , but
the evidence does not generally support reduced COC efficacy and causation (45).
Clinicians giving women information on
contraceptive options should enquire about current and previous drug use; prescription ,
nonprescription and herbal drug use; and specifically about use of drugs which
induce liver enzymes and non-liver enzyme-inducing antibiotics (46).
A COC user taking a short course (less than 3
weeks) of non-liver enzyme-inducing antibiotics should be advised to use additional contraceptive protection , such as condoms , during the
treatment and for 7 days after the antibiotic has been stopped (47). If fewer
than seven active pills are left in the pack after antibiotics have stopped ,
she should omit the pill-free interval (or discard any inactive pills) (48).
Clinicians should
monitor human immunodeficiency
virus (HIV)-infected substance users receiving concurrent methadone and ARV
therapy for symptoms of withdrawal and/or excess sedation when ARV therapy
is initiated or changed (49).
Clinicians should
assess adherence and be alert for
signs of hepatotoxicity in HIV-infected patients receiving HAART who are
concurrently using recreational drugs (50).
Each parenteral nutrition formulation
compounded should be inspected for signs of gross particulate contamination ,
discoloration , particulate formation , and phase separation at the time of
compounding and before administration (51).
EN patients who develop diarrhea should be evaluated for
antibiotic-associated causes , including Clostridium difficile (52).
In the absence of reliable information
concerning compatibility of a specific drug with an SNS formula , the
medication should be administered separately from the SNS (53).
Scabies: Recommended Regimen:Permethrin cream (5%)
applied to all areas of the body from the neck down and washed off after 8-14
hours (54). OR Ivermectin 200
micrograms/kg orally, repeated in 2 weeks (55).
Follow-Up (56).
Patients should
be informed that the rash and
pruritus of scabies might persist for up to 2 weeks after treatment (57).
Symptoms or signs that persist for >2 weeks
can be attributed to several factors (58).
Treatment failure might be caused
by resistance to medication or by faulty application of topical scabicides (59). Patients
with crusted scabies might have poor penetration into thick scaly skin and harbor
mites in these difficult-to-penetrate layers (60).
Particular attention must be given to
the fingernails of these patients (61).
Reinfection from family members or fomites might occur in
the absence of appropriate contact treatment and washing of bedding and clothing
(62). Even when treatment
is successful and reinfection is avoided , symptoms can persist or
worsen as a result of allergic dermatitis (63).
Finally , household mites can cause symptoms to persist as a result of crossreactivity between antigens (64). Some
specialists recommend re-treatment after 1-2 weeks for patients who are
still symptomatic; others recommend re-treatment on ly if if live mites are observed (65).
Patients
who do not respond to the recommended treatment should be re-treated with
an alternative regimen (1).
Bedding and clothing should be decontaminated
(ie , either machine-washed , machine-dried using the hot cycle , or dry
cleaned) or removed from body contact for at least 72 hours (2). Fumigation of
living areas is unnecessary (3).
Secondary Prevention of Withdrawal Seizures:
Benzodiazepines should be used for the secondary prevention of AWS (4).
Secondary Prevention of Withdrawal Seizures:
Phenytoin is not recommended for prevention of AWS recurrence (5). The efficacy of
other antiepileptics for secondary prevention of AWS is undocumented (6).
Patients with severe alcohol withdrawal
symptoms , regardless of seizure occurrence , should be treated pharmacologically
(7).
In patients who fail to respond to therapy
with methylprednisolone in the dose range used in the randomized ,
placebo-controlled trials , treatment with higher doses (up to 2 g daily for 5 days) should be considered (8).
A more intense , interdisciplinary
rehabilitation programme should be considered
after treatment with IV
methylprednisolone as evidence from a single trial suggests that this probably
further improves recovery (9).
Treatment with IV methylprednisolone (1 g once daily for 3 days with an oral tapering dose) may be
considered for treatment of acute
optic neuritis (10).
Correlation between IENF Density and Clinical,
Neurophysiological, Psychophysical, Autonomic, and Sural Nerve Biopsy
Examinations (11).
Studies of Skin Reinnervation: Skin biopsy
with quantification of IENF density can be
used to assess the regeneration
rate of sensory axons in peripheral neuropathies and could represent a
potential outcome measure in clinical trials (12).
The Task Force strongly recommends training
in an established cutaneous nerve laboratory before performing and processing
skin biopsies in the diagnosis of peripheral neuropathies (13).
Appropriate normative data from healthy
subjects matched for age , gender , ethnicity and anatomical site should be always used (14).
Quality control should include all
the steps of the procedure , in particular , the aspect of intra- and
inter-observer ratings for qualitative assessments and for quantitative
analysis of epidermal densities (15).
Prescription or provision of emergency
contraception in advance of need can increase
availability and use (16).
The following recommendations are based on good and consistent scientific
evidence (Level A): The two 0.75-mg doses of the levonorgestrel-only regimen
are equally effective if taken 12-24 hours apart.
Treatment with emergency contraception should be initiated as
soon as possible after unprotected or inadequately protected intercourse to
maximize efficacy (17).
Follow-Up: Failure to improve within 3 days of the
initiation of treatment requires reevaluation of both the diagnosis and therapy
(18). Swelling
and tenderness that persist after completion of antimicrobial therapy should be evaluated comprehensively
(19).
Management of Sex Partners: Patients who have acute
epididymitis, confirmed or suspected to be caused by N (20).
gonorrhoeae or C trachomatis , should be instructed
to refer sex partners for evaluation and treatment if their contact with the
index patient was within the 60 days preceding onset of the patient's symptoms (21). Patients should be instructed
to avoid sexual intercourse until they and their sex partners are cured (ie ,
until therapy is completed and patient and partners no longer have symptoms) (22).
Treatment: Empiric therapy is indicated before
laboratory test results are available (23).
As an adjunct to therapy , bed rest , scrotal
elevation , and analgesics are recommended until fever and local inflammation have subsided (24). Recommended
Regimens: For acute epididymitis most likely caused by gonococcal or chlamydial
infection: Ceftriaxone 250 mg IM in a single dose PLUS Doxycycline 100 mg
orally twice a day for 10 days For acute epididymitis most likely caused by
enteric organisms or for patients allergic to cephalosporins and/or
tetracyclines: Ofloxacin 300 mg orally twice a day for 10 days OR Levofloxacin
500 mg orally once daily for 10 days (25).
