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6ac997cc8c1e29d5586ab50c10b5da713948ec49
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Human Immunodeficiency Virus (HIV) Screening,Adolescents and Adults - Clinical Preventive Service Recommendation
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Human Immunodeficiency Virus (HIV) Screening,Adolescents and Adults - Clinical Preventive Service Recommendation
human immunodeficiency virus ( hiv ) screening, adolescents and adults - clinical preventive service recommendation clinical preventive service recommendation hiv infection, adolescents and adults grade : a recommendation the aafp supports the united states preventive services task force ( uspstf ) recommendation that clinicians screen adolescents and adults ages 15 to 65 years for hiv infection. younger adolescents and older adults who are at increased risk should also be screened. the evidence base for the new recommendation for hiv screening for adults is solid. however, the prevalence of hiv infection and rate of new infection are very low among individuals who are 13 \ - 14 and 15 \ - 17 years old. although hiv testing has excellent sensitivity and specificity, the false positive rate will be higher in these populations. the benefits of detecting hiv in a low risk 15 \ - 17 \ - year \ - old versus detecting the infection in the same adolescent at age 18 is unknown, but this detection may reduce further infections. ( 2019 \ ) grade definition clinical considerations hiv infection, pregnant persons grade : a recommendation the aafp suports the uspstf recommendation that clinicians screen all pregnant persons, including those who present in labor or at delivery whose hiv status is unknown. ( 2019 \ ) grade definition clinical considerations these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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e06b72ee5b87ce585198765ab36f25c283888833
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Breast Cancer, Breast Self Exam (BSE) - Clinical Preventive Service Recommendation
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Breast Cancer, Breast Self Exam (BSE) - Clinical Preventive Service Recommendation
breast cancer, breast self exam ( bse ) - clinical preventive service recommendation clinical preventive service recommendation grade d recommendation family physicians should discuss with each woman the potential benefits and harms of breast cancer screening tests and develop a plan for early detection of breast cancer that minimizes potential harms. these discussions should include the evidence regarding each screening test, the risk of breast cancer, and individual patient preferences. the recommendations below are based on current best evidence as summarized by the united states preventive services task force ( uspstf ) and can help to guide physicians and patients. these recommendations are intended to apply to women who are not at increased risk of developing breast cancer and only apply to routine screening procedures. the aafp recommends against clinicians teaching women breast self examination ( bse ). ( 2016 \ ) grade definition clinical considerations these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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c20ecfe22a0940e9bb33f47c0ba2eac9e48afc81
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Screening Pelvic Exam - Clinical Preventive Service Recommendation
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Screening Pelvic Exam - Clinical Preventive Service Recommendation
screening pelvic exam - clinical preventive service recommendation clinical preventive service recommendation grade : d recommendation the aafp recommends against screening pelvic exams in asymptomatic women. ( 2017 \ ) note : the aafp ’ s recommendation differs from the u. s. preventive services task force ( uspstf ). the uspstf determined there was insufficient evidence to assess the benefits and harms of performing screening pelvic examination in asymptomatic women for the early detection and treatment of certain gynecologic conditions. the uspstf ’ s review did not include screening for ovarian cancer, cervical cancer, gonorrhea, or chlamydia, as these are already covered by other uspstf recommendations. yet malignancy and pelvic inflammatory disease are the leading gynecologic causes of morbidity and mortality in women. screening for other conditions that have limited effect on morbidity or mortality are unlikely to provide substantial benefit. there is evidence of harms for performing screening pelvic exams in asymptomatic women due to the increased risk of invasive testing and unnecessary treatment. given the low likelihood of benefit and the increased risk of harm, the aafp recommends against screening pelvic exams. grade definition clinical consideration these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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f8629dafeb366677a691bba610b67540bf6f2062
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Screening for Cervical Cancer in Women Older Than 65 Years of Age
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Screening for Cervical Cancer in Women Older Than 65 Years of Age
screening for cervical cancer in women older than 65 years of age recommendation don ’ t screen women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk for cervical cancer. there is adequate evidence that screening women older than 65 years of age for cervical cancer who have had adequate prior screening and are not otherwise at high risk provides little to no benefit.
