| n | ngram | freq | conditional |
|---|---|---|---|
| 1 | a1c | 3 | 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. the effectiveness of glitazone combination therapy should be monitored against treatment targets for glycaemic control (usually in terms of haemoglobin a1c [hba1c] level) and for other cardiovascular risk factors, including lipid profile. the target hba1c level should be set between 6.5% and 7.5%, depending on other risk factors. laboratory tests:tests should include: hemoglobin a1c . urine microalbumin measurement . serum creatinine and calculated glomerular filtration rate (gfr) . fasting lipid profile. frequency: hemoglobin a1c: 2 to 4 times annually based on individual therapeutic goal,other tests at least annually. |
| 1 | abdomen | 2 | transabdominal ultrasound may be used as a complementary examination if the uterus is significantly enlarged or a wider view of the pelvis or abdomen is required. transabdominal ultrasound may also be used in the small proportion of women in whom it proves technically impossible to perform a transvaginal ultrasound. a complete survey that includes the head and neck, chest, abdomen, and pelvis is recommended when ptld is suspected. |
| 1 | abdominal | 12 | in patients with a suspected or known abdominal aortic aneurysm (aaa), the svs recommends performing physical examination that includes an assessment of femoral and popliteal arteries. persistently high base deficit or low phi (or worsening of these parameters) may be an early indicator of complications (e.g., ongoing hemorrhage or abdominal compartment syndrome). abdominal paracentesis should be performed and ascitic fluid should be obtained from inpatients and outpatients with clinically apparent new-onset ascites . lifestyle modification:current physical activity contributes to weight loss, reduces cardiovascular risk factors (e.g., hypertension and diabetes mellitus) and the risk for coronary heart disease, increases cardiorespiratory fitness independent of weight loss, and decreases body and abdominal fat. the uspstf recommends one-time screening for abdominal aortic aneurysm (aaa) by ultrasonography in men aged 65 to 75 who have ever smoked. functional abdominal pain generally can be diagnosed correctly by the primary care clinician in children 4 to 18 years of age with chronic abdominal pain when there are no alarm symptoms or signs, the physical examination is normal, and the stool sample tests are negative for occult blood, without the requirement of additional diagnostic evaluation. education of the family is an important part of treatment of the child with functional abdominal pain. it is often helpful to summarize the child's symptoms and explain in simple language that although the pain is real, there is most likely no underlying serious or chronic disease. it may be helpful to explain that chronic abdominal pain is a common symptom in children and adolescents, yet few have a disease. functional abdominal pain can be likened to a headache, a functional disorder experienced at some time by most adults, which very rarely is associated with serious disease. it is important to provide clear and age-appropriate examples of conditions associated with hyperalgesia, such as a healing scar, and manifestations of the interaction between brain and gut, such as the diarrhea or vomiting children may experience during stressful situations (e.g., before school examinations or important sports competitions). paracentesis: abdominal paracentesis may be helpful to confirm the presence of intestinal gangrene in infants with nec . indications for paracentesis are absence of pneumoperitoneum and one of the following: portal venous gas. erythema of abdominal wall. fixed, tender abdominal mass. persistently dilated intestinal segment. clinical deterioration radiologic studies:it is recommended that an abdominal radiograph be performed in infants with clinical suspicion of nec. the influences on infant outcome and diagnostic validity of the number of abdominal x-rays, the type of view(s), or the frequency or timing of abdominal radiographs have not been systematically studied. patients undergoing the following procedures are at higher risk for postoperative pulmonary complications and should be evaluated for other concomitant risk factors and receive pre- and postoperative interventions to reduce pulmonary complications: prolonged surgery (>3 hours), abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, emergency surgery, and general anesthesia. cognitive-behavioral therapy : studies on cbt in patients with moderate to severe symptoms show improvement in total somatic symptoms, abdominal pain and bowel dysfunction up to 15 months post therapy. few studies on the effects of cbt have been conducted in the last five years but evidence from earlier studies show significant improvement with cbt versus symptom monitoring or medical therapy alone. due to the generally high placebo response rate with functional bowel disorders and the well established psychopathology in ibs, updated high quality studies are needed. based on the expansive literature from the past twenty years on the use of cbt in bowel disorders, this therapy would be recommended as adjunctive therapy in patients with moderate to severe ibs symptoms who have not responded to medical treatment alone. clinical evaluation:women of childbearing age presenting to the ed with abdominal pain and/or vaginal bleeding will receive a urine test for pregnancy at triage . |
| 2 | abdominal aortic | 2 | in patients with a suspected or known abdominal aortic aneurysm (aaa), the svs recommends performing physical examination that includes an assessment of femoral and popliteal arteries. the uspstf recommends one-time screening for abdominal aortic aneurysm (aaa) by ultrasonography in men aged 65 to 75 who have ever smoked. |
| 3 | abdominal aortic aneurysm | 2 | in patients with a suspected or known abdominal aortic aneurysm (aaa), the svs recommends performing physical examination that includes an assessment of femoral and popliteal arteries. the uspstf recommends one-time screening for abdominal aortic aneurysm (aaa) by ultrasonography in men aged 65 to 75 who have ever smoked. |
| 2 | abdominal pain | 4 | functional abdominal pain generally can be diagnosed correctly by the primary care clinician in children 4 to 18 years of age with chronic abdominal pain when there are no alarm symptoms or signs, the physical examination is normal, and the stool sample tests are negative for occult blood, without the requirement of additional diagnostic evaluation. education of the family is an important part of treatment of the child with functional abdominal pain. it is often helpful to summarize the child's symptoms and explain in simple language that although the pain is real, there is most likely no underlying serious or chronic disease. it may be helpful to explain that chronic abdominal pain is a common symptom in children and adolescents, yet few have a disease. functional abdominal pain can be likened to a headache, a functional disorder experienced at some time by most adults, which very rarely is associated with serious disease. it is important to provide clear and age-appropriate examples of conditions associated with hyperalgesia, such as a healing scar, and manifestations of the interaction between brain and gut, such as the diarrhea or vomiting children may experience during stressful situations (e.g., before school examinations or important sports competitions). cognitive-behavioral therapy : studies on cbt in patients with moderate to severe symptoms show improvement in total somatic symptoms, abdominal pain and bowel dysfunction up to 15 months post therapy. few studies on the effects of cbt have been conducted in the last five years but evidence from earlier studies show significant improvement with cbt versus symptom monitoring or medical therapy alone. due to the generally high placebo response rate with functional bowel disorders and the well established psychopathology in ibs, updated high quality studies are needed. based on the expansive literature from the past twenty years on the use of cbt in bowel disorders, this therapy would be recommended as adjunctive therapy in patients with moderate to severe ibs symptoms who have not responded to medical treatment alone. clinical evaluation:women of childbearing age presenting to the ed with abdominal pain and/or vaginal bleeding will receive a urine test for pregnancy at triage . |
| 2 | abdominal paracentesis | 2 | abdominal paracentesis should be performed and ascitic fluid should be obtained from inpatients and outpatients with clinically apparent new-onset ascites . paracentesis: abdominal paracentesis may be helpful to confirm the presence of intestinal gangrene in infants with nec . indications for paracentesis are absence of pneumoperitoneum and one of the following: portal venous gas. erythema of abdominal wall. fixed, tender abdominal mass. persistently dilated intestinal segment. clinical deterioration |
| 1 | abilities | 2 | ask what types of work the patient has done and the longest time s/he held a job to identify abilities and interests, assess stability, and determine risk for comorbidities associated with toxic exposures (e.g., to asbestos, silica, coal). ask about any work-related illnesses or injuries and whether they have interfered with gainful activity (i.e., made it difficult to do work, resulted in job loss, presented obstacles to hiring). if so, consult the association of occupational and environmental clinics for referrals and assistance. assess the adolescent mother's abilities to care for her children and have resources available for referral and assistance before neonatal discharge . |
| 1 | ability | 9 | a central visual field defect can significantly affect visual functioning, such as reading ability. size, location, and density of the scotoma (relative, absolute, or both) will determine its effect on visual functioning and can influence the response to near magnification. in many cases, even with appropriate magnification, certain parameters of print reading ability (e.g., print size, reading speed, comprehension, and duration) may be compromised due to the central field disturbance and nature of the task, even though ability to navigate through the environment is relatively unaffected. in the eye with a macular scotoma, the stimulus to foveate the target may persist; however, with time or training, the patient may learn to view eccentrically. educate caregivers to assist in their ability to care for the wanderer. the discharge planning process:clarify activity level and ability, with a focus on safety and mobility. in patients suspected of having non-small cell lung cancer, who have no evidence of distant metastases, and who have normal mediastinal nodes by ct, but in whom invasive staging of the mediastinum is recommended (because of a high fn rate of ct), mediastinoscopy is the invasive procedure of choice to rule out mediastinal node involvement. this recommendation is based on the ability of mediastinoscopy to stage most of the commonly involved mediastinal node stations with a low fn rate (approximately 10%) and low morbidity (2%; outpatient procedure). for these patients, tbna, ttna, and eus-na are not recommended because of a high fn rate(approximately 10%) and low morbidity (2%; outpatient procedure). for the subset of these patients who have a left upper lobe cancer, the chamberlain procedure, extended cervical mediastinoscopy, or thoracoscopy should be additionally performed to evaluate the aortopulmonary window nodes. practice recommendations: patient empowerment and education:education is based on identified individual needs, risk factors, ulcer status, available resources, and ability to heal. nurses develop screening strategies and initial responses that respond to the needs of all women, taking into account differences based on race, ethnicity, class, religious/spiritual beliefs, age, ability, or sexual orientation. identify maternal and infant risk factors that may impact the mother's or infant's ability to breastfeed effectively and provide appropriate assistance and follow-up . assess patient/caregiver ability and compliance for outpatient therapy and need for home care resources. 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. |
| 1 | ablation | 2 | crt can be useful in patients with af and lvef of ?35% on gdmt if a) the patient requires ventricular pacing or otherwise meets crt criteria and b) atrioventricular nodal ablation or pharmacological rate control will allow near 100% ventricular pacing with crt. although endometrial ablation appears to be an effective option in controlling menorrhagia in women without leiomyomas, further studies are needed in women who have clinically significant leiomyomas. |
| 1 | able | 5 | exercise training (or regular physical activity) is recommended as safe and effective for patients with hf who are able to participate to improve functional status. (i-a) it is recommended that all parent-training/education programmes, whether group- or individual-based, should: be structured and have a curriculum informed by principles of social-learning theory include relationship-enhancing strategies offer a sufficient number of sessions, with an optimum of 8 to 12, to maximise the possible benefits for participants enable parents to identify their own parenting objectives incorporate role-play during sessions, as well as homework to be undertaken between sessions, to achieve generalisation of newly rehearsed behaviours to the home situation be delivered by appropriately trained and skilled facilitators who are supervised, have access to necessary ongoing professional development, and are able to engage in a productive therapeutic alliance with parents adhere to the programme developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. patients who are able and willing should be informed and educated about risk assessment and resulting prevention strategies. this strategy where appropriate should include carers . in patients who have extensive mediastinal infiltration with tumor (t4 involvement or involvement to the point of not being able to see discrete lymph nodes), the primary goal of an invasive procedure is to provide confirmation of the diagnosis. (the radiographic staging of mediastinal node involvement is compelling.) for these patients, transthoracic needle aspiration (ttna) and endoscopic ultrasound-guided needle aspiration (eus-na) are procedures of choice based on high sensitivity (approximately 90%) and low morbidity (outpatient procedure). for patients who are not considered candidates for surgery with curative intent, but who are willing and able to tolerate treatment with chemotherapy, considering the lack of an effective standard treatment option, gemcitabine, either alone or in combination with a fluoropyrimidine such as 5-fluorouracil (5-fu) or capecitabine, is a reasonable alternative to best supportive care, although this conclusion has not been confirmed with a randomized controlled trial. |
| 1 | abnormal | 8 | in severely compromised patients (patients who have failed oral antibiotic treatment or those with systemic signs of infection (such as temperature >38°c, tachycardia (heart rate >90 beats per minute), tachypnea (respiratory rate >24 breaths per minute) or abnormal white blood cell count (<12 000 or <400 cells/?l), or those who are immunocompromised,or those with clinical signs of deeper infection such as bullae, skin sloughing, hypotension, or evidence of organ dysfunction) broad-spectrum antimicrobial coverage may be considered patients presenting to the emergency department with headache and abnormal findings in a neurologic examination (i.e., focal deficit, altered mental status, altered cognitive function) should undergo emergent* noncontrast head computed tomography (ct) scan. patients presenting with acute sudden-onset headache should be considered for an emergent* head computed tomography scan. human immunodeficiency virus (hiv)-positive patients with a new type of headache should be considered for an urgent* neuroimaging study.patients who are older than 50 years presenting with new type of headache without abnormal findings in a neurologic examination should be considered for an urgent neuroimaging study. an underlying coagulopathy, such as von willebrand's disease, should be considered in all patients (particularly adolescents) with abnormal uterine bleeding, especially when bleeding is not otherwise easily explained or does not respond to medical therapy. although there is limited evidence evaluating the efficacy of conjugated equine estrogen therapy in anovulatory bleeding, it is effective in controlling abnormal uterine bleeding. currently, data available from class ii studies do not provide sufficient evidence that routine mri should be performed on all very low birth weight (vlbw) infants for whom results of screening cranial us are abnormal. neuroimaging should be considered in children with an abnormal neurologic examination (e.g., focal findings, signs of increased intracranial pressure, significant alteration of consciousness), the co-existence of seizures, or both. women with persistent abnormal vaginal bleeding after a nonmolar pregnancy should undergo a pregnancy test to exclude persistent gtn. persistent gtn should be considered in any woman developing acute respiratory or neurological symptoms after any pregnancy. measurement of fasting cholesterol, lipids, and triglycerides should be offered to patients with pcos, since early detection of abnormal levels might encourage improvement in diet and exercise. |
| 2 | abnormal uterine | 2 | an underlying coagulopathy, such as von willebrand's disease, should be considered in all patients (particularly adolescents) with abnormal uterine bleeding, especially when bleeding is not otherwise easily explained or does not respond to medical therapy. although there is limited evidence evaluating the efficacy of conjugated equine estrogen therapy in anovulatory bleeding, it is effective in controlling abnormal uterine bleeding. |
| 3 | abnormal uterine bleeding | 2 | an underlying coagulopathy, such as von willebrand's disease, should be considered in all patients (particularly adolescents) with abnormal uterine bleeding, especially when bleeding is not otherwise easily explained or does not respond to medical therapy. although there is limited evidence evaluating the efficacy of conjugated equine estrogen therapy in anovulatory bleeding, it is effective in controlling abnormal uterine bleeding. |
| 1 | abnormalities | 5 | in patients with structural cardiac abnormalities, including lv hypertrophy, in the absence of a history of mi or acs, blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic hf. identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities. these practices should be performed as part of routine patient care and certainly during the acute stage of cellulitis. among patients with a cryptogenic stroke and atrial septal abnormalities, there is insufficient evidence to determine the superiority of aspirin or warfarin for prevention of recurrent stroke or death. nurses should conduct a foot risk assessment for clients with known diabetes. this risk assessment includes the following: history of previous foot ulcers sensation structural and biomechanical abnormalities circulation self-care behaviour and knowledge because of the potential toxicity of mitoxantrone, it should be administered under the supervision of a physician experienced in the use of cytotoxic chemotherapeutic agents . in addition, patients being treated with mitoxantrone should be monitored routinely for cardiac, liver, and kidney function abnormalities . |
| 1 | abnormality | 2 | perform a renal ultrasound (or repeat the ultrasound if it was done prenatally). if the patient is found to have an abnormality of the urinary tract, continue monitoring for urinary tract infections and renal function. exercise testing is not recommended as part of routine evaluation in patients with hf. specific circumstances in which maximal exercise testing with measurement of expired gases should be considered include:assessing disparity between symptomatic limitation and objective indicators of disease severity.distinguishing non hf-related causes of functional limitation, specifically cardiac versus pulmonary.considering candidacy for cardiac transplantation or mechanical intervention. determining the prescription for cardiac rehabilitation.addressing specific employment capabilities.exercise testing with physiologic testing for inducible abnormality in myocardial perfusion or wall motion abnormality should be considered to screen for the presence of coronary artery disease with inducible ischemia. |
| 1 | about | 41 | patients currently treated in hospital who are potentially suitable for home haemodialysis on clinical grounds, but who have not previously been offered a choice, should be reassessed and informed about their dialysis options. the choice of treatment should be made after discussion between the responsible clinician and the woman about the risks and benefits of each option. factors to consider when making the choice include whether the woman has received tamoxifen before, the licensed indications and side-effect profiles of the individual drugs and, in particular, the assessed risk of recurrence. 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 discussions should occur with the patient or legal agent about life expectancy and quality of life. for patients requiring dialysis, but who have an uncertain prognosis or for whom a consensus cannot be reached about providing dialysis, nephrologists should consider offering a time-limited trial of dialysis. patients who are able and willing should be informed and educated about risk assessment and resulting prevention strategies. this strategy where appropriate should include carers . parents should receive appropriate information about maternal risks associated with delivery options, potential for infant survival, and risks of adverse long-term outcomes. physicians should become knowledgeable about contemporaneous local, referral center, and national comparative data regarding survival and long-term outcomes associated with extremely preterm birth. prior to the death of the resident, the bereavement leader should provide information about end-of-life care services, and assistance in contacting these services. patients with stage iiia (n2) lung cancer identified preoperatively have a relatively poor prognosis when treated with surgery as a single modality. several small trials of induction chemotherapy have yielded conflicting results about its effect on survival. the relative roles of surgery and radiation therapy as the local treatment modality are also not clearly defined. definitive treatment recommendations are difficult to make in this setting. therefore, patients in this subset should be referred for multidisciplinary evaluation before embarking on definitive treatment. patients with lung cancer should have clear understandable information about their diagnosis, treatment, and possible outcomes. patients and their families should be offered clear, full, prompt, and culturally appropriate information, preferably in both verbal and written form. women at average risk:beginning in their 20s, women should be told about the benefits and limitations of breast self-examination (bse). consideration should be given to screening all hiv-infected men and women for gonorrhea and chlamydial infections. however, because of the cost of screening and the variability of prevalence of these infections, decisions about routine screening for these infections should be based on epidemiologic factors (including prevalence of infection in the community or the population being served), availability of tests, and cost. (some hiv specialists also recommend type-specific serologic testing for herpes simplex virus type 2 for both men and women.) hormone replacement therapy should be considered for women undergoing prophylactic oophorectomy, and patients should be counseled about the risks and benefits of hormone replacement therapy prior to undergoing surgery. because there are no data on the use of raloxifene in women who have completed a 5-year course of tamoxifen therapy, such women should have an individual assessment of their risk of osteoporosis, and decisions about prevention or treatment should be made accordingly. counsel obese and overweight women about the risks of weight cycling--repeated episodes of weight loss and gain--and the benefits of adopting long-term healthy eating habits. pediatricians and child health professionals should join with the national american academy of pediatrics (aap) and aap chapters in the following activities: vigorously advocating for all children to receive comprehensive health care, including childhood immunizations in a medical home ("the medical home," 2002). children most likely to experience barriers to comprehensive care in a medical home are children who are members of racial and ethnic minorities, poor or uninsured children, children living in inner-city or rural areas, and children with chronic medical conditions. collaborating with local public and private child health services to identify children without access to a medical home and assist in referring them to a medical home. the medical home should maintain the children's medical records, including immunization records.removing economic barriers to immunizations for parents and pediatricians to participate in the vaccines for children (vfc) program or state vaccine programs reducing socioeconomic and racial disparities in immunization rates by working with all national medical groups and specialty societies that care for poor and underserved populations advocating with state vaccine purchasing or vaccines for children programs and private third-party payers of vaccine for adequate vaccine reimbursement rates that cover all costs associated with the administration of vaccines, including the vaccines product, physician work, practice administrative expense, professional liability, and all related supplies, including safety needles advocating with vaccine manufacturers and state and federal governments to maintain an adequate supply of all childhood vaccines at all times ensuring that the safest and most effective vaccines and combinations are available to children advocating with state and federal governments to ensure that timely access to all immunizations recommended by the advisory committee on immunization practices (acip), the aap, and the american academy of family physicians (aafp) for all children remains a high public policy priority supporting ongoing education and quality improvement programs for pediatricians and other child health care professionals about important vaccine-related issues, including the dissemination of peer-reviewed evidence for more effective immunization delivery. ask what types of work the patient has done and the longest time s/he held a job to identify abilities and interests, assess stability, and determine risk for comorbidities associated with toxic exposures (e.g., to asbestos, silica, coal). ask about any work-related illnesses or injuries and whether they have interfered with gainful activity (i.e., made it difficult to do work, resulted in job loss, presented obstacles to hiring). if so, consult the association of occupational and environmental clinics for referrals and assistance. does early adt improve outcomes over deferred therapy? recommendation: until data from studies using modern medical diagnostic and biochemical tests and standardized follow-up schedules become available, no specific recommendations can be issued by the panel regarding the question of early versus deferred adt using lhrh agonists or orchiectomy. a discussion about the pros and cons of early versus deferred therapy should occur between patient and practitioner. antiandrogen monotherapy is not recommended. patients should be followed clinically and started on adt once symptoms of locally progressive or metastatic disease present. education should include as a minimum, the following:basic facts about asthma,roles/rationale for medications,device technique(s),self-monitoring,action plans. key components of the prenatal assessment should include: personal and demographic variables that may influence breastfeeding rates intent to breastfeed access to support for breastfeeding, including significant others and peers attitude about breastfeeding among health care providers, significant others and peers physical factors, including breasts and nipples, that may affect a womanâ??s ability to breastfeed it is recommended that diagnostic information be obtained directly from parents/caregivers in the form of questionnaires and an interview that is structured to elicit information about family structure and dynamics, parenting styles and expectations, and pertinent family educational and psychiatric history. concern about increased new-onset diabetes among patients prescribed a thiazide-type diuretic with a beta-blocker means that this is not recommended as an initial combination for patients at raised risk of developing type ii diabetes. guideline: treatment must be preceded by thorough counseling about the nature of the syndrome, its natural history, its extracolonic manifestations, and the need for compliance with recommendations for management and surveillance. the panel recommends the following:education of physicians, dietitians, nurses, and the public about celiac disease by a trans-national institutes of health (nih) initiative, to be led by the national institute of diabetes and digestive and kidney diseases (niddk), in association with the centers for disease control and prevention. advocate with parents to school personnel about appropriate educational and therapeutic strategies including: physical, occupational, and speech therapy; nursing; and adaptive and assistive technology. sexual assault forensic examiner (safe) who is trained to perform pediatric examinations should be included on the team whenever possible to assist in the medical examination, coordination of care, and discussions about treatment regimen. a rape crisis counselor and/or child advocacy team should be involved in all cases of sexual assault to assist the child and the family in dealing with the trauma and to assist with referrals. full and unbiased information on choosing vbac should be discussed on a case-by-case basis with the pregnant woman with previous caesarean to enable her to make an informed decision about her birth choices. 