Several models for the implementation of AED
programmes outside the EMS have been described: we have identified three main
strategies that have different and to some extent opposite characteristics (26). It is recommended
that once the priorities of
implementation of an AED programme within the EMS have been achieved , a
careful analysis is conducted in order to identify the community model that is
most suitable for the specific environment (27).
A cost-effectiveness analysis is an essential part of
the implementation strategy (28).
Every hospital should analyse
whether the goal of early defibrillation is achieved and AED implementation can be an
important element in improving the in-hospital chain of survival (29). Home
programmes are still in a preliminary phase of implementation: families with a
genetic predisposition to sudden cardiac death and families with high risk
individual(s) who are not scheduled for , or cannot
receive , an implantable
cardioverter defibrillator (ICD) represent the primary target for pilot
projects on home defibrillation (30).
Legislation in Europe is heterogeneous, but where it
has relevance to AEDs it either has permitted or is likely to permit their use
by nonmedically qualified first responders (31).
The lack of data on cost-effectiveness may discourage
the support of governments for AED programmes (32).
Therefore , this type of economical evaluation
should be part of any planned developments (33).
European legislation or recommendation issued
by European policy makers and supported by all relevant major health care and
scientific societies could promote implementation of this life saving strategy
that is strongly supported by scientific evidence (34).
The goal of achieving an effective AED
programme within the EMS should become a fundamental objective in every European
country (35). Accordingly
, it is recommended that an AED and properly trained personnel should be
placed in every vehicle that may transport patients at risk of cardiac arrest (36). This should be the first priority for an early access
defibrillation programme (37).
Concern about increased new-onset diabetes
among patients prescribed a thiazide-type diuretic with a beta-blocker means
that this is not recommended as an initial combination for patients at raised
risk of developing type II diabetes (38).
Where possible , recommend treatment
with drugs taken only once a day (39).
Offer drug therapy to: Patients with persistent high
blood pressure of 160/100 mmHg or more Patients at raised cardiovascular risk
(10-year risk of coronary heart disease [CHD] >15% or cardiovascular disease
[CVD] >20% or existing cardiovascular disease or target organ damage) with
persistent blood pressure of more than 140/90 mmHg (40).
Further treatment with efalizumab is not recommended in
patients unless their psoriasis has responded adequately at 12 weeks (41).
Etanercept treatment should be discontinued in patients whose psoriasis has not responded adequately at 12 weeks (42). Further
treatment cycles are not recommended in these patients (43).
Patients who have begun a course of treatment
with efalizumab at the date of publication of this guidance should have the
option of continuing to receive treatment until the patients and their
clinicians consider it is appropriate to stop (44).
Decontamination of dermal exposures should include routine
cleansing with mild soap and water (45).
Removal of contact lenses and immediate
irrigation with room temperature tap water is
recommended for ocular exposures (46). All
patients with symptoms of eye injury should
be referred for an ophthalmologic
exam (47).
A witnessed "taste or lick" only in a
child, or an adult who unintentionally drinks and then expectorates all of a
concentrated product without swallowing, does not need referral (48).
Referral is not needed if it has been more than 24
hours since a potentially toxic unintentional exposure, the patient has been
asymptomatic, and no alcohol was co-ingested (49).
Use the bed only for sleeping (or sex) (50).
Management of medical conditions, psychological
disorders and/or symptoms that interfere with sleep such as: depression, pain,
hot flashes, anemia, or uremia (51).
For patients with a current diagnosis of a
sleep disorder , documentation and continuation of ongoing treatments , such as
continuous positive airway pressure (CPAP) , should
be maintained and reinforced by
patient and family education (52).
Patients with asymptomatic microscopic
hematuria who are at risk for urologic disease or primary renal disease should undergo an
appropriate evaluation (53).
In patients at low risk for disease , some
components of the evaluation may be deferred (54).
The initial determination of microscopic
hematuria should be based on microscopic examination of the urinary sediment
from a freshly voided , clean-catch , midstream urine specimen (55).
The prevalence of asymptomatic
microscopic hematuria varies from 0.19 percent to as high as 21 percent.
Additional Laboratory Tests (1).
It is recommended that patients with no apparent etiology of HF or no specific clinical
features suggesting unusual etiologies undergo additional directed blood and
laboratory studies to determine the cause of HF (2).
Exercise testing is not recommended as
part of routine evaluation in patients with HF (3).
It is recommended that the following laboratory tests be obtained routinely in patients
being evaluated for HF: serum electrolytes , blood urea nitrogen , creatinine ,
glucose , calcium , magnesium , lipid profile (low-density lipoprotein
cholesterol , high-density lipoprotein cholesterol , triglycerides) , complete
blood count , serum albumin , liver function tests , urinalysis , and thyroid
function (4).
If PTLD has been detected , it is recommended that
a contrast enhanced computed tomography (CT) be the modality of choice for
further evaluation (5).
Chest radiographs, ultrasound, CT, and magnetic
resonance imaging (MRI) have been used to detect PTLD (6).
A complete survey that includes the head and
neck , chest , abdomen , and pelvis is
recommended when PTLD is
suspected (7).
Routine use of imaging is not recommended to
screen for PTLD (8).
Imaging appearance is not specific for PTLD ,
so it is recommended that histologic evaluation be considered to confirm
the diagnosis (9).
It is recommended that a thorough history and physical examination including a detailed
neurologic examination and developmental assessment be performed in children
presenting with an apparent first , unprovoked seizures (10).
Neuroimaging Routine neuroimaging (magnetic
resonance imaging [MRI]/computed tomography [CT]) is not recommended in
children with first unprovoked seizures unless the history , physical exam , or
neurologic and developmental assessment suggest focality or deterioration/delay
, in which case an MRI is the procedure of choice (11).
Electroencephalogram (EEG) It is recommended that
patients with an apparent first unprovoked seizure be considered for neurologic
evaluation after consultation between the parents and treating physician (12). Neurologic
consultation may be more beneficial in situations where the diagnosis is
equivocal after a thorough history and physical or in cases of persistent
parental anxiety (13).
It is recommended that the child with OME who is at risk for developmental difficulties
be aggressively managed as appropriate to his/her condition (14).
It is recommended that all children with OME who have a positive assessment for pain be
treated with an appropriate analgesic , though ear pain in OME is not common (15).
It is recommended that the child with OME who is at risk for developmental difficulties
be identified early (16).