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guidelines
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64a029c87617b1c5cc9c8c35b1e8a3e3a6496038
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Genomic Testing For Venous Thromboembolism - Clinical Preventive Service Recommendation
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Genomic Testing For Venous Thromboembolism - Clinical Preventive Service Recommendation
genomic testing for venous thromboembolism - clinical preventive service recommendation clinical preventive service recommendation venous thromboembolism, genomics testing the aafp recommends against routine testing for factor v leiden and / or prothrombin 2012g \ > ( pt ) in asymptomatic adult family members of patients with venous thromboembolism, for the purpose of considering primary prophylactic anticoagulation. this recommendation does not extend to patients with other risk factors for thrombosis such as contraception use. ( 2012 \ ) grade definition clinical consideration aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading. these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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55ec978cc86300353513f4af8092b4ea9e786633
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Perinatal Depression - Clinical Preventive Service Recommendation
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Perinatal Depression - Clinical Preventive Service Recommendation
perinatal depression - clinical preventive service recommendation clinical preventive service recommendation perinatal depression : preventive interventions the aafp supports the u. s. preventive services task force ( uspstf ) clinical preventive service recommendation on this topic. go to uspstf recommendation
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guidelines
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0509861ad85c997800bd246f773188a98c3caecb
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Screening for Genital Herpes Simplex Virus Infection in Asymptomatic Adults
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Screening for Genital Herpes Simplex Virus Infection in Asymptomatic Adults
screening for genital herpes simplex virus infection in asymptomatic adults recommendation don ’ t screen for genital herpes simplex virus infection ( hsv ) in asymptomatic adults, including pregnant women. serologic testing for hsv infection has low specificity and a high false \ - positive rate, and no confirmatory test is currently available. the serologic tests cannot determine site of infection. given the prevalence of the infection in the united states, positive predictive value of the test is estimated at about 50 %. a positive test can cause considerable anxiety and disruption of personal relationships.
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guidelines
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2e2145aec66355b7a04bcc29a756613a2919d6bf
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Colorectal Cancer Screening, Adults - Clinical Preventive Service Recommendation
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Colorectal Cancer Screening, Adults - Clinical Preventive Service Recommendation
colorectal cancer screening, adults - clinical preventive service recommendation clinical preventive service recommendation the aafp recommends screening for colorectal cancer in all adults starting at age 50 years and continuing until age 75 years. the risks, benefits, and strength of supporting evidence of different screening methods vary. ( 2021 \ ) a recommendation the aafp recommends that clinicians selectively offer screening for colorectal cancer in adults aged 76 to 85 years. evidence indicates that the net benefit of screening all persons in this age group is small. in determining whether this service is appropriate in individual cases, patients and clinicians should consider the patient ' s overall health, prior screening history, and preferences. ( 2021 \ ) c recommendation the aafp concludes that the evidence is insufficient to assess the benefits and harms for screening for colorectal cancer in adults aged 45 to 49 years. ( 2021 \ ) i statement rationale : the aafp has reviewed the us preventive services task force recommendation for colorectal cancer screening in adults. the aafp agrees with the uspstf that screening should be recommended for adults aged 50 \ - 75 based on substantial net benefit for this age group. these recommendations do not apply to individuals who are symptomatic or at increased risk for colorectal cancer ( e. g. family history, prior diagnosis of colon cancer, adenomatous polyps, or inflammatory bowel disease ). the aafp also agrees with the uspstf that screening for colorectal cancer in adults 76 years and older should be selectively offered as the net benefit in this age group is small and will be dependent on patient screening history, overall health status and individual preferences. the aafp does not agree with the uspstf that there is sufficient evidence for screening for colorectal cancer in adults aged 45 to 49 years. the uspstf recommendation for this age group centered on indirect evidence from modeling studies. many of the trials did not include individuals under age 50 or did not provide these data separately decreasing the confidence in the data inputs. additionally, the modeling studies assumed 100 % adherence to screening and follow up protocols which may artificially elevate life years gained from earlier screening. the aafp noted that while the incidence of colorectal cancer in younger individuals is increasing, 1 it is still relatively small and that the increased risk in this age group may be overestimated. there was also concern that there is no evidence that tumors in younger adults behave similarly to