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. ask tobacco users about status of tobacco use at each visit. patient education: assess patient needs. an important first step in optimizing patient education is to adequately assess each patient's needs. take into account patients' level of knowledge about their headaches. also, be aware of their attitudes, beliefs, and cultural background and how these elements might affect the treatment process. be sensitive to environmental and social factors, which can also play a role in determining patients' receptivity to treatment. discuss treatments.once patients have a better understanding of their headache type, it is important to include them in the treatment decision process. in many cases, it is beneficial to explain that even though there is no "cure" for headache, with proper treatment headaches can be effectively managed. be sure to spend adequate time discussing all the possible treatment options and any potential side effects. be specific when explaining proper medication use, including correct dosing, when to treat, the frequency of medication usage, and how and when to use rescue medications if appropriate. educate patients about nonpharmacologic treatments, including behavior modification, a healthy diet, and exercise. set realistic treatment expectations, and encourage patients to take responsibility for their treatment. allow for a question and answer period before ending the visit. parents should take a strong stand against the use of performance-enhancing substances and, whenever possible, demand that coaches be educated about the adverse health effects of performance-enhancing substances. clinicians should assess potential interactions between haart and methadone before and during therapy by inquiring about oversedation and opioid withdrawal symptoms. if withdrawal symptoms are present, the primary care clinician should conduct a detailed history and facilitate a dose increase by educating the patient and communicating with the methadone provider. clinicians giving women information on contraceptive options should enquire about current and previous drug use; prescription, nonprescription and herbal drug use; and specifically about use of drugs which induce liver enzymes and non-liver enzyme-inducing antibiotics. also termed restructuring, this attempts to identify maladaptive and distorted cognitions that are common among those with insomnia and replace these with more adaptive beliefs and attitudes. this form of therapy seeks to alter faulty beliefs and attitudes about sleep and uses multiple patient-specific techniques. examples include decatastrophizing, reappraisal, and attention shifting. objective of this form of therapy is to diminish the cycle of insomnia, emotional stress, dysfunctional cognitions, and further sleep disturbances. clinicians should consider patient variables in ce decision making. women with 50 to 69% symptomatic stenosis did not show clear benefit in previous trials. in addition, patients with hemispheric transient ischemic attack (tia)/stroke had greater benefit from ce than patients with retinal ischemic events .clinicians should also consider several radiologic factors in decision making about ce. nurses will educate clients about self/home blood pressure monitoring techniques and appropriate equipment to assist in potential diagnosis and the monitoring of hypertension. 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. recommendation:when providing physical activity advice, primary care practitioners should take into account the individual's needs, preferences, and circumstances. they should agree goals with them. they should also provide written information about the benefits of activity and the local opportunities to be active. they should follow them up at appropriate intervals over a 3- to 6-month period. prevention services for hiv-negative persons:prevention counseling:in health-care settings, prevention counseling need not be linked explicitly to hiv testing. however, because certain patients might be more likely to think about hiv and consider their risks at the time of hiv testing, testing might present an ideal opportunity to provide or arrange for prevention counseling to assist with behavior changes that can reduce risks for acquiring hiv infection. prevention counseling should be offered or made available through referral in all health-care facilities serving patients at high risk for hiv and at facilities (e.g., std clinics) in which information on hiv risk behaviors is elicited routinely. |
| 2 | about benefits | 2 | women at average risk:beginning in their 20s, women should be told about the benefits and limitations of breast self-examination (bse). recommendation:when providing physical activity advice, primary care practitioners should take into account the individual's needs, preferences, and circumstances. they should agree goals with them. they should also provide written information about the benefits of activity and the local opportunities to be active. they should follow them up at appropriate intervals over a 3- to 6-month period. |
| 2 | about life | 2 | discussions should occur with the patient or legal agent about life expectancy and quality of life. prior to the death of the resident, the bereavement leader should provide information about end-of-life care services, and assistance in contacting these services. |
| 2 | about risks | 4 | the choice of treatment should be made after discussion between the responsible clinician and the woman about the risks and benefits of each option. factors to consider when making the choice include whether the woman has received tamoxifen before, the licensed indications and side-effect profiles of the individual drugs and, in particular, the assessed risk of recurrence. hormone replacement therapy should be considered for women undergoing prophylactic oophorectomy, and patients should be counseled about the risks and benefits of hormone replacement therapy prior to undergoing surgery. counsel obese and overweight women about the risks of weight cycling--repeated episodes of weight loss and gain--and the benefits of adopting long-term healthy eating habits. 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. |
| 3 | about risks benefits | 2 | the choice of treatment should be made after discussion between the responsible clinician and the woman about the risks and benefits of each option. factors to consider when making the choice include whether the woman has received tamoxifen before, the licensed indications and side-effect profiles of the individual drugs and, in particular, the assessed risk of recurrence. hormone replacement therapy should be considered for women undergoing prophylactic oophorectomy, and patients should be counseled about the risks and benefits of hormone replacement therapy prior to undergoing surgery. |
| 2 | about their | 3 | patients currently treated in hospital who are potentially suitable for home haemodialysis on clinical grounds, but who have not previously been offered a choice, should be reassessed and informed about their dialysis options. patients with lung cancer should have clear understandable information about their diagnosis, treatment, and possible outcomes. patients and their families should be offered clear, full, prompt, and culturally appropriate information, preferably in both verbal and written form. patient education: assess patient needs. an important first step in optimizing patient education is to adequately assess each patient's needs. take into account patients' level of knowledge about their headaches. also, be aware of their attitudes, beliefs, and cultural background and how these elements might affect the treatment process. be sensitive to environmental and social factors, which can also play a role in determining patients' receptivity to treatment. |
| 1 | above | 10 | 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 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 teach pelvic muscle exercises to be used in conjunction with the above strategy. hemoglobin levels can be raised to (or near) a concentration of 12 g/dl, at which time the dosage of epoetin should be titrated to maintain that level or restarted when the level falls to near 10 g/dl. insufficient evidence to date supports the "normalization" of hemoglobin levels to above 12 g/dl. 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. patients referred to an epilepsy surgery center for the reasons stated above who meet established criteria for an anteromesial temporal lobe resection and who accept the risks and benefits of this procedure, as opposed to continuing pharmacotherapy, should be offered surgical treatment. ufh or lmwh (as above) until the thirteenth week, change to warfarin until the middle of the third trimester, and then restart ufh or lmwh . people satisfying the conditions in the first two recommendations (see above) but for whom ribavirin is contraindicated or is not tolerated should be treated with peginterferon alfa monotherapy. regardless of genotype, individuals should be tested for viral load at 12 weeks, and if the viral load has reduced to less than 1% of its level at the start of treatment, treatment should be continued for a total of 48 weeks. if viral load has not fallen to this extent, treatment should stop at 12 weeks. |
| 2 | above agents | 4 | 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 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 |
| 3 | above agents used | 4 | 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 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 |
| 1 | abscess | 5 | a recurrent abscess at a site of previous infection should prompt a search for local causes such as a pilonidal cyst, hidradenitis suppurativa or foreign material after obtaining cultures of recurrent abscess, treat with a 5- to 10-day course of an antibiotic active against the pathogen isolated cultures of blood and abscess material should be obtained antibiotics should be administered intravenously initially, but once the patient is clinically improved oral antibiotics are appropriate for patients in whom bacteremia cleared promptly and there is no evidence of endocarditis or metastatic abscess. two to three weeks of therapy is recommended. surgical intervention is recommended for drainage of soft-tissue abscess after marrow recovery or for a progressive polymicrobial necrotizing fasciitis or myonecrosis |
| 1 | abscesses | 7 | gram stain and culture of pus from carbuncles and abscesses are recommended, but treatment without these studies is reasonable in typical cases incision and drainage is the recommended treatment for inflamed epidermoid cysts, carbuncles, abscesses and large furuncles an antibiotic active against mrsa is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment, have markedly impaired host defenses, or in patients with sirs and hypotension recurrent abscesses should be drained and cultured early in the course of infection adult patients should be evaluated for neutrophil disorders if recurrent abscesses began in early childhood less common indications for splenectomy include splenic abscesses, cysts, sinistral portal hypertension secondary to isolated splenic vein thrombosis or obstruction, or splenic mass presumed to be a primary or undiagnosed neoplasm. splenectomy is occasionally included in en bloc resection for malignancy in an adjacent organ, such as the stomach, colon, adrenal gland, or pancreas. distal pancreatectomy usually includes splenectomy if preservation of the splenic artery and vein is either contraindicated (malignancy) or technically impossible. antibiotics are an unnecessary addition to routine incision and drainage of uncomplicated perianal abscesses. |
| 1 | absence | 27 | routine repeat measurement of lv function assessment in the absence of clinical status change or treatment interventions should not be performed. in patients with structural cardiac abnormalities, including lv hypertrophy, in the absence of a history of mi or acs, blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic hf. 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). statins are not beneficial as adjunctive therapy when prescribed solely for the diagnosis of hf in the absence of other indications for their use. long-term use of either continuous or intermittent, intravenous parenteral positive inotropic agents, in the absence of specific indications or for reasons other than palliative care, is potentially harmful in the patient with hf. in patients with hfref experiencing a symptomatic exacerbation of hf requiring hospitalization during chronic maintenance treatment with gdmt, it is recommended that gdmt be continued in the absence of hemodynamic instability or contraindications. the decision to administer antibiotics directed against s. aureus as an adjunct to incision and drainage should be made based on the presence or absence of systemic inflammatory response syndrome (sirs) such as temperature >38°c or <36°c, tachypnea >24 breaths/min, tachycardia >90 beats/min or white blood cell count (wbc) >12,000 or <4000 cells/mm3 in the absence of a definitive etiologic diagnosis, broad-spectrum treatment with vancomycin plus either piperacillin/tazobactam, ampicillin/sulbactam or a carbapenem antimicrobial is recommended (sr-l). arterial reconstructive surgery is a treatment option only in healthy individuals with recently acquired erectile dysfunction secondary to a focal arterial occlusion and in the absence of any evidence of generalized vascular disease . lateral flexion and extension radiography is recommended as an adjunct to determine the presence of lumbar fusion postoperatively. the lack of motion between vertebrae, in the absence of rigid instrumentation, is highly suggestive of successful fusion. determine the presence or absence of a permanent impairment that substantially limits one or more major life activities. adult patients with headache exhibiting signs of increased intracranial pressure including papilledema, absent venous pulsations on funduscopic examination, altered mental status, or focal neurologic deficits should undergo a neuroimaging study before having an lp. in the absence of findings suggestive of increased intracranial pressure, an lp can be performed without obtaining a neuroimaging study. long-acting beta2-agonists should not be used for the treatment of acute (or chronic) symptoms of asthma in the absence of inhaled anti-inflammatory therapy. document the presence/absence of an indwelling urinary catheter. determine appropriate indwelling catheter use: severely ill patients, patient with stage iii to iv pressure ulcers of the trunk, urinary retention unresolved by other interventions. continuing epoetin treatment beyond 6-8 weeks in the absence of response (e.g., < 1-2 g/dl rise in hemoglobin level), assuming appropriate dose increase has been attempted in nonresponders, does not appear to be beneficial. patients who do not respond should be investigated for underlying tumor progression or iron deficiency. as with other failed individual therapeutic trials, consideration should be given to discontinuing the medication. in the absence of an outcomes validated approach to nutrition assessment, a combination of clinical (history and physical exam) and biochemical parameters should be used to assess the presence of malnutrition. in the absence of reliable information concerning compatibility of a specific drug with an sns formula, the medication should be administered separately from the sns . if analgesia/anesthesia is required, regional or neuraxial analgesia/anesthesia should be used because it is efficacious and safe for intrapartum management of women with severe preeclampsia in the absence of coagulopathy. in patients with persistent af or paf, age 65 to 75 years, in the absence of other risk factors, the guideline developers recommend antithrombotic therapy . either an oral vka, such as warfarin (target inr, 2.5; range 2.0 to 3.0), or aspirin, 325 mg/d, are acceptable alternatives in this group of patients who are at intermediate risk of stroke. testing may also be performed to reassure the patient, parent, and physician of the absence of organic disease, particularly if the pain significantly diminishes the quality of life of the patient. paracentesis: abdominal paracentesis may be helpful to confirm the presence of intestinal gangrene in infants with nec . indications for paracentesis are absence of pneumoperitoneum and one of the following: portal venous gas. erythema of abdominal wall. fixed, tender abdominal mass. persistently dilated intestinal segment. clinical deterioration in patients with acute cough and sputum production suggestive of acute bronchitis, the absence of the following findings reduces the likelihood of pneumonia sufficiently to eliminate the need for a chest radiograph: (1) heart rate >100 beats/min; (2) respiratory rate >24 breaths/min; (3) oral body temperature of >38 degrees c; and (4) chest examination findings of focal consolidation, egophony, or fremitus. the role of continuing bevacizumab after disease progression on a bevacizumab-containing regimen is not clear due to the absence of evidence. therefore, the continuation of bevacizumab in patients who have progressed on this therapy cannot currently be recommended outside of clinical trials. supplemental oxygen, either at night or during exertion, is not recommended for patients with hf in the absence of an indication of underlying pulmonary disease. patients with resting hypoxemia or oxygen desaturation during exercise should be evaluated for residual fluid overload or concomitant pulmonary disease. follow-up:patients should be informed that the rash and pruritus of scabies might persist for up to 2 weeks after treatment. symptoms or signs that persist for >2 weeks can be attributed to several factors. treatment failure might be caused by resistance to medication or by faulty application of topical scabicides. patients with crusted scabies might have poor penetration into thick scaly skin and harbor mites in these difficult-to-penetrate layers. particular attention must be given to the fingernails of these patients. reinfection from family members or fomites might occur in the absence of appropriate contact treatment and washing of bedding and clothing. even when treatment is successful and reinfection is avoided, symptoms can persist or worsen as a result of allergic dermatitis. finally, household mites can cause symptoms to persist as a result of crossreactivity between antigens. some specialists recommend re-treatment after 1-2 weeks for patients who are still symptomatic; others recommend re-treatment only if live mites are observed. patients who do not respond to the recommended treatment should be re-treated with an alternative regimen. |
| 2 | absence contraindications | 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). |
| 3 | absence contraindications anticoagulation | 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). |
| 2 | absence evidence | 2 | arterial reconstructive surgery is a treatment option only in healthy individuals with recently acquired erectile dysfunction secondary to a focal arterial occlusion and in the absence of any evidence of generalized vascular disease . the role of continuing bevacizumab after disease progression on a bevacizumab-containing regimen is not clear due to the absence of evidence. therefore, the continuation of bevacizumab in patients who have progressed on this therapy cannot currently be recommended outside of clinical trials. |
| 2 | absence other | 2 | statins are not beneficial as adjunctive therapy when prescribed solely for the diagnosis of hf in the absence of other indications for their use. in patients with persistent af or paf, age 65 to 75 years, in the absence of other risk factors, the guideline developers recommend antithrombotic therapy . either an oral vka, such as warfarin (target inr, 2.5; range 2.0 to 3.0), or aspirin, 325 mg/d, are acceptable alternatives in this group of patients who are at intermediate risk of stroke. |
| 1 | absent | 5 | if symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acute decompensated hf. it is recommended that patients in whom discography is positive but in whom mr imaging evidence of disc degeneration is absent not be considered candidates for operative intervention. adult patients with headache exhibiting signs of increased intracranial pressure including papilledema, absent venous pulsations on funduscopic examination, altered mental status, or focal neurologic deficits should undergo a neuroimaging study before having an lp. in the absence of findings suggestive of increased intracranial pressure, an lp can be performed without obtaining a neuroimaging study. parameters of assessment: use the three group risk assessment tool (white, karam & cowell, 1994) to assess for skin tear risk. use the payne-martin classification system to classify skin tear: category i- a skin tear without tissue loss category ii- a skin tear with partial tissue loss category iii- a skin tear with complete tissue loss, where the epidermal flap is absent. results and recommendations:which features of the neurologic examination of the comatose patient are predictive of outcome? the prognosis is invariably poor in comatose patients with absent pupillary or corneal reflexes, or absent or extensor motor responses 3 days after cardiac arrest . |
| 1 | absolute | 2 | a central visual field defect can significantly affect visual functioning, such as reading ability. size, location, and density of the scotoma (relative, absolute, or both) will determine its effect on visual functioning and can influence the response to near magnification. in many cases, even with appropriate magnification, certain parameters of print reading ability (e.g., print size, reading speed, comprehension, and duration) may be compromised due to the central field disturbance and nature of the task, even though ability to navigate through the environment is relatively unaffected. in the eye with a macular scotoma, the stimulus to foveate the target may persist; however, with time or training, the patient may learn to view eccentrically. low-carbohydrate diets are not recommended in the management of diabetes. although dietary carbohydrate is the major contributor to postprandial glucose concentration, it is an important source of energy, water-soluble vitamins and minerals, and fiber. thus, in agreement with the national academy of sciences-food and nutrition board, a recommended range of carbohydrate intake is 45-65% of total calories. in addition, because the brain and central nervous system have an absolute requirement for glucose as an energy source, restricting total carbohydrate to <130 grams/day is not recommended |
| 1 | abstinence | 2 | patients should have adequate, accurate information regarding factors that influence hiv transmission and methods for reducing the risk for transmission to others, emphasizing that the most effective methods for preventing transmission are those that protect noninfected persons against exposure to hiv (e.g., sexual abstinence; consistent and correct use of condoms made of latex, polyurethane or other synthetic materials; and sex with only a partner of the same hiv serostatus). hiv-infected patients who engage in high-risk sexual practices (i.e., capable of resulting in hiv transmission) with persons of unknown or negative hiv serostatus should be counseled to use condoms consistently and correctly. psychosocial treatments: for many patients with a cocaine use disorder, psychosocial treatments focusing on abstinence are effective . in particular, cbts ,behavioral therapies , and 12-step-oriented individual drug counseling can be useful, although efficacy of these therapies varies across subgroups of patients. |
| 1 | abuse | 8 | ssubstance users who wish to stop using drugs should be referred to substance abuse treatment when indicated. nurses know their legal obligations when a disclosure of abuse is made. atenolol, gabapentin (monotherapy), sotalol, and topiramate should be considered as treatment of limb tremor associated with et. alprazolam is recommended with caution due to its abuse potential . propranolol should be considered as treatment of head tremor in patients with et. detection/screening: screen by history for substance use at every health maintenance exam or initial pregnancy visit (repeat as indicated), using a validated screening tool (improves accuracy of detecting alcohol abuse or dependence). what to give in hospital and the community:people who meet the criteria in the table below entitled "criteria for determining people at high risk of developing refeeding problems" should be considered to be at high risk of developing refeeding problems.criteria for determining people at high risk of developing refeeding problems: patient has one or more of the following: bmi less than 16 kg/m2. unintentional weight loss greater than 15% within the last 3 to 6 months. little or no nutritional intake for more than 10 days. low levels of potassium, phosphate or magnesium prior to feeding. or patient has two or more of the following: bmi less than 18.5 kg/m2. unintentional weight loss greater than 10% within the last 3 to 6 months. little or no nutritional intake for more than 5 days a history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics. because of a lack of stat availability, there are no clinical laboratory tests that are currently appropriate for monitoring acute inhalant abuse or solvent exposure. health assessment screening, history, and counseling:ages 50 to 64 years: one health maintenance exam (hme) every 1 to 3 years according to risk status . age 65+ years: one hme at least every 2 years. each hme should include: height, weight, and body mass index (bmi). risk evaluation and counseling (nutrition, overweight/obesity, physical activity, dental health, tobacco use , immunizations, human immunodeficiency virus (hiv) prevention , sexually transmitted diseases prevention and sexual health, sexual abuse, polypharmacy including over-the-counter and herbal preparations when appropriate, sun exposure) safety (domestic violence, seat belts , helmets, firearms, smoke and carbon monoxide detectors) behavioral assessment (depression, suicide threats, alcohol/drug use, anxiety, stress reduction, coping skills). patients with exposure due to suspected self-harm, abuse, misuse, or potentially malicious administration should be referred to an emergency department immediately regardless of the doses reported . |
