| quintgram | freq | conditional |
|---|---|---|
| account individual'advocate carer should consulted | 2 | in all situations where informed discussion is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted when appropriate. in all situations where informed discussion and consent is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted. |
| acinetobacter species sensitive only polymyxins | 2 | in patients with hap/vap caused by acinetobacter species that is sensitive only to polymyxins, we recommend intravenous polymyxin (colistin or polymyxin b) in patients with hap/vap caused by acinetobacter species that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin |
| activity part properly designed controlled | 2 | recommendation :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 .individuals should only be referred to schemes that are part of such a study. 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 . measures should include intermediate outcomes such as knowledge, attitude, and skills, as well as measures of physical activity levels. |
| acute myocardial infarction presenting in | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| addition considered persistently symptomatic patients | 2 | addition of an arb may be considered in persistently symptomatic patients with hfref on gdmt addition of an arb may be considered in persistently symptomatic patients with hfref who are already being treated with an ace inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated. |
| additional risk factor cardioembolic stroke | 3 | patients with chronic hf with permanent/persistent/paroxysmal af and an additional risk factor for cardioembolic stroke (history of hypertension, diabetes mellitus, previous stroke or transient ischemic attack, or ?75 years of age) should receive chronic anticoagulant therapy (in the absence of contraindications to anticoagulation). chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| adjunctive therapy when prescribed solely | 2 | statins are not beneficial as adjunctive therapy when prescribed solely for hf statins are not beneficial as adjunctive therapy when prescribed solely for the diagnosis of hf in the absence of other indications for their use. |
| administered hours before surgery continued | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| adrenal mass ultrasonography scan scan | 2 | staging distant metastatic disease:adrenal: 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. staging distant metastatic disease:2003 recommendations:adrenal: 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. |
| advance directives should taken fully | 2 | in all situations where informed discussion is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted when appropriate. in all situations where informed discussion and consent is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted. |
| advanced anthracyclinesensitive cancer m continued | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| advanced lung cancer staging locoregional | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| advanced small cell lung cancer | 2 | the combination of paclitaxel (taxol®) or docetaxel (taxotere®) with cisplatin can be recommended as one of a number of chemotherapy options in the first-line therapy of patients with advanced non-small cell lung cancer and a good performance status. gefitinib monotherapy, if available, may be considered as a second-line and subsequent treatment option for selected symptomatic patients with advanced non-small cell lung cancer who are not candidates for chemotherapy and for whom erlotinib is not available. |
| advanced unresectable stage small cell | 2 | 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). 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. of those trials designed to improve therapeutic ratios in patients with locally advanced, unresectable stage iii non-small cell lung cancer there is insufficient data of high quality to recommend hyperfractionation over standard radiotherapy of 60 gy in 30 fractions. further randomized controlled trials are necessary to confirm the benefits, if any, of hyperfractionation radiotherapy. |
| adverse event after undergoing previous | 2 | people for whom liver biopsy poses a substantial risk (such as those with haemophilia, or those who have experienced an adverse event after undergoing a previous liver biopsy), and people with symptoms of extra-hepatic hcv infection sufficient to impair quality of life, may be treated on clinical grounds without prior histological classification. peope for whom liver biopsy poses a substantial risk(such as those with haemophilia,or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra hepatic hcv infection sufficient to impair quality of life,may be treated on clinical grounds without prior histological classification. |
| aeruginosa recommend against aminoglycoside monotherapy | 2 | for patients with hap/vap due to p. aeruginosa, we recommend against aminoglycoside monotherapy (strong recommendation, very low-quality evidence). for patients with hap/vap due to p. aeruginosa, we recommend against aminoglycoside monotherapy |
| after undergoing previous liver biopsy | 2 | people for whom liver biopsy poses a substantial risk (such as those with haemophilia, or those who have experienced an adverse event after undergoing a previous liver biopsy), and people with symptoms of extra-hepatic hcv infection sufficient to impair quality of life, may be treated on clinical grounds without prior histological classification. peope for whom liver biopsy poses a substantial risk(such as those with haemophilia,or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra hepatic hcv infection sufficient to impair quality of life,may be treated on clinical grounds without prior histological classification. |
| against routine screening elevated blood | 3 | the uspstf recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk . the uspstf recommends against routine screening for elevated blood lead levels in asymptomatic pregnant women. the uspstf concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. |
| against tetanus diphtheria pertussis they | 2 | routine tdap vaccination:recommendations for use: adults aged 19 to 64 years should receive a single dose of tdap to replace a single dose of tetanus and diphtheria toxoids vaccine (td) for active booster vaccination against tetanus, diphtheria, and pertussis if they received their last dose of td >10 years earlier. replacing 1 dose of td with tdap will reduce the morbidity associated with pertussis in adults and might reduce the risk for transmitting pertussis to persons at increased risk for pertussis and its complications. adolescents 11 to 18 years of age should receive a single dose of tdap instead of tetanus and diphtheria toxoids (td) vaccine for booster immunization against tetanus, diphtheria, and pertussis if they have completed the recommended childhood diphtheria, tetanus, and pertussis (dtp)/diphtheria and tetanus toxoids and acellular pertussis (dtap) immunization series* and have not received td; the preferred age for tdap immunization is 11 to 12 years. |
| agents adequate gramnegative activity available | 2 | in patients with suspected vap, we suggest avoiding aminoglycosides if alternative agents with adequate gram-negative activity are available in patients with suspected vap, we suggest avoiding colistin if alternative agents with adequate gram-negative activity are available |
| agents treatment proven mssa necessary | 2 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used |
| aldosterone antagonists selected patients recommended | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| alternative agents adequate gramnegative activity | 2 | in patients with suspected vap, we suggest avoiding aminoglycosides if alternative agents with adequate gram-negative activity are available in patients with suspected vap, we suggest avoiding colistin if alternative agents with adequate gram-negative activity are available |
| ambulatory unfractionated heparin administered hours | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| analysis patients clinical presentation strongly | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| angiotensin receptorneprilysin inhibitor should administered | 2 | angiotensin receptor-neprilysin inhibitor should not be administered concomitantly with ace inhibitors or within 36 hours of the last dose of an ace inhibitor. angiotensin receptor-neprilysin inhibitor should not be administered to patients with a history of angioedema. |
| antagonists selected patients recommended patients | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| anthracyclinecontaining chemotherapy indicated opinion treating | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| anthracyclinesensitive cancer m continued anthracyclinecontaining | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| anticoagulation reasonable patients chronic permanent | 2 | chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| anticoagulation recommended patients chronic hfref | 2 | anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source. (iii-b: no benefit) |
| antimicrobial resistance being treated icus | 2 | we suggest including an agent active against methicillinsensitive s. aureus (mssa) (and not mrsa) for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance, who are being treated in icus where <10%–20% of s. aureus isolates are methicillin resistant (weak recommendation, very low-quality evidence). we suggest prescribing one antibiotic active against p. aeruginosa for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance who are being treated in icus where ?10% of gram-negative isolates are resistant to the agent being considered for monotherapy |
| appropriate initial subsequent treatment waldenstrom'macroglobulinaemia | 2 | alkylating-agent based therapy is appropriate for the initial and subsequent treatment of waldenstrom's macroglobulinaemia. purine analogues are appropriate for the initial and subsequent treatment of waldenstrom's macroglobulinaemia. there is no consensus on the duration of treatment with cladribine or fludarabine, or on which purine analogue is superior. fludarabine is more active than cyclophosphamide, doxorubicin and prednisolone (cap) as salvage therapy. |
| appropriately qualified healthcare professional expertise | 2 | drug treatment should only be initiated by an appropriately qualified healthcare professional with expertise in adhd and should be based on a comprehensive assessment and diagnosis. continued prescribing and monitoring of drug therapy may be performed by general practitioners, under shared care arrangements. 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. continuation of therapy under shared-care arrangements with a general practitioner is appropriate. |
| aromatase inhibitors anastrozole exemestane letrozole | 2 | 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. 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. |
| artery revascularization coronary artery bypass | 2 | coronary artery revascularization via coronary artery bypass graft (cabg) or percutaneous intervention is indicated for patients (hfpef and hfref) on gdmt with angina and suitable coronary anatomy, especially for a left main stenosis (>50%) or left main–equivalent disease. (i-c) coronary artery revascularization via coronary artery bypass graft to improve survival is reasonable in patients with mild to moderate lv systolic dysfunction (ef 35%–50%) and significant (?70% diameter stenosis) multivessel cad or proximal left anterior descending (lad) coronary artery stenosis when viable myocardium is present in the region of intended revascularization. (iia-b) |
| aspergillus skin soft tissue infections | 2 | aspergillus skin and soft tissue infections should be treated with voriconazole alternatively to voriconazole treat aspergillus skin and soft tissue infections with lipid formulations of amphotericin b, posaconazole or echinocandin for 6-12 weeks |
| assess fibrinolytic therapy patients symptoms | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| assessment organizational readiness barriers education | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| atypical thought obscuring segment analysis | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| axis positive scanning negative scanning | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| based upon results antimicrobial susceptibility | 2 | for patients with hap/vap due to p. aeruginosa, we recommend that the choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing for patients with hap/vap due to esbl-producing gramnegative bacilli, we recommend that the choice of an antibiotic for definitive (not empiric) therapy be based upon the results of antimicrobial susceptibility testing and patient-specific factors |
| basis risk factors cost tolerability | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| behavioral interventions promote sustained weight | 3 | the uspstf recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. the uspstf concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults. the uspstf concludes that the evidence is insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. |
| being treated empirically recommend prescribing | 2 | for patients being treated empirically for hap, we recommend prescribing an antibiotic with activity against s. aureus for patients with hap who are being treated empirically, we recommend prescribing antibiotics with activity against p. aeruginosa and other gram-negative bacilli |
| beneficial adjunctive therapy when prescribed | 2 | statins are not beneficial as adjunctive therapy when prescribed solely for hf statins are not beneficial as adjunctive therapy when prescribed solely for the diagnosis of hf in the absence of other indications for their use. |
| beta blockers aldosterone antagonists selected | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| beta blockers proven reduce mortality | 2 | use of 1 of the 3 beta blockers proven to reduce mortality is recommended for all stable patients use of 1 of the 3 beta blockers proven to reduce mortality (ie, bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of hfref, unless contraindicated, to reduce morbidity and mortality. |