It is recommended , when 2 or more stimulants have been tried without success , that 2nd
tier medications be considered by clinicians if they are familiar with their
use (17).
It is recommended that diagnostic information be obtained directly from
parents/caregivers in the form of questionnaires and an interview that is
structured to elicit information about family structure and dynamics ,
parenting styles and expectations , and pertinent family educational and
psychiatric history (18).
It is recommended that the clinician provide periodic follow-up for the child diagnosed
with ADHD (19). This would include
monitoring target outcomes and adverse effects by collecting relevant
information from parents, teachers, and the child (20).
If systemic hypertension persists on
maximal therapy with calcium channel blockers , the following concomitant
drug therapy should be considered (21).
It is recommended that amlodipine be initiated at 0,1 mg/kg/day to achieve an arterial
blood pressure below the 90th percentile for age (22).
Dosing frequency may be adjusted
from once daily (Qday) to twice daily (BID) if indicated (23).
It is recommended that systemic arterial blood pressure be maintained within the normal
range for age following orthotopic cardiac transplantation (24). Continuous
monitoring of arterial blood pressure via an arterial line is recommended during
the early postoperative period (25).
Blood pressure may be affected
by pain (26). Normal values
assume adequate pain control (27).
Prevention and Education: It is recommended that
immunizations which prevent CAP be kept up-to-date , including: heptavalent
conjugated pneumococcal vaccine (28).
(PCV7, Prevnar), and annual influenza vaccine for all
children 6 to 23 months of age, and children aged >6 months with certain
risk factors (including but not limited to asthma, cardiac disease, sickle cell
disease, human immunodeficiency virus [HIV] and diabetes) (29).
It is recommended that sputum Gram stain and culture on high quality specimens be
considered when managing children with more severe disease (30). Note: A high
quality sputum is usually defined by the presence of less than 10 squamous
epithelial cells and greater than 25 white blood cells per low power field (31).
It is recommended that the severity of pneumonia be assessed based on overall clinical
appearance and behavior , including an assessment of the child's degree of
alertness and willingness to accept feedings (32).
Subcostal retractions and other evidence of increased
work of breathing increase the likelihood of a more severe form of pneumonia (33).
Radiologic Assessment: It is recommended ,
in children age 6 to 18 years and weight >18 kg [>40 lbs] (for whom surgery is being considered , that an AP pelvis x-ray also be obtained ,
to evaluate the status of growth plates near the proximal femur as well as to
aid in ruling out the presence of femoral neck fracture (34).
Implant/Cast Removal - procedure specific: It is recommended that
children treated via flexible intramedullary nailing have arrangements made for
implant removal by the end of the third month or the beginning of the fourth
month following surgery (35).
Outpatient Management: Quality of Life
Assessment: It is recommended that quality of life be assessed periodically using
the Pediatric Outcomes Data Collection Instrument (PODCI) conducted during the
course of outpatient follow up at: 6 weeks 3 months 6 months 12 months (36).
It is recommended that milrinone be started for any patient with a left atrial pressure
>15 mmHg or with signs or symptoms of low cardiac output (37). The recommended
loading dose of milrinone is 50 mcg/kg over 30 to 60 minutes, followed by an
infusion at 0,375 to 0,75 mcg/kg/min (38).
Treatment Recommendations: It is recommended that
milrinone be considered for any patient following arterial switch operation to
prevent the occurrence of low cardiac output over the first 24 hours following
arterial switch operation (39).
Clinical Assessments:It is recommended that
cardiac index be supported to maintain normal to minimally elevated left atrial
pressure (5 to 15 mmHg) with evidence of adequate tissue and organ perfusion as
defined by physical exam , urine output >1cc/kg/min , and no ongoing
metabolic acidosis or lactic acidemia (40).
It is recommended that cefuroxime , cefpodoxime , and cefdinir be second-line therapy
for pediatric ABS (41).
It is recommended that , for a child with ABS , physicians explore parental expectations
concerning the office visit , parental knowledge regarding respiratory
infections , and preventive behavior (42).
It is recommended , for older children with persistent clinical findings after
unsuccessful therapy , or for children with clinical evidence of orbital or
intracranial complications of ABS , that the decision to perform radiologic
studies be made in collaboration with the consulting ophthalmologist or
otolaryngologist (43).
Paracentesis: Abdominal paracentesis may be helpful to
confirm the presence of intestinal gangrene in infants with NEC (44).
Indications for paracentesis are absence of
pneumoperitoneum and one of the following: Portal venous gas (45). Erythema of
abdominal wall (46).
Fixed, tender abdominal mass (47).
Persistently dilated intestinal segment (48). Clinical
deterioration (49).
Radiologic Studies: It is recommended that
an abdominal radiograph be performed in infants with clinical suspicion of NEC (50). The influences on
infant outcome and diagnostic validity of the number of abdominal x-rays, the
type of view(s), or the frequency or timing of abdominal radiographs have not
been systematically studied (51).
Minimal Enteral Feeding:There is insufficient
evidence regarding the role of minimal enteral feedings in preventing NEC (52).
It is recommended that repeated clinical assessment be conducted , as this is the most
important aspect of monitoring for deteriorating respiratory status (53).
It is recommended that antihistamines , oral decongestants , and nasal vasoconstrictors
not be used for routine therapy (54).
It is recommended that inhalation therapy not be repeated nor continued if there is
no improvement in clinical appearance between 15 to 30 minutes after a trial
inhalation therapy (55).
Counsel obese and overweight women about the risks of
weight cycling--repeated episodes of weight loss and gain--and the benefits of
adopting long-term healthy eating habits (56).
For older women, assess blood pressure in both the
standing and sitting or supine position (57).
Health Promotion Strategies General
Recommendations Stress Management Educate women that feelings of anger and
hostility can contribute to higher levels of cholesterol (58).
Consider aspirin therapy (75 to 162 mg) in
intermediate-risk women as long as blood pressure is controlled and benefit is
likely to outweigh risk of gastrointestinal side effects (59).
Angiotensin-receptor blockers (ARBs) should be used in
high-risk women with clinical evidence of heart failure or an ejection fraction
who are intolerant to ACE inhibitors (60).
Pharmacotherapy
is indicated when blood pressure is >140/90 mm Hg or an
even lower blood pressure in the setting of blood pressure related target-organ
damage or diabetes (1).