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guidelines
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2e2145aec66355b7a04bcc29a756613a2919d6bf
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Colorectal Cancer Screening, Adults - Clinical Preventive Service Recommendation
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Colorectal Cancer Screening, Adults - Clinical Preventive Service Recommendation
tumors in older adults and that early detection would be as beneficial. these concerns decrease the confidence that the balance of benefits and harms is moderate in this age group. further, decreasing the age for onset of screening may exacerbate disparities due to differences in access to healthcare and screening facilities. studies have shown that disparities in colorectal cancer mortality are driven by differences in screening rates and not in true incidence of disease. 2 the aafp recognizes the increased incidence and mortality rates of colorectal cancer in black individuals due to health disparities arising from systemic racism in the healthcare system. to reduce disparities, family physicians should have a standardized screening protocol and monitor their practices for disparities. family physicians must be aware of the role of systemic racism in healthcare and work within their practices to develop anti \ - racism policies and practices. aafp has provided resources on social determinants of health and implicit bias as part of the everyone project ( www. aafp. org / everyone ). in addition to strongly encouraging more data for screening individuals under age 50, the impact of social determinants including systemic racism, the aafp continues to advocate for more research on the efficacy and harms of the newer screening modalities. 1 \. siegel rl, miller kd, fedewa sa, et al. colorectal cancer statistics, 2017 \. ca cancer j clin. 2017 ; 67 ( 3 \ ) : 177 \ - 193 \. 2 \. rutter cm, knudsen ab, lin js, et al. black and white differences in colorectal cancer screening and screening outcomes : a narrative review. cancer epidemiol biomarkers prev. 2021 jan ; 30 ( 1 \ ) : 3 \ - 12 \. grade definition uspstf clinical consideration aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading. these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be
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guidelines
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2e2145aec66355b7a04bcc29a756613a2919d6bf
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Colorectal Cancer Screening, Adults - Clinical Preventive Service Recommendation
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Colorectal Cancer Screening, Adults - Clinical Preventive Service Recommendation
implemented.
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guidelines
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0e2d8827b80ac52a03df4d9dbe1e513b5729c728
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Acute Otitis Externa - Clinical Practice Guideline
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Acute Otitis Externa - Clinical Practice Guideline
acute otitis externa - clinical practice guideline key recommendations diffuse acute otitis externa ( aoe ) should be differentiated from other causes of otalgia, otorrhea, and inflammation of the external ear canal. patients with diffuse aoe should be assessed for factors that modify management ( nonintact tympanic membrane, tympanostomy tube, diabetes, immunocompromised state, or prior therapy ). patients with aoe should be assessed for pain and recommended an analgesic treatment based on pain severity. systemic antimicrobials should not be prescribed as initial therapy for diffuse, uncomplicated aoe unless there is extension outside the ear canal or presence of specific host factors that would indicate a need for systemic therapy. topical preparations should be prescribed for initial therapy for diffuse, uncomplicated aoe and delivery enhanced through patient instruction on administration or by performing aural toilet, wick placement, or both, when the ear canal is obstructed. a non \ - ototoxic preparation should be prescribed when the patient has a known or suspected perforation of the tympanic membrane, including a tympanostomy tube. patients should be reassessed within 48 \ - 72 hours if they fail to respond to initial treatment to confirm the diagnosis of diffuse aoe and to exclude other causes of illness. see the full recommendation for further details, including information for patients and a treatment algorithm. read the full recommendation
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guidelines
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f2aa00e0ff979c072ec3afac300f55388e0f36a4
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Bronchiolitis - Clinical Practice Guideline
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Bronchiolitis - Clinical Practice Guideline