| biopsy radiographically enlarged mediastinal lymph | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| biopsy recommended mediastinal lymph nodes | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| biopsy rule metastatic disease patient | 2 | staging distant metastatic disease:adrenal: 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. staging distant metastatic disease:2003 recommendations:adrenal: 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. |
| blockers aldosterone antagonists selected patients | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| blocking drugs recommended routine treatment | 2 | calcium channel–blocking drugs are not recommended as routine treatment in hfref calcium channel–blocking drugs are not recommended as routine treatment for patients with hfref. |
| blood lead levels asymptomatic children | 2 | the uspstf recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk . the uspstf concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. |
| blood test diagnose epileptic seizures | 3 | for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)the utility of serum prl assay has not been established in the evaluation of status epilepticus, repetitive seizures, or neonatal seizures. for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)elevated serum prolactin (prl), when measured in appropriate clinical setting at 10 to 20 minutes after a suspected event, should be considered a useful adjunct to differentiate generalized tonic-clonic seizures or complex partial seizures from psychogenic nonepileptic seizures among adults and older children. for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)serum prl assay is not of utility to distinguish seizure from syncope . |
| bone scanning liver ultrasonography chest | 2 | in women with pathological stage iii tumours, bone scanning, liver ultrasonography, and chest radiography are recommended postoperatively as part of baseline staging. 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. |
| cancer guideline developers recommend against | 3 | for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of serial chest x-rays (cxrs) to screen for the presence of lung cancer. for individuals without either symptoms or a history of cancer, the guideline developers recommend against the use of single or serial sputum cytologic evaluation to screen for the presence of lung cancer. for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of a single low-dose computed tomography scan (ldct) or serial ldcts to screen for the presence of lung cancer. at-risk individuals who express an interest in undergoing low-dose computed tomography scan screening should be made aware of several ongoing high quality clinical studies of this technology. |
| cancer m continued anthracyclinecontaining chemotherapy | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| candidates chemotherapy m erlotinib available | 2 | gefitinib at a dose of 250 mg/day may be considered for second-line and subsequent therapy only for selected symptomatic patients who are not candidates for chemotherapy and for whom erlotinib is not available. gefitinib monotherapy, if available, may be considered as a second-line and subsequent treatment option for selected symptomatic patients with advanced non-small cell lung cancer who are not candidates for chemotherapy and for whom erlotinib is not available. |
| cannot stabilized standard medical treatment | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| carbapenemresistant pathogen sensitive only polymyxins | 2 | in patients with hap/vap caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we recommend intravenous polymyxins (colistin or polymyxin b) in patients with hap/vap caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin |
| caused acinetobacter species sensitive only | 3 | in patients with hap/vap caused by acinetobacter species that is sensitive only to polymyxins, we recommend intravenous polymyxin (colistin or polymyxin b) in patients with hap/vap caused by acinetobacter species that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin in patients with hap/vap caused by acinetobacter species that is sensitive only to colistin, we suggest not using adjunctive rifampicin |
| caused carbapenemresistant pathogen sensitive only | 2 | in patients with hap/vap caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we recommend intravenous polymyxins (colistin or polymyxin b) in patients with hap/vap caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin |
| causes segment elevation early repolarization | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| cefazolin preferred agents treatment proven | 2 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used |
| cefazolin preferred treatment proven mssa | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| cefepime levofloxacin imipenem meropenem oxacillin | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| cell lung cancer good performance | 2 | the combination of paclitaxel (taxol®) or docetaxel (taxotere®) with cisplatin can be recommended as one of a number of chemotherapy options in the first-line therapy of patients with advanced non-small cell lung cancer and a good performance status. 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. |
| cellmediated immunodeficiency immersion injuries animal | 2 | cultures of blood are recommended in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites ( |
| cesarean delivery transverse incision candidates | 2 | most women with one previous cesarean delivery with a low-transverse incision are candidates for vaginal birth after cesarean delivery (vbac) and should be counseled about vbac and offered a trial of labor. women with one previous cesarean delivery with a low transverse incision are candidates for and should be offered a trial of labor (tol). |
| characteristics including time international normalized | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| chemotherapy indicated opinion treating physician | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| chemotherapy neutropenia severe cellmediated immunodeficiency | 2 | cultures of blood are recommended in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites ( |
| chest scan greater than shortest | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| children otitis media effusion should | 2 | parents of children with otitis media with effusion should be advised to refrain from smoking. children with otitis media with effusion should not be treated with antibiotics. |
| chronic anticoagulation reasonable patients chronic | 2 | chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| chronic cough nonasthmatic eosinophilic bronchitis | 2 | in patients with chronic cough due to nonasthmatic eosinophilic bronchitis, the possibility of an occupation-related cause needs to be considered. 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. |
| chronic hfref out prior thromboembolic | 2 | anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source. (iii-b: no benefit) |
| chronic hfref reduce morbidity mortality | 3 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the use of ace inhibitors is beneficial for patients with prior or current symptoms of chronic hfref to reduce morbidity and mortality. |
| chronic permanent persistent paroxysmal out | 2 | chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| class ambulatory class symptoms gdmt | 3 | cardiac resynchronization therapy is indicated for patients who have lvef of 35% or less, sinus rhythm, left bundle-branch block (lbbb) with a qrs duration of 150 ms or greater, and nyha class ii, iii, or ambulatory class iv symptoms on gdmt. crt can be useful for patients who have lvef of ?35% , sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class iii/ambulatory class iv symptoms on gdmt. crt can be useful for patients who have lvef of ?35%, sinus rhythm, lbbb with a qrs duration of 120–149 ms, and nyha class ii, iii, or ambulatory class iv symptoms on gdmt. |
| clients should referred trained healthcare | 2 | nurses in all practice settings should screen clients for evidence of depression, using a validated tool (such as the stroke aphasia depression questionnaire, geriatric depression scale, hospital anxiety and depression scale or the cornell scale for depression in dementia) prior to discharge throughout the continuum of care. in situations where evidence of depression is identified, clients should be referred to a trained healthcare professional for further assessment and management. nurses in all practice settings should assess/screen caregiver burden, using a validated tool (such as the caregiver strain index or the self related burden index). in situations where concerns are identified, clients should be referred to a trained healthcare professional for further assessment and management. |
| clinical characteristics including time international | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| clinical criteria alone rather than | 4 | for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using serum pct plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using bronchoalveolar lavage fluid (balf) strem-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone rather than using crp plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we suggest using clinical criteria alone, rather than using cpis plus clinical criteria, to decide whether or not to initiate antibiotic therapy |
| clinical criteria decide whether initiate | 4 | for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using serum pct plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using bronchoalveolar lavage fluid (balf) strem-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone rather than using crp plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we suggest using clinical criteria alone, rather than using cpis plus clinical criteria, to decide whether or not to initiate antibiotic therapy |
| clinical grounds out prior histological | 2 | people for whom liver biopsy poses a substantial risk (such as those with haemophilia, or those who have experienced an adverse event after undergoing a previous liver biopsy), and people with symptoms of extra-hepatic hcv infection sufficient to impair quality of life, may be treated on clinical grounds without prior histological classification. peope for whom liver biopsy poses a substantial risk(such as those with haemophilia,or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra hepatic hcv infection sufficient to impair quality of life,may be treated on clinical grounds without prior histological classification. |
| clinical strategy inhibition reninangiotensin system | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| clinically operable nsclc biopsy recommended | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| clinicians considering laboratory blood test | 3 | for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)the utility of serum prl assay has not been established in the evaluation of status epilepticus, repetitive seizures, or neonatal seizures. for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)elevated serum prolactin (prl), when measured in appropriate clinical setting at 10 to 20 minutes after a suspected event, should be considered a useful adjunct to differentiate generalized tonic-clonic seizures or complex partial seizures from psychogenic nonepileptic seizures among adults and older children. for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)serum prl assay is not of utility to distinguish seizure from syncope . |
| combination hydralazine isosorbide dinitrate recommended | 2 | the combination of hydralazine and isosorbide dinitrate is recommended for african americans with nyha class iii–iv hfref on gdmt the combination of hydralazine and isosorbide dinitrate is recommended to reduce morbidity and mortality for patients selfdescribed as african americans with nyha class iii–iv hfref receiving optimal therapy with ace inhibitors and beta blockers, unless contraindicated. |
| combination hydralazine isosorbide dinitrate useful | 2 | a combination of hydralazine and isosorbide dinitrate can be useful in patients with hfref who cannot be given ace inhibitors or arbs a combination of hydralazine and isosorbide dinitrate can be useful to reduce morbidity or mortality in patients with current or prior symptomatic hfref who cannot be given an ace inhibitor or arb because of drug intolerance, hypotension, or renal insufficiency, unless contraindicated. |
| compression placed intraoperatively continued until | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| concludes evidence insufficient recommend against | 7 | the uspstf concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. the u.s. preventive services task force concludes that the evidence is insufficient to recommend for or against routine clinical breast examination (cbe) alone to screen for breast cancer. the u.s. preventive services task force concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (bse). the uspstf concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (hpv) testing as a primary screening test for cervical cancer. the uspstf concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer. the uspstf concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults. the uspstf concludes that the evidence is insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. |
| concomitant estrogen therapy cannot recommended | 2 | testosterone therapy without concomitant estrogen therapy cannot be recommended, because there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen. testosterone therapy without concomitant estrogen therapy cannot be recommended becasue there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen. |
| conjunction evidencebased beta blockers aldosterone | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| considered patients lvef sinus rhythm | 2 | crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of 120–149 ms, and nyha class iii/ambulatory class iv on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class ii symptoms on gdmt. |
| considered persistently symptomatic patients hfref | 2 | addition of an arb may be considered in persistently symptomatic patients with hfref on gdmt addition of an arb may be considered in persistently symptomatic patients with hfref who are already being treated with an ace inhibitor and a beta blocker in whom an aldosterone antagonist is not indicated or tolerated. |