Thiazide diuretics should be part of the
drug regimen for most patients unless contraindicated (2).
Glutamine may
be beneficial in select patients (3). To identify
which patients may benefit , each
constituent RCT should be reviewed and clinical judgement should be exercised (4).
Gastric residual values and tolerance (5).
Parenteral Nutrition (PN) in preference to Standard
Care (6).
Educate caregivers to assist in their ability to care
for the wanderer (7).
Assess for neurocognitive deficits and wandering
patterns using the Algase Wandering Scale (AWS) (8).
Provide stimulation clues such as pictures and signs (9).
Risk Assessment:Offer genetic testing for family
members, as appropriate (10).
Education/Health Promotion:Provide contact
information for support groups as requested (11).
Prenatal Diagnosis:If the family mutation is known,
preimplantation diagnosis is feasible (12).
Coordinate signing and sending sympathy card (13).
Prior to the death of the resident , the
Bereavement Leader should provide information about end-of-life care services , and
assistance in contacting these services (14).
Organize and participate in the Memorial Service (15).
Pediatricians should create a
variety of ways for children and families to serve as advisors as members of
child or family advisory councils , committees , and task forces dealing with
operational issues in hospitals , clinics , and office-based practices; as
participants in quality improvement initiatives; as educators of staff and
professionals in training; and as leaders or coleaders of peer support programs
(16).
Pediatricians should promote
the active participation of all children in the management and direction of
their own health care , beginning at an early age and continuing into adult
health care (17).
Health care institutions should design
their facilities to promote the philosophy of family-centered care (18).
Complete disability certification forms objectively,
accurately and in a timely manner (19).
Determine the presence or absence of a permanent
impairment that substantially limits one or more major life activities (20).
Assess fitness for duty and employability by
comparing the patient's work capacity to workplace demands (21). Obtain a
functional capacity examination if needed (22).
Previously Treated Patients with Intermediate- or
High-Risk Chronic Lymphocytic Leukemia Fludarabine is an acceptable treatment
option after failure of first-line therapy (23).
Choice of treatment should be influenced by previously used regimens and patient preference (24).
It is recommended that patients who have been treated with fludarabine receive
irradiated blood products because of the risk of transfusion related graft
versus host disease (25).
As first line treatment in patients with
intermediate- or high-risk chronic lymphocytic leukemia, fludarabine or
conventional chemotherapy (chlorambucil) are acceptable treatment options (26). Fludarabine improves
progression-free survival but has a greater risk of toxicity, including
specific infections (27).
Recommendation:When providing physical
activity advice , primary care practitioners should
take into account the individual's
needs , preferences , and circumstances (28).
They should agree goals with them (29).
They should
also provide written information
about the benefits of activity and the local opportunities to be active (30). They should follow them
up at appropriate intervals over a 3- to 6-month period (31).
Recommendation (32).
Practitioners , policy makers , and
commissioners should only endorse exercise referral schemes to promote
physical activity that are part of a properly designed and controlled research
study to determine effectiveness (33).
Individuals should
only be referred to schemes that
are part of such a study (34).
Recommendation: Practitioners , policy makers
, and commissioners should only endorse pedometers and walking and cycling
schemes to promote physical activity that are part of a properly designed and
controlled research study to determine effectiveness (35).
Measures should
include intermediate outcomes such
as knowledge , attitude , and skills , as well as measures of physical activity
levels (36).
Available evidence does not support a recommendation
for or against moderate caloric restriction in obese women with gestational
diabetes mellitus (GDM) (37).
However , if caloric restriction is used ,
the diet should be restricted by no more than 33% of calories (38).
The laboratory screening test should consist of
a 50-g , 1-hour oral glucose challenge
at 24 to 28 weeks of gestation , which may be
administered without regard to the
time of the last meal (39).
The screening test generally should be performed on
venous plasma or serum samples using well-calibrated and well-maintained
laboratory instruments (40).
The first line of treatment in primary open angle
glaucoma (POAG) is medical therapy and the choice of the drug depends on the
target IOP, the safety profile of the drug, patient acceptance, and cost (41).
Surgery is
indicated in patients who fail or
are unable to comply with medical therapy and may be combined with cataract
removal for enhanced visual rehabilitation (42).
The target IOP is an estimate of the mean IOP
achieved with treatment that is expected to prevent further optic nerve damage (43). An
individualised target IOP range should be set for every glaucoma patient (44).
Patients currently treated in hospital who are
potentially suitable for home haemodialysis on clinical grounds , but who have
not previously been offered a choice , should
be reassessed and informed about
their dialysis options (45).
It is recommended that all suitable patients should be offered the choice between home
haemodialysis or haemodialysis in a hospital/satellite unit (46).
Patients performing haemodialysis at home and their
carers will require initial training and an accessible and responsive support
service (47). The support
service should offer the possibility of respite hospital/satellite
unit dialysis as required (48).
Capecitabine monotherapy is recommended as
an option for people with locally advanced or metastatic breast cancer who have
not previously received capecitabine in combination therapy and for whom
anthracycline and taxane-containing regimens have failed or further
anthracycline therapy is contraindicated (49).
In the treatment of locally advanced or
metastatic breast cancer , capecitabine in combination with docetaxel is recommended in
preference to single-agent docetaxel in people for whom
anthracycline-containing regimens are unsuitable or have failed (50). The
decision regarding treatment should be made jointly by the individual and the clinician(s) responsible
for treatment (51).
The decision should be made after an
informed discussion between the clinician(s) and the patient; this discussion should take into account
contraindications and the side-effect profile of the agents , alternative
treatments for locally advanced or metastatic breast cancer , and the clinical
condition and preferences of the individual (52).
Valid consent should be obtained in
all cases where the individual has the ability to grant or refuse consent (53). The
decision to use ECT should be made jointly by the individual and the clinician(s)
responsible for treatment , on the basis of an informed discussion (54). This
discussion should be enabled by the provision of full and appropriate
information about the general risks associated with ECT and about the risks and
potential benefits specific to that individual (55).
Consent should
be obtained without pressure or
coercion , which may occur as a
result of the circumstances and clinical setting , and the individual should be
reminded of their right to withdraw consent at any point (56).
There should be strict adherence to recognised guidelines about consent and the
involvement of patient advocates and/or carers to facilitate informed
discussion is strongly encouraged (57).
As the longer-term benefits and risks of ECT
have not been clearly established , it is not
recommended as a maintenance
therapy in depressive illness (58).