bronchiolitis - clinical practice guideline key recommendations the diagnosis of bronchiolitis and assessment of disease severity should be based on history and physical examination. laboratory and radiologic studies should not be routinely ordered for diagnosis. risk factors for severe disease such as age \ < 12 weeks, premature birth, underlying cardiopulmonary disease, or immunodeficiency should be assessed when making decisions about evaluation and management of children with bronchiolitis. bronchodilators ( albuterol, salbutamol ), epinephrine, and corticosteroids should not be administered to infants and children with the diagnosis of bronchiolitis. nebulized hypertonic saline should not be administered to infants with the diagnosis of bronchiolitis in the emergency department. nebulized hypertonic saline may be administered to infants and children hospitalized for bronchiolitis. antibiotics should not be used in children with bronchiolitis unless there is a concomitant bacterial infection. supplemental oxygen is not necessary in children and infants with a diagnosis of bronchiolitis if spo2 exceeds 90 %. continuous pulse oximetry is optional for infants and children with bronchiolitis. chest physiotherapy should not be used in the management of bronchiolitis. palivizumab prophylaxis should be administered during the first year of life to infants with hemodynamically significant heart disease or chronic lung disease of prematurity ( \ 21 % o2 for the first 28 days of life ). to prevent spread of respiratory syncytial virus ( rsv ), hands should be decontaminated before and after direct contact with patients, after contact with inanimate objects in vicinity of patient, and after removing gloves. alcohol rubs are the preferred method for hand decontamination. clinicians should educate personnel and family on hand sanitation. infants should not be exposed to tobacco smoke. exclusive breastfeeding for at least 6 months is recommended to decrease the morbidity of respiratory infections. read the full recommendation
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guidelines
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68e0b96a8aac6a1b534ff237913ed4ebe278bfee
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HIV Infection: Human Immunodeficiency Virus (HIV) - Clinical Preventive Service Recommendations
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HIV Infection: Human Immunodeficiency Virus (HIV) - Clinical Preventive Service Recommendations
hiv infection : human immunodeficiency virus ( hiv ) - clinical preventive service recommendations clinical preventive service recommendation prevention of human immunodeficiency virus ( hiv ) infection : preexposure prophylaxis the aafp supports the u. s. preventive services task force ( uspstf ) clinical preventive service recommendation on this topic. ( 2019 \ ) go to uspstf recommendation aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading. these guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute the individual judgment brought to each clinical situation by the patient ’ s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these guidelines are only one element in the complex process of improving the health of america. to be effective, the guidelines must be implemented.
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guidelines
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d69dbbb0ed59e9ae9f70edb7b3e014c4eb662f8b
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Cholesterol - Clinical Practice Guideline
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Cholesterol - Clinical Practice Guideline
cholesterol - clinical practice guideline key recommendations all adults should receive counseling on healthy diet and lifestyle to reduce risk of cardiovascular disease ( cvd ). cvd risk screening should include a lipid profile and a risk calculation \ *. routine screening for dyslipidemia outside of the context of a cardiovascular risk assessment is not recommended. individuals with an increased 10 \ - year risk for cardiovascular disease ( greater than 12 % ) should be counseled on healthy diet and lifestyle modifications to reduce risk. additionally, shared decision making should be conducted to determine options for moderate intensity statins for primary prevention, if desired by the individual. individuals with established atherosclerotic cardiovascular disease ( ascvd ) should be treated with a moderate \ - dose statin following a shared decision \ - making discussion of benefits and harms. routine use of non \ - statin lipid lowering drugs are not recommended. routine monitoring of lipid level goals as part of secondary prevention is not recommended for individuals with established ascvd. individuals may be offered a high \ - dose statin only in select instances ( e. g., acs, multiple uncontrolled risk factors or recurrent cvd events on moderate \ - dose statin ) following a discussion of the additional harms, small additional benefits, and patient preferences. the aafp uses the category of “ affirmation of value ” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. the primary reasons for not endorsing this guideline included : the guideline possessed small methodological flaws and issued several recommendations without strong evidence. screening recommendations were not completely aligned with current aafp \ - supported uspstf recommendations for dyslipidemia.