| considering laboratory blood test diagnose | 3 | for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)the utility of serum prl assay has not been established in the evaluation of status epilepticus, repetitive seizures, or neonatal seizures. for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)elevated serum prolactin (prl), when measured in appropriate clinical setting at 10 to 20 minutes after a suspected event, should be considered a useful adjunct to differentiate generalized tonic-clonic seizures or complex partial seizures from psychogenic nonepileptic seizures among adults and older children. for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)serum prl assay is not of utility to distinguish seizure from syncope . |
| contiguous limb leads greater than | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| contiguous precordial leads lacking features | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| continued anthracyclinecontaining chemotherapy indicated opinion | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| continued until patient fully ambulatory | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| continuous intravenous inotropic support reasonable | 2 | continuous intravenous inotropic support is reasonable as “bridge therapy” in patients with stage d hf refractory to gdmt and device therapy who are eligible for and awaiting mcs or cardiac transplantation. short-term, continuous intravenous inotropic support may be reasonable in those hospitalized patients presenting with documented severe systolic dysfunction who present with low blood pressure and significantly depressed cardiac output to maintain systemic perfusion and preserve end-organ performance. |
| controlled research study determine effectiveness | 2 | recommendation :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 .individuals should only be referred to schemes that are part of such a study. 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 . measures should include intermediate outcomes such as knowledge, attitude, and skills, as well as measures of physical activity levels. |
| coronary artery revascularization coronary artery | 2 | coronary artery revascularization via coronary artery bypass graft (cabg) or percutaneous intervention is indicated for patients (hfpef and hfref) on gdmt with angina and suitable coronary anatomy, especially for a left main stenosis (>50%) or left main–equivalent disease. (i-c) coronary artery revascularization via coronary artery bypass graft to improve survival is reasonable in patients with mild to moderate lv systolic dysfunction (ef 35%–50%) and significant (?70% diameter stenosis) multivessel cad or proximal left anterior descending (lad) coronary artery stenosis when viable myocardium is present in the region of intended revascularization. (iia-b) |
| cost tolerability patient preference potential | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| criteria alone rather than using | 4 | for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using serum pct plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using bronchoalveolar lavage fluid (balf) strem-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone rather than using crp plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we suggest using clinical criteria alone, rather than using cpis plus clinical criteria, to decide whether or not to initiate antibiotic therapy |
| criteria decide whether initiate antibiotic | 4 | for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using serum pct plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using bronchoalveolar lavage fluid (balf) strem-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone rather than using crp plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we suggest using clinical criteria alone, rather than using cpis plus clinical criteria, to decide whether or not to initiate antibiotic therapy |
| culture exudates skin lesions impetigo | 2 | gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma are recommended to help identify whether staphylococcus aureus and/or a ?-hemolytic streptococcus is the cause treatment without gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma is reasonable in typical cases |
| data safety efficacy testosterone therapy | 2 | testosterone therapy without concomitant estrogen therapy cannot be recommended, because there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen. testosterone therapy without concomitant estrogen therapy cannot be recommended becasue there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen. |
| decide whether initiate antibiotic therapy | 4 | for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using serum pct plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using bronchoalveolar lavage fluid (balf) strem-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone rather than using crp plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we suggest using clinical criteria alone, rather than using cpis plus clinical criteria, to decide whether or not to initiate antibiotic therapy |
| dedication qualified individual provide support | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| density lipoprotein cholesterol highdensity lipoprotein | 2 | all women with pcos should be screened for dyslipidemia with a fasting lipoprotein profile, including total cholesterol, low-density lipoprotein (ldl) cholesterol, high-density lipoprotein (hdl) cholesterol, and triglyceride determinations. 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. |
| designed controlled research study determine | 2 | recommendation :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 .individuals should only be referred to schemes that are part of such a study. 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 . measures should include intermediate outcomes such as knowledge, attitude, and skills, as well as measures of physical activity levels. |
| develop plan implementation includes assessment | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| dexrazoxane protect against cardiotoxicity associated | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| diagnostic evaluation patients advanced lung | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| diphtheria tetanus toxoids acellular pertussis | 2 | routine tdap vaccination: recommendations for use:prevention of pertussis among infants aged <12 months by vaccinating their adult contacts: adults who have or who anticipate having close contact with an infant aged <12 months (e.g., parents, grandparents aged <65 years, child-care providers, and health-care personnel [hcp]) should receive a single dose of tdap at intervals <10 years since the last td to protect against pertussis if they have not previously received tdap. ideally, these adults should receive tdap at least 2 weeks before beginning close contact with the infant. an interval as short as 2 years from the last dose of td is suggested to reduce the risk for local and systemic reactions after vaccination; shorter intervals may be used. infants aged <12 months are at highest risk for pertussis-related complications and hospitalizations compared with older age groups. young infants have the highest risk for death. vaccinating adult contacts might reduce the risk for transmitting pertussis to these infants (see "infant pertussis and transmission to infants" in the original guideline document). infants should be vaccinated on-time with pediatric diphtheria and tetanus toxoids, acellular pertussis antigens (dtap) ("pertussis vaccination," 1997; cdc, "recommended childhood and adolescent immunization schedule," 2006). when possible, women should receive tdap before becoming pregnant. approximately half of all pregnancies in the united states are unplanned (henshaw, 1998). any woman of childbearing age who might become pregnant is encouraged to receive a single dose of tdap if she has not previously received tdap (see "vaccination during pregnancy" below). women, including those who are breastfeeding, should receive a dose of tdap in the immediate postpartum period if they have not previously received tdap. the postpartum tdap should be administered before discharge from the hospital or birthing center. if tdap cannot be administered before discharge, it should be administered as soon as feasible. adolescents 11 to 18 years of age should receive a single dose of tdap instead of tetanus and diphtheria toxoids (td) vaccine for booster immunization against tetanus, diphtheria, and pertussis if they have completed the recommended childhood diphtheria, tetanus, and pertussis (dtp)/diphtheria and tetanus toxoids and acellular pertussis (dtap) immunization series* and have not received td; the preferred age for tdap immunization is 11 to 12 years. |
| directives should taken fully into | 2 | in all situations where informed discussion is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted when appropriate. in all situations where informed discussion and consent is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted. |
| discussion education reinforce importance best | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| disease cannot stabilized standard medical | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| disease patient otherwise considered potentially | 2 | staging distant metastatic disease:adrenal: 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. staging distant metastatic disease:2003 recommendations:adrenal: 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. |
| distantsite palliative effects externalbeam radiation | 2 | treatment:radiotherapy:local- and distant-site palliative effects of external-beam radiation treatment:radiotherapy:2003 recommendations:local- and distant-site palliative effects of external-beam radiation no change. |
| docetaxel m2 over hour every | 3 | in anthracycline-naive patients, who would ordinarily be offered treatment with a single-agent anthracycline (doxorubicin or epirubicin) or an anthracycline in a standard combination, the following options are also reasonable:treatment with single-agent docetaxel 100 mg/m2 over one hour every three weeks.docetaxel or paclitaxel in combination with doxorubicin. in anthracycline-naive patients for whom anthracyclines are contraindicated: treatment with single-agent docetaxel 100 mg/m2 over one hour every three weeks is recommended. in anthracycline-resistant patients or patients who have previously received an anthracycline as adjuvant therapy: either docetaxel (100 mg/m2 over one hour every three weeks) or paclitaxel (175 mg/m2 over three hours every three weeks) may be considered as a treatment option after failure of prior anthracycline treatment or in women whose disease is resistant to anthracyclines. the evidence supporting the use of single-agent docetaxel is more consistent and is based on a larger number of trials and patients than the evidence for paclitaxel. in selected patients, the combination of docetaxel and capecitabine is a therapeutic option. due to the toxicity of the combination, patient selection for good performance status or younger age is recommended. it is recommended that capecitabine in the docetaxel/capecitabine combination be given at 75% of full dose. |
| does preclude biopsy radiographically enlarged | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| drug interactions other clinical characteristics | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| drugs potentially harmful patients hfref | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| duration nyha class ambulatory class | 3 | crt can be useful for patients who have lvef of ?35% , sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class iii/ambulatory class iv symptoms on gdmt. crt can be useful for patients who have lvef of ?35%, sinus rhythm, lbbb with a qrs duration of 120–149 ms, and nyha class ii, iii, or ambulatory class iv symptoms on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of 120–149 ms, and nyha class iii/ambulatory class iv on gdmt. |
| duration nyha class symptoms gdmt | 2 | crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class ii symptoms on gdmt. crt may be considered for patients who have lvef of ?30%, ischemic etiology of hf, sinus rhythm, lbbb with a qrs duration of ?150 ms, and nyha class i symptoms on gdmt. |
| early repolarization pericarditis left ventricular | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| education reinforce importance best practices | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| effective shortterm treatment infantile spasms | 2 | vigabatrin is also possibly effective for the short-term treatment of infantile spasms in the majority of children with tuberous sclerosis. acth is probably effective for the short-term treatment of infantile spasms and in resolution of hypsarrhythmia . |
| effective should considered acute treatment | 2 | sumatriptan nasal spray is effective and should be considered for the acute treatment of migraine in adolescents. ibuprofen is effective and should be considered for the acute treatment of migraine in children. |
| efficacy testosterone therapy women using | 2 | testosterone therapy without concomitant estrogen therapy cannot be recommended, because there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen. testosterone therapy without concomitant estrogen therapy cannot be recommended becasue there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen. |
| elevated blood lead levels asymptomatic | 3 | the uspstf recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk . the uspstf recommends against routine screening for elevated blood lead levels in asymptomatic pregnant women. the uspstf concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. |
| elevation early repolarization pericarditis left | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| elevations greater than equal millivolts | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| empiric coverage above agents used | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| empiric treatment above agents used | 2 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used |