The effectiveness of glitazone combination
therapy should be monitored against treatment targets for glycaemic control
(usually in terms of haemoglobin A1c [HbA1c] level) and for other
cardiovascular risk factors , including lipid profile (59).
The target HbA1c level should be set
between 6,5% and 7,5% , depending on other risk factors (60).
For people with type 2 diabetes, the use of a
glitazone as second-line therapy added to either metformin or a
sulphonylurea--as an alternative to treatment with a combination of metformin
and a sulphonylurea--is not recommended except for those who are unable to take
metformin and a sulphonylurea in combination because of intolerance or a
contraindication to one of the drugs (61).
In this instance , the glitazone should replace in
the combination the drug that is poorly tolerated or contraindicated (62).
It is recommended that a GP IIb/IIIa inhibitor is considered as an adjunct to PCI for
all patients with diabetes undergoing elective PCI , and for those patients
undergoing complex procedures (for example , multi-vessel PCI , insertion of
multiple stents , vein graft PCI , or PCI for bifurcation lesions); currently
only abciximab is licensed as an adjunct to PCI (63).
In procedurally uncomplicated, elective PCI,
where the risk of adverse sequelae is low , use of a GP IIb/IIIa inhibitor is not recommended unless
unexpected immediate complications occur (64).
It is recommended that in determining who is at high risk , clinicians should take into account combinations of risk factors such as:
clinical history , including age , previous MI , and previous PCI or CABG;
clinical signs , including continuing pain despite initial treatment; and
clinical investigations , such as electrocardiogram (ECG) changes (particularly
dynamic or unstable patterns indicating myocardial ischaemia) , haemodynamic
changes , and raised cardiac troponin levels (65).
Cardiac troponin testing is useful for diagnosing
acute coronary syndromes and in risk stratification (66).
However, it is recommended that in patients
considered to be at high risk, treatment with a small-molecule GP IIb/IIIa
inhibitor is initiated as soon as high-risk status is determined even though
this may be before the result of a troponin test is known (67).
Hotodynamic therapy (PDT) is recommended for
the treatment of wet age-related macular degeneration for individuals who have
a confirmed diagnosis of classic with no occult subfoveal choroidal
neovascularisation (CNV) (that is , whose lesions are composed of classic CNV
with no evidence of an occult component) and best-corrected visual acuity 6/60
or better (68). PDT should be carried out
only by retinal specialists with expertise in the use of this technology (69).
The use of PDT in occult CNV associated with wet
age-related macular degeneration was not considered because the
photosensitising agent (verteporfin) was not licensed for this indication when
this appraisal began (70).
No recommendation is made with regard to the use of
this technology in people with this form of the condition (71).
PDT is not
recommended for the treatment of
people with predominantly classic subfoveal CNV (that is , 50% or more of the
entire area of the lesion is classic CNV but some occult CNV is present)
associated with wet age-related macular degeneration , except as part of
ongoing or new clinical studies that are designed to generate robust and
relevant outcome data , including data on optimum treatment regimens ,
long-term outcomes , quality of life , and costs (72).
Patients who have not responded to one of
these hypnotic drugs should not be prescribed
any of the others (73).
These are the only circumstances in which the
drugs with the higher acquisition costs are
recommended (74).
Zanamivir and oseltamivir are not recommended for
the treatment of influenza in children or adults unless they are considered to
be at risk (75).
At-risk adults and children are defined for the
purpose of this guidance as those who are in at least one of the following
groups (76). People who: Have
chronic respiratory disease (including asthma and chronic obstructive pulmonary
disease) (77). Have significant
cardiovascular disease (excluding people with hypertension only) (78). Have chronic renal
disease (79). Are
immunocompromised (80).
Have diabetes mellitus (81).
Are aged 65 years or older (82).
Community-based virological surveillance
schemes should be used to indicate when influenza virus is circulating
in the community (83).
Community-based virological surveillance
schemes , such as those organised by the Royal College of General Practitioners
and the Public Health Laboratory Service , should
be used to indicate when influenza
virus is circulating in the community (84).
Such schemes should ensure that the onset
of the circulation of influenza virus (A or B) within a defined area is
identified as rapidly as possible (85).
Recommend patients
with wounds and LEAD seek care guided by a clinical wound expert (86).
Relate wound treatments to adequacy of perfusion
status (87).
Prior to treatment, assess causative and contributive
factors and significant signs and symptoms to differentiate types of
lower-extremity ulcers, which require varying treatment modalities (88).
Refer the patient for further evaluation for
suspected infection, positive probe to bone, and radiographic changes
demonstrating Charcot osteoarthropathy (89).
Refer high-risk patients to foot care specialists for
ongoing preventive care and lifelong surveillance (90).
Ensure adequate offloading of pressure through wound
closure (91).
Prevention: Continue preventive measures even when a
patient has a pressure ulcer to prevent additional pressure areas from
developing (92).
Prevention: Avoid vigorous massage over bony
prominences (93).
Perform wound care using topical dressings determined
by wound, patient needs, cost, caregiver time, and availability (94).
Assessment
of pain in children with juvenile FMS (JFMS) should
be developmentally based and should include both
child and parent components (1).
Include pain history, behavioral observation,
physiologic cues, and evaluation of comorbid mood disorders, psychosocial
distress, and functional status, including school attendance, for a
comprehensive assessment (2).
Provide education for the child and family on the
diagnosis of JFMS, interrelationship of symptoms, and management of symptoms (3). Provide education
to the child and family on an ongoing basis to increase self-care skills,
improve self-efficacy, and enhance understanding of the interrelationships
between pain, mood, stress, exercise, and the role of factors concerning the
parental and family environment (4).
Include background information regarding the
prevalence of pain in children (5).
Encourage people with FMS to perform
muscle-strengthening exercise two times per week (6).
Patients should
be instructed in the correct use of
glucose meters , including quality control (7).
Comparison between SMBG and concurrent
laboratory glucose analysis should be
performed at regular intervals to
evaluate the accuracy of patient results (8).
At a minimum , the end-points should be glycated
hemoglobin (GHb) and frequency of hypoglycemic episodes (9).
Ideally , outcomes (eg , long-term
complications and hypoglycemia) should also be examined (10).
Intraoperatively , the endoscopic general
surgeon should participate in positioning the patient and selecting the proper
locations of the trocars (11).