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guidelines
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067066273891840ef0b0336918c94f402d0ead5e
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Treatment of Low Bone Density or Osteoporosis
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Treatment of Low Bone Density or Osteoporosis
treatment of low bone density or osteoporosis key recommendations pharmacologic treatment with alendronate, risedronate, zoledronic acid, or denosumab should be prescribed for women with osteoporosis to reduce the risk of hip and vertebral fractures. pharmacologic treatment should continue for five years, during which time bone density monitoring should not be done. menopausal estrogen therapy, menopausal estrogen plus progesterone, or raloxifene should not be used in women with osteoporosis. the decision to treat women 65 years of age or older who have osteopenia and are at a high risk for fracture should be based on a discussion of patient preferences, fracture risk profile, benefits and harms of treatment, and costs of medications. treatment with bisphosphonates should be offered to men who have osteoporosis to reduce the risk of vertebral fractures.
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guidelines
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acc96e91bb385a7358b986b0093408bca5e4bb3f
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Hypertension in Adults Over 60
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Hypertension in Adults Over 60
hypertension in adults over 60 key recommendations adults over age 60 with persistent systolic blood pressure ≥150 mm hg should be treated to achieve a target systolic blood pressure of \ < 150 mm hg. adults 60 years or older with a history of stroke or tia may be treated to a lower target blood pressure of \ < 140 mm hg to reduce the risk of recurrent stroke. adults over age 60 with a high cardiovascular risk may be treated to a lower target blood pressure of \ < 140 mm hg. treatment goals should be based on a periodic discussion of the benefits and harms of specific blood pressure targets. the aafp continues its endorsement of the jnc8 guideline for the management of high blood pressure in adults. these recommendations are consistent with jnc8 and should be used to augment its guidance. read the full recommendation
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guidelines
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7d5b4f1d0db821ccd3c13a3836189ddc8a4cc2ce
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Cerumen Impaction
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Cerumen Impaction
cerumen impaction key recommendations individuals with an accumulation of cerumen should be counseled on proper ear hygiene to prevent cerumen impaction. an individual should be diagnosed with cerumen impaction when an accumulation of cerumen is associated with symptoms, prevents needed assessment of the ear, or both. individuals with cerumen impaction should be assessed by history and / or physical examination for factors that modify management, such as one or more of the following : nonintact tympanic membrane, ear canal stenosis, exostoses, diabetes mellitus, immunocompromised state, or anticoagulant therapy. individuals who are asymptomatic and whose ears can be adequately examined should not be routinely treated for cerumen accumulation. individuals with obstructing cerumen in the ear canal who may not be able to express symptoms ( young children and cognitively \ - impaired children and adults ) should be identified and the need for intervention promptly evaluated. individuals with hearing aids should be examined for the presence of cerumen impaction. an individual with cerumen impaction should be treated with an appropriate intervention, including one or more of the following : cerumenolytic agents, irrigation, or manual removal requiring instrumentation. individuals should be discouraged from using ear candling for the treatment or prevention of cerumen impaction. individuals should be reassessed at the conclusion of in \ - office treatment of cerumen impaction and the resolution of impaction should be documented. if the impaction is not resolved, additional treatment should be prescribed. if full or partial symptoms persist despite resolution of impaction, alternative diagnoses should be considered.