| empiric treatment includes coverage mssa | 3 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| empiric treatment suspected only patients | 2 | we suggest including an agent active against mrsa for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients being treated in units where >10%–20% of s. aureus isolates are methicillin resistant, and patients in units where the prevalence of mrsa is not known we suggest prescribing 2 antipseudomonal antibiotics from different classes for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients in units where >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, and patients in an icu where local antimicrobial susceptibility rates are not available |
| empiric treatment suspected patients out | 2 | we suggest including an agent active against methicillinsensitive s. aureus (mssa) (and not mrsa) for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance, who are being treated in icus where <10%–20% of s. aureus isolates are methicillin resistant (weak recommendation, very low-quality evidence). we suggest prescribing one antibiotic active against p. aeruginosa for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance who are being treated in icus where ?10% of gram-negative isolates are resistant to the agent being considered for monotherapy |
| enoxaparin administered hours before surgery | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| equal millivolts more contiguous limb | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| equal more contiguous precordial leads | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| estimated glomerular filtration rate m | 2 | inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency when serum creatinine is >2.5 mg/dl in men or >2.0 mg/dl in women (or estimated glomerular filtration rate <30 ml/min/1.73 m2), and/or potassium >5.0 meq/l. aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with nyha class ii–iv and who have lvef of ?35%, unless contraindicated, to reduce morbidity and mortality. patients with nyha class ii should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. creatinine levels should be ?2.5 mg/dl in men or ?2.0 mg/dl in women (or estimated glomerular filtration rate >30 ml/min/1.73 m2) 2) and potassium levels should be <5.0 meq/l. careful monitoring of potassium levels, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency. |
| evaluation patients advanced lung cancer | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| event after undergoing previous liver | 2 | people for whom liver biopsy poses a substantial risk (such as those with haemophilia, or those who have experienced an adverse event after undergoing a previous liver biopsy), and people with symptoms of extra-hepatic hcv infection sufficient to impair quality of life, may be treated on clinical grounds without prior histological classification. peope for whom liver biopsy poses a substantial risk(such as those with haemophilia,or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra hepatic hcv infection sufficient to impair quality of life,may be treated on clinical grounds without prior histological classification. |
| evidence insufficient recommend against routine | 4 | the uspstf concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. the u.s. preventive services task force concludes that the evidence is insufficient to recommend for or against routine clinical breast examination (cbe) alone to screen for breast cancer. the uspstf concludes that the evidence is insufficient to recommend for or against the routine use of human papillomavirus (hpv) testing as a primary screening test for cervical cancer. the uspstf concludes that the evidence is insufficient to recommend for or against the routine use of new technologies to screen for cervical cancer. |
| evidence supports dexrazoxane protect against | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| evidencebased beta blockers aldosterone antagonists | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| except palliation patients stage disease | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| experienced adverse event after undergoing | 2 | people for whom liver biopsy poses a substantial risk (such as those with haemophilia, or those who have experienced an adverse event after undergoing a previous liver biopsy), and people with symptoms of extra-hepatic hcv infection sufficient to impair quality of life, may be treated on clinical grounds without prior histological classification. peope for whom liver biopsy poses a substantial risk(such as those with haemophilia,or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra hepatic hcv infection sufficient to impair quality of life,may be treated on clinical grounds without prior histological classification. |
| exudates skin lesions impetigo ecthyma | 2 | gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma are recommended to help identify whether staphylococcus aureus and/or a ?-hemolytic streptococcus is the cause treatment without gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma is reasonable in typical cases |
| factors antimicrobial resistance being treated | 2 | we suggest including an agent active against methicillinsensitive s. aureus (mssa) (and not mrsa) for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance, who are being treated in icus where <10%–20% of s. aureus isolates are methicillin resistant (weak recommendation, very low-quality evidence). we suggest prescribing one antibiotic active against p. aeruginosa for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance who are being treated in icus where ?10% of gram-negative isolates are resistant to the agent being considered for monotherapy |
| factors cost tolerability patient preference | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| features infarction causes segment elevation | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| fibrinolytic therapy patients symptoms suggestive | 3 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations:assess for fibrinolytic therapy in patients with symptoms suggestive of ami and presenting within 12 hours of symptom onset if ecg reveals: 1.new or presumably new right bundle branch block (rbbb). 2.rbbb, atypical bbb, or ventricular paced and concordant st-segment deviations greater than or equal to 0.1 mv (1 mm) towards the major qrs deflection or discordant st-segment deviations greater than or equal to 0.5 mv (5 mm) away from the major qrs deflection in 2 or more contiguous leads. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| finding isolated adrenal mass ultrasonography | 2 | staging distant metastatic disease:adrenal: 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. staging distant metastatic disease:2003 recommendations:adrenal: 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. |
| following lumbar fusion surgery recommended | 2 | the use of lumbar brace therapy as a preoperative diagnostic tool to predict outcome following lumbar fusion surgery is not recommended. the use of transpedicular external fixation as a tool to predict outcome following lumbar fusion surgery is not recommended. |
| following recommendations based primarily consensus | 2 | the following recommendations are based primarily on consensus and expert opinion:in addition to health risks and benefits, patient counseling should include consideration of how oophorectomy may relate to the individual patient's body image, perceptions concerning sexuality, and personal feelings. the following recommendations are based primarily on consensus and expert opinion (level c): epidural anesthesia appears to be safe in women taking unfractionated low-dose heparin if the aptt is normal. |
| following risk factor antimicrobial resistance | 2 | we suggest including an agent active against mrsa for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients being treated in units where >10%–20% of s. aureus isolates are methicillin resistant, and patients in units where the prevalence of mrsa is not known we suggest prescribing 2 antipseudomonal antibiotics from different classes for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients in units where >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, and patients in an icu where local antimicrobial susceptibility rates are not available |
| force concludes evidence insufficient recommend | 2 | the u.s. preventive services task force concludes that the evidence is insufficient to recommend for or against routine clinical breast examination (cbe) alone to screen for breast cancer. the u.s. preventive services task force concludes that the evidence is insufficient to recommend for or against teaching or performing routine breast self-examination (bse). |
| found chest scan greater than | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| fully ambulatory unfractionated heparin administered | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| fully into account individual'advocate carer | 2 | in all situations where informed discussion is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted when appropriate. in all situations where informed discussion and consent is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted. |
| gdmt reasonable expectation meaningful survival | 2 | icd therapy is recommended for primary prevention of sudden cardiac death (scd) to reduce total mortality in selected patients with nonischemic dcm or ischemic heart disease ?40 days post-mi with lvef of ?35% and nyha class ii or iii symptoms on chronic gdmt, who have a reasonable expectation of meaningful survival for >1 year.a .a (i-a) icd therapy is recommended for primary prevention of scd to reduce total mortality in selected patients at least 40 days post-mi with lvef of 30% or less and nyha class i symptoms while receiving gdmt, who have a reasonable expectation of meaningful survival for more than 1 year. |
| gdmt titrated attain systolic blood | 2 | patients with hfref and hypertension should be prescribed gdmt titrated to attain systolic blood pressure <130 mm hg. patients with hfpef and persistent hypertension after management of volume overload should be prescribed gdmt titrated to attain systolic blood pressure <130 mm hg |
| glomerular filtration rate m potassium | 2 | inappropriate use of aldosterone receptor antagonists is potentially harmful because of life-threatening hyperkalemia or renal insufficiency when serum creatinine is >2.5 mg/dl in men or >2.0 mg/dl in women (or estimated glomerular filtration rate <30 ml/min/1.73 m2), and/or potassium >5.0 meq/l. aldosterone receptor antagonists (or mineralocorticoid receptor antagonists) are recommended in patients with nyha class ii–iv and who have lvef of ?35%, unless contraindicated, to reduce morbidity and mortality. patients with nyha class ii should have a history of prior cardiovascular hospitalization or elevated plasma natriuretic peptide levels to be considered for aldosterone receptor antagonists. creatinine levels should be ?2.5 mg/dl in men or ?2.0 mg/dl in women (or estimated glomerular filtration rate >30 ml/min/1.73 m2) 2) and potassium levels should be <5.0 meq/l. careful monitoring of potassium levels, renal function, and diuretic dosing should be performed at initiation and closely followed thereafter to minimize risk of hyperkalemia and renal insufficiency. |
| gram stain culture exudates skin | 2 | gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma are recommended to help identify whether staphylococcus aureus and/or a ?-hemolytic streptococcus is the cause treatment without gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma is reasonable in typical cases |
| gramnegative isolates resistant agent being | 2 | we suggest prescribing 2 antipseudomonal antibiotics from different classes for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients in units where >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, and patients in an icu where local antimicrobial susceptibility rates are not available we suggest prescribing one antibiotic active against p. aeruginosa for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance who are being treated in icus where ?10% of gram-negative isolates are resistant to the agent being considered for monotherapy |
| greater than equal millivolts more | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| greater than equal more contiguous | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| greater than shortest transverse axis | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| grounds out prior histological classification | 2 | people for whom liver biopsy poses a substantial risk (such as those with haemophilia, or those who have experienced an adverse event after undergoing a previous liver biopsy), and people with symptoms of extra-hepatic hcv infection sufficient to impair quality of life, may be treated on clinical grounds without prior histological classification. peope for whom liver biopsy poses a substantial risk(such as those with haemophilia,or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra hepatic hcv infection sufficient to impair quality of life,may be treated on clinical grounds without prior histological classification. |
| guideline developers recommend against single | 2 | for individuals without either symptoms or a history of cancer, the guideline developers recommend against the use of single or serial sputum cytologic evaluation to screen for the presence of lung cancer. for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of a single low-dose computed tomography scan (ldct) or serial ldcts to screen for the presence of lung cancer. at-risk individuals who express an interest in undergoing low-dose computed tomography scan screening should be made aware of several ongoing high quality clinical studies of this technology. |
| harmful patients hfref except palliation | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| healthcare professional further assessment management | 2 | nurses in all practice settings should screen clients for evidence of depression, using a validated tool (such as the stroke aphasia depression questionnaire, geriatric depression scale, hospital anxiety and depression scale or the cornell scale for depression in dementia) prior to discharge throughout the continuum of care. in situations where evidence of depression is identified, clients should be referred to a trained healthcare professional for further assessment and management. nurses in all practice settings should assess/screen caregiver burden, using a validated tool (such as the caregiver strain index or the self related burden index). in situations where concerns are identified, clients should be referred to a trained healthcare professional for further assessment and management. |