| 1 | academy | 6 | vision screening should be performed at the earliest possible age and at regular intervals during childhood as recommended by the american academy of pediatrics (aap). the goal remains to eliminate preventable blindness and treatable visual disability. whenever conscious or deep sedation is required to perform any procedure, the guidelines developed by the american academy of pediatrics for patient monitoring and resuscitative equipment should be followed. pediatricians and child health professionals should join with the national american academy of pediatrics (aap) and aap chapters in the following activities: vigorously advocating for all children to receive comprehensive health care, including childhood immunizations in a medical home ("the medical home," 2002). children most likely to experience barriers to comprehensive care in a medical home are children who are members of racial and ethnic minorities, poor or uninsured children, children living in inner-city or rural areas, and children with chronic medical conditions. collaborating with local public and private child health services to identify children without access to a medical home and assist in referring them to a medical home. the medical home should maintain the children's medical records, including immunization records.removing economic barriers to immunizations for parents and pediatricians to participate in the vaccines for children (vfc) program or state vaccine programs reducing socioeconomic and racial disparities in immunization rates by working with all national medical groups and specialty societies that care for poor and underserved populations advocating with state vaccine purchasing or vaccines for children programs and private third-party payers of vaccine for adequate vaccine reimbursement rates that cover all costs associated with the administration of vaccines, including the vaccines product, physician work, practice administrative expense, professional liability, and all related supplies, including safety needles advocating with vaccine manufacturers and state and federal governments to maintain an adequate supply of all childhood vaccines at all times ensuring that the safest and most effective vaccines and combinations are available to children advocating with state and federal governments to ensure that timely access to all immunizations recommended by the advisory committee on immunization practices (acip), the aap, and the american academy of family physicians (aafp) for all children remains a high public policy priority supporting ongoing education and quality improvement programs for pediatricians and other child health care professionals about important vaccine-related issues, including the dissemination of peer-reviewed evidence for more effective immunization delivery. trivalent inactivated influenza vaccine (tiv) indications:young, healthy children are at high risk of hospitalization for influenza infection; therefore, the american academy of pediatrics recommends influenza immunization of healthy children between 6 and 24 months of age . this applies to any child who will be 6 through 23 months of age at any time during the influenza season, which extends from the beginning of october through march. children should not be immunized before they reach 6 months of age. influenza immunization of household contacts and out-of- home caregivers of children younger than 24 months of age also is recommended (evidence grade iii). immunization of close contacts of children younger than 6 months may be particularly important, because these infants will not be immunized. low-carbohydrate diets are not recommended in the management of diabetes. although dietary carbohydrate is the major contributor to postprandial glucose concentration, it is an important source of energy, water-soluble vitamins and minerals, and fiber. thus, in agreement with the national academy of sciences-food and nutrition board, a recommended range of carbohydrate intake is 45-65% of total calories. in addition, because the brain and central nervous system have an absolute requirement for glucose as an energy source, restricting total carbohydrate to <130 grams/day is not recommended pediatricians can actively promote bone health and support the goal of achieving adequate calcium intakes by children and adolescents by promoting the recommended adequate intakes of the food and nutrition board of the national academy of sciences.the prevention of future osteoporosis and the possibility of a decreased risk of fractures in childhood and adolescence should be discussed with patients and families as potential benefits for achieving these goals. |
| 2 | academy pediatrics | 4 | vision screening should be performed at the earliest possible age and at regular intervals during childhood as recommended by the american academy of pediatrics (aap). the goal remains to eliminate preventable blindness and treatable visual disability. whenever conscious or deep sedation is required to perform any procedure, the guidelines developed by the american academy of pediatrics for patient monitoring and resuscitative equipment should be followed. pediatricians and child health professionals should join with the national american academy of pediatrics (aap) and aap chapters in the following activities: vigorously advocating for all children to receive comprehensive health care, including childhood immunizations in a medical home ("the medical home," 2002). children most likely to experience barriers to comprehensive care in a medical home are children who are members of racial and ethnic minorities, poor or uninsured children, children living in inner-city or rural areas, and children with chronic medical conditions. collaborating with local public and private child health services to identify children without access to a medical home and assist in referring them to a medical home. the medical home should maintain the children's medical records, including immunization records.removing economic barriers to immunizations for parents and pediatricians to participate in the vaccines for children (vfc) program or state vaccine programs reducing socioeconomic and racial disparities in immunization rates by working with all national medical groups and specialty societies that care for poor and underserved populations advocating with state vaccine purchasing or vaccines for children programs and private third-party payers of vaccine for adequate vaccine reimbursement rates that cover all costs associated with the administration of vaccines, including the vaccines product, physician work, practice administrative expense, professional liability, and all related supplies, including safety needles advocating with vaccine manufacturers and state and federal governments to maintain an adequate supply of all childhood vaccines at all times ensuring that the safest and most effective vaccines and combinations are available to children advocating with state and federal governments to ensure that timely access to all immunizations recommended by the advisory committee on immunization practices (acip), the aap, and the american academy of family physicians (aafp) for all children remains a high public policy priority supporting ongoing education and quality improvement programs for pediatricians and other child health care professionals about important vaccine-related issues, including the dissemination of peer-reviewed evidence for more effective immunization delivery. trivalent inactivated influenza vaccine (tiv) indications:young, healthy children are at high risk of hospitalization for influenza infection; therefore, the american academy of pediatrics recommends influenza immunization of healthy children between 6 and 24 months of age . this applies to any child who will be 6 through 23 months of age at any time during the influenza season, which extends from the beginning of october through march. children should not be immunized before they reach 6 months of age. influenza immunization of household contacts and out-of- home caregivers of children younger than 24 months of age also is recommended (evidence grade iii). immunization of close contacts of children younger than 6 months may be particularly important, because these infants will not be immunized. |
| 1 | accelerated | 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. |
| 2 | accelerated radiation | 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. |
| 3 | accelerated radiation therapy | 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. |
| 1 | accept | 2 | patients referred to an epilepsy surgery center for the reasons stated above who meet established criteria for an anteromesial temporal lobe resection and who accept the risks and benefits of this procedure, as opposed to continuing pharmacotherapy, should be offered surgical treatment. it is recommended that the severity of pneumonia be assessed based on overall clinical appearance and behavior, including an assessment of the child's degree of alertness and willingness to accept feedings. subcostal retractions and other evidence of increased work of breathing increase the likelihood of a more severe form of pneumonia . |
| 1 | acceptable | 10 | if candida parapsilosis has been isolated treat with fluconazole as an acceptable alternative to lipid formulation amphotericin-b 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. combination platinum-based chemotherapy can be administered safely and with acceptable and manageable toxicity profiles in patients with good ps who have stage iv nsclc. for af occurring shortly after open-heart surgery and lasting >48 hours, the guideline developers suggest anticoagulation with an oral vka, such as warfarin, if bleeding risks are acceptable (grade 2c). the target inr is 2.5 (range, 2.0 to 3.0). the guideline developers suggest continuing anticoagulation for several weeks following reversion to normal sinus rhythm (nsr), particularly if patients have risk factors for thromboembolism. in patients with persistent af or paf, age 65 to 75 years, in the absence of other risk factors, the guideline developers recommend antithrombotic therapy . either an oral vka, such as warfarin (target inr, 2.5; range 2.0 to 3.0), or aspirin, 325 mg/d, are acceptable alternatives in this group of patients who are at intermediate risk of stroke. either open or laparoscopic adrenalectomy is an acceptable procedure for resection of an adrenal mass. for control of meningococcal outbreaks caused by vaccine-preventable serogroups (a, c, y, or w-135), mpsv4 or mcv4 should be used for people 11 years or older . mcv4 is preferred, but mpsv4 is acceptable. for children 2 to 10 years of age, mpsv4 should be used. laparoscopic surgery is recommended as an acceptable option for the treatment of stage i, ii, or iii colon cancer and should be considered an alternative to conventional open surgery for colon cancer in specified patients. metoprolol tartrate (short-acting formulation) titrated to maximum tolerated dosage, is an acceptable but less well-established alternative to carvedilol, metoprolol cr/xl, or bisoprolol. |
| 2 | acceptable treatment | 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. |
| 1 | accepted | 2 | organize randomized controlled trials (rcts) to extend treatment to special populations not represented in current clinical trials and to determine the applicability of accepted antiviral drug combinations to populations such as children and adolescents, and patients with acute hepatitis. effective approaches are needed for drug users receiving drug treatment, alcohol abusers, prisoners, patients with stabilized depression, those with co-infection with human immunodeficiency virus, patients with decompensated cirrhosis, and hcv infections in transplant recipients. such efforts should lead to decreased morbidity and mortality from the disease, as well as a decrease in the reservoir of disease. the laparoscopic colon cancer surgery expert panel recommends that surgeons should have completed a number of laparoscopic colectomies to a level of accepted competence, as determined by their peers in a structured mentoring process. the best evidence available indicates that primary outcomes are not statistically different between laparoscopic and open surgery for colon cancer after at least one member of the team has performed 20 laparoscopic colon resections, for either benign or malignant disease. therefore, it is recommended that either this number be adhered to or an equivalent process, including peer evaluation, be undertaken. |
| 1 | access | 13 | programme providers should also ensure that support is available to enable the participation of parents who might otherwise find it difficult to access these programmes. it is recommended that all parent-training/education programmes, whether group- or individual-based, should: be structured and have a curriculum informed by principles of social-learning theory include relationship-enhancing strategies offer a sufficient number of sessions, with an optimum of 8 to 12, to maximise the possible benefits for participants enable parents to identify their own parenting objectives incorporate role-play during sessions, as well as homework to be undertaken between sessions, to achieve generalisation of newly rehearsed behaviours to the home situation be delivered by appropriately trained and skilled facilitators who are supervised, have access to necessary ongoing professional development, and are able to engage in a productive therapeutic alliance with parents adhere to the programme developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. if a patient has gfr <30 ml/min/1.73 m2 and it has been determined that s/he will receive hemodialysis, veins suitable for placement of vascular access should be preserved . pediatricians and child health professionals should join with the national american academy of pediatrics (aap) and aap chapters in the following activities: vigorously advocating for all children to receive comprehensive health care, including childhood immunizations in a medical home ("the medical home," 2002). children most likely to experience barriers to comprehensive care in a medical home are children who are members of racial and ethnic minorities, poor or uninsured children, children living in inner-city or rural areas, and children with chronic medical conditions. collaborating with local public and private child health services to identify children without access to a medical home and assist in referring them to a medical home. the medical home should maintain the children's medical records, including immunization records.removing economic barriers to immunizations for parents and pediatricians to participate in the vaccines for children (vfc) program or state vaccine programs reducing socioeconomic and racial disparities in immunization rates by working with all national medical groups and specialty societies that care for poor and underserved populations advocating with state vaccine purchasing or vaccines for children programs and private third-party payers of vaccine for adequate vaccine reimbursement rates that cover all costs associated with the administration of vaccines, including the vaccines product, physician work, practice administrative expense, professional liability, and all related supplies, including safety needles advocating with vaccine manufacturers and state and federal governments to maintain an adequate supply of all childhood vaccines at all times ensuring that the safest and most effective vaccines and combinations are available to children advocating with state and federal governments to ensure that timely access to all immunizations recommended by the advisory committee on immunization practices (acip), the aap, and the american academy of family physicians (aafp) for all children remains a high public policy priority supporting ongoing education and quality improvement programs for pediatricians and other child health care professionals about important vaccine-related issues, including the dissemination of peer-reviewed evidence for more effective immunization delivery. assessors and multidisciplinary teams:: assessors of older people should be part of (or have ready access to) a wider multidisciplinary team (mdt) to whom they can quickly refer the older person for more in-depth assessment or for help in any particular domain. the endoscopic general surgeon should arrange to interview and examine the patient preoperatively and should participate with the spine surgeon in development of an operative plan. special attention should be directed towards suitability of the patient for anesthesia and for the proposed endoscopic procedure. the endoscopic surgeon should not feel obligated to participate in any procedure that he/she does not feel is in the best interest of the patient. risks and complications unique to the endoscopic access portion of the procedure should be identified and communicated to the patient at this time, as well as the specific roles and responsibilities of the endoscopic general surgeon. the endoscopic general surgeon and spine surgeon should each communicate their individual experience in this procedure to the patient. this results in a true informed consent. both co-surgeons must be named on the patient consent form. the goal of achieving an effective aed programme within the ems should become a fundamental objective in every european country. accordingly, it is recommended that an aed and properly trained personnel should be placed in every vehicle that may transport patients at risk of cardiac arrest. this should be the first priority for an early access defibrillation programme. key components of the prenatal assessment should include: personal and demographic variables that may influence breastfeeding rates intent to breastfeed access to support for breastfeeding, including significant others and peers attitude about breastfeeding among health care providers, significant others and peers physical factors, including breasts and nipples, that may affect a womanâ??s ability to breastfeed pediatricians should promote parental education in pediatric basic life support. families of children with special health care needs, neonatal intensive care unit graduates, children who have ready access to water, or children who are active in water sports should be especially encouraged to undergo training and should be assisted in obtaining access to the training. nurses will assess and evaluate vascular access devices for occlusion in order to facilitate treatment and improve client outcomes. health care organizations have access to infusion therapy nursing expertise to support optimal vascular access outcomes. help ensure that all adolescents have knowledge of and access to contraception including barrier methods and emergency contraception supplies. nurses embrace the following values and beliefs: respect; human dignity; clients are experts for their own lives; clients as leaders; clients' goals coordinate care of the healthcare team; continuity and consistency of care and caregiver; timeliness; responsiveness and universal access to care. these values and beliefs must be incorporated into, and demonstrated throughout, every aspect of client care and services. |
| 1 | accessible | 3 | patients performing haemodialysis at home and their carers will require initial training and an accessible and responsive support service. the support service should offer the possibility of respite hospital/satellite unit dialysis as required. optimize your practice.appointing a coordinator for all patient education activities is an important step toward tailoring patient education for your practice. depending on the practice, allied health professionals or even nonmedical office staff should play an important role on the patient education team. proper training may be necessary to ensure that the staff is adequately prepared to handle patients effectively. choose the right tools educational handouts, such as brochures or fact sheets, can be quite helpful (refer to table 2.2 of the original guideline document). creating your own educational materials, while giving you complete control over content, can be both time-consuming and costly. pharmaceutical manufacturers can often supply your practice with educational resources, although you should be sure that the content is clinically sound and not overly promotional. clinicians can also refer patients to headache-focused patient organizations such as the national headache foundation (www.headaches.org, 888-643-5552) and the american council for headache education (www.achenet.org, 856-423-0258). make your office patient-education-friendly once you have chosen your educational materials, make sure they are accessible to your patients. potential locations include the office entryway, reception area, bathrooms, and exam rooms. in some cases, it may be ideal to create a "patient library" in a spare room or closet, to store all patient education materials. also, consider making your educational charts patient-friendly by using checklists or diagrams. maximize your time finding the time to properly educate your patients may be a challenge. the table below provides some quick tips to help you maximize your time and effectively communicate all the information your patient needs. content of the preanesthesia evaluation includes but is not limited to (1) readily accessible medical records, (2) patient interview, (3) a directed preanesthesia examination, (4) preoperative tests when indicated, and (5) other consultations when appropriate. at a minimum, a directed preanesthesia physical examination should include an assessment of the airway, lungs, and heart. |
| 1 | accompanied | 3 | to be most effective, condom availability programs should be developed through a collaborative community process and accompanied by comprehensive sequential sexuality education, which is ideally part of a k-12 health education program, with parental involvement, counseling, and positive peer support. if thrombocytopenia is accompanied by other cytopenias or splenomegaly and is mild (>50,000 cells/mm3), hypersplenism caused by infectious causes or coincident liver disease should be suspected. the recommended dose for strontium-89 is 148 mbq (4mci) by slow intravenous injection (1 to 2 minutes), accompanied by intravenous or oral hydration (at least 500 ml). the recommended dose for samarium-153 is 37 mbq/kg (1 mci/kg) by slow intravenous injection (1 to 2 minutes), accompanied by intravenous or oral hydration (at least 500 ml). |
| 1 | accompanying | 2 | clinicians should refer patients with had who present with accompanying depression, mania, psychosis, behavioral disturbance, or substance use for psychiatric consultation to assist in psychopharmacologic treatment and management. in most patients with a diagnosis of acute bronchitis, beta2-agonist bronchodilators should not be routinely used to alleviate cough.in select adult patients with a diagnosis of acute bronchitis and wheezing accompanying the cough, treatment with beta2-agonist bronchodilators may be useful. |
| 1 | accomplished | 2 | gh therapy is best accomplished under the direct supervision of a clinical endocrinologist. short-term gh treatment is safe in both children and adults. continued monitoring of side effects and long-term treatment results is needed. the foot examination can be accomplished in a primary care setting and should include the use of a monofilament, tuning fork, palpation, and a visual examination. |
| 1 | accordance | 6 | hypertension and lipid disorders should be controlled in accordance with contemporary guidelines to lower the risk of hf. in patients with structural cardiac abnormalities, including lv hypertrophy, in the absence of a history of mi or acs, blood pressure should be controlled in accordance with clinical practice guidelines for hypertension to prevent symptomatic hf. systolic and diastolic blood pressure should be controlled in patients with hfpef in accordance with published clinical practice guidelines to prevent morbidity. massive haemorrhage should be dealt with in accordance with the recommendations of the reports of the confidential enquiries into maternal deaths. when, after due consideration of the use of nonpharmacological measures, hypnotic drug therapy is considered appropriate for the management of severe insomnia interfering with normal daily life, it is recommended that hypnotics should be prescribed for short periods of time only, in strict accordance with their licensed indications. symptomatic patients with tca poisoning might require prehospital interventions, such as intravenous fluids, cardiovascular agents, and respiratory support, in accordance with standard advanced cardiac life support (acls) guidelines as outlined by the american heart association. |
| 1 | according | 10 | management of af according to published clinical practice guidelines in patients with hfpef is reasonable to improve symptomatic hf. we suggest that patients with suspected hap (non-vap) be treated according to the results of microbiologic studies performed on respiratory samples obtained noninvasively, rather than being treated empirically risk-stratify patients with fever and neutropenia according to susceptibility to infection: high-risk patients are those with anticipated prolonged (>7 days) and profound neutropenia (anc <100 cells/?l) or with a multinational association for supportive care (mascc) score of <21; low-risk patients are those with anticipated brief (<7 days) periods of neutropenia and few comorbidities or with a mascc of ?21 perform a comprehensive neurological examination according to international standards for neurological and functional classification between 3 and 7 days after injury. antibiotics prolong the latency period and improve perinatal outcome in patients with preterm prom and should be administered according to one of several published protocols if expectant management is to be pursued prior to 35 weeks of gestation. each co-surgeon must adequately document his/her respective preoperative, intraoperative, and postoperative participation according to joint commission on accreditation of healthcare organizations (jcaho) standards. follow-up examinations should be recommended by the examining ophthalmologist on the basis of retinal findings classified according to the international classification. what to give in hospital and the community:nutrition support should be cautiously introduced in seriously ill or injured people requiring enteral tube feeding or parenteral nutrition. it should be started at no more than 50% of the estimated target energy and protein needs. it should be built up to meet full needs over the first 24 to 48 hours according to metabolic and gastrointestinal tolerance. full requirements of fluid, electrolytes, vitamins and minerals should be provided from the outset of feeding. children 7 through 9 years of age who never received any pediatric dtp/dtap/dt or td dose generally should receive 3 doses of td: dose 2 is administered 4 weeks or more after dose 1, and dose 3 is administered 6 to 12 months or longer after dose 2. a 10-year-old child could receive boostrix for 1 of these doses. a single dose of tdap is recommended for adolescents 11 to 18 years of age who have completed a 3-dose td series if the series did not include boostrix during the 10th year; an interval of at least 5 years between the most recent td dose and tdap is suggested . children 7 to 10 years of age who received other incomplete immunization schedules against tetanus, diphtheria, and pertussis should be immunized against tetanus and diphtheria according to catch-up recommendations (aap, 2003) using an all-td schedule (except children in their 10th year, who could receive a single dose of boostrix substituted for 1 dose of td).children with no history or an incomplete history of pediatric dtp/dtap/dt or td immunization could have received doses. health care professionals can obtain serologic testing for antibodies against tetanus and diphtheria. toxoids in these children. if tetanus and diphtheria toxoid antibody concentrations are each protective at >0.1 iu/ml, then the child can be presumed to have been immunized against tetanus, diphtheria, and possibly pertussis, and td immunization may be deferred until the child is 11 to 12 years of age, when tdap vaccine should be given. health assessment screening, history, and counseling:ages 50 to 64 years: one health maintenance exam (hme) every 1 to 3 years according to risk status . age 65+ years: one hme at least every 2 years. each hme should include: height, weight, and body mass index (bmi). risk evaluation and counseling (nutrition, overweight/obesity, physical activity, dental health, tobacco use , immunizations, human immunodeficiency virus (hiv) prevention , sexually transmitted diseases prevention and sexual health, sexual abuse, polypharmacy including over-the-counter and herbal preparations when appropriate, sun exposure) safety (domestic violence, seat belts , helmets, firearms, smoke and carbon monoxide detectors) behavioral assessment (depression, suicide threats, alcohol/drug use, anxiety, stress reduction, coping skills). |
