AUGUST EDITION New Guidelines and Recommendations Review the latest information released by the following organizat ¥ American Academy of Pediatric Dentistry ¥ American Academy of Pediatrics ¥ American Academy of Sleep Medicine ¥ American CancerSociety ~ American Society of Clinical Oncology ¥ American ThoracicSaciety Y Collaboration on FASD Prevalence Y Collaborative Initiative on Fetal Alcohol Spectrum Disorders European League Against Rheumatism ¥ Infectious Diseases Society of America ¥ Myasthenia Gravis Foundation of America National Institute on Alcohol Abuseand Alcoholism Forpermeioy i reuse ME coMmnt peSEE comet Ifeseeape at germienone@owone netFetal Alcohol Spectrum Disorders Guidelines on fetal alcohol spectrum disorders by collaborative efforts, including the National Institute on Alcohol Abuse and Alcoholism, Collaborative Initiative on Fetal Alcohol Spectrum Disorders, and the Collaboration on FASD Prevalence*? + The guideline retains the 4 diagnostic categories from the original Institute of Medicine guideline—fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (PFAS}, alcohol-related neurodevelopmental disorder (ARND), and alcohol-related birth defects (ARBD). * The definition of alcohol exposure includes at least 6 drinks/wk during at least 2 wk of pregnancy, or at least 3 drinks per occasion on 2 or more occasions. * After assessing maternal alcohol intake, the guidelines recommend evaluating facial features. A positive result includes 2 of the following 3 criteria: short palpebral fissures, smooth philtrum, and thin vermilion border of the upper lip. If either this test or maternal alcohol intake is positive, a neuropsychology evaluation is recommended. Continued on next slide Molocape | Mesias orgs Lotus ©256 weabD. LLC Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttFetal Alcohol Spectrum Disorders ing Guidelines on fetal alcohol spectrum disorders by collaborative efforts, including the National Institute on Alcohol Abuse and Alcoholism, Collaborative Initiative on Fetal Alcohol Spectrum Disorders, and the Collaboration on FASD Prevalence*? + Dysmorphology evaluation: Cutoff levels for height, weight, head circumference, and palpebral fissure length are <10th percentile. The guideline includes a new lip and philtrum photographic guide and provides an updated dysmorphology scoring system. + Neurodevelopment and neuropsychology assessment: Cutoffs for standardized testing are 21.5 standard deviations below the mean of the normative group used to develop the test. Molocape | Mesias orgs Lotus ©256 weabD. LLC Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn tter cena LL OAL Ud LA ad LED Guidelines on chronic painin cancer survivors by the American Society of Clinical Oncology’ * Screen for pain each time you see the patient by using a quantitative tool, suchas a 2-question verbal screen. This can be as simple as asking, "Have you had frequent or persistent pain since the last time you were seen?" Ifthe answer is yes, then ask, "How severe has this pain been, on average, during the past week?" A verbal rating scale or a numeric scale can then be used to identify patients who should undergo an initial comprehensive pain assessment. * Create the initial comprehensive pain assessment using an in-depth interview to determine cause and develop a treatment plan. The interview should solicit information on cancer treatment, comorbid conditions, and psychosocial and psychiatric history—including substance use—and prior treatments for pain. + Be aware that many patients with a history of cancer may also report chronic pain unrelated to the cancer, such as arthritis, degenerative disk disease, or diabetic neuropathy. * Evaluate, treat, and monitor recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain. icomtinttecl on nent ences Molocape | Mesias orgs Lotus ©256 weabD. LLC Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttrece a LM OSL URSA Le Ld Guidelines on chronic painin cancer survivors by the American Society of Clinical Oncology’ * Determine the need to get other health professionals involved. Refer accordingly. * Inthe absence of serious drug-drug interactions, nonsteroidal anti-inflammatory drugs, acetaminophen, adjuvant analgesics (including selected antidepressants, such as duloxetine), and selected anticonvulsants (such as gabapentin or pregabalin and anticonvulsants for neuropathic pain conditions or chronic widespread pain) may be prescribed. * The efficacy and long-term effectiveness of other systemic nonopioids, including other antidepressants and anticonvulsant drugs, as well as complementary or alternative medicines, have not been established. * Topical analgesics, such as nonsteroidal anti-inflammatory drugs, local anesthetics, or compounded creams/gels containing baclofen, amitriptyline, and ketamine, may be