| heparin administered hours before surgery | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| hfref except palliation patients stage | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| hfref out prior thromboembolic event | 2 | anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source. (iii-b: no benefit) |
| high risk mortality suggest prescribing | 3 | for patients with hap who are being treated empirically and have either a risk factor for mrsa infection (ie, prior intravenous antibiotic use within 90 days, hospitalization in a unit where >20% of s. aureus isolates are methicillin resistant, or the prevalence of mrsa is not known, or who are at high risk for mortality, we suggest prescribing an antibiotic with activity against mrsa for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used for patients with hap who are being treated empirically and have factors increasing the likelihood for pseudomonas or other gram-negative infection (ie, prior intravenous antibiotic use within 90 days; also see remarks) or a high risk for mortality, we suggest prescribing antibiotics from 2 different classes with activity against p. aeruginosa |
| highrisk chronic lymphocytic leukemia fludarabine | 2 | previously treated patients with intermediate- or high-risk chronic lymphocytic leukemia fludarabine is an acceptable treatment option after failure of first-line therapy. choice of treatment should be influenced by previously used regimens and patient preference. as first line treatment in patients with intermediate- or high-risk chronic lymphocytic leukemia, fludarabine or conventional chemotherapy (chlorambucil) are acceptable treatment options. fludarabine improves progression-free survival but has a greater risk of toxicity, including specific infections. |
| history acute coronary syndrome reduced | 2 | in all patients with a recent or remote history of mi or acute coronary syndrome and reduced ef, angiotensin-converting enzyme (ace) inhibitors should be used to prevent symptomatic hf and reduce mortality. in patients intolerant of ace inhibitors, angiotensin-receptor blockers are appropriate unless contraindicated. in all patients with a recent or remote history of mi or acute coronary syndrome and reduced ef, evidence-based beta blockers should be used to reduce mortality. |
| history cancer guideline developers recommend | 3 | for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of serial chest x-rays (cxrs) to screen for the presence of lung cancer. for individuals without either symptoms or a history of cancer, the guideline developers recommend against the use of single or serial sputum cytologic evaluation to screen for the presence of lung cancer. for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of a single low-dose computed tomography scan (ldct) or serial ldcts to screen for the presence of lung cancer. at-risk individuals who express an interest in undergoing low-dose computed tomography scan screening should be made aware of several ongoing high quality clinical studies of this technology. |
| hormonal therapies other than correct | 2 | hormonal therapies other than to correct deficiencies are not recommended in hfref hormonal therapies other than to correct deficiencies are not recommended for patients with current or prior symptoms of hfref. |
| hours before surgery continued postoperatively | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| hours symptom onset reveals elevations | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| hypertrophy incomplete bundle branch block | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| identified clients should referred trained | 2 | nurses in all practice settings should screen clients for evidence of depression, using a validated tool (such as the stroke aphasia depression questionnaire, geriatric depression scale, hospital anxiety and depression scale or the cornell scale for depression in dementia) prior to discharge throughout the continuum of care. in situations where evidence of depression is identified, clients should be referred to a trained healthcare professional for further assessment and management. nurses in all practice settings should assess/screen caregiver burden, using a validated tool (such as the caregiver strain index or the self related burden index). in situations where concerns are identified, clients should be referred to a trained healthcare professional for further assessment and management. |
| imipenem meropenem oxacillin nafcillin cefazolin | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| immunodeficiency immersion injuries animal bites | 2 | cultures of blood are recommended in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites ( |
| implementation includes assessment organizational readiness | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| implementation process ongoing opportunities discussion | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| improves survival over standard radiotherapy | 2 | 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). 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. evidence from a comparative cohort study suggests that hyperfractionated accelerated radiation therapy (hart) also improves survival over standard radiotherapy. |
| in hours symptom onset reveals | 3 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations:assess for fibrinolytic therapy in patients with symptoms suggestive of ami and presenting within 12 hours of symptom onset if ecg reveals: 1.new or presumably new right bundle branch block (rbbb). 2.rbbb, atypical bbb, or ventricular paced and concordant st-segment deviations greater than or equal to 0.1 mv (1 mm) towards the major qrs deflection or discordant st-segment deviations greater than or equal to 0.5 mv (5 mm) away from the major qrs deflection in 2 or more contiguous leads. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| in their licensed indications recommended | 2 | 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. olanzapine and valproate semisodium, within their licensed indications, are recommended as options for control of the acute symptoms associated with the manic phase of bipolar i disorder. |
| includes assessment organizational readiness barriers | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| including piperacillintazobactam cefepime levofloxacin imipenem | 3 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| including time international normalized ratio | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| incomplete bundle branch block type | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| indicated suggest regimen including piperacillintazobactam | 3 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| individual provide support needed education | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| individualized basis risk factors cost | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| individuals out symptoms history cancer | 2 | for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of serial chest x-rays (cxrs) to screen for the presence of lung cancer. for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of a single low-dose computed tomography scan (ldct) or serial ldcts to screen for the presence of lung cancer. at-risk individuals who express an interest in undergoing low-dose computed tomography scan screening should be made aware of several ongoing high quality clinical studies of this technology. |
| infarction causes segment elevation early | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| infarction presenting in hours symptom | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| infected patients cd lymphocyte counts | 2 | hiv-infected patients with cd4+ lymphocyte counts of <200 cells/microl or those patients with counts of >200 cells/microl with unexplained fever, weight loss, or thrush who have unexplained cough should be suspected of having pneumocystis pneumonia, tuberculosis, and other opportunistic infections, and should be evaluated accordingly. in human immunodeficiency (hiv)-infected patients, cd4+ lymphocyte counts should be used in constructing the list of differential diagnostic possibilities potentially causing cough. |
| infection prior intravenous antibiotic in | 2 | for patients with hap who are being treated empirically and have either a risk factor for mrsa infection (ie, prior intravenous antibiotic use within 90 days, hospitalization in a unit where >20% of s. aureus isolates are methicillin resistant, or the prevalence of mrsa is not known, or who are at high risk for mortality, we suggest prescribing an antibiotic with activity against mrsa for patients with hap who are being treated empirically and have factors increasing the likelihood for pseudomonas or other gram-negative infection (ie, prior intravenous antibiotic use within 90 days; also see remarks) or a high risk for mortality, we suggest prescribing antibiotics from 2 different classes with activity against p. aeruginosa |
| infused positive inotropic drugs potentially | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| inhibitors anastrozole exemestane letrozole in | 2 | 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. 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. |
| inotropic drugs potentially harmful patients | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| interactions other clinical characteristics including | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| intermediate highrisk chronic lymphocytic leukemia | 2 | previously treated patients with intermediate- or high-risk chronic lymphocytic leukemia fludarabine is an acceptable treatment option after failure of first-line therapy. choice of treatment should be influenced by previously used regimens and patient preference. as first line treatment in patients with intermediate- or high-risk chronic lymphocytic leukemia, fludarabine or conventional chemotherapy (chlorambucil) are acceptable treatment options. fludarabine improves progression-free survival but has a greater risk of toxicity, including specific infections. |
| international normalized ratio therapeutic range | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| interpretation serum human chorionic gonadotropin | 2 | 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. 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. |
| interval between oral health reviews | 2 | 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. he longest interval between oral health reviews for patients younger than 18 years should be 12 months. |
| interventions promote sustained weight loss | 3 | the uspstf recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. the uspstf concludes that the evidence is insufficient to recommend for or against the use of counseling of any intensity and behavioral interventions to promote sustained weight loss in overweight adults. the uspstf concludes that the evidence is insufficient to recommend for or against the use of moderate- or low-intensity counseling together with behavioral interventions to promote sustained weight loss in obese adults. |
| into account individual'advocate carer should | 2 | in all situations where informed discussion is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted when appropriate. in all situations where informed discussion and consent is not possible advance directives should be taken fully into account and the individual's advocate and/or carer should be consulted. |
| intraoperatively continued until patient fully | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| isolated adrenal mass ultrasonography scan | 2 | staging distant metastatic disease:adrenal: 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. staging distant metastatic disease:2003 recommendations:adrenal: 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. |
| isolates resistant agent being considered | 2 | we suggest prescribing 2 antipseudomonal antibiotics from different classes for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients in units where >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, and patients in an icu where local antimicrobial susceptibility rates are not available we suggest prescribing one antibiotic active against p. aeruginosa for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance who are being treated in icus where ?10% of gram-negative isolates are resistant to the agent being considered for monotherapy |
| jointly individual clinician responsible treatment | 3 | of the drugs available for the treatment of acute mania, the choice of which to prescribe should be made jointly by the individual and the clinician(s) responsible for treatment. the choice should be based on an informed discussion of the relative benefits and side-effect profiles of each drug, and should take into account the needs of the individual and the particular clinical situation. the decision regarding treatment should be made jointly by the individual and the clinician(s) responsible for treatment. 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. valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent. 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. 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. 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. 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. |
| laboratory blood test diagnose epileptic | 3 | for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)the utility of serum prl assay has not been established in the evaluation of status epilepticus, repetitive seizures, or neonatal seizures. for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)elevated serum prolactin (prl), when measured in appropriate clinical setting at 10 to 20 minutes after a suspected event, should be considered a useful adjunct to differentiate generalized tonic-clonic seizures or complex partial seizures from psychogenic nonepileptic seizures among adults and older children. for clinicians considering a laboratory blood test to diagnose epileptic seizures (es)serum prl assay is not of utility to distinguish seizure from syncope . |