| 2 | according international | 2 | perform a comprehensive neurological examination according to international standards for neurological and functional classification between 3 and 7 days after injury. follow-up examinations should be recommended by the examining ophthalmologist on the basis of retinal findings classified according to the international classification. |
| 1 | accordingly | 3 | because there are no data on the use of raloxifene in women who have completed a 5-year course of tamoxifen therapy, such women should have an individual assessment of their risk of osteoporosis, and decisions about prevention or treatment should be made accordingly. the goal of achieving an effective aed programme within the ems should become a fundamental objective in every european country. accordingly, it is recommended that an aed and properly trained personnel should be placed in every vehicle that may transport patients at risk of cardiac arrest. this should be the first priority for an early access defibrillation programme. 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. |
| 1 | account | 11 | patient's and carer's perceptions and expectations of peg feeding should be taken into account and the benefits, risks and burden of care fully explained before initiating feeding. patient education: assess patient needs. an important first step in optimizing patient education is to adequately assess each patient's needs. take into account patients' level of knowledge about their headaches. also, be aware of their attitudes, beliefs, and cultural background and how these elements might affect the treatment process. be sensitive to environmental and social factors, which can also play a role in determining patients' receptivity to treatment. nurses develop screening strategies and initial responses that respond to the needs of all women, taking into account differences based on race, ethnicity, class, religious/spiritual beliefs, age, ability, or sexual orientation. in patients with immune deficiency, the initial diagnostic algorithm for patients with acute, subacute, and chronic cough is the same as that for immunocompetent persons, taking into account an expanded list of differential diagnoses that considers the type and severity of immune defect and geographic factors. 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. 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. 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. 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. it is recommended that in determining who is at high risk, clinicians should take into account combinations of risk factors such as: clinical history, including age, previous mi, and previous pci or cabg; clinical signs, including continuing pain despite initial treatment; and clinical investigations, such as electrocardiogram (ecg) changes (particularly dynamic or unstable patterns indicating myocardial ischaemia), haemodynamic changes, and raised cardiac troponin levels . where myeloma and al amyloidosis co-exist, choice of treatment for myeloma should take into account the extent of organ involvement with amyloid and the potential toxicities of individual treatments . recommendation:when providing physical activity advice, primary care practitioners should take into account the individual's needs, preferences, and circumstances. they should agree goals with them. they should also provide written information about the benefits of activity and the local opportunities to be active. they should follow them up at appropriate intervals over a 3- to 6-month period. |
| 2 | account individual'advocate | 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. |
| 3 | 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. |
| 4 | 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. |
| 5 | 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. |
| 1 | accuracy | 3 | patients should be instructed in the correct use of glucose meters, including quality control. comparison between smbg and concurrent laboratory glucose analysis should be performed at regular intervals to evaluate the accuracy of patient results. detection/screening: screen by history for substance use at every health maintenance exam or initial pregnancy visit (repeat as indicated), using a validated screening tool (improves accuracy of detecting alcohol abuse or dependence). staging:if t and n category determinations will drive decisions on the use of neoadjuvant therapy, transrectal ultrasound or mri with endorectal coil is recommended. operator skill is more likely to influence the accuracy of transrectal ultrasound versus mri with endorectal coil. it is likely that advances in technology will demonstrate similar staging accuracy for routine mri versus mri with endorectal coil. |
| 1 | accurate | 6 | all patients undergoing resection for stage i nsclc (ia and ib) should have intraoperative systematic surgical mediastinal lymph node evaluation for accurate pathologic staging. patients should have adequate, accurate information regarding factors that influence hiv transmission and methods for reducing the risk for transmission to others, emphasizing that the most effective methods for preventing transmission are those that protect noninfected persons against exposure to hiv (e.g., sexual abstinence; consistent and correct use of condoms made of latex, polyurethane or other synthetic materials; and sex with only a partner of the same hiv serostatus). hiv-infected patients who engage in high-risk sexual practices (i.e., capable of resulting in hiv transmission) with persons of unknown or negative hiv serostatus should be counseled to use condoms consistently and correctly. children and adolescents with newly suspected and/or recurrent malignancy should be referred to a pediatric cancer center for prompt and accurate diagnosis and management. arterial cannulation should be performed in patients with shock to provide a more accurate measurement of intra-arterial pressure and to allow beat-to-beat analysis so that decisions regarding therapy can be based on immediate and reproducible blood pressure information. retinal examinations in preterm infants should be performed by an ophthalmologist who has sufficient knowledge and experience to enable accurate identification of the location and sequential retinal changes of rop. "the international classification of retinopathy of prematurity revisited" (international committee for the classification of retinopathy of prematurity, 2005) should be used to classify, diagram, and record these retinal findings at the time of examination. accurate history taking by emergency responders and medical personnel at the time of death and immediate transmission of this historical information to the medical examiner or coroner. |
| 1 | accurately | 2 | complete disability certification forms objectively, accurately and in a timely manner. results and recommendations:do biochemical markers accurately predict outcome? serum neuron-specific enolase (nse) levels >33 micrograms/l at days 1 to 3 post-cpr accurately predict poor outcome . |
| 1 | acei | 2 | hfref nyha class i–iv (stage c) acei or arb and gdmt beta blocker; diuretics as needed (cor i) nyha class ii–iii hf adequate bp on acei or arb; no c/i to arb or sacubitril then discontinue acei or arb; initiate arni |
| 1 | acellular | 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. |
| 2 | 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. |
| 1 | acetaminophen | 3 | nonsteroidal anti-inflammatory drugs (nsaids) or acetaminophen may be used as adjuncts to opioids in selected patients. opioids should be used for patients with oa or ra when other medications and nonpharmacologic interventions produce inadequate pain relief and the patientâ??s quality of life is affected by the pain. morphine, oxycodone, hydrocodone, or other mu agonist opioids, as a single agent or combined with an nsaid or with acetaminophen, should be used for moderate to severe oa or ra pain that has not responded to other treatments. the use of codeine and propoxyphene should be avoided because of their side effects and limited analgesic effectiveness. activated charcoal can be considered if local poison center policies support its prehospital use, a toxic dose of acetaminophen has been taken, and fewer than 2 hours have elapsed since the ingestion . gastrointestinal decontamination could be particularly important if acetylcysteine cannot be administered within 8 hours of ingestion. |
| 1 | achieve | 7 | effective systems of care coordination with special attention to care transitions should be deployed for every patient with chronic hf that facilitate and ensure effective care that is designed to achieve gdmt and prevent hospitalization. it is recommended that all parent-training/education programmes, whether group- or individual-based, should: be structured and have a curriculum informed by principles of social-learning theory include relationship-enhancing strategies offer a sufficient number of sessions, with an optimum of 8 to 12, to maximise the possible benefits for participants enable parents to identify their own parenting objectives incorporate role-play during sessions, as well as homework to be undertaken between sessions, to achieve generalisation of newly rehearsed behaviours to the home situation be delivered by appropriately trained and skilled facilitators who are supervised, have access to necessary ongoing professional development, and are able to engage in a productive therapeutic alliance with parents adhere to the programme developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. it is recommended that amlodipine be initiated at 0.1 mg/kg/day to achieve an arterial blood pressure below the 90th percentile for age. dosing frequency may be adjusted from once daily (qday) to twice daily (bid) if indicated. encourage public and private sources to direct funding toward research into effective strategies to prevent overweight and obesity and to maximize limited family and community resources to achieve healthful outcomes for youth. regulation of blood glucose to achieve near-normal levels is a primary goal in the management of diabetes, and, thus, dietary techniques that limit hyperglycemia following a meal are likely important in limiting the complications of diabetes. a qualified provider includes a physician, nurse practitioner, or physician assistant. recommendations for the evaluation of care provided to the immunocompetent adult patient with community-acquired pneumonia (cap) who is being treated at home or in an unskilled residential facility are summarized below. future research should be focused on evidence for appropriate assessment and in-home treatment, such as diagnostic tests, home care interventions, and the exploration of the efficacy of telephone triage in selected groups of patients who are at low risk and are well-known to the provider. finally, the approach to the in-home management of cap that has been outlined herein, and others, should be studied to assess their impact on patient outcomes (especially in the elderly) and to ensure that in-home management can achieve the same level of quality and patient outcomes as at any other treatment site for appropriate patient subsets. medical recommendations: care should focus on smoking, hypertension, lipids, and glycemic control:treatment of hypertension using up to 3 or 4 anti-hypertensive medications to achieve adult target of <130 systolic and <80 diastolic . prescription of angiotensin-converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) in patients with hypertension or albuminuria. statin therapy for primary prevention against macrovascular complications in patients with diabetes who are >age 40 or who have a low-density lipoprotein cholesterol (ldl-c) >100 mg/dl. management of cardiovascular risk factors assurance of appropriate immunization status (tetanus, diphtheria, pertussis, influenza, pneumococcal vaccine) . anti-platelet therapy : low dose aspirin daily for primary prevention in those at increased cardiovascular risk with type 1 and type 2 diabetes, unless contraindicated. |
| 1 | achieved | 4 | several models for the implementation of aed programmes outside the ems have been described: we have identified three main strategies that have different and to some extent opposite characteristics. it is recommended that once the priorities of implementation of an aed programme within the ems have been achieved, a careful analysis is conducted in order to identify the community model that is most suitable for the specific environment. a cost-effectiveness analysis is an essential part of the implementation strategy. every hospital should analyse whether the goal of early defibrillation is achieved and aed implementation can be an important element in improving the in-hospital chain of survival. home programmes are still in a preliminary phase of implementation: families with a genetic predisposition to sudden cardiac death and families with high risk individual(s) who are not scheduled for, or cannot receive, an implantable cardioverter defibrillator (icd) represent the primary target for pilot projects on home defibrillation. intravenous narcotics, by divided doses or demand modalities, may be used as initial management for lower risk patients presenting with stable and adequate pulmonary performance as long as the desired clinical response is achieved. the target iop is an estimate of the mean iop achieved with treatment that is expected to prevent further optic nerve damage. an individualised target iop range should be set for every glaucoma patient. patients who have previously received rituximab and who have achieved a response of at least one year's duration to the last rituximab administration and who are appropriate candidates for chemotherapy should receive this chemotherapy in combination with rituximab. |
| 1 | achieving | 3 | treatment of extensive-stage scl first-line treatment patients achieving a complete remission (cr) should be offered prophylactic cranial irradiation (pci). the goal of achieving an effective aed programme within the ems should become a fundamental objective in every european country. accordingly, it is recommended that an aed and properly trained personnel should be placed in every vehicle that may transport patients at risk of cardiac arrest. this should be the first priority for an early access defibrillation programme. pediatricians can actively promote bone health and support the goal of achieving adequate calcium intakes by children and adolescents by promoting the recommended adequate intakes of the food and nutrition board of the national academy of sciences.the prevention of future osteoporosis and the possibility of a decreased risk of fractures in childhood and adolescence should be discussed with patients and families as potential benefits for achieving these goals. |
| 1 | acid | 9 | omega-3 polyunsaturated fatty acid (pufa) supplementation is reasonable to use as adjunctive therapy in patients with nyha class ii–iv symptoms and hfref or hfpef, unless contraindicated, to reduce mortality and cardiovascular hospitalizations. combination oxaliplatin, short-term infusional 5-fluorouracil (5fu), and folinic acid (fa) (folfox) is an important component of therapy and oxaliplatin should be made available for the treatment of advanced colorectal cancer. esophageal ph recording is indicated to evaluate patients with either normal or equivocal endoscopic findings and reflux symptoms that are refractory to proton pump inhibitor therapy (ph study done after withholding antisecretory drug regimen for >= 1 week if the study is done to confirm excessive acid exposure or while taking the antisecretory drug regimen if symptom-reflux correlation is to be scored). protein requirements histidine is a conditionally essential amino acid for neonates and infants up to 6 months of age and should be specifically supplemented. periconceptional folic acid supplementation is recommended because it has been shown to reduce the occurrence and recurrence of neural tube defects (ntds). the ideal dose for folic acid supplementation has not been appropriately evaluated in prospective clinical studies. a 400 microgram supplement currently is recommended for women capable of becoming pregnant. there is insufficient evidence to recommend other treatments (valproic acid, benzodiazepines, pyridoxine, newer antiepileptic drugs, or other or novel therapies) for the treatment of infantile spasms . in patients with chronic cough who live in areas with a high prevalence of tb, this diagnosis should be considered, but not to the exclusion of the more common etiologies. sputum smears and cultures for acid fast bacilli and a chest radiograph should be obtained whenever possible. single-agent pemetrexed (alimta®) at a dose of 500 mg/m2 every three weeks is also an option for second-line therapy of recurrent or progressive disease, if available. this chemotherapy should be administered with vitamin supplements: oral folic acid 350-1,000 micrograms daily and intramuscular vitamin b12 1,000 micrograms every nine weeks, beginning between one to two weeks before, and continuing until three weeks after chemotherapy. |
| 2 | acid supplementation | 2 | periconceptional folic acid supplementation is recommended because it has been shown to reduce the occurrence and recurrence of neural tube defects (ntds). the ideal dose for folic acid supplementation has not been appropriately evaluated in prospective clinical studies. a 400 microgram supplement currently is recommended for women capable of becoming pregnant. |
| 1 | acidosis | 2 | if a patient has gfr <30 ml/min/1.73 m2 then his/her chronic metabolic acidosis should be corrected to a serum bicarbonate of >22 mmol/l . clinical assessments:it is recommended that cardiac index be supported to maintain normal to minimally elevated left atrial pressure (5 to 15 mmhg) with evidence of adequate tissue and organ perfusion as defined by physical exam, urine output >1cc/kg/min, and no ongoing metabolic acidosis or lactic acidemia. |
| 1 | acinetobacter | 5 | in patients with hap/vap caused by acinetobacter species, we suggest treatment with either a carbapenem or ampicillin/sulbactam if the isolate is susceptible to these agents 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 in patients with hap/vap caused by acinetobacter species, we recommend against the use of tigecycline |
| 2 | acinetobacter species | 5 | in patients with hap/vap caused by acinetobacter species, we suggest treatment with either a carbapenem or ampicillin/sulbactam if the isolate is susceptible to these agents 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 in patients with hap/vap caused by acinetobacter species, we recommend against the use of tigecycline |
| 3 | 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 |
| 4 | 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 |
| 5 | 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 |
| 1 | acip | 2 | in primary care and specialty medical settings, acip recommends implementation of standing orders to identify adults recommended for hepatitis b vaccination and administer vaccination as part of routine services. to ensure vaccination of adults at risk for hbv infection who have not completed the vaccine series, acip recommends the following implementation strategies: provide information to all adults regarding the health benefits of hepatitis b vaccination, including risk factors for hbv infection and persons for whom vaccination is recommended. help all adults assess their need for vaccination by obtaining a history that emphasizes risks for sexual transmission and percutaneous or mucosal exposure to blood. vaccinate all adults who report risks for hbv infection. vaccinate all adults requesting protection from hbv infection, without requiring them to acknowledge a specific risk factor. pediatricians and child health professionals should join with the national american academy of pediatrics (aap) and aap chapters in the following activities: vigorously advocating for all children to receive comprehensive health care, including childhood immunizations in a medical home ("the medical home," 2002). children most likely to experience barriers to comprehensive care in a medical home are children who are members of racial and ethnic minorities, poor or uninsured children, children living in inner-city or rural areas, and children with chronic medical conditions. collaborating with local public and private child health services to identify children without access to a medical home and assist in referring them to a medical home. the medical home should maintain the children's medical records, including immunization records.removing economic barriers to immunizations for parents and pediatricians to participate in the vaccines for children (vfc) program or state vaccine programs reducing socioeconomic and racial disparities in immunization rates by working with all national medical groups and specialty societies that care for poor and underserved populations advocating with state vaccine purchasing or vaccines for children programs and private third-party payers of vaccine for adequate vaccine reimbursement rates that cover all costs associated with the administration of vaccines, including the vaccines product, physician work, practice administrative expense, professional liability, and all related supplies, including safety needles advocating with vaccine manufacturers and state and federal governments to maintain an adequate supply of all childhood vaccines at all times ensuring that the safest and most effective vaccines and combinations are available to children advocating with state and federal governments to ensure that timely access to all immunizations recommended by the advisory committee on immunization practices (acip), the aap, and the american academy of family physicians (aafp) for all children remains a high public policy priority supporting ongoing education and quality improvement programs for pediatricians and other child health care professionals about important vaccine-related issues, including the dissemination of peer-reviewed evidence for more effective immunization delivery. |
| 1 | acne | 3 | the task force recommends the following endpoints be considered for safety and risk assessment in future studies: appearance of or change in hirsutism, acne, male pattern balding, clitoromegaly, and deepening of the voice. cardiovascular and metabolic evaluation, with and without estrogen replacement, should include fasting lipid profiles, vascular reactivity, markers of insulin sensitivity, and markers of inflammation. effects on the breast, with or without estrogen replacement, should be measured. breast biopsy studies with in vitro markers of cell proliferation and apoptosis should be considered. alterations in the endometrium with and without estrogen coadministration alterations in mood using validated instruments. benefits and side effects of corticosteroid therapy need to be monitored. timed function tests, pulmonary function tests, and age at loss of independent ambulation are useful to assess benefits. an offer of treatment with corticosteroids should include a balanced discussion of potential risks. potential side effects of corticosteroid therapy (weight gain, cushingoid appearance, cataracts, short stature [i.e., a decrease in linear growth], acne, excessive hair growth, gastrointestinal symptoms, and behavioral changes) also need to be assessed. if excessive weight gain occurs (>20% over estimated normal weight for height over a 12-month period), based on available data, it is recommended that the dosage of prednisone be decreased (to 0.5 mg/kg/day with a further decrease after three to four months to 0.3 mg/kg/day if excessive weight gain continues). adverse effects may occur with androgen replacement therapy at supraphysiologic levels. acne, hirsutism, and a significant reduction in high-density lipoprotein (hdl) cholesterol levels have been described |
| 1 | acquired | 2 | oral penicillin v 500 mg qid for 7-10 days is the recommended treatment for naturally acquired cutaneous anthrax (sr-h). arterial reconstructive surgery is a treatment option only in healthy individuals with recently acquired erectile dysfunction secondary to a focal arterial occlusion and in the absence of any evidence of generalized vascular disease . |
| 1 | acquisition | 3 | diagnosis of primary tumorin patients with a central lesion who present with or without hemoptysis, sputum cytology (at least three specimens) is a reasonable first step (in centers with a formal program directed at the acquisition, handling, and interpretation of sputum samples) in the diagnostic workup. basiliximab or daclizumab, used as part of a calcineurin-inhibitor-based immunosuppressive regimen, are recommended as options for induction therapy in the prophylaxis of acute organ rejection in adults undergoing renal transplantation. the induction therapy (basiliximab or daclizumab) with the lowest acquisition cost should be used. it is recommended that switching from one of these hypnotics to another should only occur if a patient experiences adverse effects considered to be directly related to a specific agent. these are the only circumstances in which the drugs with the higher acquisition costs are recommended. |
| 1 | across | 2 | minimize skin injury due to friction and shearing. do not drag skin across linens when positioning or lifting up the patient in bed. use lifting devices such as a trapeze, lifting sheet, or hoyer lift. psychosocial treatments: for many patients with a cocaine use disorder, psychosocial treatments focusing on abstinence are effective . in particular, cbts ,behavioral therapies , and 12-step-oriented individual drug counseling can be useful, although efficacy of these therapies varies across subgroups of patients. |
| 1 | action | 4 | the task force recommends further study of physiologic targets of androgen action such as: sexual dysfunction cognition mood bone cardiovascular function body composition muscle strength and function a written action plan can give the patient and/or parent a sense of control. most important is to clarify the plan of care in language they can understand. for those who are comfortable with written information, summarize key points on a pocket card that can be carried with them. ask if there is another person who can help the patient or family cope with illness. the opinions and experiences of lung cancer patients and carers should be collected and used to improve the delivery of lung cancer services. patients should receive feedback on any action taken as a result of such survey. repeated courses of intravenous immunoglobulin could be considered as an adjuvant, maintenance agent in patients with recalcitrant disease who have failed more conventional therapies. in view of reports of a rapid action in some cases, it could be used to help induce remission in patients with severe pv while slower-acting drugs take effect . |