prescribed. * Corticosteroids are not recommended for long-term relief of chronic pain in cancer survivors. Continued on next slide Molocape | Mesias orgs Lotus ©256 weabD. LLC Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttrece a LM OSL URSA Le Ld Guidelines on chronic painin cancer survivors by the American Society of Clinical Oncology’ * Clinicians may follow specific state regulations that allow access to medical cannabis or cannabinoids. + Atrial of opioids may be prescribed in selected cancer survivors after assessment of risks for adverse effects and the potential risks and benefits with long-term use. + Patients and family member/caregivers should be educated about use of opioids, and the patient's literacy level and/or cultural background should be considered. * Auniversal precautions approach to minimize abuse, including random toxicology screening, is recommended. * Exercise caution in co-prescribing other centrally acting drugs, particularly benzodiazepines. * If opioids are no longer warranted, taper the dose to avoid abstinence syndrome and consider co-therapies to reduce adverse effects. Molocape | Mesias orgs Lotus ©256 weabD. LLC Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttDalat lN ees) 9)] eu mm Cered 3) Guidelines on human papillomavirus vaccination by the American Cancer Society* + The American Cancer Society (ACS) recommends that all girls and boys aged 11-12 yr receive the HPV vaccine. * The HPV vaccination series can be started at age 9 yr. + The vaccination series should be completed by age 13 yr to increase effectiveness; late vaccination should be completed as soon as possible. * Vaccination should occur in females aged 13-26 yr and males aged 13-21 yr who. have not been previously vaccinated or who have not completed the 3-dose series. Males aged 22-26 yr may also be vaccinated. + Vaccination is recommended through age 26 yr in men who have sex with men and for immunocompromised individuals, including those with HIV, if not previously vaccinated. + Patients aged 22-26 yr who have not received the vaccine or have not completed the series should be advised that the vaccine becomes less effective at lowering cancer riskat older ages. Continued on next slide Molocape | Mesias orgs Lotus ©256 weabD. LLC Forpemasion 1 rete Ps om, plate comet Wasaga pease juenn ttgn a eel] Vee Guidelines on human papillomavirus vaccination by the American Cancer Society* * HPV vaccination should be given along with other routine adolescent vaccines, such as Tdap and MCV4. * Females can receive vaccination with the bivalent (2vHPV), quadrivalent (4vHPV) (as long as the vaccine remains available), or 9VHPV vaccine. * Males can receive vaccination with the 4vHPV (as long as the vaccine remains available) or SVHPV vaccine. Makape | Meseeape Orgs &Oenees ©2016 wee, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rtHospita-Acquired and Ventilator-Associated Pneumonia Guidelines on management of adults with hospital-acquired and ventilator-associated pneumonia by the Infectious Diseases Society of America and the American Thoracic Society® * Recommended that each hospital generate antibiograms to guide healthcare professionals with respect to the optimal choice of antibiotics. * In an effort to minimize patient harm and exposure to unnecessary antibiotics and reduce the development of antibiotic resistance, the guidelines recommend that the antibiogram data be utilized to decrease the unnecessary use of dual gram- negative and empiric methicillin-resistant Staphylococcus aureus (MRSA) a! treatment. * Short-course antibiotic therapy recommended for most patients with HAP or VAP independent of microbial etiology, as well as antibiotic de-escalation. * Suggested that noninvasive sampling be done with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures and rather than noninvasive sampling with quantitative cultures. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Forpermcioe ty reute Mie coMnt lEBEE covet Ideceeape at germenonemuems netHospita-Acquired and Ventilator-Associated Pneumonia cont'd Guidelines on management of adults with hospital-acquired and ventilator-associated pneumonia by the Infectious Diseases Society of America and the American Thoracic Society® * However, the panel recognizes that invasive quantitative cultures will occasionally be performed by some clinicians. For patients with suspected VAP whose invasive quantitative culture results are below the diagnostic threshold for VAP, the guidelines suggest that antibiotics be withheld rather than continued. * Suggested 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. * For patients with suspected HAP/VAP, the guidelines recommend using clinical criteria alone, rather than using serum procalcitonin (PCT) plus clinical crit bronchoalveolar lavage fluid (BALF) sTREM-1 plus