| lacking features infarction causes segment | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| lbbb pattern duration nyha class | 3 | crt can be useful for patients who have lvef of ?35% , sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class iii/ambulatory class iv symptoms on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of 120–149 ms, and nyha class iii/ambulatory class iv on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class ii symptoms on gdmt. |
| lead levels asymptomatic children aged | 2 | the uspstf recommends against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 years who are at average risk . the uspstf concludes that evidence is insufficient to recommend for or against routine screening for elevated blood lead levels in asymptomatic children aged 1 to 5 who are at increased risk. |
| leads greater than equal more | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| leads lacking features infarction causes | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| left atypical thought obscuring segment | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| left ventricular hypertrophy incomplete bundle | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| less than laar active ingredient | 2 | pregnant patients with unintentional exposure to less than 1 mg of laar active ingredient should be evaluated by their obstetrician or primary care provider as an outpatient. immediate referral to an emergency department or clinic is not required. patients with unintentional ingestion of less than 1 mg of laar active ingredient can be safely observed at home without laboratory monitoring. this includes practically all unintentional ingestions in children less than 6 years of age. |
| levofloxacin imipenem meropenem oxacillin nafcillin | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| limb leads greater than equal | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| limitedstage small cell lung cancer | 2 | in patients with limited-stage small cell lung cancer, the addition of thoracic radiotherapy to standard combination chemotherapy improves both local control and overall survival and should be incorporated into a comprehensive treatment plan of combined modality therapy for limited-stage small cell lung cancer. based on currently available data, hyperfractionated thoracic radiotherapy is not recommended for limited-stage small cell lung cancer outside of a clinical trial. |
| lipoprotein cholesterol highdensity lipoprotein cholesterol | 2 | all women with pcos should be screened for dyslipidemia with a fasting lipoprotein profile, including total cholesterol, low-density lipoprotein (ldl) cholesterol, high-density lipoprotein (hdl) cholesterol, and triglyceride determinations. 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. |
| liver biopsy poses substantial risk | 2 | people for whom liver biopsy poses a substantial risk (such as those with haemophilia, or those who have experienced an adverse event after undergoing a previous liver biopsy), and people with symptoms of extra-hepatic hcv infection sufficient to impair quality of life, may be treated on clinical grounds without prior histological classification. peope for whom liver biopsy poses a substantial risk(such as those with haemophilia,or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra hepatic hcv infection sufficient to impair quality of life,may be treated on clinical grounds without prior histological classification. |
| liver ultrasonography chest radiography indicated | 2 | 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. in women who have pathological stage ii tumours, a postoperative bone scan is recommended as part of baseline staging. 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. |
| locally advanced metastatic breast cancer | 3 | 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. 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. the decision regarding treatment should be made jointly by the individual and the clinician(s) responsible for treatment. 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. |
| locally advanced unresectable stage small | 2 | 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). 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. of those trials designed to improve therapeutic ratios in patients with locally advanced, unresectable stage iii non-small cell lung cancer there is insufficient data of high quality to recommend hyperfractionation over standard radiotherapy of 60 gy in 30 fractions. further randomized controlled trials are necessary to confirm the benefits, if any, of hyperfractionation radiotherapy. |
| longterm infused positive inotropic drugs | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| lung cancer good performance status | 2 | the combination of paclitaxel (taxol®) or docetaxel (taxotere®) with cisplatin can be recommended as one of a number of chemotherapy options in the first-line therapy of patients with advanced non-small cell lung cancer and a good performance status. 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. |
| lvef sinus rhythm lbbb pattern | 3 | crt can be useful for patients who have lvef of ?35% , sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class iii/ambulatory class iv symptoms on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of 120–149 ms, and nyha class iii/ambulatory class iv on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class ii symptoms on gdmt. |
| lymph nodes found chest scan | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| m continued anthracyclinecontaining chemotherapy indicated | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| m liver biopsy poses substantial | 2 | people for whom liver biopsy poses a substantial risk (such as those with haemophilia, or those who have experienced an adverse event after undergoing a previous liver biopsy), and people with symptoms of extra-hepatic hcv infection sufficient to impair quality of life, may be treated on clinical grounds without prior histological classification. peope for whom liver biopsy poses a substantial risk(such as those with haemophilia,or those who have experienced an adverse event after undergoing a previous liver biopsy) and people with symptoms of extra hepatic hcv infection sufficient to impair quality of life,may be treated on clinical grounds without prior histological classification. |
| m2 over hour every three | 3 | in anthracycline-naive patients, who would ordinarily be offered treatment with a single-agent anthracycline (doxorubicin or epirubicin) or an anthracycline in a standard combination, the following options are also reasonable:treatment with single-agent docetaxel 100 mg/m2 over one hour every three weeks.docetaxel or paclitaxel in combination with doxorubicin. in anthracycline-naive patients for whom anthracyclines are contraindicated: treatment with single-agent docetaxel 100 mg/m2 over one hour every three weeks is recommended. in anthracycline-resistant patients or patients who have previously received an anthracycline as adjuvant therapy: either docetaxel (100 mg/m2 over one hour every three weeks) or paclitaxel (175 mg/m2 over three hours every three weeks) may be considered as a treatment option after failure of prior anthracycline treatment or in women whose disease is resistant to anthracyclines. the evidence supporting the use of single-agent docetaxel is more consistent and is based on a larger number of trials and patients than the evidence for paclitaxel. in selected patients, the combination of docetaxel and capecitabine is a therapeutic option. due to the toxicity of the combination, patient selection for good performance status or younger age is recommended. it is recommended that capecitabine in the docetaxel/capecitabine combination be given at 75% of full dose. |
| made after informed discussion between | 2 | the decision about which of the procedures (open or laparoscopic) is undertaken should be made after informed discussion between the patient and the surgeon. in particular, they should consider: the suitability of the lesion for laparoscopic resection the risks and benefits of the two procedures the experience of the surgeon in both procedures the decision regarding treatment should be made jointly by the individual and the clinician(s) responsible for treatment. 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. |
| made jointly individual clinician responsible | 3 | of the drugs available for the treatment of acute mania, the choice of which to prescribe should be made jointly by the individual and the clinician(s) responsible for treatment. the choice should be based on an informed discussion of the relative benefits and side-effect profiles of each drug, and should take into account the needs of the individual and the particular clinical situation. the decision regarding treatment should be made jointly by the individual and the clinician(s) responsible for treatment. 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. valid consent should be obtained in all cases where the individual has the ability to grant or refuse consent. 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. 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. 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. 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. |
| makers commissioners should only endorse | 2 | recommendation :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 .individuals should only be referred to schemes that are part of such a study. 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 . measures should include intermediate outcomes such as knowledge, attitude, and skills, as well as measures of physical activity levels. |
| malignancy chemotherapy neutropenia severe cellmediated | 2 | cultures of blood are recommended in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites ( |
| management recommendations assess fibrinolytic therapy | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| mass ultrasonography scan scan requires | 2 | staging distant metastatic disease:adrenal: 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. staging distant metastatic disease:2003 recommendations:adrenal: 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. |
| mediastinal lymph nodes found chest | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| meropenem oxacillin nafcillin cefazolin preferred | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| metastatic breast cancer being considered | 2 | single-agent gemcitabine is not recommended for women with metastatic breast cancer who are being considered for first-line single-agent anthracycline chemotherapy. the combination of gemcitabine, epirubicin, and paclitaxel (get) is not recommended as first-line chemotherapy for women with metastatic breast cancer who are being considered for anthracycline-based combination chemotherapy. |
| metastatic disease patient otherwise considered | 2 | staging distant metastatic disease:adrenal: 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. staging distant metastatic disease:2003 recommendations:adrenal: 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. |
| might reduce risk transmitting pertussis | 2 | routine tdap vaccination:recommendations for use: adults aged 19 to 64 years should receive a single dose of tdap to replace a single dose of tetanus and diphtheria toxoids vaccine (td) for active booster vaccination against tetanus, diphtheria, and pertussis if they received their last dose of td >10 years earlier. replacing 1 dose of td with tdap will reduce the morbidity associated with pertussis in adults and might reduce the risk for transmitting pertussis to persons at increased risk for pertussis and its complications. routine tdap vaccination: recommendations for use:prevention of pertussis among infants aged <12 months by vaccinating their adult contacts: adults who have or who anticipate having close contact with an infant aged <12 months (e.g., parents, grandparents aged <65 years, child-care providers, and health-care personnel [hcp]) should receive a single dose of tdap at intervals <10 years since the last td to protect against pertussis if they have not previously received tdap. ideally, these adults should receive tdap at least 2 weeks before beginning close contact with the infant. an interval as short as 2 years from the last dose of td is suggested to reduce the risk for local and systemic reactions after vaccination; shorter intervals may be used. infants aged <12 months are at highest risk for pertussis-related complications and hospitalizations compared with older age groups. young infants have the highest risk for death. vaccinating adult contacts might reduce the risk for transmitting pertussis to these infants (see "infant pertussis and transmission to infants" in the original guideline document). infants should be vaccinated on-time with pediatric diphtheria and tetanus toxoids, acellular pertussis antigens (dtap) ("pertussis vaccination," 1997; cdc, "recommended childhood and adolescent immunization schedule," 2006). when possible, women should receive tdap before becoming pregnant. approximately half of all pregnancies in the united states are unplanned (henshaw, 1998). any woman of childbearing age who might become pregnant is encouraged to receive a single dose of tdap if she has not previously received tdap (see "vaccination during pregnancy" below). women, including those who are breastfeeding, should receive a dose of tdap in the immediate postpartum period if they have not previously received tdap. the postpartum tdap should be administered before discharge from the hospital or birthing center. if tdap cannot be administered before discharge, it should be administered as soon as feasible. |
| millivolts more contiguous limb leads | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| more contiguous limb leads greater | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| more contiguous precordial leads lacking | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| mortality suggest prescribing antibiotic activity | 2 | for patients with hap who are being treated empirically and have either a risk factor for mrsa infection (ie, prior intravenous antibiotic use within 90 days, hospitalization in a unit where >20% of s. aureus isolates are methicillin resistant, or the prevalence of mrsa is not known, or who are at high risk for mortality, we suggest prescribing an antibiotic with activity against mrsa for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| most women previous cesarean delivery | 2 | most women with one previous cesarean delivery with a low-transverse incision are candidates for vaginal birth after cesarean delivery (vbac) and should be counseled about vbac and offered a trial of labor. the use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged. |
