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17 Αυγούστου 2019, 23:41:44

Αποστολέας Θέμα: Practice Guidelines  (Αναγνώστηκε 92124 φορές)

0 μέλη και 1 επισκέπτης διαβάζουν αυτό το θέμα.

28 Σεπτεμβρίου 2008, 20:57:08
Απάντηση #30
Αποσυνδεδεμένος

Gatekeeper

Επώνυμοι
Management of suspected bacterial UTI in adults

SIGN July 2006
“It’s a poor sort of memory that onlyworks backwards, the Queen remarked.”
Lewis Carroll, 1872,
Through the Looking Glass

1 Οκτωβρίου 2008, 20:48:43
Απάντηση #31
Αποσυνδεδεμένος

Gatekeeper

Επώνυμοι
Influenza (prophylaxis) - amantadine, oseltamivir and zanamivir

Summary
NICE has said that its recommendations about oseltamivir and zanamivir should not reduce efforts to give vaccination (also called the flu jab) to people for whom it is recommended in national guidelines.

The guidance does not cover widespread epidemics.

Oseltamivir and zanamivir are recommended to prevent flu if all of the following apply:

The amount of flu virus going around is enough that if someone has a flu-like illness it is likely that it has been caused by the flu virus
The person is in an at-risk group (see page 4).
The person has been in contact with someone with a flu-like illness and can start treatment within 36 hours (for zanamivir) or within 48 hours (for oseltamivir)
The person has not been effectively protected by vaccination
“It’s a poor sort of memory that onlyworks backwards, the Queen remarked.”
Lewis Carroll, 1872,
Through the Looking Glass

8 Οκτωβρίου 2008, 18:22:33
Απάντηση #32
Αποσυνδεδεμένος

Gatekeeper

Επώνυμοι
Clinical Practice Guidelines Issued for Managing Earwax Impaction

September 5, 2008 The American Academy of Otolaryngology–Head and Neck Surgery Foundation has issued evidence-based, clinical practice guidelines for managing cerumen (earwax) impaction and has published them in the September issue of Otolaryngology–Head and Neck Surgery. The new guidelines, which are intended for all clinicians who are likely to diagnose and manage patients with cerumen impaction, discourage routinely cleaning out cerumen.

"Unfortunately, many people feel the need to manually remove earwax, called cerumen, which serves an important protective function for the ear," lead author Peter S. Roland, MD, chairman of Otolaryngology–Head and Neck Surgery at University of Texas Southwestern Medical Center in Dallas, said in a news release. "Cotton swabs and some other home remedies can push cerumen further into the canal, potentially foiling the natural removal process and instead cause build-up, known as impaction."

Cerumen impaction is defined as an accumulation of cerumen that causes symptoms, prevents ear examination, or both. Although the term impaction suggests complete obstruction of the ear canal with cerumen, this working definition of cerumen impaction does not require complete obstruction.

The water-soluble mixture of secretions in cerumen produced in the outer third of the ear canal, along with hair and dead skin, serves a critical protective function for the ear and should not be removed unless it causes symptoms or prevents evaluation.

The objectives of these guidelines are to improve diagnostic accuracy regarding cerumen impaction, facilitate appropriate management for patients with cerumen impaction, highlight the need for assessment and intervention in special populations, ensure the implementation of indicated therapies with outcomes assessment, and improve counseling and education for the prevention of cerumen impaction.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation appointed an expert panel of specialists in audiology, family medicine, geriatrics, internal medicine, nursing, otolaryngology–head and neck surgery, and pediatrics to review the appropriate evidence and to formulate these guidelines.

The panel made a strong recommendation that the indications for treating cerumen impaction are symptoms reported by the patient, or build-up sufficient to prevent indicated clinical examination.

Recommendations made by the panel were as follows:

Cerumen impaction should be diagnosed when accumulated cerumen is symptomatic or when it prevents needed examination of the external auditory canal, tympanic membrane, or both.