The endoscopic general surgeon is not only
responsible for safe entry into either the peritoneum or the retroperitoneum
but also must participate in safe dissection to expose the proper spinal
anatomy (12). He/she should be immediately
available throughout the entire operative procedure (13).
At the conclusion of the procedure, the endoscopic
surgeon is responsible for safely exiting the peritoneum or retroperitoneum and
for closure of trocar sites (14).
The endoscopic surgeon must be capable
of recognizing and managing intraoperative laparoscopic complications (15).
Each co-surgeon must adequately
document his/her respective preoperative , intraoperative , and postoperative
participation according to Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) standards (16).
Special attention should be directed
towards suitability of the patient for anesthesia and for the proposed
endoscopic procedure (17).
The endoscopic surgeon should not feel obligated to participate in any procedure that he/she does not feel is in the
best interest of the patient (18).
Risks and complications unique to the
endoscopic access portion of the procedure should
be identified and communicated to
the patient at this time , as well as the specific roles and responsibilities
of the endoscopic general surgeon (19).
The endoscopic general surgeon and spine
surgeon should each communicate their individual experience in this
procedure to the patient (20).
This results in a true informed consent (21). Both
co-surgeons must be named on the patient consent form (22).
Orotracheal intubation guided by direct laryngoscopy
is the emergency tracheal intubation procedure of choice for trauma patients (23).
The laryngeal mask airway and Combitube are
alternatives to cricothyrostomy and may be selected when cricothyrostomy expertise is
limited (24).
Tracheal Intubation Immediately Following Traumatic Injury Emergency tracheal
intubation is needed in trauma patients with the following traits: airway
obstruction hypoventilation severe hypoxemia (hypoxemia despite supplemental
oxygen) severe cognitive impairment (Glasgow Coma Score [GCS] <8) cardiac
arrest severe hemorrhagic shock.
In children with cough , cough suppressants
and other over the counter (OTC) cough medicines should not be used as
patients , especially young children , may experience significant morbidity and mortality (25).
Children with chronic cough should undergo ,
as a minimum , a chest radiograph and spirometry (if age appropriate) (26).
In children with nonspecific cough and risk
factors for asthma , a short trial (ie , 2 to 4 weeks) of beclomethasone , 400
micrograms/day , or the equivalent dosage with budesonide may be warranted (27).
Children and adolescents with newly suspected
and/or recurrent malignancy should be
referred to a pediatric cancer
center for prompt and accurate diagnosis and management (28).
Multidisciplinary team members should have pediatric
expertise within their specialty area (29).
Glucose-6-phosphate dehydrogenase deficiency
predisposes to haematological side effects and should be excluded
in predisposed races (30).
The side-effect profile of dapsone and sulphonamides
is potentially hazardous in the elderly (31).
These treatments should be considered only
if other treatments are ineffective or contraindicated (32).
The total published experience of intravenous
immunoglobulin in BP amounts to five small series that suggest that it is of
limited value (33).
Used mainly at a dose of 0.4 mg/kg polyvalent immunoglobulin daily for 5 days,
either as a sole treatment or with oral prednisolone, it produced some
occasional dramatic but unfortunately very transient responses that were too
short-lived to be useful.
Erythromycin should be considered for
treatment , particularly in children (adult dose 1,000-3,000 mg daily) and
perhaps in combination with topical corticosteroids (34).
A beneficial effect may be seen
within 1 to 3 weeks after commencing treatment (35).
Long-term follow up in a specialized clinic is
unnecessary for uncomplicated disease that is well controlled clinically using
small amounts of a topical corticosteroid , and follow up should be reserved
for patients with complicated LS that is unresponsive to treatment and those
patients who have persistent disease with history of a previous SCC (36).
Surgery , Laser , Photodynamic Therapy and
Cryotherapy: Adult Female Anogenital Lichen Sclerosus: There is no indication
for removal of vulval tissue in the management of uncomplicated LS , and
surgery should be used exclusively for malignancy and postinflammatory
sequelae (37). In one study, nine
of 12 patients with severe itch due to vulval LS unresponsive to topical
treatment responded to cryotherapy, 50% for 3 years (38).
An ultrapotent topical corticosteroid is the
first-line treatment for LS in either sex at any site, but there are no
randomized controlled trials comparing corticosteroid potency, frequency of
application, and duration of treatment (39).
Repeated courses of intravenous immunoglobulin
could be considered as an adjuvant , maintenance agent in patients with
recalcitrant disease who have failed more conventional therapies (40). In view of
reports of a rapid action in some cases , it
could be used to help induce
remission in patients with severe PV while slower-acting drugs take effect (41).
Tetracyclines with or without nicotinamide could be considered as
adjuvant treatment , perhaps in milder cases of PV (42).
In situ lumbar PLF is recommended as
a treatment option in addition to decompression in patients with lumbar
stenosis without deformity in whom there is evidence of spinal instability (43).
In situ posterolateral lumbar fusion is not recommended as
a treatment option in patients with lumbar stenosis in whom there is no
evidence of preexisting spinal instability or likely iatrogenic instability due
to facetectomy (44).
The addition of pedicle screw instrumentation is not recommended in
conjunction with PLF following decompression for lumbar stenosis in patients
without spinal deformity or instability (45).
The use of lumbar brace therapy as a
preoperative diagnostic tool to predict outcome following lumbar fusion surgery
is not recommended (46).
The use of transpedicular external fixation as
a tool to predict outcome following lumbar fusion surgery is not recommended (47).
Lumbar braces are recommended as
a means of decreasing the number of sick days lost due to low-back pain among
workers with a previous lumbar injury (48).
They are not
recommended as a means of
decreasing low-back pain in the general working population (49).
Lateral flexion and extension radiography is recommended as
an adjunct to determine the presence of lumbar fusion postoperatively (50). The lack of motion
between vertebrae, in the absence of rigid instrumentation, is highly
suggestive of successful fusion (51).
Static lumbar radiographs are not recommended as
a stand-alone means to assess fusion status following lumbar arthrodesis
surgery (52).
Technetium- 99 bone scanning is not recommended as
a means to assess lumbar fusion (53).
It is recommended that patients in whom discography is positive but in whom MR imaging
evidence of disc degeneration is absent not be considered candidates for
operative intervention (54).
It is recommended that discography be reserved for use in patients with equivocal MR
imaging findings , especially at levels adjacent to clearly pathological levels
(55).