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guidelines
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d3a88309c45b9a6a01973fe663836c3cc50e4b1c
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BRCA Mutation Testing - Clinical Preventive Service Recommendation
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BRCA Mutation Testing - Clinical Preventive Service Recommendation
brca mutation testing - clinical preventive service recommendation clinical preventive service recommendation brca \ - related cancer : risk assessment, genetic counseling, and genetic testing the aafp supports the u. s. preventive services task force ( uspstf ) clinical preventive service recommendation on this topic. go to uspstf recommendation aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading. these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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aedea96035fb194004beaba45f94f13a09ed44e5
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Opioid Use Disorder Screening
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Opioid Use Disorder Screening
opioid use disorder screening clinical preventive service recommendation opioid use disorder ( oud ) : screening opioid use disorder ( oud ) grade : c recommendation the aafp recommends that clinicians selectively screen and refer adults age 18 years and older to oud treatment after weighing the benefits and harms of screening and treatment. clinicians should consider all benefits and harms including health, social, and legal outcomes. screening programs should only be implemented if services for accurate diagnosis, effective treatment, and psychosocial supports can be offered or referred. clinical and implementation considerations : the aafp emphasizes the importance of early diagnosis, treatment, and referral of individuals with oud. the aafp recognizes that oud is a complex health issue that has significant impacts of individuals, families, and communities. family physicians play a key role in the diagnosis, treatment, and prevention of opioid use disorder. the aafp strongly urges its members to be knowledgeable of and utilize evidence \ - based strategies to identify and treat oud in the primary care setting, including medication assisted treatment ( mat ). the aafp has reviewed the uspstf ’ s recommendation on unhealthy drug use screening for adolescents and adults. screening in this setting refers to asking questions about unhealthy drug use of asymptomatic persons. after careful review of the evidence reports commissioned by the uspstf, the aafp concludes that there is evidence to support a " c recommendation " to screen for opioid use disorder in adults age 18 years and older. the primary evidence report utilized by the uspstf found that screening tools have acceptable sensitivity and specificity to identify drug use and substance use disorders in primary care. 1 there are a variety of validated tools available and include self \ - administered or interviewer \ - administered tools that can be implemented in the primary care setting. a second evidence report provided support in treatment seeking populations with opioid use disorders, that medication assisted therapies with opioid agonist therapy and naltrexone decreased risk of drug use relapse and increased likelihood of retention in treatment. 2 the number needed to treated ( nnt ) to prevent one case of relapse with naltrexone therapy is 5 \. 3 and with opioid agonist therapy is 2 \. 9 \. the nnt for one additional case of treatment retention with naltrexone is 6 \. 7 and
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guidelines
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aedea96035fb194004beaba45f94f13a09ed44e5
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Opioid Use Disorder Screening
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Opioid Use Disorder Screening
with opioid agonist therapy is 2 \. 6 \. benefit of mat in screen identified populations is uncertain. evaluation of harms of pharmacotherapy is limited and inconsistent. no statistically significant improvements were observed in the screen \ - detected population. specifically, brief interventions and psychosocial interventions aimed at reducing the use of illicit or non \ - prescription drugs in screen detected populations do not reduce drug use or improve health, social or legal outcomes. 1 therefore, the aafp has weighed the benefit as small, which is indicative of a c recommendation. when implementing this recommendation, readiness for treatment is a key in successful treatment of substance use disorders. when considering implementing a screening program for oud, clinicians must consider potential harms such as stigmatization and medicolegal consequences of labeling. clinicians must be careful not to participate in punitive screening programs, be aware of applicable state and federal laws, and implement strategies to reduce stigmatization of their patients. this recommendation is specific for opioid use disorder in adults, including persons who are pregnant, but does not apply to adolescents. this recommendation is separate from aafp ’ s statement on screening for other types of unhealthy drug use.
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guidelines
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16bff427989c71cbb3b9a5a632e84ea501091a75
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Testosterone Treatment
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Testosterone Treatment
testosterone treatment key recommendations for individuals with age \ - related low testosterone and sexual dysfunction who want to improve sexual function, the decision to initiate testosterone therapy should occur following a discussion of the potential benefits, harms, costs, and patient ' s preferences. for individuals with age \ - related low testosterone and sexual dysfunction who decide to initiate testosterone therapy, symptoms should be reevaluated within 12 months and treatment should be discontinued when there is no improvement in sexual function. for individuals with age \ - related low testosterone and sexual dysfunction who decide to initiate testosterone therapy, intramuscular and transdermal formulations have similar clinical effectiveness and harms. however, intramuscular formulations are preferred as the costs are considerably lower. testosterone therapy is not recommended in men with age \ - related low testosterone to improve energy, vitality, physical function, or cognition.