History and physical examination of the patient with cerumen impaction should focus on factors that could affect management, including a tympanic membrane that is not intact, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy.


Patients with hearing aids should be evaluated during a healthcare encounter for the presence of cerumen impaction because cerumen can cause feedback, reduced sound intensity, or damage to the hearing aid. However, it is not necessary to perform this examination more often than once every 3 months.


Appropriate interventions for cerumen impaction may include ceruminolytic agents, irrigation, and/or manual removal other than irrigation. Ceruminolytic agents are effective, but evidence is lacking regarding the superiority of any particular agent. Irrigation or ear syringing is most effective when a ceruminolytic agent is instilled 15 to 30 minutes before treatment.


When in-office treatment of cerumen impaction is completed, clinicians should evaluate the patient and document that the impaction has resolved. Additional treatment should be prescribed if the impaction has not resolved. Alternative diagnoses should be considered if full or partial symptoms persist despite resolution of the impaction.
Options, which carry less weight than the recommendations, offered by the panel were as follows:

Patients with cerumen that is not impacted, is asymptomatic, and does not prevent adequate examination when an evaluation is indicated may be observed without active intervention.


In a patient who may not be able to express symptoms but who has cerumen obstructing the ear canal, clinicians may promptly evaluate the need for intervention.


The patient with cerumen impaction may be treated with ceruminolytic agents, irrigation, or manual removal other than irrigation.


Clinicians may educate and counsel patients who have cerumen impaction and/or excessive cerumen regarding appropriate control measures.


To avoid damaging the ear or create more impaction, suction devices or other specialty instruments should be used only under supervised medical care. Removal with specialty instruments is preferred for patients with narrow ear canals, eardrum perforation or tube, or immune deficiency.
The guidelines warn against patients using cotton-tipped swabs and against home use of oral jet irrigators. Ear candling, an alternative to traditional methods of earwax removal, is ineffective and is potentially dangerous.

"The complications from cerumen impaction can be painful and include infections and hearing loss," Dr. Roland said. "It is hoped that these guidelines will give clinicians the tools they need to spot an issue early and avoid serious outcomes."

The authors note that this clinical practice guideline is not intended to be the only source of guidance in managing cerumen impaction, nor is it intended to replace clinical judgment or to establish a protocol for all individuals with this condition. Although it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies, it may not provide the only appropriate approach to diagnosing and managing this problem.

Three of the guidelines authors have disclosed various financial relationships with Alcon Labs, MedEl Corporation, Advanced Bionics, Cochlear Corporation, GlaxoSmithKline, Acclarent, Sinexus, National Institutes of Health, Krames Communication, Schering-Plough, and/or sanofi-aventis.

Otolaryngol–Head Neck Surg. 2008;139:S1-S21.