Health practitioners should provide workers
at risk of occupational asthma with health surveillance at least annually and
more frequently in the first two years of exposure (56).
SIGN 2+ Sensitisation and occupational asthma are
most likely to develop in the first years of exposure for workers exposed to
enzymes, complex platinum salts, isocyanates, and laboratory animal allergens (57).
Employers and their health and safety
personnel should ensure that when respiratory protective equipment
is worn , the appropriate type is used and maintained , fit testing is
performed and workers understand how to wear , remove , and replace their
respiratory protective equipment (58).
Use with caution in patients at risk for development
of prolonged QT syndrome: congestive heart failure (CHF), bradycardia, cardiac
hypertrophy, hypokalemia/magnesemia, on other drugs known to prolong the QT
interval (59).
Anesthetic agents such as propofol and sedation
adjuncts such as droperidol, promethazine, and diphenhydramine are useful in
certain patients undergoing endoscopic procedures (60).
While propofol provides faster onset and deeper sedation
than standard benzodiazepines and narcotics, as well as faster recovery,
clinically important benefits have not been consistently demonstrated in
average-risk patients undergoing standard upper and lower endoscopy (61).
Trained personnel dedicated to the continuous and
uninterrupted monitoring of the patients physiologic parameters and
administration of propofol (62).
Key Recommendations by Diagnosis: Candidemia and
Acute Hematogenously Disseminated Candidiasis:For clinically stable patients
who have not recently received azole therapy, fluconazole (>6 mg/kg per day;
ie, >400 mg/day for a 70-kg patient) is another appropriate choice (63).
Key Recommendations by Diagnosis: Candidal
Endocarditis , Pericarditis , Suppurative Phlebitis , and Myocarditis: Both
native valve and prosthetic valve infection should
be managed with surgical
replacement of the infected valve (64).
Medical therapy with amphotericin B with or without
flucytosine at maximal tolerated doses has most often been used (65).
Key Recommendations by Diagnosis:Disseminated
Cutaneous Neonatal Candidiasis: Prematurely born neonates , neonates with low
birth weight , or infants with prolonged rupture of membranes who demonstrate
the clinical findings associated with disseminated neonatal cutaneous
candidiasis should be considered for systemic therapy (66).
Amphotericin B deoxycholate (0,5-1 mg/kg per day, for
a total dose of 10-25 mg/kg) is generally used (67).
Where myeloma and AL amyloidosis co-exist ,
choice of treatment for myeloma should take
into account the extent of organ
involvement with amyloid and the potential toxicities of individual treatments (68).
Midodrine
is the most effective drug for orthostatic hypotension in patients with
amyloidosis , but can cause supine hypertension (1).
Solitary extramedullary plasmacytoma should be treated by
radical radiotherapy encompassing the primary tumour with a margin of at least 2 cm (2).
Reconstruction of the anterior column may be beneficial
(3).
Alkylating-agent based therapy is appropriate for the
initial and subsequent treatment of Waldenstrom's Macroglobulinaemia (4). Purine analogues are
appropriate for the initial and subsequent treatment of Waldenstrom's
Macroglobulinaemia (5).
There is no consensus on the duration of treatment
with cladribine or fludarabine, or on which purine analogue is superior (6). Fludarabine is more
active than cyclophosphamide, doxorubicin and prednisolone (CAP) as salvage
therapy (7). 1-2 procedures,
exchanging 1-1 calculated plasma volumes is advised for the treatment of
hyperviscosity syndrome (HVS) in Waldenstrm's macroglobulinaemia (WM) (8). In patients
who are drug resistant this may be indicated as long term management (9).
Esophageal pH recording is possibly indicated to detect refractory reflux in patients with chest pain after cardiac
evaluation using a symptom reflux association scheme , preferably the symptom
association probability calculation (pH study done after a trial of proton pump
inhibitor therapy for at least 4 weeks) (10).
Esophageal pH recording is possibly indicated to document concomitant gastroesophageal reflux disease in an adult
onset , nonallergic asthmatic suspected of having reflux-induced asthma (pH
study done after withholding antisecretory drugs for > 1 week) (11). Note: a positive
test does not prove causality (12).
Esophageal pH recording is indicated to
evaluate patients with either normal or equivocal endoscopic findings and
reflux symptoms that are refractory to proton pump inhibitor therapy (pH study
done after withholding antisecretory drug regimen for >= 1 week if the
study is done to confirm excessive acid exposure or while taking the
antisecretory drug regimen if symptom-reflux correlation is to be scored) (13).
School personnel involved in detection of head
lice infestation should be appropriately trained (14).
The importance and difficulty of correctly
diagnosing an active head lice infestation should
be acknowledged (15).
Head lice screening programs have not been proven to
have a significant effect on the incidence of head lice in the school setting
over time and are not cost-effective (16).
Parent education programs may be helpful in
the management of head lice in the school setting (17).
None of the currently available pediculicides are
100% ovicidal and resistance has been reported with lindane, pyrethrins, and
permethrin (18).
Treatment failure does not equate with resistance,
and most instances of such failure represent misdiagnosis/misidentification or
noncompliance with the treatment regimen (19).
Perform a renal ultrasound (or repeat the ultrasound
if it was done prenatally) (20).
If the patient is found to have an abnormality of the
urinary tract, continue monitoring for urinary tract infections and renal
function (21).
Continue to evaluate the child's renal status
(urinalysis and culture, as indicated) if a renal anomaly is present (22).
Check the adolescent annually for scoliosis and
kyphosis (23).
For patients with systolic dysfunction (ejection fraction [EF] <40%) who
have no contraindications:Aldosterone antagonist (low dose) for patients with
rest dyspnea or with a history of rest dyspnea or for symptomatic patients who
have suffered a recent myocardial infarction.
Bi-ventricular pacemakers considered for patients
requiring defibrillators who have symptomatic HF and QRS durations > 120
msec (24).
Implantable defibrillators considered for prophylaxis against sudden cardiac
death in patients with EF < 35%.
Evaluate the patient for the presence of risk factors
for heart failure (25).
Monitor the patient's condition and response to
treatment (26).
Treat the chronic underlying cardiac condition (27).
Routine post-vaccination antibody measurement is not recommended because
of the generally high efficacy of the vaccine (28).