| mssa necessary empiric coverage above | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| mssa necessary empiric treatment above | 2 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used |
| mucor rhizopus infections should treated | 2 | mucor/rhizopus infections should be treated with lipid formulation amphotericin b mucor/rhizopus infections should be treated with posaconazole |
| myocardial infarction presenting in hours | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| nafcillin cefazolin preferred agents treatment | 2 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used |
| nafcillin cefazolin preferred treatment proven | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| necessary empiric coverage above agents | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| necessary empiric treatment above agents | 2 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used |
| negative scanning does preclude biopsy | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| neutropenia severe cellmediated immunodeficiency immersion | 2 | cultures of blood are recommended in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites ( |
| nodes found chest scan greater | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| normalized ratio therapeutic range patient | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| nsclc biopsy recommended mediastinal lymph | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| nutritional supplements treatment recommended patients | 2 | nutritional supplements as treatment for hf are not recommended in patients with current or prior symptoms of hfref. ( nutritional supplements as treatment for hf are not recommended in patients with current or prior symptoms of hfref. |
| nyha class ambulatory class symptoms | 3 | cardiac resynchronization therapy is indicated for patients who have lvef of 35% or less, sinus rhythm, left bundle-branch block (lbbb) with a qrs duration of 150 ms or greater, and nyha class ii, iii, or ambulatory class iv symptoms on gdmt. crt can be useful for patients who have lvef of ?35% , sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class iii/ambulatory class iv symptoms on gdmt. crt can be useful for patients who have lvef of ?35%, sinus rhythm, lbbb with a qrs duration of 120–149 ms, and nyha class ii, iii, or ambulatory class iv symptoms on gdmt. |
| obscuring segment analysis patients clinical | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| ongoing opportunities discussion education reinforce | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| only patients following risk factor | 2 | we suggest including an agent active against mrsa for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients being treated in units where >10%–20% of s. aureus isolates are methicillin resistant, and patients in units where the prevalence of mrsa is not known we suggest prescribing 2 antipseudomonal antibiotics from different classes for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients in units where >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, and patients in an icu where local antimicrobial susceptibility rates are not available |
| only polymyxins suggest adjunctive inhaled | 2 | in patients with hap/vap caused by acinetobacter species that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin in patients with hap/vap caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin |
| onset reveals elevations greater than | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| operable nsclc biopsy recommended mediastinal | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| opportunities discussion education reinforce importance | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| organizational readiness barriers education involvement | 2 | nursing best practice guidelines can be successfully implemented only where there are adequate planning, resources, organizational and administrative support, as well as appropriate facilitation. organizations may wish to develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process dedication of a qualified individual to provide the support needed for the education and implementation process ongoing opportunities for discussion and education to reinforce the importance of best practices opportunities for reflection on personal and organizational experience in implementing guidelines organizations should develop a plan for implementation that includes: an assessment of organizational readiness and barriers to education. involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process. ongoing opportunities for discussion and education to reinforce the importance of best practices. dedication of a qualified individual to provide the support needed for the education and implementation process. |
| other clinical characteristics including time | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| other than correct deficiencies recommended | 2 | hormonal therapies other than to correct deficiencies are not recommended in hfref hormonal therapies other than to correct deficiencies are not recommended for patients with current or prior symptoms of hfref. |
| out additional risk factor cardioembolic | 2 | chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| out concomitant estrogen therapy cannot | 2 | testosterone therapy without concomitant estrogen therapy cannot be recommended, because there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen. testosterone therapy without concomitant estrogen therapy cannot be recommended becasue there are no data on the safety and efficacy of testosterone therapy in women not using concomitant estrogen. |
| out prior thromboembolic event cardioembolic | 2 | anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source. (iii-b: no benefit) |
| out risk factors antimicrobial resistance | 2 | we suggest including an agent active against methicillinsensitive s. aureus (mssa) (and not mrsa) for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance, who are being treated in icus where <10%–20% of s. aureus isolates are methicillin resistant (weak recommendation, very low-quality evidence). we suggest prescribing one antibiotic active against p. aeruginosa for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance who are being treated in icus where ?10% of gram-negative isolates are resistant to the agent being considered for monotherapy |
| out symptoms history cancer guideline | 2 | for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of serial chest x-rays (cxrs) to screen for the presence of lung cancer. for individuals without symptoms or a history of cancer, the guideline developers recommend against the use of a single low-dose computed tomography scan (ldct) or serial ldcts to screen for the presence of lung cancer. at-risk individuals who express an interest in undergoing low-dose computed tomography scan screening should be made aware of several ongoing high quality clinical studies of this technology. |
| outcome following lumbar fusion surgery | 2 | the use of lumbar brace therapy as a preoperative diagnostic tool to predict outcome following lumbar fusion surgery is not recommended. the use of transpedicular external fixation as a tool to predict outcome following lumbar fusion surgery is not recommended. |
| over hour every three weeks | 2 | in anthracycline-naive patients for whom anthracyclines are contraindicated: treatment with single-agent docetaxel 100 mg/m2 over one hour every three weeks is recommended. in anthracycline-resistant patients or patients who have previously received an anthracycline as adjuvant therapy: either docetaxel (100 mg/m2 over one hour every three weeks) or paclitaxel (175 mg/m2 over three hours every three weeks) may be considered as a treatment option after failure of prior anthracycline treatment or in women whose disease is resistant to anthracyclines. the evidence supporting the use of single-agent docetaxel is more consistent and is based on a larger number of trials and patients than the evidence for paclitaxel. in selected patients, the combination of docetaxel and capecitabine is a therapeutic option. due to the toxicity of the combination, patient selection for good performance status or younger age is recommended. it is recommended that capecitabine in the docetaxel/capecitabine combination be given at 75% of full dose. |
| oxacillin nafcillin cefazolin preferred agents | 2 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used |
| oxacillin nafcillin cefazolin preferred treatment | 2 | for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| palliation patients stage disease cannot | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| paroxysmal out additional risk factor | 2 | chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| paroxysmal should individualized basis risk | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| part properly designed controlled research | 2 | recommendation :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 .individuals should only be referred to schemes that are part of such a study. 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 . measures should include intermediate outcomes such as knowledge, attitude, and skills, as well as measures of physical activity levels. |
| patient fully ambulatory unfractionated heparin | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| patient management recommendations assess fibrinolytic | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| patient otherwise considered potentially resectable | 2 | staging distant metastatic disease:adrenal: 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. staging distant metastatic disease:2003 recommendations:adrenal: 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. |
| patient preference potential drug interactions | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| patients advanced anthracyclinesensitive cancer m | 2 | the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose epirubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician. there are no data indicating the optimal cumulative dose of epirubicin at which dexrazoxane should be instituted. for doxorubicin, use of dexrazoxane is recommended after the cumulative dose reaches 300 mg/m2 (i.e., 55% of the recommended maximum). a similar formula could be used for epirubicin; that is, institution of dexrazoxane when the cumulative dose of epirubicin reaches 550 mg/m2, as the recommended maximum cumulative dose in canada is 1,000 mg/m2. the evidence supports the use of dexrazoxane to protect against the cardiotoxicity associated with conventional-dose doxorubicin in patients with advanced but anthracycline-sensitive cancer, in whom the continued use of anthracycline-containing chemotherapy is indicated in the opinion of the treating physician, and who have received 300 mg/m2 or more of doxorubicin. |
| patients advanced lung cancer staging | 2 | diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. diagnostic evaluation of patients with advanced lung cancer: staging locoregional disease:2003 recommendations:for patients with clinically operable nsclc, biopsy is recommended of mediastinal lymph nodes found on chest ct scan to be greater than 1.0 cm in shortest transverse axis, or positive on fdg-pet scanning. negative fdg-pet scanning does not preclude biopsy of radiographically enlarged mediastinal lymph nodes. |
| patients advanced small cell lung | 2 | the combination of paclitaxel (taxol®) or docetaxel (taxotere®) with cisplatin can be recommended as one of a number of chemotherapy options in the first-line therapy of patients with advanced non-small cell lung cancer and a good performance status. gefitinib monotherapy, if available, may be considered as a second-line and subsequent treatment option for selected symptomatic patients with advanced non-small cell lung cancer who are not candidates for chemotherapy and for whom erlotinib is not available. |
| patients aeruginosa recommend against aminoglycoside | 2 | for patients with hap/vap due to p. aeruginosa, we recommend against aminoglycoside monotherapy (strong recommendation, very low-quality evidence). for patients with hap/vap due to p. aeruginosa, we recommend against aminoglycoside monotherapy |
| patients being treated empirically recommend | 3 | for patients being treated empirically for hap, we recommend prescribing an antibiotic with activity against s. aureus for patients with hap who are being treated empirically, we recommend prescribing antibiotics with activity against p. aeruginosa and other gram-negative bacilli for patients with hap who are being treated empirically, we recommend not using an aminoglycoside as the sole antipseudomonal agent |
| patients caused acinetobacter species sensitive | 3 | in patients with hap/vap caused by acinetobacter species that is sensitive only to polymyxins, we recommend intravenous polymyxin (colistin or polymyxin b) in patients with hap/vap caused by acinetobacter species that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin in patients with hap/vap caused by acinetobacter species that is sensitive only to colistin, we suggest not using adjunctive rifampicin |
| patients caused carbapenemresistant pathogen sensitive | 2 | in patients with hap/vap caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we recommend intravenous polymyxins (colistin or polymyxin b) in patients with hap/vap caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin |
| patients chronic cough nonasthmatic eosinophilic | 2 | in patients with chronic cough due to nonasthmatic eosinophilic bronchitis, the possibility of an occupation-related cause needs to be considered. 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. |
| patients chronic hfref out prior | 2 | anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source anticoagulation is not recommended in patients with chronic hfref without af, a prior thromboembolic event, or a cardioembolic source. (iii-b: no benefit) |