| 1 | actions | 3 | if evacuation is necessary: in some very rare cases, extreme smoke and fire conditions may force the evacuation of the or where the fire occurs. in such cases, the acronym race defines the actions that should take place: rescue the patient if possible, alert staff in nearby ors and activate fire alarm systems, confine the smoke and fire by shutting all doors and closing off gas, vacuum, and power systems, and evacuate the or and, if necessary, the surgical suite. legislation in europe is heterogeneous, but where it has relevance to aeds it either has permitted or is likely to permit their use by nonmedically qualified first responders. automated external defibrillation does not require establishing a clinical diagnosis and therefore it should be lifted from the list of actions "reserved to doctors." slow implementation is mainly the result of limited perception of the importance of early defibrillation programmes and by traditions and reluctance to "de-medicalise" the act of defibrillation. the lack of data on cost-effectiveness may discourage the support of governments for aed programmes. therefore, this type of economical evaluation should be part of any planned developments. european legislation or recommendation issued by european policy makers and supported by all relevant major health care and scientific societies could promote implementation of this life saving strategy that is strongly supported by scientific evidence. clinicians working in juvenile justice settings must be vigilant for personal safety and security issues and aware of actions that may compromise their safety and/or the safety and containment of the incarcerated youth . |
| 1 | active | 28 | the effect of hf treatment should be monitored with careful measurement of fluid intake and output, vital signs, body weight that is determined at the same time each day, and clinical signs and symptoms of systemic perfusion and congestion. daily serum electrolytes, urea nitrogen, and creatinine concentrations should be measured during the use of intravenous diuretics or active titration of hf medications. in patients hospitalized with volume overload, including hf, who have persistent severe hyponatremia and are at risk for or having active cognitive symptoms despite water restriction and maximization of gdmt, vasopressin antagonists may be considered in the short term to improve serum sodium concentration in hypervolemic, hyponatremic states with either a v2 receptor–selective or a nonselective vasopressin antagonist. 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 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 oral therapy for ecthyma or impetigo should be a 7-day regimen with an agent active against s. aureus unless cultures yield streptococci alone (when oral penicillin is the recommended agent) an antibiotic active against mrsa is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment, have markedly impaired host defenses, or in patients with sirs and hypotension after obtaining cultures of recurrent abscess, treat with a 5- to 10-day course of an antibiotic active against the pathogen isolated typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections after operations on the axilla, gastrointestinal (gi) tract, perineum or female genital tract vancomycin is recommended for initial empiric therapy. an agent active against enteric gram-negative bacilli should be added for infection in immunocompromised patients or after open trauma to the muscles (sr-m). an antimicrobial agent or agents active against both aerobic and anaerobic bacteria such as amoxicillin-clavulanate should be used 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. research is encouraged to identify methods to increase correct and consistent condom use by sexually active adolescents and to evaluate effectiveness of strategies to promote condom use, including condom education and availability programs in schools. school personnel involved in detection of head lice infestation should be appropriately trained. the importance and difficulty of correctly diagnosing an active head lice infestation should be acknowledged. schools should examine any lice related policies they may have with this in mind. the u.s. preventive services task force (uspstf) strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. expectant management of patients with preterm labor or preterm premature rupture of membranes and active hsv may be warranted. in women with no active lesions or prodromal symptoms during labor, cesarean delivery should not be performed on the basis of a history of recurrent disease. pediatricians should promote the active participation of all children in the management and direction of their own health care, beginning at an early age and continuing into adult health care. although the available evidence suggests a lower vap rate with passive humidification than with active humidification, other issues related to the use of passive humidifiers (resistance, dead space volume, airway occlusion risk) preclude a recommendation for the general use of these devices. the decision to use a passive humidifier should not be based solely on infection control considerations. the drug regimen of choice is currently unknown because no randomized comparative trials have been conducted in this patient population. options include tenofovir, emtricitabine, interferon alfa-2b, lamivudine, or adefovir; there are insufficient data to recommend combinations of drugs at this time. if lamivudine is given for treatment of hepatitis b, it should never be used alone but in combination with other hiv-active antiretroviral agents as a component of highly active antiretroviral therapy (haart). pediatricians should promote parental education in pediatric basic life support. families of children with special health care needs, neonatal intensive care unit graduates, children who have ready access to water, or children who are active in water sports should be especially encouraged to undergo training and should be assisted in obtaining access to the training. a coc user taking a short course (less than 3 weeks) of non-liver enzyme-inducing antibiotics should be advised to use additional contraceptive protection, such as condoms, during the treatment and for 7 days after the antibiotic has been stopped. if fewer than seven active pills are left in the pack after antibiotics have stopped, she should omit the pill-free interval (or discard any inactive pills) epidemiology and prevention:clinicians should encourage all patients with hcv and all patients with hiv who are sexually active to use condoms. 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. recommendation:when providing physical activity advice, primary care practitioners should take into account the individual's needs, preferences, and circumstances. they should agree goals with them. they should also provide written information about the benefits of activity and the local opportunities to be active. they should follow them up at appropriate intervals over a 3- to 6-month period. 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. |
| 2 | active against | 10 | 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 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 oral therapy for ecthyma or impetigo should be a 7-day regimen with an agent active against s. aureus unless cultures yield streptococci alone (when oral penicillin is the recommended agent) an antibiotic active against mrsa is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment, have markedly impaired host defenses, or in patients with sirs and hypotension after obtaining cultures of recurrent abscess, treat with a 5- to 10-day course of an antibiotic active against the pathogen isolated typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci agents active against gram-negative bacteria and anaerobes, such as a cephalosporin or fluoroquinolone in combination with metronidazole, are recommended for infections after operations on the axilla, gastrointestinal (gi) tract, perineum or female genital tract vancomycin is recommended for initial empiric therapy. an agent active against enteric gram-negative bacilli should be added for infection in immunocompromised patients or after open trauma to the muscles (sr-m). an antimicrobial agent or agents active against both aerobic and anaerobic bacteria such as amoxicillin-clavulanate should be used |
| 3 | active against mrsa | 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 an antibiotic active against mrsa is recommended for patients with carbuncles or abscesses who have failed initial antibiotic treatment, have markedly impaired host defenses, or in patients with sirs and hypotension |
| 2 | 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. |
| 1 | actively | 2 | to reduce the incidence and mortality rate of cervix cancer, effective screening and preventive strategy must be actively pursued, in addition to early detection of disease and effective therapy . pediatricians can actively promote bone health and support the goal of achieving adequate calcium intakes by children and adolescents by promoting the recommended adequate intakes of the food and nutrition board of the national academy of sciences.the prevention of future osteoporosis and the possibility of a decreased risk of fractures in childhood and adolescence should be discussed with patients and families as potential benefits for achieving these goals. |
| 1 | activities | 8 | every patient with hf should have a clear, detailed, and evidencebased plan of care that ensures the achievement of gdmt goals, effective management of comorbid conditions, timely follow-up with the healthcare team, appropriate dietary and physical activities, and compliance with secondary prevention guidelines for cardiovascular disease. this plan of care should be updated regularly and made readily available to all members of each patient’s healthcare team. (i-c) determine the presence or absence of a permanent impairment that substantially limits one or more major life activities. low lighting levels, music, and simulated nature sounds may improve eating behaviors for persons with dementia, and intensive multimodality group training may improve activities of daily living, but these approaches lack conclusive supporting data. pediatricians should undertake assessment and improvement activities necessary to maximize their practices' effectiveness in immunizing children. pediatricians and child health professionals should join with the national american academy of pediatrics (aap) and aap chapters in the following activities: vigorously advocating for all children to receive comprehensive health care, including childhood immunizations in a medical home ("the medical home," 2002). children most likely to experience barriers to comprehensive care in a medical home are children who are members of racial and ethnic minorities, poor or uninsured children, children living in inner-city or rural areas, and children with chronic medical conditions. collaborating with local public and private child health services to identify children without access to a medical home and assist in referring them to a medical home. the medical home should maintain the children's medical records, including immunization records.removing economic barriers to immunizations for parents and pediatricians to participate in the vaccines for children (vfc) program or state vaccine programs reducing socioeconomic and racial disparities in immunization rates by working with all national medical groups and specialty societies that care for poor and underserved populations advocating with state vaccine purchasing or vaccines for children programs and private third-party payers of vaccine for adequate vaccine reimbursement rates that cover all costs associated with the administration of vaccines, including the vaccines product, physician work, practice administrative expense, professional liability, and all related supplies, including safety needles advocating with vaccine manufacturers and state and federal governments to maintain an adequate supply of all childhood vaccines at all times ensuring that the safest and most effective vaccines and combinations are available to children advocating with state and federal governments to ensure that timely access to all immunizations recommended by the advisory committee on immunization practices (acip), the aap, and the american academy of family physicians (aafp) for all children remains a high public policy priority supporting ongoing education and quality improvement programs for pediatricians and other child health care professionals about important vaccine-related issues, including the dissemination of peer-reviewed evidence for more effective immunization delivery. a young adults engaged in demanding physical activities with a first traumatic shoulder dislocation should be referred for orthopaedic evaluation. optimize your practice.appointing a coordinator for all patient education activities is an important step toward tailoring patient education for your practice. depending on the practice, allied health professionals or even nonmedical office staff should play an important role on the patient education team. proper training may be necessary to ensure that the staff is adequately prepared to handle patients effectively. choose the right tools educational handouts, such as brochures or fact sheets, can be quite helpful (refer to table 2.2 of the original guideline document). creating your own educational materials, while giving you complete control over content, can be both time-consuming and costly. pharmaceutical manufacturers can often supply your practice with educational resources, although you should be sure that the content is clinically sound and not overly promotional. clinicians can also refer patients to headache-focused patient organizations such as the national headache foundation (www.headaches.org, 888-643-5552) and the american council for headache education (www.achenet.org, 856-423-0258). make your office patient-education-friendly once you have chosen your educational materials, make sure they are accessible to your patients. potential locations include the office entryway, reception area, bathrooms, and exam rooms. in some cases, it may be ideal to create a "patient library" in a spare room or closet, to store all patient education materials. also, consider making your educational charts patient-friendly by using checklists or diagrams. maximize your time finding the time to properly educate your patients may be a challenge. the table below provides some quick tips to help you maximize your time and effectively communicate all the information your patient needs. for all patients, encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work). |
| 1 | activity | 25 | exercise training (or regular physical activity) is recommended as safe and effective for patients with hf who are able to participate to improve functional status. (i-a) routine use of nitrates or phosphodiesterase-5 inhibitors to increase activity or qol in patients with hfpef is ineffective. 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 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 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, we recommend prescribing antibiotics with activity against p. aeruginosa and other gram-negative bacilli 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 empiric administration of vancomycin or other agents with gram-positive activity (linezolid, daptomycin or ceftaroline) should be added if not already being administered if potential for improving mobility and activity status exists for particular patients, begin rehabilitation (i.e., range of motion exercises, encourage ambulation). consider a physical therapy referral. the discharge planning process:clarify activity level and ability, with a focus on safety and mobility. ask what types of work the patient has done and the longest time s/he held a job to identify abilities and interests, assess stability, and determine risk for comorbidities associated with toxic exposures (e.g., to asbestos, silica, coal). ask about any work-related illnesses or injuries and whether they have interfered with gainful activity (i.e., made it difficult to do work, resulted in job loss, presented obstacles to hiring). if so, consult the association of occupational and environmental clinics for referrals and assistance. lifestyle modification:current physical activity contributes to weight loss, reduces cardiovascular risk factors (e.g., hypertension and diabetes mellitus) and the risk for coronary heart disease, increases cardiorespiratory fitness independent of weight loss, and decreases body and abdominal fat. lifestyle modification:a program of diet plus nonstructured, moderate-intensity lifestyle activity appeared as effective as diet plus structured aerobic activity for reducing weight in obese women. any increase in daily physical activity is likely to have some benefit in obese women. lifestyle modification:the combination of dietary caloric restriction, physical activity, and behavioural modification results in greater and more sustained weight loss than the individual modalities. patients with hypertension should also undergo measurement of serum potassium and plasma aldosterone concentration/plasma renin activity ratio. all schools should implement age-appropriate and culturally sensitive curricula on changing students' patterns of dietary intake, physical activity, and smoking behaviors. consider referral to a program that provides guidance on nutrition, physical activity, and psychosocial concerns. individuals at high risk for developing diabetes need to become aware of the benefits of modest weight loss and participating in regular physical activity. for all patients, encourage 30 to 60 minutes of moderate-intensity aerobic activity, such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities (e.g., walking breaks at work, gardening, household work). recommendation:when providing physical activity advice, primary care practitioners should take into account the individual's needs, preferences, and circumstances. they should agree goals with them. they should also provide written information about the benefits of activity and the local opportunities to be active. they should follow them up at appropriate intervals over a 3- to 6-month period. 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. health assessment screening, history, and counseling:ages 50 to 64 years: one health maintenance exam (hme) every 1 to 3 years according to risk status . age 65+ years: one hme at least every 2 years. each hme should include: height, weight, and body mass index (bmi). risk evaluation and counseling (nutrition, overweight/obesity, physical activity, dental health, tobacco use , immunizations, human immunodeficiency virus (hiv) prevention , sexually transmitted diseases prevention and sexual health, sexual abuse, polypharmacy including over-the-counter and herbal preparations when appropriate, sun exposure) safety (domestic violence, seat belts , helmets, firearms, smoke and carbon monoxide detectors) behavioral assessment (depression, suicide threats, alcohol/drug use, anxiety, stress reduction, coping skills). |
| 2 | activity against | 5 | 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 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, we recommend prescribing antibiotics with activity against p. aeruginosa and other gram-negative bacilli 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 |
| 3 | activity against aeruginosa | 2 | 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 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 |
| 2 | 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 |
| 2 | activity part | 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. |
| 3 | activity part properly | 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. |
| 4 | 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. |
| 5 | 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. |
| 1 | actual | 2 | determine magnification required (task dependent) the magnification required for distance vision improvement is predicted by the ratio of the denominator of the present visual acuity to the denominator of the desired visual acuity. example: if actual visual acuity is 10/60 and desired visual acuity is 10/20, then 60/20 = 3x magnification required. in patients with a clinical suspicion of pah, doppler echocardiography should be performed as a noninvasive screening test that can detect pulmonary hypertension (ph), though it may be imprecise in determining actual pressures compared to invasive evaluation in a portion of patients. |
| 1 | acuity | 3 | determine magnification required (task dependent) the magnification required for distance vision improvement is predicted by the ratio of the denominator of the present visual acuity to the denominator of the desired visual acuity. example: if actual visual acuity is 10/60 and desired visual acuity is 10/20, then 60/20 = 3x magnification required. vision assessment can include vision screening and a full ophthalmologic examination (visual acuity, extraoculo-movements, fundoscopic). hotodynamic therapy (pdt) is recommended for the treatment of wet age-related macular degeneration for individuals who have a confirmed diagnosis of classic with no occult subfoveal choroidal neovascularisation (cnv) (that is, whose lesions are composed of classic cnv with no evidence of an occult component) and best-corrected visual acuity 6/60 or better. pdt should be carried out only by retinal specialists with expertise in the use of this technology. |
| 1 | acute | 49 | patients with suspected or new-onset hf, or those presenting with acute decompensated hf, should undergo a chest x-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. invasive hemodynamic monitoring can be useful for carefully selected patients with acute hf who have persistent symptoms despite empiric adjustment of standard therapies, and: • whose fluid status, perfusion, or systemic or pulmonary vascular resistance is uncertain; • whose systolic pressure remains low, or is associated with symptoms, despite initial therapy; • whose renal function is worsening with therapy; • who require parenteral vasoactive agents; or • who may need consideration for mechanical circulatory support (mcs) or transplantation. routine use of invasive hemodynamic monitoring is not recommended in normotensive patients with acute decompensated hf and congestion with symptomatic response to diuretics and vasodilators. 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. aldosterone receptor antagonists are recommended to reduce morbidity and mortality following an acute mi in patients who have lvef of ?40% who develop symptoms of hf or who have a history of diabetes mellitus, unless contraindicated. until definitive therapy (eg, coronary revascularization, mcs, heart transplantation) or resolution of the acute precipitating problem, patients with cardiogenic shock should receive temporary intravenous inotropic support to maintain systemic perfusion and preserve endorgan performance. nondurable mcs, including the use of percutaneous and extracorporeal ventricular assist devices, is reasonable as a “bridge to recovery” or a “bridge to decision” for carefully selecteda hfref a h patients with acute, profound hemodynamic compromise. acs precipitating acute hf decompensation should be promptly identified by ecg and serum biomarkers, including cardiac troponin testing, and treated optimally as appropriate to the overall condition and prognosis of the patient. common precipitating factors for acute hf should be considered during initial evaluation, as recognition of these conditions is critical to guide appropriate therapy. if symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acute decompensated hf. identify and treat predisposing conditions such as edema, obesity, eczema, venous insufficiency, and toe web abnormalities. these practices should be performed as part of routine patient care and certainly during the acute stage of cellulitis. pain response to therapy should not be used as the sole diagnostic indicator of the underlying etiology of an acute headache. patients presenting to the emergency department with headache and abnormal findings in a neurologic examination (i.e., focal deficit, altered mental status, altered cognitive function) should undergo emergent* noncontrast head computed tomography (ct) scan. patients presenting with acute sudden-onset headache should be considered for an emergent* head computed tomography scan. human immunodeficiency virus (hiv)-positive patients with a new type of headache should be considered for an urgent* neuroimaging study.patients who are older than 50 years presenting with new type of headache without abnormal findings in a neurologic examination should be considered for an urgent neuroimaging study. distinguish between acute otitis media (aom) and otitis media with effusion (ome) in making therapeutic decisions. organize randomized controlled trials (rcts) to extend treatment to special populations not represented in current clinical trials and to determine the applicability of accepted antiviral drug combinations to populations such as children and adolescents, and patients with acute hepatitis. effective approaches are needed for drug users receiving drug treatment, alcohol abusers, prisoners, patients with stabilized depression, those with co-infection with human immunodeficiency virus, patients with decompensated cirrhosis, and hcv infections in transplant recipients. such efforts should lead to decreased morbidity and mortality from the disease, as well as a decrease in the reservoir of disease. metered dose inhalers (mdis) plus spacers are at least as effective as wet nebulisers in mild to moderate acute asthmatic episodes. long-acting beta2-agonists should not be used for the treatment of acute (or chronic) symptoms of asthma in the absence of inhaled anti-inflammatory therapy. methotrexate in ectopic pregnancy:because the symptoms associated with gastrointestinal side effects of methotrexate therapy may mimic an acute ectopic rupture, rule out ectopic rupture resulting from treatment failure before attributing gastrointestinal symptoms to methotrexate toxicity. all patients with acute stroke should undergo brain scanning (computed tomography [ct] or magnetic resonance imaging [mri]) as soon as possible preferably within 24 hours (gpp). a local protocol for more urgent scans should be made available. key recommendations by diagnosis:candidemia and acute hematogenously disseminated candidiasis:for clinically stable patients who have not recently received azole therapy, fluconazole (>6 mg/kg per day; i.e., >400 mg/day for a 70-kg patient) is another appropriate choice. recognize the signs and symptoms of pesticide exposures (both acute and chronic). if required, offer supervised exercise by a recognised treatment provider to improve range of movement after the acute pain has settled. for acute stroke patients with restricted mobility, the guideline developers recommend prophylactic low-dose subcutaneous heparin or low molecular weight heparins or heparinoids. for patients with recurrent acute mi, the guideline developers suggest clinicians do not use repeat administration of streptokinase. 