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guidelines
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c06d1da8819e19e07563cd820493e62b781a62f3
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Diabetes
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Diabetes
diabetes key recommendations metformin should be prescribed for patients with type 2 diabetes when pharmacologic therapy is needed to improve glycemic control. a sulfonylurea, thiazolidinedione, sglt \ - 2 inhibitor, or dpp \ - 4 inhibitor should be considered when a second oral medication is added to improve glycemic control. selection of a second agent should be based on a discussion of benefits, adverse effects, and costs. see full recommendation for further details.
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guidelines
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84f5bdd05e5c6b9f5f41e780ea6c3f29e314ce80
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Scoliosis - Clinical Preventive Service Recommendation
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Scoliosis - Clinical Preventive Service Recommendation
scoliosis - clinical preventive service recommendation clinical preventive service recommendation the aafp supports the u. s. preventive services task force ( uspstf ) clinical preventive service recommendation on this topic. go to uspstf recommendation aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading.
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guidelines
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a7f200e76011943f2eaf5d4fba19a8cf70609707
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Depression Following Acute Coronary Syndrome - Clinical Practice Guideline
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Depression Following Acute Coronary Syndrome - Clinical Practice Guideline
depression following acute coronary syndrome - clinical practice guideline key recommendations a standardized depression screening tool ( e. g. bdi \ - ii, hads, gds, phq ) should be used to screen for depression in patients who have recently experienced an acute coronary syndrome ( acs ) event. in patients who screen positive for depression, further assessment should be performed to confirm the diagnosis of depression antidepressant medication, preferably ssris / snris, and / or cbt should be prescribed to improve symptoms of depression in patients who have a history of acs and have been diagnosed with depression. tricyclic antidepressants ( tcas ) have multiple adverse events, including potential cardiotoxicity and should not be used in patients with heart disease. see the full recommendation for further details. read the full recommendation
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guidelines
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94496282d691d270280da4d7af3918d7220fcec2
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Management of Acute Musculoskeletal Pain - Clinical Practice Guideline
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Management of Acute Musculoskeletal Pain - Clinical Practice Guideline
management of acute musculoskeletal pain - clinical practice guideline key recommendations topical nsaids, with or without menthol gel, should be used as first line therapy for adults with acute pain from non \ - low back, musculoskeletal injuries. oral nsaids and acetaminophen may be considered as options for pharmacologic treatment for adults with acute pain from non \ - low back, musculoskeletal injuries. non \ - pharmacologic options for patients include specific acupressure or transcutaneous electrical nerve stimulation ( tens ). opioids, including tramadol, should not be used as first line treatments for adults with acute pain from non \ - low back musculoskeletal injuries. severity of the injury and patient intolerance of other treatments, and potential harms should be considered before initiating treatment with opioids. read full recommendation see all musculoskeletal ( msk ) clinical recommendations \ & guidelines
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guidelines
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8058867c30a25836e05649ceb85ab0aebc9f3921
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Genomic Testing for Colorectal Cancer
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Genomic Testing for Colorectal Cancer
genomic testing for colorectal cancer clinical preventive service recommendation the aafp recommends offering genetic testing for lynch syndrome to patients newly diagnosed with colorectal cancer to reduce morbidity and mortality in relatives. genetic testing should be offered to first degree relatives of those found to have lynch syndrome, and those positive for lynch syndrome should be offered earlier and more frequent screening for colorectal cancer. ( 2012 \ ) grade definition clinical considerations aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading. these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented. learn about aafp about aafp board of directors advocacy work at aafp contact us physician support cme events physician careers advocacy wins news let us help you join aafp pay dues engage with aafp sponsored resources media center popular searches my account report cme view transcript aafp credit system chapter staff download the aafp app connect with us follow our tweets we ' re on facebook
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guidelines
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7665203913c38f4e5353a34d5c955fc782c2a773
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Scoliosis in Adolescents
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Scoliosis in Adolescents
scoliosis in adolescents recommendation due to recently \ - published evidence related to screening adolescents for scoliosis, the aafp has withdrawn this recommendation.