| patients chronic hfref reduce morbidity | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| patients chronic permanent persistent paroxysmal | 3 | patients with chronic hf with permanent/persistent/paroxysmal af and an additional risk factor for cardioembolic stroke (history of hypertension, diabetes mellitus, previous stroke or transient ischemic attack, or ?75 years of age) should receive chronic anticoagulant therapy (in the absence of contraindications to anticoagulation). chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| patients clinical presentation strongly suggestive | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| patients current prior symptoms hfref | 5 | nutritional supplements as treatment for hf are not recommended in patients with current or prior symptoms of hfref. ( drugs known to adversely affect the clinical status of patients with current or prior symptoms of hfref are potentially harmful and should be avoided or withdrawn whenever possible (eg, most antiarrhythmic drugs, most calcium channel–blocking drugs [except amlodipine], nonsteroidal anti-inflammatory drugs, or thiazolidinediones). use of 1 of the 3 beta blockers proven to reduce mortality (ie, bisoprolol, carvedilol, and sustained-release metoprolol succinate) is recommended for all patients with current or prior symptoms of hfref, unless contraindicated, to reduce morbidity and mortality. nutritional supplements as treatment for hf are not recommended in patients with current or prior symptoms of hfref. hormonal therapies other than to correct deficiencies are not recommended for patients with current or prior symptoms of hfref. |
| patients diabetes admitted hospital should | 2 | all patients with diabetes admitted to the hospital should be identified in the medical record as having diabetes. all patients with diabetes admitted to the hospital should have an a1c obtained for discharge planning if the result of testing in the previous 2 to 3 months is not available. |
| patients eastern cooperative oncology group | 2 | 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). 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. 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. patients with a ps of eastern cooperative oncology group (ecog) 0 or 1 should be offered chemotherapy. data are not yet sufficient to routinely recommend chemotherapy to patients with a ps of ecog level 2 . patients with a ps of ecog level 3 or 4 should not receive chemotherapy. |
| patients following risk factor antimicrobial | 2 | we suggest including an agent active against mrsa for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients being treated in units where >10%–20% of s. aureus isolates are methicillin resistant, and patients in units where the prevalence of mrsa is not known we suggest prescribing 2 antipseudomonal antibiotics from different classes for the empiric treatment of suspected vap only in patients with any of the following: a risk factor for antimicrobial resistance (table 2), patients in units where >10% of gram-negative isolates are resistant to an agent being considered for monotherapy, and patients in an icu where local antimicrobial susceptibility rates are not available |
| patients hfref current prior symptoms | 2 | ace inhibitors are recommended in patients with hfref and current or prior symptoms, unless contraindicated, to reduce morbidity and mortality. (i-a) arbs are recommended in patients with hfref with current or prior symptoms who are ace inhibitor–intolerant, unless contraindicated, to reduce morbidity and mortality. |
| patients hfref except palliation patients | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| patients intermediate highrisk chronic lymphocytic | 2 | previously treated patients with intermediate- or high-risk chronic lymphocytic leukemia fludarabine is an acceptable treatment option after failure of first-line therapy. choice of treatment should be influenced by previously used regimens and patient preference. as first line treatment in patients with intermediate- or high-risk chronic lymphocytic leukemia, fludarabine or conventional chemotherapy (chlorambucil) are acceptable treatment options. fludarabine improves progression-free survival but has a greater risk of toxicity, including specific infections. |
| patients locally advanced unresectable stage | 2 | 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). 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. of those trials designed to improve therapeutic ratios in patients with locally advanced, unresectable stage iii non-small cell lung cancer there is insufficient data of high quality to recommend hyperfractionation over standard radiotherapy of 60 gy in 30 fractions. further randomized controlled trials are necessary to confirm the benefits, if any, of hyperfractionation radiotherapy. |
| patients lvef sinus rhythm lbbb | 4 | crt can be useful for patients who have lvef of ?35% , sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class iii/ambulatory class iv symptoms on gdmt. crt can be useful for patients who have lvef of ?35%, sinus rhythm, lbbb with a qrs duration of 120–149 ms, and nyha class ii, iii, or ambulatory class iv symptoms on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of 120–149 ms, and nyha class iii/ambulatory class iv on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class ii symptoms on gdmt. |
| patients malignancy chemotherapy neutropenia severe | 2 | cultures of blood are recommended in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites cultures and microscopic examination of cutaneous aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites ( |
| patients out risk factors antimicrobial | 2 | we suggest including an agent active against methicillinsensitive s. aureus (mssa) (and not mrsa) for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance, who are being treated in icus where <10%–20% of s. aureus isolates are methicillin resistant (weak recommendation, very low-quality evidence). we suggest prescribing one antibiotic active against p. aeruginosa for the empiric treatment of suspected vap in patients without risk factors for antimicrobial resistance who are being treated in icus where ?10% of gram-negative isolates are resistant to the agent being considered for monotherapy |
| patients prior current symptoms chronic | 2 | the use of ace inhibitors is beneficial for patients with prior or current symptoms of chronic hfref to reduce morbidity and mortality. the use of arbs to reduce morbidity and mortality is recommended in patients with prior or current symptoms of chronic hfref who are intolerant to ace inhibitors because of cough or angioedema. |
| patients recent remote history acute | 3 | in all patients with a recent or remote history of mi or acute coronary syndrome and reduced ef, angiotensin-converting enzyme (ace) inhibitors should be used to prevent symptomatic hf and reduce mortality. in patients intolerant of ace inhibitors, angiotensin-receptor blockers are appropriate unless contraindicated. in all patients with a recent or remote history of mi or acute coronary syndrome and reduced ef, evidence-based beta blockers should be used to reduce mortality. in all patients with a recent or remote history of mi or acute coronary syndrome, statins should be used to prevent symptomatic hf and cardiovascular events. |
| patients recommend course antimicrobial therapy | 2 | for patients with vap, we recommend a 7-day course of antimicrobial therapy rather than a longer duration for patients with hap, we recommend a 7-day course of antimicrobial therapy |
| patients recommended patients chronic hfref | 2 | the clinical strategy of inhibition of the renin-angiotensin system with ace inhibitors or arbs in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. the clinical strategy of inhibition of the renin-angiotensin system with arni in conjunction with evidence-based beta blockers, and aldosterone antagonists in selected patients, is recommended for patients with chronic hfref to reduce morbidity and mortality. |
| patients reduced prevent symptomatic even | 2 | ace inhibitors should be used in all patients with a reduced ef to prevent symptomatic hf, even if they do not have a history of mi. beta blockers should be used in all patients with a reduced ef to prevent symptomatic hf, even if they do not have a history of mi. |
| patients stage disease cannot stabilized | 2 | long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment long-term use of infused positive inotropic drugs is potentially harmful for patients with hfref, except as palliation for patients with end-stage disease who cannot be stabilized with standard medical treatment (see recommendations for stage d starting on page 34). |
| patients suspected recommend using clinical | 3 | for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using serum pct plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone, rather than using bronchoalveolar lavage fluid (balf) strem-1 plus clinical criteria, to decide whether or not to initiate antibiotic therapy for patients with suspected hap/vap, we recommend using clinical criteria alone rather than using crp plus clinical criteria, to decide whether or not to initiate antibiotic therapy |
| patients symptoms suggestive acute myocardial | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| pattern duration nyha class ambulatory | 2 | crt can be useful for patients who have lvef of ?35% , sinus rhythm, a non-lbbb pattern with a qrs duration of ?150 ms, and nyha class iii/ambulatory class iv symptoms on gdmt. crt may be considered for patients who have lvef of ?35%, sinus rhythm, a non-lbbb pattern with a qrs duration of 120–149 ms, and nyha class iii/ambulatory class iv on gdmt. |
| pericarditis left ventricular hypertrophy incomplete | 2 | patient management recommendations. assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. patient management recommendations: assess for fibrinolytic therapy in patients with symptoms suggestive of acute myocardial infarction (ami) and presenting within 12 hours of symptom onset if ecg reveals: 1.st elevations greater than or equal to 0.1 millivolts (mv) (1 mm) in 2 or more contiguous limb leads or greater than or equal to 0.2 mv (2 mm) in 2 or more contiguous precordial leads lacking features of non-infarction causes of st-segment elevation (e.g., early repolarization, pericarditis, left ventricular hypertrophy [lvh], incomplete bundle branch block [bbb]). 2.any type of bbb (right, left, and atypical ? new or old) thought to be obscuring st-segment analysis in patients with clinical presentation strongly suggestive of ami. |
| permanent persistent paroxysmal out additional | 2 | chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| permanent persistent paroxysmal should individualized | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| persistent paroxysmal out additional risk | 2 | chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). ( chronic anticoagulation is reasonable for patients with chronic hf who have permanent/persistent/paroxysmal af but are without an additional risk factor for cardioembolic stroke (in the absence of contraindications to anticoagulation). |
| persistent paroxysmal should individualized basis | 2 | the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. ( the selection of an anticoagulant agent (warfarin, dabigatran, apixaban, or rivaroxaban) for permanent/persistent/paroxysmal af should be individualized on the basis of risk factors, cost, tolerability, patient preference, potential for drug interactions, and other clinical characteristics, including time in the international normalized ratio therapeutic range if the patient has been taking warfarin. |
| persons increased risk syphilis infection | 2 | the uspstf recommends against routine screening of asymptomatic persons who are not at increased risk for syphilis infection. the uspstf strongly recommends that clinicians screen persons at increased risk for syphilis infection. |
| physical activity part properly designed | 2 | recommendation :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 .individuals should only be referred to schemes that are part of such a study. 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 . measures should include intermediate outcomes such as knowledge, attitude, and skills, as well as measures of physical activity levels. |
| piperacillintazobactam cefepime levofloxacin imipenem meropenem | 3 | when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem (weak recommendation, very low-quality evidence). oxacillin, nafcillin, or cefazolin are preferred agents for treatment of proven mssa, but are not necessary for the empiric treatment of vap if one of the above agents is used. for patients with hap who are being treated empirically and have no risk factors for mrsa infection and are not at high risk of mortality, we suggest prescribing an antibiotic with activity against mssa. when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used when empiric treatment that includes coverage for mssa (and not mrsa) is indicated, we suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. oxacillin, nafcillin, or cefazolin are preferred for the treatment of proven mssa, but are not necessary for empiric coverage of hap if one of the above agents is used |
| placed intraoperatively continued until patient | 2 | alternatives for thromboprophylaxis for moderate-risk* patients undergoing gynecologic surgery include the following: thigh-high graduated compression stockings placed intraoperatively and continued until the patient is fully ambulatory pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 2 hours before surgery and continued postoperatively every 8 hours until discharge. low-molecular-weight heparin (dalteparin, 2,500 antifactor-xa u, or enoxaparin, 40 mg) administered 12 hours before surgery and once a day postoperatively until discharge. alternatives for prophylaxis for high-risk* patients undergoing gynecologic surgery, especially for malignancy, include: pneumatic compression placed intraoperatively and continued until the patient is fully ambulatory. unfractionated heparin (5,000 u) administered 8 hours before surgery and continued postoperatively until discharge. dalteparin (5,000 antifactor-xa u) administered 12 hours before surgery and then once a day thereafter. enoxaparin (40 mg) administered 12 hours before surgery and then once a day thereafter. |
| plan implementation includes assessment organizational | 2 |