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. clinicians should maintain a high level of suspicion for acute hiv infection in all patients presenting with a compatible clinical syndrome. when acute retroviral syndrome is suspected, a plasma hiv rna assay should be used in conjunction with hiv-1 antibody test to diagnose acute or primary hiv infection. women with persistent abnormal vaginal bleeding after a nonmolar pregnancy should undergo a pregnancy test to exclude persistent gtn. persistent gtn should be considered in any woman developing acute respiratory or neurological symptoms after any pregnancy. patients less than 6 years of age should be referred to an emergency department if the estimated acute ingestion amount is unknown or is 200 mg/kg or more. patients can be observed at home if the dose ingested is less than 200 mg/kg . basiliximab or daclizumab, used as part of a calcineurin-inhibitor-based immunosuppressive regimen, are recommended as options for induction therapy in the prophylaxis of acute organ rejection in adults undergoing renal transplantation. the induction therapy (basiliximab or daclizumab) with the lowest acquisition cost should be used. drug holidays (i.e., stopping neuromuscular blocking agents daily until forced to restart them based on the patientâ??s condition) may decrease the incidence of acute quadriplegic myopathy syndrome (aqms). in most patients with a diagnosis of acute bronchitis, beta2-agonist bronchodilators should not be routinely used to alleviate cough.in select adult patients with a diagnosis of acute bronchitis and wheezing accompanying the cough, treatment with beta2-agonist bronchodilators may be useful. in a patient with an acute respiratory infection manifested predominantly by cough, with or without sputum production, lasting no more than 3 weeks, a diagnosis of acute bronchitis should not be made unless there is no clinical or radiographic evidence of pneumonia and the common cold, acute asthma, or an exacerbation of chronic obstructive pulmonary disease (copd) have been ruled out as the cause of cough. in patients with acute cough and sputum production suggestive of acute bronchitis, the absence of the following findings reduces the likelihood of pneumonia sufficiently to eliminate the need for a chest radiograph: (1) heart rate >100 beats/min; (2) respiratory rate >24 breaths/min; (3) oral body temperature of >38 degrees c; and (4) chest examination findings of focal consolidation, egophony, or fremitus. in patients with immune deficiency, the initial diagnostic algorithm for patients with acute, subacute, and chronic cough is the same as that for immunocompetent persons, taking into account an expanded list of differential diagnoses that considers the type and severity of immune defect and geographic factors. in patients with acute cough due to the common cold, preparations containing zinc are not recommended. because of a lack of stat availability, there are no clinical laboratory tests that are currently appropriate for monitoring acute inhalant abuse or solvent exposure. 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. 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. cardiac troponin testing is useful for diagnosing acute coronary syndromes and in risk stratification. however, it is recommended that in patients considered to be at high risk, treatment with a small-molecule gp iib/iiia inhibitor is initiated as soon as high-risk status is determined even though this may be before the result of a troponin test is known. regardless of surgical staging, adjuvant external beam radiotherapy is recommended for patients at high risk of recurrence is not recommended in patients at low risk of recurrence is a reasonable treatment option for patients at intermediate risk of recurrence two randomized trials detected that adjuvant external beam radiotherapy improved pelvic control, but not survival, when compared to no further treatment. in patients with no adjuvant therapy, salvage radiotherapy may be effective upon vaginal recurrence. when considering adjuvant radiotherapy, the potential improvement in pelvic control needs to be weighed against the toxicity of radiotherapy. radiotherapy was associated with a low incidence of severe acute and late adverse effects; however, many patients experienced mild (grade 1 or 2) side effects. the long-term effects of radiotherapy are unknown at this time. it is strongly recommended that patients with an acute edh in coma (gcs score <9) with anisocoria undergo surgical evacuation as soon as possible. treatment with iv methylprednisolone (1 g once daily for 3 days with an oral tapering dose) may be considered for treatment of acute optic neuritis. management of sex partners: patients who have acute epididymitis, confirmed or suspected to be caused by n. gonorrhoeae or c. trachomatis, should be instructed to refer sex partners for evaluation and treatment if their contact with the index patient was within the 60 days preceding onset of the patient's symptoms. patients should be instructed to avoid sexual intercourse until they and their sex partners are cured (i.e., until therapy is completed and patient and partners no longer have symptoms). treatment: empiric therapy is indicated before laboratory test results are available. the goals of treatment of acute epididymitis caused by c. trachomatis or n. gonorrhoeae are 1) microbiologic cure of infection, 2) improvement of signs and symptoms, 3) prevention of transmission to others, and 4) a decrease in potential complications (e.g., infertility or chronic pain). as an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided. recommended regimens: for acute epididymitis most likely caused by gonococcal or chlamydial infection: ceftriaxone 250 mg im in a single dose plus doxycycline 100 mg orally twice a day for 10 days for acute epididymitis most likely caused by enteric organisms or for patients allergic to cephalosporins and/or tetracyclines: ofloxacin 300 mg orally twice a day for 10 days or levofloxacin 500 mg orally once daily for 10 days. 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. |
| 2 | acute bronchitis | 3 | in most patients with a diagnosis of acute bronchitis, beta2-agonist bronchodilators should not be routinely used to alleviate cough.in select adult patients with a diagnosis of acute bronchitis and wheezing accompanying the cough, treatment with beta2-agonist bronchodilators may be useful. in a patient with an acute respiratory infection manifested predominantly by cough, with or without sputum production, lasting no more than 3 weeks, a diagnosis of acute bronchitis should not be made unless there is no clinical or radiographic evidence of pneumonia and the common cold, acute asthma, or an exacerbation of chronic obstructive pulmonary disease (copd) have been ruled out as the cause of cough. in patients with acute cough and sputum production suggestive of acute bronchitis, the absence of the following findings reduces the likelihood of pneumonia sufficiently to eliminate the need for a chest radiograph: (1) heart rate >100 beats/min; (2) respiratory rate >24 breaths/min; (3) oral body temperature of >38 degrees c; and (4) chest examination findings of focal consolidation, egophony, or fremitus. |
| 2 | acute coronary | 4 | 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. cardiac troponin testing is useful for diagnosing acute coronary syndromes and in risk stratification. however, it is recommended that in patients considered to be at high risk, treatment with a small-molecule gp iib/iiia inhibitor is initiated as soon as high-risk status is determined even though this may be before the result of a troponin test is known. |
| 3 | acute coronary syndrome | 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. |
| 4 | 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. |
| 2 | acute cough | 2 | in patients with acute cough and sputum production suggestive of acute bronchitis, the absence of the following findings reduces the likelihood of pneumonia sufficiently to eliminate the need for a chest radiograph: (1) heart rate >100 beats/min; (2) respiratory rate >24 breaths/min; (3) oral body temperature of >38 degrees c; and (4) chest examination findings of focal consolidation, egophony, or fremitus. in patients with acute cough due to the common cold, preparations containing zinc are not recommended. |
| 2 | acute decompensated | 3 | patients with suspected or new-onset hf, or those presenting with acute decompensated hf, should undergo a chest x-ray to assess heart size and pulmonary congestion and to detect alternative cardiac, pulmonary, and other diseases that may cause or contribute to the patient’s symptoms. routine use of invasive hemodynamic monitoring is not recommended in normotensive patients with acute decompensated hf and congestion with symptomatic response to diuretics and vasodilators. if symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acute decompensated hf. |
| 2 | acute epididymitis | 2 | management of sex partners: patients who have acute epididymitis, confirmed or suspected to be caused by n. gonorrhoeae or c. trachomatis, should be instructed to refer sex partners for evaluation and treatment if their contact with the index patient was within the 60 days preceding onset of the patient's symptoms. patients should be instructed to avoid sexual intercourse until they and their sex partners are cured (i.e., until therapy is completed and patient and partners no longer have symptoms). treatment: empiric therapy is indicated before laboratory test results are available. the goals of treatment of acute epididymitis caused by c. trachomatis or n. gonorrhoeae are 1) microbiologic cure of infection, 2) improvement of signs and symptoms, 3) prevention of transmission to others, and 4) a decrease in potential complications (e.g., infertility or chronic pain). as an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided. recommended regimens: for acute epididymitis most likely caused by gonococcal or chlamydial infection: ceftriaxone 250 mg im in a single dose plus doxycycline 100 mg orally twice a day for 10 days for acute epididymitis most likely caused by enteric organisms or for patients allergic to cephalosporins and/or tetracyclines: ofloxacin 300 mg orally twice a day for 10 days or levofloxacin 500 mg orally once daily for 10 days. |
| 2 | 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. |
| 3 | acute myocardial infarction | 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. |
| 4 | acute myocardial infarction presenting | 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. |
| 5 | 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. |
| 2 | acute respiratory | 2 | women with persistent abnormal vaginal bleeding after a nonmolar pregnancy should undergo a pregnancy test to exclude persistent gtn. persistent gtn should be considered in any woman developing acute respiratory or neurological symptoms after any pregnancy. in a patient with an acute respiratory infection manifested predominantly by cough, with or without sputum production, lasting no more than 3 weeks, a diagnosis of acute bronchitis should not be made unless there is no clinical or radiographic evidence of pneumonia and the common cold, acute asthma, or an exacerbation of chronic obstructive pulmonary disease (copd) have been ruled out as the cause of cough. |
| 2 | acute stroke | 2 | all patients with acute stroke should undergo brain scanning (computed tomography [ct] or magnetic resonance imaging [mri]) as soon as possible preferably within 24 hours (gpp). a local protocol for more urgent scans should be made available. for acute stroke patients with restricted mobility, the guideline developers recommend prophylactic low-dose subcutaneous heparin or low molecular weight heparins or heparinoids. |
| 2 | 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. |
| 3 | acute treatment migraine | 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. |
| 1 | acutely | 3 | measurement of baseline levels of natriuretic peptide biomarkers and/or cardiac troponin on admission to the hospital is useful to establish a prognosis in acutely decompensated hf. fentanyl is preferred for a rapid onset of analgesia in acutely distressed patients. weight loss should not be a goal for the acutely ill, hospitalized obese child. |
| 1 | acyclovir | 2 | acyclovir should be administered to patients suspected or confirmed to have cutaneous or disseminated herpes simplex (hsv) or varicella zoster virus (vzv) infection (sr-m). intravenous acyclovir should be added to the patient’s antimicrobial regimen for suspected or confirmed cutaneous or disseminated hsv or vzv infections (sr-m). |
| 2 | acyclovir should | 2 | acyclovir should be administered to patients suspected or confirmed to have cutaneous or disseminated herpes simplex (hsv) or varicella zoster virus (vzv) infection (sr-m). intravenous acyclovir should be added to the patient’s antimicrobial regimen for suspected or confirmed cutaneous or disseminated hsv or vzv infections (sr-m). |
| 1 | adaptive | 3 | in patients with nyha class ii–iv hfref and central sleep apnea, adaptive servo-ventilation causes harm advocate with parents to school personnel about appropriate educational and therapeutic strategies including: physical, occupational, and speech therapy; nursing; and adaptive and assistive technology. also termed restructuring, this attempts to identify maladaptive and distorted cognitions that are common among those with insomnia and replace these with more adaptive beliefs and attitudes. this form of therapy seeks to alter faulty beliefs and attitudes about sleep and uses multiple patient-specific techniques. examples include decatastrophizing, reappraisal, and attention shifting. objective of this form of therapy is to diminish the cycle of insomnia, emotional stress, dysfunctional cognitions, and further sleep disturbances. |
| 1 | added | 7 | vancomycin is recommended for initial empiric therapy. an agent active against enteric gram-negative bacilli should be added for infection in immunocompromised patients or after open trauma to the muscles (sr-m). yeasts and molds remain the primary cause of infection-associated fever and neutropenia. therefore, empiric antifungal therapy (table 5) should be added to the antibacterial regimen (sr-h). empiric administration of vancomycin or other agents with gram-positive activity (linezolid, daptomycin or ceftaroline) should be added if not already being administered intravenous acyclovir should be added to the patient’s antimicrobial regimen for suspected or confirmed cutaneous or disseminated hsv or vzv infections (sr-m). for patients with asthmatic cough that is refractory to treatment with inhaled corticosteroids and bronchodilators, in whom poor compliance or another contributing condition has been excluded, an leukotriene receptor antagonist (ltra) may be added to the therapeutic regimen before the escalation of therapy to systemic corticosteroids. the decision to include bevacizumab in 5-fu-based regimens requires discussion with the patient regarding risks of added toxicity and potential benefit. for people with type 2 diabetes, the use of a glitazone as second-line therapy added to either metformin or a sulphonylurea--as an alternative to treatment with a combination of metformin and a sulphonylurea--is not recommended except for those who are unable to take metformin and a sulphonylurea in combination because of intolerance or a contraindication to one of the drugs. in this instance, the glitazone should replace in the combination the drug that is poorly tolerated or contraindicated. |
| 1 | adding | 2 | clinical experience suggests that partial efficacy of a selective serotonin reuptake inhibitor may be enhanced by adding lithium. there is insufficient evidence to recommend adding a third drug to a gemcitabine-platinum combination. |
| 1 | addition | 28 | 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. when diuresis is inadequate to relieve symptoms, it is reasonable to intensify the diuretic regimen using either: a. higher doses of intravenous loop diuretics (iia-b), or b. addition of a second (eg, thiazide) diuretic (iia-b). low-dose dopamine infusion may be considered in addition to loop diuretic therapy to improve diuresis and better preserve renal functio and renal blood flow. in addition to infection, differential diagnosis of skin lesions should include drug eruption, cutaneous infiltration with the underlying malignancy, chemotherapy- or radiation-induced reactions, sweet’s syndrome, erythema multiforme, leukocytoclastic vasculitis and graftversus-host disease among allogeneic transplant recipients (sr-h). the addition of an echinocandin could be considered based on synergy in murine models of mucormycosis and observational clinical data (wr-l). in situ lumbar plf is recommended as a treatment option in addition to decompression in patients with lumbar stenosis without deformity in whom there is evidence of spinal instability. the addition of pedicle screw instrumentation is not recommended in conjunction with plf following decompression for lumbar stenosis in patients without spinal deformity or instability. fire hoses are sometimes found in hallways and stairwells of older facilities. water from hoses is not sterile. the water can also create an electric shock hazard. in addition, the water stream itself can deliver sufficient force to cause injury or mechanical damage and can make the hose difficult to hold onto. the guideline developers do not recommend the uses of fire hoses to extinguish surgical fires. to reduce the incidence and mortality rate of cervix cancer, effective screening and preventive strategy must be actively pursued, in addition to early detection of disease and effective therapy . the addition of post-operative treatment using a combination of chemotherapy and radiotherapy has been shown to improve survival outcome for patients with tumour involvement of pelvic lymph nodes, resection margins, and/or parametrial tissue. 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. 5.5% amorolfine (loceryl)* applied once weekly for 15 months in combination with terbinafine (lamasil) 250mg orally every day for 12 weeks is strongly supported as the most effective means of mycological and clinical cure for severe dermatophyte onychomycosis. in addition, studies indicate combination therapy to be the most cost-effective means of treatment as compared to monotherapy. is combined androgen blockade better than castration alone? recommendation: a discussion should occur between the patient and his practitioner. the patient needs to appreciate that there is a small potential gain in overall survival (os) with the addition of a nonsteroidal antiandrogen to medical or surgical castration and that increased side effects may occur as a result. because of the potential toxicity of mitoxantrone, it should be administered under the supervision of a physician experienced in the use of cytotoxic chemotherapeutic agents . in addition, patients being treated with mitoxantrone should be monitored routinely for cardiac, liver, and kidney function abnormalities . in women with prosthetic heart valves at high risk, the guideline developers suggest the addition of low-dose aspirin, 75 to 162 mg/day. recommendations for surgery based upon tumor size are derived from studies not standardized for inclusion criteria, length of follow-up, or methods of estimating the risk of carcinoma. nevertheless, patients with tumors greater than 6 cm usually are treated surgically, while those with tumors less than 4 cm are generally monitored. in patients with tumors between 4 and 6 cm, criteria in addition to size should be considered in making the decision to monitor or proceed to adrenalectomy. low-carbohydrate diets are not recommended in the management of diabetes. although dietary carbohydrate is the major contributor to postprandial glucose concentration, it is an important source of energy, water-soluble vitamins and minerals, and fiber. thus, in agreement with the national academy of sciences-food and nutrition board, a recommended range of carbohydrate intake is 45-65% of total calories. in addition, because the brain and central nervous system have an absolute requirement for glucose as an energy source, restricting total carbohydrate to <130 grams/day is not recommended when assessing adherence, clinicians should use precise language that the patient can understand. in addition, clinicians should verify that patients are taking the medications as prescribed, specifically, correct medications, correct number of pills per dose, and correct number of doses per day. antibiotics are an unnecessary addition to routine incision and drainage of uncomplicated perianal abscesses. clinicians should consider patient variables in ce decision making. women with 50 to 69% symptomatic stenosis did not show clear benefit in previous trials. in addition, patients with hemispheric transient ischemic attack (tia)/stroke had greater benefit from ce than patients with retinal ischemic events .clinicians should also consider several radiologic factors in decision making about ce. for patients with advanced colorectal cancer receiving 5-fluorouracil (5-fu)-based chemotherapy as first-line therapy, the addition of bevacizumab, at a dose of 5 mg/kg every two weeks, is recommended to improve overall survival in patients with no contraindications to bevacizumab. the addition of bevacizumab to 5-fu-based chemotherapy is also recommended for patients with advanced colorectal cancer receiving second-line therapy if they did not receive bevacizumab as part of their initial treatment. consent should be obtained and documented for every procedure. in addition to the risks associated with all endoscopic procedures, the consent should address the relevant and substantial complications pertaining to each specific eus procedure. if blood pressure remains >130/80 mm hg then the addition of a diuretic is recommended, followed by a calcium antagonist or other antihypertensive drugs. addition of a beta-blocker (dose equivalent to heart failure [hf] trials) is recommended even if blood pressure is controlled. one randomized phase ii study and six phase ii studies have shown encouraging response rates when thalidomide is combined with temozolomide. however, dosing schedules of temozolomide in those studies differed from conventional prescribed doses and schedules. it is not clear whether the improved response rates were due to the small number of patients in the studies, the different dose schedules of temozolomide, or the addition of thalidomide. further phase iii studies are required to confirm whether there is a benefit associated with the combination of temozolomide and thalidomide. therefore, it is not recommended that thalidomide be combined with temozolomide at this time. the addition of moderate-dose interferon-alpha 2b has produced a significantly higher response rate than single-agent temozolomide in a large randomized phase iii study. however, overall survival was not altered and grade 3 and 4 hematologic toxicities were higher with the combined treatment. at the present time, the addition of interferon-alpha to temozolomide is not recommended. in stable cad patients who tolerate aspirin well (and who are not post-procedure), clopidogrel is not recommended as either a substitute for or in addition to aspirin. |
| 2 | addition considered | 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. |
| 3 | addition considered persistently | 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. |
| 4 | addition considered persistently symptomatic | 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. |
| 5 | 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. |
| 2 | addition patients | 2 | because of the potential toxicity of mitoxantrone, it should be administered under the supervision of a physician experienced in the use of cytotoxic chemotherapeutic agents . in addition, patients being treated with mitoxantrone should be monitored routinely for cardiac, liver, and kidney function abnormalities . clinicians should consider patient variables in ce decision making. women with 50 to 69% symptomatic stenosis did not show clear benefit in previous trials. in addition, patients with hemispheric transient ischemic attack (tia)/stroke had greater benefit from ce than patients with retinal ischemic events .clinicians should also consider several radiologic factors in decision making about ce. |
| 1 | additional | 20 | patients are stage d refractory nyha class iii-iv consider additional therapy of palliative care (cor i) or transplant (cor i) or left ventricular assist device (cor iia) or investigational studies 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). azithromycin is recommended for cat scratch disease. patients >45 kg, 500 mg on day 1 followed by 250 mg for 4 additional days. patients <45 kg, 10 mg/kg on day 1 and 5 mg/kg for 4 more days determine the extent of infection through a thorough physical examination, blood cultures, chest radiograph and additional imaging (including chest ct) the task force recommends additional research in the following human model systems to define the clinical syndrome of androgen deficiency and to study the benefits and risks of androgen therapy . surgical menopause is a condition in which the ovarian, but not adrenal androgen precursors are removed abruptly independent of age. hypopituitarism, although uncommon, can be used to study the physiological replacement of both ovarian androgens and adrenal androgen precursors. anorexia nervosa may be used as a model of androgen deficiency secondary to dysfunction of the hypothalamic-pituitary and adrenal axes. primary adrenal insufficiency allows for the investigation of the loss of adrenal androgen precursors in the presence of intact ovarian androgen function. ablation-replacement models in normal women using gnrh analogs to eliminate ovarian androgens, with or without suppression of adrenal androgen precursors, offer another way to assess the effects of androgen withdrawal and replacement. subjects with complete androgen insensitivity syndrome offer a way to investigate target tissue effects which are dependent on the androgen receptor but are independent of aromatization. there are studies in patients with low weight and hiv and with natural aging; however, these systems are too complex to recommend as initial models to understand the potential therapeutic role of androgens in women. 11.patients with positive resection margins should be evaluated for additional local treatment modalities (surgical re-resection or radiation therapy). fire drills: fire drills not only allow staff to practice for a fire but also help troubleshoot any difficulties that might occur. some elements to consider in planning a fire drill are: the proper response of each surgical team member and the operating suite staff. how the patient can easily and safely be moved to another or how the spread of smoke should be prevented (for example, through the use of smoke doors and air duct dampers). the location and operation of fire extinguishers, fire alarm pull stations, and exits. what the response of additional fire-fighting personnel (such as the fire response team and local fire department) should be. prevention:continue preventive measures even when a patient has a pressure ulcer to prevent additional pressure areas from developing. measurements of tissue (subcutaneous or muscle) oxygen and/or carbon dioxide levels may identify patients who require additional resuscitation and are at risk for multiple organ dysfunction syndrome and death. for patients with inrs of >9.0 and no significant bleeding, hold warfarin therapy and administer a higher dose of vitamin k1 (5 to 10 mg orally) with the expectation that the inr will be reduced substantially in 24 to 48 hours. monitor the patient more frequently and use additional vitamin k1 if necessary. resume therapy at a lower dose when inr is in the therapeutic range . for patients undergoing laparoscopic procedures and who have additional thromboembolic risk factors, the guideline developers recommend the use of thromboprophylaxis with one or more of the following: lduh, lmwh, ipc, or gcs. when the patient's level of consciousness is minimally depressed and verbal communication can be continually monitored, pulse oximetry may not be necessary. consider capnometry to provide additional information regarding early identification of hypoventilation. functional abdominal pain generally can be diagnosed correctly by the primary care clinician in children 4 to 18 years of age with chronic abdominal pain when there are no alarm symptoms or signs, the physical examination is normal, and the stool sample tests are negative for occult blood, without the requirement of additional diagnostic evaluation. a coc user taking a short course (less than 3 weeks) of non-liver enzyme-inducing antibiotics should be advised to use additional contraceptive protection, such as condoms, during the treatment and for 7 days after the antibiotic has been stopped. if fewer than seven active pills are left in the pack after antibiotics have stopped, she should omit the pill-free interval (or discard any inactive pills) confirm that the infant has a scheduled appointment with a primary care provider or health worker within five to seven days after birth. schedule additional visits as needed until a consistent weight gain pattern has been established (iii).identify breastfeeding support resources within the community such as: international board certified lactation consultants (ibclcs) community health workers and home visitors trained to provide breastfeeding support breastfeeding clinic staff health department staff carotid endarterectomy (ce) is established as effective for recently symptomatic (within previous 6 months) patients with 70 to 99% internal carotid artery (ica) angiographic stenosis . ce should not be considered for symptomatic patients with less than 50% stenosis . ce may be considered for patients with 50 to 69% symptomatic stenosis but the clinician should consider additional clinical and angiographic variables. it is recommended that the patient have at least a 5-year life expectancy and that the perioperative stroke/death rate should be <6% for symptomatic patients .medical management is preferred to ce for symptomatic patients with <50% stenosis . additional laboratory tests. it is recommended that patients with no apparent etiology of hf or no specific clinical features suggesting unusual etiologies undergo additional directed blood and laboratory studies to determine the cause of hf. additional considerations for hiv screening: :communicating test results. the central goal of hiv screening in health-care settings is to maximize the number of persons who are aware of their hiv infection and receive care and prevention services. definitive mechanisms should be established to inform patients of their test results. |