Study Highlights
The prevalence of cerumen impaction varies and in the United States has been estimated as affecting 10% of children, 5% of healthy adults, up to 57% of older persons in nursing homes, and 36% of those with mental disabilities.
12 million people seek treatment annually for cerumen impaction, and 8 million procedures are performed by healthcare professionals.
Treatment of impaction has resulted in complications such as ear canal laceration, infection, hearing loss, otitis externa, pain, syncope, and dizziness at the rate of 1 in 1000 ear irrigations.
Recommendations
The diagnosis of impaction requires a targeted history, physical examination, otoscopy, binocular microscopic examination, and audiologic evaluation.
Clinicians should diagnose impaction when it is associated with symptoms, prevents assessment of the ear, or both.
Factors that modify management include a tympanic membrane that is not intact, ear canal stenosis, exostosis, diabetes mellitus, anticoagulant treatment, or immunocompromise.
Narrow ear canals may be found in those with Down's syndrome and other craniofacial disorders.
Those with hearing aids should be examined for an impacted cerumen every 6 to 12 months because impaction can cause poor fit of the hearing aid and reduced sound intensity or feedback.
Appropriate interventions for an impacted cerumen include ceruminolytic agents, irrigation, or manual removal other than irrigation.
Manual removal other than irrigation includes a curette, probe, forceps, suction, and hook.
Mechanical removal is the preferred technique when the eardrum is not intact.
In the presence of anatomic anomalies, safe and effective irrigation is not always possible, and the binocular microscope with microinstrumentation may be needed.
Patients receiving anticoagulants are at higher risk for hemorrhage.
Clinicians should examine patients at the end of an intervention and document resolution of the impaction.
Alternative treatment and alternative diagnoses should be considered if resolution of the impaction does not occur.
Ear candling is potentially unsafe and is not endorsed by the US Food and Drug Administration to treat impaction.
Options
Observation of impaction is reasonable in the absence of symptoms, and a needs assessment of the ear can be conducted.
Elderly patients, young children, and those with cognitive impairment are at high risk for impaction and may not be able to express symptoms.
The clinician should weigh potential benefits and harms of treating impaction in this population.
Clinicians may use ceruminolytic agents including water or saline to manage impaction or instruct patients in home use.
Ceruminolytic agents may be water based or oil based.
No specific ceruminolytic agent has been found to be superior to another in clinical trials.
The use of cerumenolytics up to 15 minutes or days before irrigation improves the success of irrigation.
Clinicians may use irrigation in the management of impaction.
Clinicians may use manual removal other than irrigation for impaction, especially in those with abnormal otologic findings, systemic illness, or compromised immunity.
Clinicians should ensure adequate training and use of appropriate equipment for procedures.
Clinicians may educate patients on control measures including use of prophylactic topical preparations, irrigation of the ear canal, or routine cleaning by a clinician.


“It’s a poor sort of memory that onlyworks backwards, the Queen remarked.”
Lewis Carroll, 1872,
Through the Looking Glass

22 Νοεμβρίου 2008, 23:44:47
Απάντηση #33
Αποσυνδεδεμένος

OBELIX


Για ογκολογικά: Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος
Πρόκειται για τα επίσημα Αμερικάνικα Guidelines του Νational Comprehensive Cancer Network κυρίως για θεραπεία

27 Δεκεμβρίου 2008, 18:46:40
Απάντηση #34
Αποσυνδεδεμένος

πρώτη & καλύτερη

Ιατροί
Στον παρακάτω πίνακα κατατάσσονται οι ασθενείς με κολπική μαρμαρυγή ανάλογα με τον κίνδυνο εμφάνισης stroke και δίδονται οδηγίες για την πρόληψή του με ασπιρίνη ή αντιπηκτικά peros.

27 Δεκεμβρίου 2008, 21:39:59
Απάντηση #35
Αποσυνδεδεμένος

Argirios Argiriou

Moderator
BMJ, 29.01.2005,

Recent developments in atrial fibrillation:

............
.............................

Determine thromboembolic risk. (see figure number 3)

.............................................

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Before ordering a test decide what you will do if it is (1) positive, or (2) negative. If both answers are the same, don't do the test. Archie Cochrane.

23 Ιανουαρίου 2009, 18:08:24
Απάντηση #36
Αποσυνδεδεμένος

KERASIDISN


A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council, American Heart Association

Stroke published online Jan 22, 2009

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6 Απριλίου 2009, 18:00:05
Απάντηση #37
Αποσυνδεδεμένος

flone

Ιατροί
Carotid endarterectomy—An evidence-based review: Report of the Therapeutics and Technology Assessment Subcommittee  of the American Academy of Neurology

AHA Conference Proceedings: Controversies in Carotid Artery Revascularization

17 Μαΐου 2009, 20:07:20
Απάντηση #38
Αποσυνδεδεμένος

Μαρία Χόρτη

Ιατροί
Geriatrics Society Changes Its Pain Management Guidelines

Older patients with moderate-to-severe pain are candidates for opioid therapy and should only "rarely" receive nonselective NSAIDs and COX-2 selective inhibitors, according to a revision of the American Geriatrics Society's pain management guidelines.