Clinicians should
administer HAV vaccination early in
the course of human immunodeficiency virus (HIV) infection (29). If a patient's CD4 count is <300
cells/mm3 or the patient has symptomatic HIV disease, it is preferable to defer
vaccination until several months after initiation of antiretroviral (ARV)
therapy in an attempt to maximize the antibody response to the vaccine.
The full series should be given (initial
dose and a second dose 6 to 12 months later) to ensure maximal antibody
response (30).
Treatment of Hepatitis C Infection: Treatment
for HCV should be considered for all patients co-infected with HIV and HCV (31).
Sexual Assault Forensic Examiner (SAFE) who is
trained to perform pediatric examinations should
be included on the team whenever
possible to assist in the medical examination , coordination of care , and
discussions about treatment regimen (32).
A rape crisis counselor and/or child advocacy
team should be involved in all cases of sexual assault to assist
the child and the family in dealing with the trauma and to assist with
referrals (33).
Non-occupational PEP should not be prescribed when there is negligible or low risk of HIV transmission (34).
Recommending nPEP For Sexual Assault
Survivors: Starter packs of medication should
be available on-site for rapid
initiation of nPEP following sexual assault (35).
Arrangements should be made to ensure that
the patient receives a continued supply of medication and is referred to an HIV
specialist (36).
If thrombocytopenia is accompanied by other
cytopenias or splenomegaly and is mild (>50 ,000 cells/mm3) , 000
cells/mm3) , hypersplenism caused by infectious causes or coincident liver
disease should be suspected (37).
If endogenous erythropoietin levels are <500 mUnits/mL, erythropoietin
therapy (50-200 iu/kg/dose 3 times/week) should be administered to reduce the
need for transfusion. Supplemental oral iron
(3-6 mg/kg/day of elemental iron) and folate (1 mg/day) should be administered when erythropoietin is initiated (38).
Antiretroviral therapy should be the
primary treatment of HIV-associated thrombocytopenic purpura unless 1) it has
been previously demonstrated to be ineffective , 2) the count needs to be
increased within 2 weeks, or 3) there are other reasons not to initiate it,
such as refusal, intolerance, or limited antiretroviral susceptibility (39). Treatment of
asymptomatic, mild to moderate, HIV-associated thrombocytopenia is usually not
necessary (40).
This guidance applies to the use of the aromatase
inhibitors anastrozole, exemestane, and letrozole, within the marketing
authorisations for each drug at the time of this appraisal, for the treatment
of early oestrogen-receptor-positive breast cancer; that is: Anastrozole for
primary adjuvant therapy Exemestane for adjuvant therapy following 2?3 years of
adjuvant tamoxifen therapy Letrozole for primary adjuvant therapy and extended
adjuvant therapy following standard tamoxifen therapy (41).
The aromatase inhibitors anastrozole ,
exemestane , and letrozole , within their licensed indications , are recommended as
options for the adjuvant treatment of early oestrogen-receptor-positive invasive
breast cancer in postmenopausal women (42).
The choice of treatment should be made after
discussion between the responsible clinician and the woman about the risks and
benefits of each option (43).
Factors to consider when making the choice include
whether the woman has received tamoxifen before, the licensed indications and
side-effect profiles of the individual drugs and, in particular, the assessed
risk of recurrence (44).
It is recommended that , in women with a
previous VTE , with or without an underlying heritable thrombophilia , oral HRT
should usually be avoided in view of the relatively high risk of recurrent VTE
(45).
HRT should
be considered a risk factor for VTE
when assessing women preoperatively (46).
However, HRT does not require to be routinely stopped
prior to surgery provided that appropriate thromboprophylaxis, such as low-dose
or low-molecular-weight heparin, with or without thromboembolic deterrent
stockings, is used (47).
Prior to commencing HRT , a personal history
and a family history assessing the presence of venous thromboembolism (VTE) in
a first- or second-degree relative should be
obtained (48).
Consider referral to a program that provides guidance
on nutrition, physical activity, and psychosocial concerns (49).
Weight loss surgery should be considered only
for patients in whom other methods of treatment have failed and who have
clinically severe obesity (ie , BMI >40 or BMI >35 with life-threatening
comorbid conditions (50).
Assess current eating, exercise behaviors, history of
weight loss attempts, and psychological factors contributing to weight gain (51).
Pediatricians can work locally , nationally , and internationally to help change cultural norms conducive to eating disorders
and proactively to change media messages (52).
Pediatricians should be familiar
with the screening and counseling guidelines for disordered eating and other
related behaviors (53).
Mycophenolate mofetil is recommended for
adults as an option as part of an immunosuppressive regimen only: Where there
is proven intolerance to calcineurin inhibitors , particularly nephrotoxicity
leading to risk of chronic allograft dysfunction , or In situations where there
is a very high risk of nephrotoxicity necessitating minimisation or avoidance
of a calcineurin inhibitor (54).
Basiliximab or daclizumab , used as part of a
calcineurin-inhibitor-based immunosuppressive regimen , are recommended as
options for induction therapy in the prophylaxis of acute organ rejection in
adults undergoing renal transplantation (55).
The induction therapy (basiliximab or
daclizumab) with the lowest acquisition cost should
be used (56).
Tacrolimus is an alternative to ciclosporin
when a calcineurin inhibitor is indicated as part of an initial or a maintenance
immunosuppressive regimen in renal transplantation for adults (57). The initial
choice of tacrolimus or ciclosporin should be
based on the relative importance of
their side-effect profiles for individual people (58).
Patients should
have adequate , accurate
information regarding factors that influence HIV transmission and methods for
reducing the risk for transmission to others , emphasizing that the most
effective methods for preventing transmission are those that protect
noninfected persons against exposure to HIV (eg , sexual abstinence; consistent
and correct use of condoms made of latex , polyurethane or other synthetic
materials; and sex with only a partner of the same HIV serostatus) (59). HIV-infected
patients who engage in high-risk sexual practices (ie , capable of resulting in
HIV transmission) with persons of unknown or negative HIV serostatus should be counseled to use condoms consistently and correctly (60).
[1] http://www.acetic.fr
[2] http://www.textworld.com/scp/
[3] Gersende Georg, Marie-Christine Jaulent. A Document Engineering Environment for Clinical Guidelines. In: Peter R. King & Steven J. Simske. DocEng'07 - Proceedings of the 2007 ACM Symposium on Document Engineering. 28-31 August 2007, Winnipeg, Manitoba, Canada. ACM Press, New York NY, USA. 2007;:69-78.