| 2 | additional risk | 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). |
| 3 | additional risk factor | 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). |
| 4 | additional risk factor cardioembolic | 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). |
| 5 | 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). |
| 1 | address | 7 | multidisciplinary hf disease-management programs are recommended for patients at high risk for hospital readmission, to facilitate the implementation of gdmt, to address different barriers to behavioral change, and to reduce the risk of subsequent rehospitalization for hf. surveillance interventions (potential areas to address):ensure adequate functional status before discharge or refer for appropriate home care needs. children and adolescents who are sexually assaulted should be managed in an emergency department or other setting where appropriate resources are available to address the medical, psychosocial, and legal issues of such an offense. school policies should address all foods and snacks consumed on- and off-premises during school hours. identify resources and supports to assist families address the life event, whether this is expected or unexpected. resources should be identified within the following three categories: intrafamilial interfamilial extrafamilial assess family in the context of the event(s) to identify whether assistance is required by the nurse to strengthen and support the family. while a family assessment should include information in the following areas, it should be tailored to address the uniqueness of each family through examining: family perceptions of the event(s) family structure environmental conditions family strengths consent should be obtained and documented for every procedure. in addition to the risks associated with all endoscopic procedures, the consent should address the relevant and substantial complications pertaining to each specific eus procedure. |
| 1 | addressed | 2 | throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (i-b): a. initiation of gdmt if not previously established and not contraindicated b. precipitant causes of hf, barriers to optimal care transitions, and limitations in postdischarge support c. assessment of volume status and supine/upright hypotension with adjustment of hf therapy, as appropriate d. titration and optimization of chronic oral hf therapy e. assessment of renal function and electrolytes, where appropriate f. assessment and management of comorbid conditions g. reinforcement of hf education, self-care, emergency plans, and need for adherence h. consideration for palliative care or hospice care in selected patients clinicians initiating a haart regimen consisting of efavirenz or nevirapine in patients receiving methadone should contact the methadone maintenance program clinicians to ensure that the onset of withdrawal symptoms, if they occur, is promptly addressed by increasing the patient's methadone dose. |
| 1 | adefovir | 3 | the drug regimen of choice is currently unknown because no randomized comparative trials have been conducted in this patient population. options include tenofovir, emtricitabine, interferon alfa-2b, lamivudine, or adefovir; there are insufficient data to recommend combinations of drugs at this time. if lamivudine is given for treatment of hepatitis b, it should never be used alone but in combination with other hiv-active antiretroviral agents as a component of highly active antiretroviral therapy (haart). 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. adefovir dipivoxil should not normally be given before treatment with lamivudine. it may be used either alone or in combination with lamivudine when: treatment with lamivudine has resulted in viral resistance, or lamivudine resistance is likely to occur rapidly (for example, in the presence of highly replicative hepatitis b disease), and development of lamivudine resistance is likely to have an adverse outcome (for example, if a flare of the infection is likely to precipitate decompensated liver disease). |
| 2 | adefovir dipivoxil | 2 | 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. adefovir dipivoxil should not normally be given before treatment with lamivudine. it may be used either alone or in combination with lamivudine when: treatment with lamivudine has resulted in viral resistance, or lamivudine resistance is likely to occur rapidly (for example, in the presence of highly replicative hepatitis b disease), and development of lamivudine resistance is likely to have an adverse outcome (for example, if a flare of the infection is likely to precipitate decompensated liver disease). |
| 3 | adefovir dipivoxil should | 2 | 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. adefovir dipivoxil should not normally be given before treatment with lamivudine. it may be used either alone or in combination with lamivudine when: treatment with lamivudine has resulted in viral resistance, or lamivudine resistance is likely to occur rapidly (for example, in the presence of highly replicative hepatitis b disease), and development of lamivudine resistance is likely to have an adverse outcome (for example, if a flare of the infection is likely to precipitate decompensated liver disease). |
| 1 | adenomatous | 3 | genetic testing along with counseling is recommended for individuals with hereditary forms of crc, including familial adenomatous polyposis (fap) and hereditary nonpolyposis colon cancer (hnpcc) . screening people at increased risk people with a first-degree relative with colon cancer or adenomatous polyp diagnosed at age >60 years or 2 second-degree relatives with colorectal cancer should be advised to be screened as average risk persons, but beginning at age 40 years. surveillance with colonoscopy should be considered for patients who are at increased risk because they have been treated for colorectal cancer, have an adenomatous polyp diagnosed, or have a disease that predisposes them to colorectal cancer, such as inflammatory bowel disease. |
| 2 | adenomatous polyp | 2 | screening people at increased risk people with a first-degree relative with colon cancer or adenomatous polyp diagnosed at age >60 years or 2 second-degree relatives with colorectal cancer should be advised to be screened as average risk persons, but beginning at age 40 years. surveillance with colonoscopy should be considered for patients who are at increased risk because they have been treated for colorectal cancer, have an adenomatous polyp diagnosed, or have a disease that predisposes them to colorectal cancer, such as inflammatory bowel disease. |
| 3 | adenomatous polyp diagnosed | 2 | screening people at increased risk people with a first-degree relative with colon cancer or adenomatous polyp diagnosed at age >60 years or 2 second-degree relatives with colorectal cancer should be advised to be screened as average risk persons, but beginning at age 40 years. surveillance with colonoscopy should be considered for patients who are at increased risk because they have been treated for colorectal cancer, have an adenomatous polyp diagnosed, or have a disease that predisposes them to colorectal cancer, such as inflammatory bowel disease. |
| 1 | adequacy | 4 | invasive hemodynamic monitoring with a pulmonary artery catheter should be performed to guide therapy in patients who have respiratory distress or clinical evidence of impaired perfusion in whom the adequacy or excess of intracardiac filling pressures cannot be determined from clinical assessment. relate wound treatments to adequacy of perfusion status. reassess ulcers at least weekly to determine the adequacy of the treatment plan. each patient should be appropriately monitored with use of dual-energy x-ray absorptiometry as well as known clinical factors of fracture risk to determine the adequacy of an administered dose of estrogen . |
| 1 | adequate | 19 | nyha class ii–iii hf adequate bp on acei or arb; no c/i to arb or sacubitril then discontinue acei or arb; initiate arni 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 surveillance interventions (potential areas to address):ensure adequate functional status before discharge or refer for appropriate home care needs. patients should have adequate, accurate information regarding factors that influence hiv transmission and methods for reducing the risk for transmission to others, emphasizing that the most effective methods for preventing transmission are those that protect noninfected persons against exposure to hiv (e.g., sexual abstinence; consistent and correct use of condoms made of latex, polyurethane or other synthetic materials; and sex with only a partner of the same hiv serostatus). hiv-infected patients who engage in high-risk sexual practices (i.e., capable of resulting in hiv transmission) with persons of unknown or negative hiv serostatus should be counseled to use condoms consistently and correctly. it is recommended that systemic arterial blood pressure be maintained within the normal range for age following orthotopic cardiac transplantation. continuous monitoring of arterial blood pressure via an arterial line is recommended during the early postoperative period. blood pressure may be affected by pain. normal values assume adequate pain control. pediatricians and child health professionals should join with the national american academy of pediatrics (aap) and aap chapters in the following activities: vigorously advocating for all children to receive comprehensive health care, including childhood immunizations in a medical home ("the medical home," 2002). children most likely to experience barriers to comprehensive care in a medical home are children who are members of racial and ethnic minorities, poor or uninsured children, children living in inner-city or rural areas, and children with chronic medical conditions. collaborating with local public and private child health services to identify children without access to a medical home and assist in referring them to a medical home. the medical home should maintain the children's medical records, including immunization records.removing economic barriers to immunizations for parents and pediatricians to participate in the vaccines for children (vfc) program or state vaccine programs reducing socioeconomic and racial disparities in immunization rates by working with all national medical groups and specialty societies that care for poor and underserved populations advocating with state vaccine purchasing or vaccines for children programs and private third-party payers of vaccine for adequate vaccine reimbursement rates that cover all costs associated with the administration of vaccines, including the vaccines product, physician work, practice administrative expense, professional liability, and all related supplies, including safety needles advocating with vaccine manufacturers and state and federal governments to maintain an adequate supply of all childhood vaccines at all times ensuring that the safest and most effective vaccines and combinations are available to children advocating with state and federal governments to ensure that timely access to all immunizations recommended by the advisory committee on immunization practices (acip), the aap, and the american academy of family physicians (aafp) for all children remains a high public policy priority supporting ongoing education and quality improvement programs for pediatricians and other child health care professionals about important vaccine-related issues, including the dissemination of peer-reviewed evidence for more effective immunization delivery. 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 the panel recommends the following:development of an adequate testing procedure for gluten in foods and definition of standards for gluten-free foods in the united states to lay the foundation for rational food labeling. ensure adequate offloading of pressure through wound closure. there is some class i and adequate class ii evidence to indicate that paravertebral or extrapleural infusions are effective in improving subjective pain perception and may improve pulmonary function. intravenous narcotics, by divided doses or demand modalities, may be used as initial management for lower risk patients presenting with stable and adequate pulmonary performance as long as the desired clinical response is achieved. discuss treatments.once patients have a better understanding of their headache type, it is important to include them in the treatment decision process. in many cases, it is beneficial to explain that even though there is no "cure" for headache, with proper treatment headaches can be effectively managed. be sure to spend adequate time discussing all the possible treatment options and any potential side effects. be specific when explaining proper medication use, including correct dosing, when to treat, the frequency of medication usage, and how and when to use rescue medications if appropriate. educate patients about nonpharmacologic treatments, including behavior modification, a healthy diet, and exercise. set realistic treatment expectations, and encourage patients to take responsibility for their treatment. allow for a question and answer period before ending the visit. encourage adequate fluid and fibre intake. reduce caffeine intake (e.g. coffee, tea, colas). a program for the purpose of gaining or losing weight should (a) be started early to permit a gradual weight gain or loss over a realistic time period, (b) permit a change of 1.5% or less of one's body weight per week, (c) permit the loss of weight to be fat loss and the gain of weight to be muscle mass, (d) be coupled with an appropriate training program (both strength and conditioning), and (e) incorporate a well-balanced diet with adequate energy (calories), carbohydrates, protein, and fat. after athletes obtain their desired weight, they should be encouraged to maintain a constant weight and avoid fluctuations of weight. a weight-loss plan for athletic purposes should never be instituted before the 9th grade. pediatricians can actively promote bone health and support the goal of achieving adequate calcium intakes by children and adolescents by promoting the recommended adequate intakes of the food and nutrition board of the national academy of sciences.the prevention of future osteoporosis and the possibility of a decreased risk of fractures in childhood and adolescence should be discussed with patients and families as potential benefits for achieving these goals. currently, the average dietary intake of calcium by children and adolescents (fig 1 in the original guideline document) is well below the recommended levels of adequate intake . information regarding calcium content of various foods should be given to patients and families for whom calcium intake seems inadequate. a registered dietitian may be consulted for a more thorough assessment of diet and to make the necessary recommendations to improve calcium. patients with hf, especially those on diuretic therapy and restricted diets, should be considered for daily multivitamin-mineral supplementation to ensure adequate intake of the recommended daily value of essential nutrients. evaluation for specific vitamin or nutrient deficiencies is rarely necessary. clinical assessments:it is recommended that cardiac index be supported to maintain normal to minimally elevated left atrial pressure (5 to 15 mmhg) with evidence of adequate tissue and organ perfusion as defined by physical exam, urine output >1cc/kg/min, and no ongoing metabolic acidosis or lactic acidemia. |
| 2 | adequate gramnegative | 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 |
| 3 | 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 |
| 4 | 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 |
| 2 | adequate intake | 2 | currently, the average dietary intake of calcium by children and adolescents (fig 1 in the original guideline document) is well below the recommended levels of adequate intake . information regarding calcium content of various foods should be given to patients and families for whom calcium intake seems inadequate. a registered dietitian may be consulted for a more thorough assessment of diet and to make the necessary recommendations to improve calcium. patients with hf, especially those on diuretic therapy and restricted diets, should be considered for daily multivitamin-mineral supplementation to ensure adequate intake of the recommended daily value of essential nutrients. evaluation for specific vitamin or nutrient deficiencies is rarely necessary. |
| 1 | adequately | 7 | further treatment with efalizumab is not recommended in patients unless their psoriasis has responded adequately at 12 weeks . etanercept treatment should be discontinued in patients whose psoriasis has not responded adequately at 12 weeks. further treatment cycles are not recommended in these patients. when sns is indicated, pn should be used when the gastrointestinal tract is not functional or cannot be accessed and in patients who cannot be adequately nourished by oral diets or en. each co-surgeon must adequately document his/her respective preoperative, intraoperative, and postoperative participation according to joint commission on accreditation of healthcare organizations (jcaho) standards. studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations . these treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors patient education: assess patient needs. an important first step in optimizing patient education is to adequately assess each patient's needs. take into account patients' level of knowledge about their headaches. also, be aware of their attitudes, beliefs, and cultural background and how these elements might affect the treatment process. be sensitive to environmental and social factors, which can also play a role in determining patients' receptivity to treatment. optimize your practice.appointing a coordinator for all patient education activities is an important step toward tailoring patient education for your practice. depending on the practice, allied health professionals or even nonmedical office staff should play an important role on the patient education team. proper training may be necessary to ensure that the staff is adequately prepared to handle patients effectively. choose the right tools educational handouts, such as brochures or fact sheets, can be quite helpful (refer to table 2.2 of the original guideline document). creating your own educational materials, while giving you complete control over content, can be both time-consuming and costly. pharmaceutical manufacturers can often supply your practice with educational resources, although you should be sure that the content is clinically sound and not overly promotional. clinicians can also refer patients to headache-focused patient organizations such as the national headache foundation (www.headaches.org, 888-643-5552) and the american council for headache education (www.achenet.org, 856-423-0258). make your office patient-education-friendly once you have chosen your educational materials, make sure they are accessible to your patients. potential locations include the office entryway, reception area, bathrooms, and exam rooms. in some cases, it may be ideal to create a "patient library" in a spare room or closet, to store all patient education materials. also, consider making your educational charts patient-friendly by using checklists or diagrams. maximize your time finding the time to properly educate your patients may be a challenge. the table below provides some quick tips to help you maximize your time and effectively communicate all the information your patient needs. |
| 2 | adequately weeks | 2 | further treatment with efalizumab is not recommended in patients unless their psoriasis has responded adequately at 12 weeks . etanercept treatment should be discontinued in patients whose psoriasis has not responded adequately at 12 weeks. further treatment cycles are not recommended in these patients. |
| 1 | adhd | 3 | it is recommended that the clinician provide periodic follow-up for the child diagnosed with adhd. this would include monitoring target outcomes and adverse effects by collecting relevant information from parents, teachers, and the child. 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. where drug treatment is considered appropriate, methylphenidate, atomoxetine and dexamfetamine are recommended, within their licensed indications, as options for the management of attention deficit hyperactivity disorder (adhd) in children and adolescents. |
| 1 | adhere | 2 | it is recommended that all parent-training/education programmes, whether group- or individual-based, should: be structured and have a curriculum informed by principles of social-learning theory include relationship-enhancing strategies offer a sufficient number of sessions, with an optimum of 8 to 12, to maximise the possible benefits for participants enable parents to identify their own parenting objectives incorporate role-play during sessions, as well as homework to be undertaken between sessions, to achieve generalisation of newly rehearsed behaviours to the home situation be delivered by appropriately trained and skilled facilitators who are supervised, have access to necessary ongoing professional development, and are able to engage in a productive therapeutic alliance with parents adhere to the programme developer's manual and employ all of the necessary materials to ensure consistent implementation of the programme. adhere to a checklist protocol for anesthesia machines and equipment to assure that the desired anesthetic drugs and doses will be delivered. |
| 1 | adherence | 7 | throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (i-b): a. initiation of gdmt if not previously established and not contraindicated b. precipitant causes of hf, barriers to optimal care transitions, and limitations in postdischarge support c. assessment of volume status and supine/upright hypotension with adjustment of hf therapy, as appropriate d. titration and optimization of chronic oral hf therapy e. assessment of renal function and electrolytes, where appropriate f. assessment and management of comorbid conditions g. reinforcement of hf education, self-care, emergency plans, and need for adherence h. consideration for palliative care or hospice care in selected patients hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient or if outpatient treatment is failing when assessing adherence, clinicians should use precise language that the patient can understand. in addition, clinicians should verify that patients are taking the medications as prescribed, specifically, correct medications, correct number of pills per dose, and correct number of doses per day. clinicians should reassess potential barriers to adherence at least every 3 to 4 months and whenever adherence problems are identified. clinicians should assess adherence and be alert for signs of hepatotoxicity in hiv-infected patients receiving haart who are concurrently using recreational drugs. 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. topical therapy: the choice of topical antimicrobial for initial therapy of diffuse aoe should be based upon efficacy, low incidence of adverse events, likelihood of adherence to therapy, and cost. |
| 2 | adherence therapy | 2 | hospitalization is recommended if there is concern for a deeper or necrotizing infection, for patients with poor adherence to therapy, for infection in a severely immunocompromised patient or if outpatient treatment is failing topical therapy: the choice of topical antimicrobial for initial therapy of diffuse aoe should be based upon efficacy, low incidence of adverse events, likelihood of adherence to therapy, and cost. |
| 1 | adjacent | 2 | it is recommended that discography be reserved for use in patients with equivocal mr imaging findings, especially at levels adjacent to clearly pathological levels. less common indications for splenectomy include splenic abscesses, cysts, sinistral portal hypertension secondary to isolated splenic vein thrombosis or obstruction, or splenic mass presumed to be a primary or undiagnosed neoplasm. splenectomy is occasionally included in en bloc resection for malignancy in an adjacent organ, such as the stomach, colon, adrenal gland, or pancreas. distal pancreatectomy usually includes splenectomy if preservation of the splenic artery and vein is either contraindicated (malignancy) or technically impossible. |
| 1 | adjunct | 9 | the decision to administer antibiotics directed against s. aureus as an adjunct to incision and drainage should be made based on the presence or absence of systemic inflammatory response syndrome (sirs) such as temperature >38°c or <36°c, tachypnea >24 breaths/min, tachycardia >90 beats/min or white blood cell count (wbc) >12,000 or <4000 cells/mm3 adjunct colony-stimulating factor therapy (g-csf, gm-csf) or granulocyte transfusions lateral flexion and extension radiography is recommended as an adjunct to determine the presence of lumbar fusion postoperatively. the lack of motion between vertebrae, in the absence of rigid instrumentation, is highly suggestive of successful fusion. blood ketone determinations that rely on the nitroprusside reaction should be used only as an adjunct to diagnose dka and should not be used to monitor treatment of dka. in patients who do not respond to external beam radiation for the relief of pain caused by bony metastases, bisphosphonates can be administered alone or as an adjunct to external radiation therapy for bone metastases. magnetic resonance imaging of the breast (mrib) is an adjunct to mammography, clinical breast examination, and ultrasonography for breast cancer detection in women at high risk of breast cancer based on family history or brca mutations. 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. it is recommended that a gp iib/iiia inhibitor is considered as an adjunct to pci for all patients with diabetes undergoing elective pci, and for those patients undergoing complex procedures (for example, multi-vessel pci, insertion of multiple stents, vein graft pci, or pci for bifurcation lesions); currently only abciximab is licensed as an adjunct to pci. in procedurally uncomplicated, elective pci, where the risk of adverse sequelae is low, use of a gp iib/iiia inhibitor is not recommended unless unexpected immediate complications occur. treatment: empiric therapy is indicated before laboratory test results are available. the goals of treatment of acute epididymitis caused by c. trachomatis or n. gonorrhoeae are 1) microbiologic cure of infection, 2) improvement of signs and symptoms, 3) prevention of transmission to others, and 4) a decrease in potential complications (e.g., infertility or chronic pain). as an adjunct to therapy, bed rest, scrotal elevation, and analgesics are recommended until fever and local inflammation have subsided. recommended regimens: for acute epididymitis most likely caused by gonococcal or chlamydial infection: ceftriaxone 250 mg im in a single dose plus doxycycline 100 mg orally twice a day for 10 days for acute epididymitis most likely caused by enteric organisms or for patients allergic to cephalosporins and/or tetracyclines: ofloxacin 300 mg orally twice a day for 10 days or levofloxacin 500 mg orally once daily for 10 days. |