In its first revision since 2002, the society makes several recommendations, among them:

-Acetaminophen should be the "initial and ongoing" drug treatment for persistent — "particularly musculoskeletal" — pain.
-Nonselective NSAIDs and COX-2 selective inhibitors may be considered "with extreme caution" for patients in whom "other (safer) therapies have failed."
-Patients with fibromyalgia or neuropathic pain are candidates for adjuvant analgesics.
-Breakthrough pain should be anticipated with opioid use, and it should be treated with short-acting, immediate-release opioids.

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25 Μαΐου 2009, 12:38:21
Απάντηση #39
Αποσυνδεδεμένος

Raptor

Ιατροί
New AHA/ASA Guidelines on TIA Management and Telemedicine in Acute Stroke Released

May 15, 2009 — The American Heart Association (AHA)/American Stroke Association (ASA) has released 2 new guideline documents, 1 advocating urgent treatment for transient ischemic attacks (TIA) and changing the clinical definition and the other giving a green light to the use of telemedicine consults in acute stroke assessment.

Along with the 2 scientific statements, a policy statement has also been published to provide recommendations on how best to implement telemedicine in stroke care systems.

The TIA and telemedicine stroke documents are published online May 7 and will appear in the June and July issues of Stroke, respectively.

New Definition of TIA

In the scientific statement examining the definition and evaluation of TIAs, the writing group points out that large cohort and population-based studies reported in the past 5 years have shown that the risk for stroke after a TIA is higher than previously thought. "Ten percent to 15% of patients have a stroke within 3 months, with half occurring within 48 hours," the group, chaired by J. Donald Easton, MD, professor and chair of the department of clinical neurosciences at Alpert Medical School of Brown University and the Rhode Island Hospital, in Providence, writes.

Accordingly, the authors recommend that TIAs be subject to the same urgent assessment and care given to acute strokes and, to that end, have changed the clinical definition of TIA. "We think a TIA should be treated as an emergency, just like a major stroke," Dr. Easton said in a news release from the AHA/ASA. "Because we know the high risk for a future stroke, this is a golden opportunity to prevent a catastrophic event."

The traditional clinical definition, dating to the mid-1960s, is "a sudden neurological deficit of presumed vascular origin lasting less than 24 hours." The new statement changes this definition to "a transient episode of neurological dysfunction caused by focal brain, spinal-cord, or retinal ischemia, without acute infarction."

The presence of infarction has been the main distinction between stroke and TIA, but the advent of more sensitive imaging of tissue damage using magnetic resonance imaging (MRI) has suggested that infarction with presumed TIAs may occur often.

"Research around the globe has shown that the arbitrary threshold based on duration of symptoms was too broad, because up to half of TIAs defined this way actually caused sustained brain injury according to an MRI," Dr. Easton noted.

Long-Distance Stroke Assessment

In the scientific statement on telemedicine, the writing group, chaired by Lee Schwamm, MD, from Harvard Medical School and Massachusetts General Hospital, in Boston, provides an evidence-based review of the scientific evidence supporting the use of telemedicine for stroke care delivery and concludes that high-quality videoconferencing systems can be used by remote stroke specialists to carry out National Institutes of Health Stroke Scale (NIHSS)-telestroke examinations when a bedside assessment is not immediately available for patients who may be having an acute stroke and provide results comparable to the beside assessment.

It is recommended that these examinations be supported by the use of a Food and Drug Administration (FDA)–approved teleradiology system, where computed-tomography (CT) and MRI scans can also be viewed by the remote stroke specialist, the authors note. The specialist can then make recommendations to the on-site providers about whether tissue plasminogen activator should be used or not.

Similarly, these systems can be used to provide occupational and physical therapy remotely, the document notes.