clinical criteria, or C-reactive protein (CRP) plus clinical criteria to decide whether or not to initiate antibiot therapy. + Inpatients with suspected VAP, include coverage for S aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens. @ 8 8 pine reg Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Forpermcioe ty reute Mie coMnt lEBEE covet Ideceeape at germenonemuems netGuidelines on management of adults with hospital-acquired and ventilator-associated pneumonia by the Infectious Diseases Society of America and the American Thoracic Society® Ifempiric coverage for MRSA is indicated, either vancomycin or linezolid is recommended. When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, the guidelines suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. Oxacillin, nafcillin, and 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 being treated empirically for HAP, prescribe an antibiotic with activity against $ aureus. For patients with HAP who require empiric coverage for MRSA, vancomycin or linezolid is recommended. For patients with HAP/VAP due to P aeruginosa, the guidelines recommend that the choice of an antibiotic for definitive (not empiric) therapy be based on the results of antimicrobial susceptibility testing. For patients with VAP or HAP, a 7-day course of antimicrobial therapy is recommended. Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Forpermcioe ty reute Mie coMnt lEBEE covet Ideceeape at germenonemuems neteS eee Guidelines on the management of aspergillosis by the Infectious Diseases Society of America®’ + Submit tissue and fluid specimens for histopathologic, cytologic, and culture examination to diagnose invasive aspergillosis, However, molecular techniques, such as DNA sequencing, should be used to identify Aspergillus species in cases that involve either isolates with atypical growth or concern for resistance. + Ifinvasive pulmonary aspergillosis (IPA) is suspected, the guidelines recommend performing computed tomography scanning of the chest, regardless of chest radiography findings. Bronchoscopy with bronchoalveolar lavage is also recommended in such cases, unless significant comorbidities (eg, bleeding or severe hypoxemia) preclude it. * Detection of galactomannan (a component of the Aspergillus cell wall) in serum or bronchoalveolar lavage fluid is recommended as an accurate marker for the diagnosis of invasive aspergillosis in adults and children, when used in certain patient subpopulations, such as hematopoietic stem cell transplant recipients or patients with hematologic malignancies. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natAspergillosis c Guidelines on the management of aspergillosis by the Infectious Diseases Society of America®’ Serum assays for (1 3-3)-B-D-glucan are recommended for diagnosing invasive aspergillosis in high-risk patients (hematologic malignancy, allogeneic hematopoietic stem cell transplant), but are not specific for Aspergillus. If IPA is suspected, antifungal therapy should be initiated while diagnostic evaluation is ongoing. Voriconazole is recommended for primary treatment of IPA, although combination therapy with voriconazole and echinocandin may be warranted for some high-risk patients. * Antifungal therapy for IPA should continue for at least 6-12 wk. Antifungal prophylaxis should also be instituted for patients with prolonged neutropenia who are at high risk for invasive aspergillosis. Prophylactic regimens with posaconazole, voriconazole, and/or micafungin are considered to be most effective. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natyor 16)] es es Guidelines on the management of aspergillosis by the Infectious Diseases Society of America®’ “Amphotericin B (AmB) deoxycholate and its lipid derivatives are appropriate options for initial and salvage therapy of Aspergillus infections when voriconazole cannot be administered. However, AmB deoxycholate should be reserved for use in resource-limited settings in which no alternative agents are available. Lipid formulations of AmB should be considered in settings in which azoles are contraindicated or not tolerated. Aerosolized formulations of AmB may be considered as prophylaxis in patients with prolonged neutropenia (patients receiving induction/reinduction therapy for acute leukemia and allogeneic HSCT recipients following conditioning or during treatment of graft-vs-host disease [GVHD)]) and in lung transplant recipients. * Echinocandins are effective in salvage therapy (either alone or in combination) against invasive aspergillosis, but they are not recommended for routine use as monotherapy for the primary treatment of invasive aspergillosis. Triazoles are preferred agents for treatment and prevention of invasive aspergillosis in most patients. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natyor 16)] es es Guidelines on the management of aspergillosis by the Infectious Diseases Society of America®’ + Surgery for aspergillosis should be considered for localized disease that is easily accessible to debridement (eg, invasive fungal sinusitis or localized cutaneous disease). + The guidelines recommend that both surgery and either systemic voriconazole or a lipid formulation of AmB be used in invasive Aspergillus fungal sinusitis, but surgical removal alone can be used to treat Aspergillus fungal ball of the paranasal sinus. Enlargement of the sinus ostomy may be needed to improve drainage and prevent recurrence, + Prophylaxis recommended with posaconazole, voriconazole, and/or micafungin during prolonged neutropenia for those who are at high risk for invasive aspergillosis. * The guidelines do not recommend routine testing for antifungal susceptibility testing. Instead, it should be reserved for cases in which infection with an azole- resistant isolate is suspected or in which a patient is unresponsive to antifungal agents. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natyor 16)] es es Guidelines on the management of aspergillosis by the Infectious Diseases Society of America®’ The guidelines recommend using the same antifungal agents for treatment of aspergillosis in children as are used in adults. However, dosing of many of these agents may be different for children. The authors also note that although voriconazole is only approved by the US Food and Drug Administration for children aged 12 yr and older, it is the cornerstone of aspergillosis treatment in children of all ages. + A follow-up chest CT scan is suggested to assess the response of IPA to treatment after a minimum of 2 wk of treatment; earlier assessment is indicated if the patient clinically deteriorates. When a nodule is close to a large vessel, more frequent monitoring may be required. Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natLae UMM egt Lcd) Guidelines on pediatric sedation by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry®? + The safe sedation of children requires a systematic approach that includes the following: Ay 6. 7. 8 No administration of sedating medication without the safety net of medical/dental supervision. jons that, Careful pre-sedation evaluation for underlying medical or surgical cot would place the child at increased risk from sedating medications. Appropriate fasting for elective proceduresand a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure. A focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increasethe potential for airway obstruction. A clear understanding of the medication’s pharmacokineticand pharmacodynamic effectsand drug interactions. Appropriate training and skills in airway management to allow rescue of the patient. Age- andsize-appropriate equipment for airway management and venousaccess. Appropriate medications andreversal agents. Continued on next slide Meclacape | Wasteape Drage £ olaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natLeast eMac Lc cL) Guidelines on pediatric sedation by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry®? (cont'd) 9. Sufficient numbers of staffto both carry out the procedureand monitor the patient. 10. Appropriate physiologic monitoring during and after the procedure. 11. A properly equipped and staffed recovery area. 12. Recovery to the pre-sedation level of consciousness before discharge from medical/dental supervision. 13. Appropriate discharge instructions, * Its common for children to pass from the intended level of sedation to a deeper, unintended level of sedation, making the concept of rescue essential to safe sedation. Practitioners who use sedation must have the facilities, personnel, and equipment to manage emergencies and rescue the child. They must have ready access to emergency medical services but also must be able to manage emergencies until those services arrive. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natLeast eMac Lc cL) Guidelines on pediatric sedation by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry®? + The assistant tothe person who is doing the sedating should have pediatric advanced life support training. * Ifthe intended level of sedation is minimal, practitioners must be able to rescue from moderate sedation; if the intended level of sedation is moderate, practitioners must have the skills to rescue from deep sedation; if the intended level of sedation is deep, practitioners must have the skills to rescue from a state of general anesthesia. The ability to rescue means that practitioners must be able to recognize the various levels of sedation and have the skills and age- and size- appropriate equipment necessary to provide appropriate cardiopulmonary support ifneeded. + The skills needed to rescue a child with apnea, laryngospasm, and/or airway obstruction include the ability to open the airway; suction secretions; provide continuous positive airway pressure (CPAP); perform successful bag-valve-mask ventilation; insert an oral airway, a nasopharyngeal airway, or a laryngeal mask airway (LMA); and, rarely, perform tracheal intubation. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Forpermcioe ty reute Mie coMnt lEBEE covet Ideceeape at germenonemuems netLeast eMac Lc cL) Guidelines on pediatric sedation by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry®? 1 physiologic monitoring and continuous observation by personnel not volved with the procedure allow for the accurate and rapid diagnosis of complications and initiation of appropriate rescue interventions. * Children younger than 6 yr (particularly those younger than 6 mo) may be at greatest risk of an adverse event. Children in this age group are particularly vulnerable to the sedating medication’s effects on respiratory drive, airway patency, and protective airway reflexes. Other modalities, such as careful preparation, parental presence, hypnosis, distraction, topical local anesthetics, electronic devices with age-appropriate games or videos, guided imagery, and the techniques advised by child life specialists, may reduce the need for, or the needed depth of, pharmacologic sedation. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natLeast eMac Lc cL) Guidelines on pediatric sedation by the American Academy of Pediatrics and the American Academy of Pediatric Dentistry®? + The practitioner who uses sedation must have immediately available facilities, personnel, and equipment to manage emergency and rescue situations. The most common serious complications of sedation involve compromise of the airway or depressed respirations resulting in airway obstruction, hypoventilation, laryngospasm, hypoxemia, and apnea. Hypotension and cardiopulmonary arrest may occur, usually from the inadequate recognition and treatment of respiratory compromise. Other rare complications may include seizures, vomiting, and allergic reactions. Facilities providing pediatric sedation should monitor for, and be prepared to treat, such complications. * An emergency cart or kit must be immediately accessible. This cart or kit must contain the necessary age- and size-appropriate equipment (eg, oral and nasal airways, bag-valve-mask device, LMAs or other supraglottic devices, laryngoscope blades, tracheal tubes, face masks, blood pressure cuffs, intravenous catheters) to resuscitate a nonbreathing and unconscious chi Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Forpermcioe ty reute Mie coMnt lEBEE covet Ideceeape at germenonemuems netGuidelines on fibromyalgia by the European League Against Rheumatism” A ‘strong for’ recommendation for the use of exercise, particularly given its effect on pain, physical function and well-being, availability, relatively low cost, and lack of safety concerns. Some non-pharmacologic therapies not recommended because of lack of effectiveness and/or low study quality include biofeedback, capsaicin, hypnotherapy, massage, and SAMe and other complementary and alternative therapies. A ‘strong against’ evaluation for chiropractic, based on safety concerns. Psychological therapies may be considered for those with mood disorder or unhelpful coping strategies: cognitive-behavioral therapy has shown effectiveness at producing modest, long-term reductions in pain and disability, as well as improving mood. Pharmacologic therapies may be considered for patients with severe pain (eg, duloxetine, pregabalin, tramadol) or sleep disturbance (eg, amitriptyline, cyclobenzaprine, pregabalin). Several pharmacologic therapies not recommended, including NSAIDs, MAOIs and SSRIs because of lack of efficacy. A ‘strong against’ evaluation for growth hormone, sodium oxybate, strong opioids, and corticosteroids, based on lack of efficacy and high risk of side effects. Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme nat‘YY Myasthenia Gravis Guidelines on myasthenia gravis by the Myasthenia Gravis Foundation of America!! + Pyridostigmine should be part of the initial treatment in most patients. The dose should be adjusted as needed on the basis of symptoms. The ability to discontinue pyridostigmine may indicate that the patient has met treatment goals and may guide the tapering of other therapies. * Corticosteroids or immunosuppressive therapy should be used in all patients who have not met treatment goals after an adequate trial of pyridostigmine. * Anonsteroidal immunosuppressive agent should be used alone when corticosteroids are contraindicated or the patient declines them or can be used initially in conjunction with corticosteroids when the risk for steroid side effects is high based on medical comorbidities. * Anonsteroidal immunosuppressive agent should be added to corticosteroids when significant steroid side effects develop, response to steroids is inadequate, or the steroid dose cannot be reduced because of symptom relapse. Nonsteroidal immunosuppressive agents that can be used include azathioprine, cyclosporine, mycophenolate mofetil, methotrexate, and tacrolimus. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Forpermcioe ty reute Mie coMnt lEBEE covet Ideceeape at germenonemuems net‘YY Myasthenia Gravis cont’ Guidelines on myasthenia gravis by the Myasthenia Gravis Foundation of America!! * Patients with refractory myasthenia gravis should be referred to an expert in management of the condition, and the following therapies may also be used: chronic intravenous immunoglobulin and plasma exchange, cyclophosphamide, and rituximab. * Immunosuppressive agent dosage and duration of treatment: Once patients achieve treatment goals, the corticosteroid dose should be gradually tapered. In many patients, continuing a low dose of corticosteroids long term can help maintain the treatment goal. * For nonsteroidal immunosuppressive agents, once treatment goals have been achieved and maintained for 6 mo to 2 yr, the dose should be tapered slowly to the minimal effective amount. Dosage should be adjusted no more frequently than every 3-6 mo. Tapering of drugs is associated with risk for relapse, which may necessitate upward adjustments in dose. The risk for relapse is higher in patients who are symptomatic or after rapid taper. It is usually necessary to maintain some immunosuppression for many years, sometimes for life. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natbMS eS ne) Guidelines on myasthenia gravis by the Myasthenia Gravis Foundation of America!’ * Patients must be monitored for potential adverse effects and complications from immunosuppressive drugs. Changing to an altemative agent should be considered if adverse effects and complications are medically significant or create undue hardship for the patient. Movlscipe | Meshap ones Oasaes ©2016 wenbD ULe Furgemin © re ns conan pate coma Uses a pemssinsgesane re9 sui eeu) Guidelines on adolescent suicide prevention by the American Academy of Pediatrics’? CULL) * Include questions about risk factors for suicide in routine history taking, perhaps including a depression scale. The report suggests specific questions to start conversations and sensitively inquire about suicide ideation, as well as how to follow up on the answers. The AAP advises conducting interviews without the parents present, but informing patients that parents will be notified if suicide risk is found. * Be familiar with and educate appropriate patients about possible benefits and risks of antidepressants. Recognize that adolescents with mood disorders present in several ways. * Work closely with family members, other healthcare professionals, and emergency departments to best assist adolescents at risk for suicide. * Provide information on local resources for preventing suicide. * Obtain additional training in diagnosing and treating mood disorders in adolescents, if necessary. + Identify homes that have firearms, inquire about how the weapons are stored, and inform parents about the increased risk for adolescent suicide in homes that have guns. Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natz" Sleep Requirements. for Children Guidelines on sleep requirements for children by the American Academy of Sleep Medicine’ * Infants 4-12 mo: 12-16 hr of sleep (including naps) * Children 1-2 yr of age: 11-14 hr (including naps) * Children 3-5 yr of age: 10-13 hr (including naps) * Children 6-12 yr of age: 9-12 hr * Teenagers 13-18 yr of age: 8-10 hr Movlscipe | Meshap ones Oasaes ©2016 wenbD ULe Furgemin © re ns conan pate coma Uses a pemssinsgesane rera eres Guidelines on pancreatic cancer by the American Society of Clinical Oncology" > Potentially Curable Pancreatic Cancer Even potentially curable pancreatic cancer, which represents only about 20% of all patients, has a 5-yr overall survival rate of 25-30% at best. After histopathologic confirmation of the diagnosis, clinicians should perform a multiphase CT scan of the abdomen and pelvis using a pancreatic protocol or MRI to gauge the anatomic relations of the tumor to other internal structures and to evaluate patients for the presence of intra-abdominal metastases. Supplemental studies might include endoscopic ultrasound, diagnostic laparoscopy, or both. Appropriate candidates for primary tumor and regional lymph node resection should meet the following criteria: (1) No clinical evidence for metastatic disease, (2) a performance status and comorbidity profile that can withstand major abdominal surgery, (3) no radiographic interface between primary tumor and mesenteric vasculature, and (4) a CA 19-9 level suggestive of localized disease. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natreer Ua Oxo LL LL Guidelines on pancreatic cancer by the American Society of Clinical Oncology" > Potentially Curable Pancreatic Cancer cont'd Recommended first-line treatment for metastatic pancreatic cancer is the so- called FOLFIRINOX regimen, which consists of leucovorin, fluorouracil, irinotecan, and oxaliplatin. This protocol can be offered to anyone with a performance status of 0 or 1 and a favorable comorbidity profile who wants to and is able to withstand an aggressive medical regimen. Alternatively, patients who meet the same eligibility criteria can be treated with gemcitabine plus nanoparticle albumin-bound (NAB)-paclitaxel. For those with more advanced disease (performance status, 2) or who cannot tolerate a more aggressive regimen but who still wish to receive cancer-directed therapy, gemcitabine can be given alone or together with either capecitabine or erloti For patients who experience either disease progression on first-line therapy or intolerable toxicity, gemcitabine plus NAB-paclitaxel may be used as second-line therapy, provided patients want and can tolerate aggressive medical treatment. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natreer Ua Oxo LL LL Guidelines on pancreatic cancer by the American Society of Clinical Oncology" > Potentially Curable Pancreatic Cancer cont'd Alternatively, fluorouracil plus oxaliplatin, irinotecan, or nanoliposomal irinotecan can be given as second-line therapy if patients have already received gemcitabine plus NAB-paclitaxel and want to and are able to withstand an aggressive treatment protocol. For those who cannot tolerate aggressive therapy, clinicians can offer either gemcitabine or fluorouracil as a second-line option. All patients with resected pancreatic cancer who did not receive preoperative therapy should be offered 6 mo of adjuvant chemotherapy with either gemcitabine or fluorouracil plus folinic acid in the absence of medical or surgical contraindications. Patients who might benefit from preoperative therapy include those in whom radiographic findings are suspicious but not diagnostic for extrapancreatic disease. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natreer Ua Oxo LL LL Guidelines on pancreatic cancer by the American Society of Clinical Oncology" > Potentially Curable Pancreatic Cancer cont'd * Treatment should be ii jated in the 8 wk after surgery (assuming full recovery). Patients who have not received preoperative therapy and who have microscopically positive margins or node-positive disease after 4-6 mo of adjuvant chemotherapy should be offered adjuvant chemoradiation. * Patients should receive a total of 6 mo of adjuvant therapy, including time spent ‘on the preoperative regimen. * Patients might also need ongoing supportive care for symptoms that result from the treatment itself, and they should be followed every 3-6 mo after completion of their treatment course. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natreer Ua Oxo LL LL Guidelines on pancreatic cancer by the American Society of Clinical Oncology" > Locally Advanced Pancreatic Cancer With an expected 5-yr overall survival rate of less than 5%, recommendations for the management of locally advanced pancreatic (LAPC) are more limited than they are for potentially curable disease. Clinicians should use multiple CT scans to assess disease extent in the chest, abdomen, and pelvis, but the guidelines do not recommend the use of other staging studies on a routine basis. Patients should be assessed for baseline performance status, symptom burden, and comorbidities, and clinicians again need to discuss the goals of treatment in collaboration with a multidisciplinary team shaped by patient preferences. Chemoradiotherapy (CRT) or stereotactic body radiotherapy (SBRT) may be offered to patients with local progression but no metastases, provided they have a performance status of 2 or less and a favorable comorbidity profile. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natGuidelines on pancreatic cancer by the American Society of Clinical Oncology" ® Locally Advanced Pancreatic Cancer cont'd * CRT may be offered to patients who have responded to an initial 6 mo of chemotherapy or have stable disease, have developed unacceptable chemotherapy-related toxicities, or show a decline in performance status as a consequence of chemotherapy toxicity. * If patients respond to CRT or if their disease has at least stabilized after 6 mo of induction CRT, CRT may be offered as an alternative to continuing chemotherapy alone for any patient with LAPC. + Patients with LAPC can be offered SBRT even though evidence supporting SBRT is not robust. * On completion of treatment, LAPC patients whose disease has stabilized or who have no disease progression should have a follow-up visit every 2-3 mo in which they undergo liver and renal function tests. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natTrea OL LLL Guidelines on pancreatic cancer by the American Society of Clinical Oncology > Locally Advanced Pancreatic Cancer cont'd * Patients should be tested for CA 19-9 levels and undergo CT scans at least every 3 mo inthe first 2 yr after completion of treatment, and every 6 mo if disease remains stable. * Any patient who does not benefit from first-line treatment recommendations and who progresses despite clinicians’ best efforts should be treated according to the ASCO guidelines for the treatment of metastatic pancreatic cancer (see below). > Metastatic Pancreatic Cancer + For patients with metastatic pancreatic cancer, median life expectancy is less than 1 yr, and the S-yr overall survival rate is only 2%. Continued on next slide Meclscape | MADEeRpe Drage & Oneszes ©2016 WeRVD. ULE Forpemnesion 1 reuse Pic some place some Maser at permistioneguenne netreer Ua Oxo LL LL Guidelines on pancreatic cancer by the American Society of Clinical Oncology" > Metastatic Pancreatic Cancer cont'd Recommended first-line treatment for metastatic pancreatic cancer is the so- called FOLFIRINOX regimen, which consists of leucovorin, fluorouracil, irinotecan, and oxaliplatin. This protocol can be offered to anyone with a performance status of 0 or 1 and a favorable comorbidity profile who wants to and is able to withstand an aggressive medical regimen. The FOLFIRINOX regimen also requires that patients have a chemotherapy por and access to infusion pump services. Alternatively, patients who meet the same eligibility criteria can be treated with gemcitabine plus nanoparticle albumin-bound (NAB)-paclitaxel. For those with more advanced disease (performance status, 2) or who cannot tolerate a more aggressive regimen but who still wish to receive cancer-directed therapy, gemcitabine can be given alone or together with either capecitabine or erlotinib. Continued on next slide Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natreer Ua Oxo LL LL Guidelines on pancreatic cancer by the American Society of Clinical Oncology" > Meclseape Metastatic Pancreatic Cancer cont'd In contrast, cancer-directed therapy should only be offered on a case-by-case basis to patients with a performance status of 3 or higher whose comorbid conditions are poorly controlled despite best efforts. For patients who experience either disease progression on first-line therapy or intolerable toxicity, gemcitabine plus NAB-paclitaxel may be used. Alternatively, fluorouracil plus oxaliplatin, irinotecan, or nanoliposomal irinotecan can be given as second-line therapy if patients have already received gemcitabine plus NAB-paclitaxel and want to and are able to withstand an aggressive treatment protocol. For those who cannot tolerate aggressive therapy, cli gemcitabine or fluorouracil as a second-line option. cians can offer either If patients are on cancer-directed therapy, they should undergo imaging— preferably CT scan with contrast—to assess first response to treatment 2-3 mo after treatment initi n. Continued on next slide | weseeape Orage e oiestes © 20%6 weDUO. LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natreer Ua Oxo LL LL Guidelines on pancreatic cancer by the American Society of Clinical Oncology" > Metastatic Pancreatic Cancer cont'd * Patients with metastatic pancreatic cancer should be offered aggressive treatment to contro! pain and other symptoms related to the cancer or the treatment, the mainstay of which are opiate medications for pain. Physicians must address the level of pain and the degree of pain relief from analgesics at every clinical visit Meclecape | Masteape Drage £ iaates ©2016 WeaUD, LLC Ferpemugson wp rue tie comm, pues somes wasesane at permineneg@uenme natREFERENCES 1 Skwarecki 8. Updated guidelines for fetal alcohol spectrum disorders. Medscape Medical News. ‘WebMD inc. July 28, 2016. http://www.medscape.com/viewarticle/866770 Adler C, Stapleton B. Updated guidelines for diagnosing fetal alcohol spectrum disorders. 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WebMD Inc. http; .medscape.com/viewarticle/864647 Makape | Meseeape Orgs &Oenees ©2016 wee, LLC Forpemason © mse me suet pate some Mesezape at pemenone geome rt(eer a em ele) Authors John Anello Richard Lindsey Editorial Director, Medscape Drugs & Diseases Senior Editor, Medscape Drugs & Diseases Brian Feinberg Cristina Wojdylo Senior Editor, Medscape Drugs & Diseases Senior Editor, Medscape Drugs & Diseases John Heinegg Wong, DO Senior Editor, Medscape Drugs & Diseases Senior Editor, Medscape Drugs & Diseases Mucseape | Meoreape Drage &.Dieates ©2016 weatiO, LLC Forpemnesion 1 reuse Pic some place some Maser at permistioneguenne net