| 1 | adjunctive | 12 | statins are not beneficial as adjunctive therapy when prescribed solely for hf omega-3 pufa supplementation is reasonable to use as adjunctive therapy in hfref or hfpef patients statins are not beneficial as adjunctive therapy when prescribed solely for the diagnosis of hf in the absence of other indications for their use. omega-3 polyunsaturated fatty acid (pufa) supplementation is reasonable to use as adjunctive therapy in patients with nyha class ii–iv symptoms and hfref or hfpef, unless contraindicated, to reduce mortality and cardiovascular hospitalizations. 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 in patients with hap/vap caused by a carbapenem-resistant pathogen that is sensitive only to polymyxins, we suggest adjunctive inhaled colistin adjunctive systemic antimicrobial therapy is not routinely indicated but in conjunction with incision and drainage may be beneficial for surgical site infections associated with a significant systemic response such as erythema and induration extending >5 cm from the wound edge, temperature >38.5ºc, heart rate >110/min, or wbc count >12,000/mm3 there is insufficient evidence to support a role for iv bisphosphonates as an adjunctive therapy to radiation therapy in women with pain caused by metastatic bone disease when systemic chemotherapy and/or hormonal therapy is not being used. the role of bisphosphonates vis-a-vis radiation therapy as the sole therapy in this setting has not been determined. in women already being treated with local radiotherapy who have persistent or recurrent pain, bisphosphonates are an attractive but little-studied salvage therapy. studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations . these treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors the task force suggests that clinicians consider short-term testosterone therapy as an adjunctive therapy in human immunodeficiency virus (hiv)-infected men with low testosterone levels and weight loss to promote weight maintenance and gains in lean body mass (lbm) and muscle strength. cognitive-behavioral therapy : studies on cbt in patients with moderate to severe symptoms show improvement in total somatic symptoms, abdominal pain and bowel dysfunction up to 15 months post therapy. few studies on the effects of cbt have been conducted in the last five years but evidence from earlier studies show significant improvement with cbt versus symptom monitoring or medical therapy alone. due to the generally high placebo response rate with functional bowel disorders and the well established psychopathology in ibs, updated high quality studies are needed. based on the expansive literature from the past twenty years on the use of cbt in bowel disorders, this therapy would be recommended as adjunctive therapy in patients with moderate to severe ibs symptoms who have not responded to medical treatment alone. |
| 2 | 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 |
| 3 | adjunctive inhaled colistin | 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 |
| 2 | adjunctive therapy | 7 | statins are not beneficial as adjunctive therapy when prescribed solely for hf omega-3 pufa supplementation is reasonable to use as adjunctive therapy in hfref or hfpef patients statins are not beneficial as adjunctive therapy when prescribed solely for the diagnosis of hf in the absence of other indications for their use. omega-3 polyunsaturated fatty acid (pufa) supplementation is reasonable to use as adjunctive therapy in patients with nyha class ii–iv symptoms and hfref or hfpef, unless contraindicated, to reduce mortality and cardiovascular hospitalizations. there is insufficient evidence to support a role for iv bisphosphonates as an adjunctive therapy to radiation therapy in women with pain caused by metastatic bone disease when systemic chemotherapy and/or hormonal therapy is not being used. the role of bisphosphonates vis-a-vis radiation therapy as the sole therapy in this setting has not been determined. in women already being treated with local radiotherapy who have persistent or recurrent pain, bisphosphonates are an attractive but little-studied salvage therapy. the task force suggests that clinicians consider short-term testosterone therapy as an adjunctive therapy in human immunodeficiency virus (hiv)-infected men with low testosterone levels and weight loss to promote weight maintenance and gains in lean body mass (lbm) and muscle strength. cognitive-behavioral therapy : studies on cbt in patients with moderate to severe symptoms show improvement in total somatic symptoms, abdominal pain and bowel dysfunction up to 15 months post therapy. few studies on the effects of cbt have been conducted in the last five years but evidence from earlier studies show significant improvement with cbt versus symptom monitoring or medical therapy alone. due to the generally high placebo response rate with functional bowel disorders and the well established psychopathology in ibs, updated high quality studies are needed. based on the expansive literature from the past twenty years on the use of cbt in bowel disorders, this therapy would be recommended as adjunctive therapy in patients with moderate to severe ibs symptoms who have not responded to medical treatment alone. |
| 3 | adjunctive therapy patients | 2 | omega-3 polyunsaturated fatty acid (pufa) supplementation is reasonable to use as adjunctive therapy in patients with nyha class ii–iv symptoms and hfref or hfpef, unless contraindicated, to reduce mortality and cardiovascular hospitalizations. cognitive-behavioral therapy : studies on cbt in patients with moderate to severe symptoms show improvement in total somatic symptoms, abdominal pain and bowel dysfunction up to 15 months post therapy. few studies on the effects of cbt have been conducted in the last five years but evidence from earlier studies show significant improvement with cbt versus symptom monitoring or medical therapy alone. due to the generally high placebo response rate with functional bowel disorders and the well established psychopathology in ibs, updated high quality studies are needed. based on the expansive literature from the past twenty years on the use of cbt in bowel disorders, this therapy would be recommended as adjunctive therapy in patients with moderate to severe ibs symptoms who have not responded to medical treatment alone. |
| 3 | adjunctive therapy when | 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. |
| 4 | 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. |
| 5 | 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. |
| 1 | adjuncts | 2 | nonsteroidal anti-inflammatory drugs (nsaids) or acetaminophen may be used as adjuncts to opioids in selected patients. anesthetic agents such as propofol and sedation adjuncts such as droperidol, promethazine, and diphenhydramine are useful in certain patients undergoing endoscopic procedures. while propofol provides faster onset and deeper sedation than standard benzodiazepines and narcotics, as well as faster recovery, clinically important benefits have not been consistently demonstrated in average-risk patients undergoing standard upper and lower endoscopy |
| 1 | adjusted | 2 | fluid and electrolytes water and electrolyte requirements should be adjusted in pediatric patients undergoing surgical procedures or who have on-going losses from stomas or other sites. it is recommended that amlodipine be initiated at 0.1 mg/kg/day to achieve an arterial blood pressure below the 90th percentile for age. dosing frequency may be adjusted from once daily (qday) to twice daily (bid) if indicated. |
| 1 | adjustment | 3 | invasive hemodynamic monitoring can be useful for carefully selected patients with acute hf who have persistent symptoms despite empiric adjustment of standard therapies, and: • whose fluid status, perfusion, or systemic or pulmonary vascular resistance is uncertain; • whose systolic pressure remains low, or is associated with symptoms, despite initial therapy; • whose renal function is worsening with therapy; • who require parenteral vasoactive agents; or • who may need consideration for mechanical circulatory support (mcs) or transplantation. throughout the hospitalization as appropriate, before hospital discharge, at the first postdischarge visit, and in subsequent follow-up visits, the following should be addressed (i-b): a. initiation of gdmt if not previously established and not contraindicated b. precipitant causes of hf, barriers to optimal care transitions, and limitations in postdischarge support c. assessment of volume status and supine/upright hypotension with adjustment of hf therapy, as appropriate d. titration and optimization of chronic oral hf therapy e. assessment of renal function and electrolytes, where appropriate f. assessment and management of comorbid conditions g. reinforcement of hf education, self-care, emergency plans, and need for adherence h. consideration for palliative care or hospice care in selected patients the use of intra-oral devices should be monitored following initiation of therapy to allow device adjustment and assessment of osahs control and symptoms. |
| 1 | adjuvant | 14 | if symptomatic hypotension is absent, intravenous nitroglycerin, nitroprusside, or nesiritide may be considered as an adjuvant to diuretic therapy for relief of dyspnea in patients admitted with acute decompensated hf. 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. in the patient with fully resected stage iiia lung cancer, adjuvant chemotherapy administered alone might offer a very modest survival advantage, but this modality should not be routinely utilized outside of a clinical trial. 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. in selected patients (e.g., those with good performance status, less than 70 years of age, and with no other major comorbidities) who are anthracycline-resistant or who have previously received an anthracycline as adjuvant therapy, the combination of docetaxel and capecitabine is an appropriate therapeutic option. women who have not undergone optimal surgical staging can be offered two options. the first option is that they undergo reoperation to optimally define the tumour stage and then be offered adjuvant therapy based on the findings. the other option is that they be offered platinum-based chemotherapy to decrease the risk of recurrence and improve survival. there is insufficient evidence to make a recommendation on the role of adjuvant pelvic radiation, whole abdominal-pelvic radiotherapy, or intraperitoneal radioactive chromic phosphate. chlorambucil could be considered as an adjuvant drug if more established options cannot be used but there are limited data to support its use. repeated courses of intravenous immunoglobulin could be considered as an adjuvant, maintenance agent in patients with recalcitrant disease who have failed more conventional therapies. in view of reports of a rapid action in some cases, it could be used to help induce remission in patients with severe pv while slower-acting drugs take effect . tetracyclines with or without nicotinamide could be considered as adjuvant treatment, perhaps in milder cases of pv . regardless of surgical staging, adjuvant external beam radiotherapy is recommended for patients at high risk of recurrence is not recommended in patients at low risk of recurrence is a reasonable treatment option for patients at intermediate risk of recurrence two randomized trials detected that adjuvant external beam radiotherapy improved pelvic control, but not survival, when compared to no further treatment. in patients with no adjuvant therapy, salvage radiotherapy may be effective upon vaginal recurrence. when considering adjuvant radiotherapy, the potential improvement in pelvic control needs to be weighed against the toxicity of radiotherapy. radiotherapy was associated with a low incidence of severe acute and late adverse effects; however, many patients experienced mild (grade 1 or 2) side effects. the long-term effects of radiotherapy are unknown at this time. with the potential for substantial grade changes upon pathology review, which may influence decisions regarding adjuvant radiotherapy, it may be important for each jurisdiction to establish a level of quality assurance with specific indications for pathology review. however, the extent to which quality assurance can be determined is outside of the scope of this report. for patients with metastatic breast cancer who have received prior (neo)adjuvant anthracycline therapy, the combination of gemcitabine plus paclitaxel is superior compared to paclitaxel alone as first-line chemotherapy. |
| 2 | adjuvant radiotherapy | 2 | regardless of surgical staging, adjuvant external beam radiotherapy is recommended for patients at high risk of recurrence is not recommended in patients at low risk of recurrence is a reasonable treatment option for patients at intermediate risk of recurrence two randomized trials detected that adjuvant external beam radiotherapy improved pelvic control, but not survival, when compared to no further treatment. in patients with no adjuvant therapy, salvage radiotherapy may be effective upon vaginal recurrence. when considering adjuvant radiotherapy, the potential improvement in pelvic control needs to be weighed against the toxicity of radiotherapy. radiotherapy was associated with a low incidence of severe acute and late adverse effects; however, many patients experienced mild (grade 1 or 2) side effects. the long-term effects of radiotherapy are unknown at this time. with the potential for substantial grade changes upon pathology review, which may influence decisions regarding adjuvant radiotherapy, it may be important for each jurisdiction to establish a level of quality assurance with specific indications for pathology review. however, the extent to which quality assurance can be determined is outside of the scope of this report. |
| 2 | adjuvant therapy | 5 | 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. 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. in selected patients (e.g., those with good performance status, less than 70 years of age, and with no other major comorbidities) who are anthracycline-resistant or who have previously received an anthracycline as adjuvant therapy, the combination of docetaxel and capecitabine is an appropriate therapeutic option. women who have not undergone optimal surgical staging can be offered two options. the first option is that they undergo reoperation to optimally define the tumour stage and then be offered adjuvant therapy based on the findings. the other option is that they be offered platinum-based chemotherapy to decrease the risk of recurrence and improve survival. regardless of surgical staging, adjuvant external beam radiotherapy is recommended for patients at high risk of recurrence is not recommended in patients at low risk of recurrence is a reasonable treatment option for patients at intermediate risk of recurrence two randomized trials detected that adjuvant external beam radiotherapy improved pelvic control, but not survival, when compared to no further treatment. in patients with no adjuvant therapy, salvage radiotherapy may be effective upon vaginal recurrence. when considering adjuvant radiotherapy, the potential improvement in pelvic control needs to be weighed against the toxicity of radiotherapy. radiotherapy was associated with a low incidence of severe acute and late adverse effects; however, many patients experienced mild (grade 1 or 2) side effects. the long-term effects of radiotherapy are unknown at this time. |
| 2 | adjuvant treatment | 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. tetracyclines with or without nicotinamide could be considered as adjuvant treatment, perhaps in milder cases of pv . |
| 1 | administer | 7 | the decision to administer antibiotics directed against s. aureus as an adjunct to incision and drainage should be made based on the presence or absence of systemic inflammatory response syndrome (sirs) such as temperature >38°c or <36°c, tachypnea >24 breaths/min, tachycardia >90 beats/min or white blood cell count (wbc) >12,000 or <4000 cells/mm3 in primary care and specialty medical settings, acip recommends implementation of standing orders to identify adults recommended for hepatitis b vaccination and administer vaccination as part of routine services. to ensure vaccination of adults at risk for hbv infection who have not completed the vaccine series, acip recommends the following implementation strategies: provide information to all adults regarding the health benefits of hepatitis b vaccination, including risk factors for hbv infection and persons for whom vaccination is recommended. help all adults assess their need for vaccination by obtaining a history that emphasizes risks for sexual transmission and percutaneous or mucosal exposure to blood. vaccinate all adults who report risks for hbv infection. vaccinate all adults requesting protection from hbv infection, without requiring them to acknowledge a specific risk factor. for patients with inrs of >9.0 and no significant bleeding, hold warfarin therapy and administer a higher dose of vitamin k1 (5 to 10 mg orally) with the expectation that the inr will be reduced substantially in 24 to 48 hours. monitor the patient more frequently and use additional vitamin k1 if necessary. resume therapy at a lower dose when inr is in the therapeutic range . for patients undergoing cabg who have no other indication for vitamin k antagonists (vkas), the guideline developers suggest clinicians not administer vkas . clinicians should administer hav vaccination early in the course of human immunodeficiency virus (hiv) infection. if a patient's cd4 count is <300 cells/mm3 or the patient has symptomatic hiv disease, it is preferable to defer vaccination until several months after initiation of antiretroviral (arv) therapy in an attempt to maximize the antibody response to the vaccine. the decision regarding which product to use should be based on the following: the presence of comorbid conditions (for example, tic disorders, tourette's syndrome, epilepsy) the different adverse effects of the drugs specific issues regarding compliance identified for the individual child or adolescent, for example problems created by the need to administer a mid-day treatment dose at school the potential for drug diversion (where the medication is forwarded on to others for non-prescription uses) and/or misuse the preferences of the child/adolescent and/or his or her parent or guardian. clinicians should inform patients how to administer topical drops. when the ear canal is obstructed, delivery of topical preparations should be enhanced by aural toilet, placement of a wick, or both. |
| 2 | administer vaccination | 2 | in primary care and specialty medical settings, acip recommends implementation of standing orders to identify adults recommended for hepatitis b vaccination and administer vaccination as part of routine services. to ensure vaccination of adults at risk for hbv infection who have not completed the vaccine series, acip recommends the following implementation strategies: provide information to all adults regarding the health benefits of hepatitis b vaccination, including risk factors for hbv infection and persons for whom vaccination is recommended. help all adults assess their need for vaccination by obtaining a history that emphasizes risks for sexual transmission and percutaneous or mucosal exposure to blood. vaccinate all adults who report risks for hbv infection. vaccinate all adults requesting protection from hbv infection, without requiring them to acknowledge a specific risk factor. clinicians should administer hav vaccination early in the course of human immunodeficiency virus (hiv) infection. if a patient's cd4 count is <300 cells/mm3 or the patient has symptomatic hiv disease, it is preferable to defer vaccination until several months after initiation of antiretroviral (arv) therapy in an attempt to maximize the antibody response to the vaccine. |
| 1 | administered | 26 | 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. antibiotics should be administered intravenously initially, but once the patient is clinically improved oral antibiotics are appropriate for patients in whom bacteremia cleared promptly and there is no evidence of endocarditis or metastatic abscess. two to three weeks of therapy is recommended. tetanus toxoid should be administered to patients without toxoid vaccination within 10 years. tdap is preferred over td if the former has not been previously given (sr-l). acyclovir should be administered to patients suspected or confirmed to have cutaneous or disseminated herpes simplex (hsv) or varicella zoster virus (vzv) infection (sr-m). empiric administration of vancomycin or other agents with gram-positive activity (linezolid, daptomycin or ceftaroline) should be added if not already being administered 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. neuropsychologic batteries should be considered useful in identifying patients with dementia, particularly when administered to a population at increased risk of cognitive impairment. in the absence of reliable information concerning compatibility of a specific drug with an sns formula, the medication should be administered separately from the sns . in the patient with fully resected stage iiia lung cancer, adjuvant chemotherapy administered alone might offer a very modest survival advantage, but this modality should not be routinely utilized outside of a clinical trial. combination platinum-based chemotherapy can be administered safely and with acceptable and manageable toxicity profiles in patients with good ps who have stage iv nsclc. in patients who do not respond to external beam radiation for the relief of pain caused by bony metastases, bisphosphonates can be administered alone or as an adjunct to external radiation therapy for bone metastases. if endogenous erythropoietin levels are <500 munits/ml, erythropoietin therapy (50-200 iu/kg/dose 3 times/week) should be administered to reduce the need for transfusion. supplemental oral iron (3-6 mg/kg/day of elemental iron) and folate (1 mg/day) should be administered when erythropoietin is initiated. antibiotics prolong the latency period and improve perinatal outcome in patients with preterm prom and should be administered according to one of several published protocols if expectant management is to be pursued prior to 35 weeks of gestation. 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. the laboratory screening test should consist of a 50-g, 1-hour oral glucose challenge at 24â??28 weeks of gestation, which may be administered without regard to the time of the last meal. because of the potential toxicity of mitoxantrone, it should be administered under the supervision of a physician experienced in the use of cytotoxic chemotherapeutic agents . in addition, patients being treated with mitoxantrone should be monitored routinely for cardiac, liver, and kidney function abnormalities . the most commonly used taxane-based regimens in north america have been administered on a three-weekly schedule and include: i) docetaxel 75 mg/m2 with cisplatin 75 mg/m2, ii) paclitaxel 225 mg/m2 as a 3-hour infusion with carboplatin area under the curve (auc) 6, and iii) paclitaxel 135 mg/m2 as a 24-hour infusion with cisplatin 75 mg/m2. however, there have been few direct comparisons of different doses and schedules for taxane-based combinations, and firm recommendations regarding optimal doses and schedules cannot be made at this time. activated charcoal can be considered if local poison center policies support its prehospital use, a toxic dose of acetaminophen has been taken, and fewer than 2 hours have elapsed since the ingestion . gastrointestinal decontamination could be particularly important if acetylcysteine cannot be administered within 8 hours of ingestion. children 7 through 9 years of age who never received any pediatric dtp/dtap/dt or td dose generally should receive 3 doses of td: dose 2 is administered 4 weeks or more after dose 1, and dose 3 is administered 6 to 12 months or longer after dose 2. a 10-year-old child could receive boostrix for 1 of these doses. a single dose of tdap is recommended for adolescents 11 to 18 years of age who have completed a 3-dose td series if the series did not include boostrix during the 10th year; an interval of at least 5 years between the most recent td dose and tdap is suggested . children 7 to 10 years of age who received other incomplete immunization schedules against tetanus, diphtheria, and pertussis should be immunized against tetanus and diphtheria according to catch-up recommendations (aap, 2003) using an all-td schedule (except children in their 10th year, who could receive a single dose of boostrix substituted for 1 dose of td).children with no history or an incomplete history of pediatric dtp/dtap/dt or td immunization could have received doses. health care professionals can obtain serologic testing for antibodies against tetanus and diphtheria. toxoids in these children. if tetanus and diphtheria toxoid antibody concentrations are each protective at >0.1 iu/ml, then the child can be presumed to have been immunized against tetanus, diphtheria, and possibly pertussis, and td immunization may be deferred until the child is 11 to 12 years of age, when tdap vaccine should be given. if tdap (or td) vaccine and mcv4 are both indicated for adolescents but only 1 vaccine is available, the available vaccine generally should be administered and the other administered when the missed vaccine becomes available. if simultaneous immunization is not feasible, the aap suggests a minimum interval of 1 month between administration of tdap and mcv4. to foster client centred care consistently throughout an organization, healthcare services must be organized and administered in ways that ensure that all caregivers, regardless of their personal attributes, enact this practice successfully. single-agent pemetrexed (alimta®) at a dose of 500 mg/m2 every three weeks is also an option for second-line therapy of recurrent or progressive disease, if available. this chemotherapy should be administered with vitamin supplements: oral folic acid 350-1,000 micrograms daily and intramuscular vitamin b12 1,000 micrograms every nine weeks, beginning between one to two weeks before, and continuing until three weeks after chemotherapy. each patient should be appropriately monitored with use of dual-energy x-ray absorptiometry as well as known clinical factors of fracture risk to determine the adequacy of an administered dose of estrogen . recommendations:desensitization: patients who have a positive skin test to one of the penicillin determinants can be desensitized (see table 1 in the original guideline for an oral desensitization protocol). this is a straightforward, relatively safe procedure that can be performed orally or intravenously. although the two approaches have not been compared, oral desensitization is regarded as safer to use and easier to perform. patients should be desensitized in a hospital setting because serious ige-mediated allergic reactions can occur. desensitization usually can be completed in approximately 4 hours, after which the first dose of penicillin is administered. after desensitization, patients must be maintained on penicillin continuously for the duration of the course of therapy. |
| 2 | administered alone | 2 | in the patient with fully resected stage iiia lung cancer, adjuvant chemotherapy administered alone might offer a very modest survival advantage, but this modality should not be routinely utilized outside of a clinical trial. in patients who do not respond to external beam radiation for the relief of pain caused by bony metastases, bisphosphonates can be administered alone or as an adjunct to external radiation therapy for bone metastases. |
| 2 | 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. |
| 3 | administered hours before | 2 | alternatives for thromboprophylaxis fo |