"Telemedicine is an effective avenue to eliminate disparities in access to acute stroke care, erasing the inequities introduced by geography, income, or social circumstance," Dr. Schwamm said in news release from the AHA/ASA.

Changes in reimbursement for telemedicine activities, though, are required for implementation of a telestroke system and require consideration of a number of other issues, including cost recovery, liability, and training of provider. For that reason, a second document of policy recommendations accompanies the scientific statement.

The recommendations include:

Whenever local or on-site acute stroke expertise or resources are insufficient to provide around-the-clock coverage for a healthcare facility, telestroke systems should be deployed to supplement resources at participating sites.
New models and codes for reimbursement of telestroke services should be developed to reflect the increased up-front costs to providers and reduced long-term healthcare costs to insurers.
Organizations providing or requesting telemedicine services should operate by contractual agreements that explicitly deal with such issues as assignment of costs for developing and maintaining the telemedicine network; compliance with relevant federal, state, and local statute boundaries and any existing noncompete relationships; assessment of medicolegal risk and provision of adequate malpractice coverage; and administrative and credentialing requirements for all providers.
"Telestroke can enable the initiation of cost-effective interventions proven to reduce complications and stroke recurrence and can identify and facilitate transfer of patients in the community for specific tertiary-care interventions, such as neurointensive care, decompressive surgery for life-threatening, space-occupying cerebral infarction, and prompt surgical or endovascular repair of ruptured cerebral aneurysms," the authors conclude.

.

Stroke. Published online May 7, 2009.

"Success is getting what you want" "Happiness is wanting what you get"
"The secret of happiness is not found in seeking more, but in the capacity to enjoy less."

2 Ιουνίου 2009, 14:06:46
Απάντηση #40
Αποσυνδεδεμένος

Raptor

Ιατροί
Recommendation Statement From USPSTF: Aspirin for the Prevention of Cardiovascular Disease

Summary of Recommendations

The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. Go to the Clinical Considerations section for discussion of benefits and harms. Grade: A recommendation.


The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. Go to the Clinical Considerations section for discussion of benefits and harms. Grade: A recommendation.


The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of aspirin for cardiovascular disease prevention in men and women 80 years or older. Grade: I statement.


The USPSTF recommends against the use of aspirin for stroke prevention in women younger than 55 years and for myocardial infarction prevention in men younger than 45 years. Grade: D recommendation
"Success is getting what you want" "Happiness is wanting what you get"
"The secret of happiness is not found in seeking more, but in the capacity to enjoy less."

18 Ιουνίου 2009, 22:56:52
Απάντηση #41
Αποσυνδεδεμένος

Gatekeeper

Επώνυμοι
Low back pain 
Early management of persistent non-specific low back pain

NICE guideline 27 May 2009
« Τελευταία τροποποίηση: 23 Ιουνίου 2009, 00:01:19 από Nektarios Nikolopoulos »
“It’s a poor sort of memory that onlyworks backwards, the Queen remarked.”
Lewis Carroll, 1872,
Through the Looking Glass

21 Ιουνίου 2009, 19:55:40
Απάντηση #42
Αποσυνδεδεμένος

Μαρία Χόρτη

Ιατροί
Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger. (GINA) 2009

Δεν είναι ορατοί οι σύνδεσμοι (links). Εγγραφή ή Είσοδος

Pocket Guide for Asthma Management and Prevention in Children 5 Years and Younger

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9 Ιουλίου 2009, 12:15:03
Απάντηση #43
Αποσυνδεδεμένος

Raptor

Ιατροί
    Asthma Guideline update

    The Scottish Intercollegiate Guidelines Network (SIGN) / British Thoracic Society (BTS) Guideline on the Management of Asthma has been updated

    The update includes a review of the sections on pharmacological management, acute asthma and the management of asthma in pregnancy and key messages include:


    ---  Oxygen levels in patients with acute asthma should be maintained at SpO2 94-98%
    ---  Oxygen saturation should be measured by pulse oximeters in adults and children. Pulse oximeters should therefore be available for use by all health professionals assessing acute asthma in both primary and secondary care settings
    ---The importance of action plans in controlling asthma and reducing future hospitalisation is reinforced
    ---  Reinforced advice on the safe use of treatment during pregnancy [/li][/list]

    In addition, inhaled steroid doses are now referenced to CFC-free metered dose inhaler devices due to the phased withdrawal of CFC containing inhalers.

    « Τελευταία τροποποίηση: 9 Ιουλίου 2009, 12:16:42 από Raptor »
    "Success is getting what you want" "Happiness is wanting what you get"
    "The secret of happiness is not found in seeking more, but in the capacity to enjoy less."

    22 Αυγούστου 2009, 10:02:12
    Απάντηση #44
    Αποσυνδεδεμένος

    Μαρία Χόρτη

    Ιατροί
    The new recommendations were developed by an expert panel from the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA) to assist primary care providers who care for HIV-infected patients or patients who may be at risk for acquiring HIV infection.
    Specific changes and/or additions to the updated guidelines (and their accompanying level of evidence rating) since the previous 2004 update are as follows:

    • Regardless of whether antiretroviral therapy will be started, all HIV-infected patients should have a genotypic resistance test at baseline (A-III).

    • As soon as possible (within 96 hours) after exposure to a person with chickenpox or shingles, patients who are seronegative for varicella zoster virus (VZV) or with no history of chickenpox or shingles should receive postexposure prophylaxis with VZV immune globulin (VariZIG; A-III).

    • Clinicians may consider varicella primary vaccination for HIV-infected, VZV-seronegative persons older than 8 years who have CD4 cell counts higher than 200 cells/mm3 (C-III) and in HIV-infected children aged 1 to 8 years who have CD4 cell percentages at least 15% (B-II).

    • Cerebrospinal analysis is recommended for persons with syphilis who have neurologic or ocular signs or symptoms, active tertiary syphilis, syphilis treatment failure, or late-latent syphilis, including those with syphilis of unknown duration (A-II).

    • To decrease the risk for a hypersensitivity reaction, human leukocyte antigen (HLA)-B*5701 testing is recommended before starting treatment with abacavir (A-I). Abacavir therapy should not be given to patients who are positive for the HLA B*5701 haplotype (A-II).

    • Baseline urinalysis and calculated creatinine clearance may be helpful, particularly in black patients, because of greater risk for HIV-associated nephropathy (B-II).

    • Before starting treatment with potentially nephrotoxic drugs such as tenofovir or indinavir, urinalysis and calculated creatinine clearance are recommended (B-II).

    • Before starting treatment with a chemokine receptor 5 (CCR5)-antagonist antiretroviral drug, tropism testing is recommended (A-II).

    • Women aged 40 to 49 years should periodically undergo individualized evaluation of risk for breast cancer and be informed regarding the potential benefits and risks of screening mammography (B-II).

    • Routine use of hormone replacement therapy is not currently recommended because of slightly increased risk for breast cancer, cardiovascular disease, and thromboembolic disease (A-I). If hormone replacement is considered in women who experience vasomotor symptoms, vaginal dryness, or other severe menopausal symptoms, it should generally be used only for a limited period and at the lowest effective doses (B-II).

    • The importance of adherence to care should be emphasized, rather than just adherence to medications (B-II).

    “As we seek to make each patient comfortable and promote his or her engagement in primary care, it is important to keep in mind that HIV/AIDS affects a diverse group of persons in terms of race/ethnicity, culture, gender, and lifestyle,” the study authors conclude. “Each patient should be treated as an individual, and HIV treatment sites should provide culturally competent and appropriate care to the community of patients being served. A broad range of components, from having staff of the same race, culture, or lifestyle to having art and reading material in the clinic that reflects the culture of the local community, may be useful in facilitating this goal.”

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