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guidelines
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3a5d3630ae1536f75091764c355e6198e56b9f20
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Prostate Cancer - Clinical Preventive Service Recommendation
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Prostate Cancer - Clinical Preventive Service Recommendation
prostate cancer - clinical preventive service recommendation clinical preventive service recommendation psa \ - based prostate cancer screening in men aged 55 \ - 69 grade : c recommendation the aafp does not recommend routine prostate \ - specific antigen ( psa ) \ - based screening for prostate cancer. for men aged 55 through 69 who are considering periodic prostate cancer screening, clinicians should discuss the risks and benefits and engage in shared decision \ - making that enables an informed choice. screening for prostate cancer using psa may prevent mortality from prostate cancer for a small number of men, while putting many men at risk for long term harms, such as urinary incontinence and erectile dysfunction. whether this potentially small benefit in mortality outweighs the potential harms is dependent on the values and preferences of individual men. therefore, for men who express a desire for prostate cancer screening, it should only be performed following a discussion of the potential benefits and harms. routine screening for prostate cancer should not be done. see clinical considerations for more information. grade definition prostate cancer screening in men aged 70 and older grade : d recommendation the aafp recommends against screening for prostate cancer in men aged 70 and older. men aged 70 years and older have a higher rate of prostate cancer, but because they are more likely to die from a cause other than their prostate cancer, the potential benefit screening is diminished. older men experience more harms from screening, including increased rates of false positives, overdiagnosis, and increased risk of harms from biopsy and treatment. for these reasons, prostate cancer screening should not be done in men aged 70 years and older. grade definition clinical and implementation considerations for men aged 55 \ - 69 screening for prostate cancer using psa may prevent mortality from prostate cancer for a small number of men, while putting many men at risk for long term harms, such as urinary incontinence and erectile dysfunction. whether this potentially small benefit in mortality outweighs the potential harms is dependent on the values and preferences of individual men. therefore, for men who express a desire for prostate cancer screening, it should only be performed following a discussion of the potential benefits and harms. routine screening for prostate cancer should not be done. benefits and harms of screening based on results of one major trial on screening ( erspc ) and three clinical trials examining treatment, it is estimated that after 13 years, of 1, 000 men screened for prostate cancer, 100
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guidelines
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3a5d3630ae1536f75091764c355e6198e56b9f20
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Prostate Cancer - Clinical Preventive Service Recommendation
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Prostate Cancer - Clinical Preventive Service Recommendation
will be diagnosed with prostate cancer. as the result of early treatment, 1 \. 3 men will avoid dying of prostate cancer, while 5 men will die of prostate cancer despite treatment. it is also estimated that screening will result in three fewer cases of metastatic prostate cancer. while the mortality benefit of prostate cancer screening is the result of early treatment, the treatment of prostate cancer causes the most serious harms ( table 1 \ ). these potential harms are particularly concerning given the high rate of overdiagnosis associated with prostate cancer screening. overdiagnosis involves the diagnosis of asymptomatic cancer that never would have resulted in symptoms or death. the exact rate of overdiagnosis is impossible to determine, but it is estimated to be as high as 50 % for prostate cancer screening. this means that up to half of men exposed to the harms of treatment would never have been affected by their cancer. men at high risk for prostate cancer it is unclear which men may benefit from prostate cancer screening. there is insufficient evidence to determine whether men at increased risk for prostate cancer are more likely to benefit from screening or are more likely to experience harms compared to the general population. african american men have a higher rate of prostate cancer and a higher mortality rate from prostate cancer, but there is not sufficient data in this population to recommend routine screening or a different screening strategy. men with a family history of prostate cancer are also at a higher risk. however, limited data does not support an additional mortality benefit of screening in these men. at this time, the evidence is insufficient for the aafp to make a screening recommendation specific to men at increased risk for prostate cancer. due to the lack of evidence in these populations, african american men and men with a family history of prostate cancer should be informed of their increased risk of developing prostate cancer in addition to the benefits and harms of screening so that they may make an informed choice. screening intervals and thresholds the studies of prostate cancer screening used different screening intervals and different psa thresholds. the ideal screening strategy has not been determined, but single screens were not shown to be effective. for men who choose to undergo screening for prostate cancer, they should not be screened more frequently than every 2 years. a psa level of 4 \. 0 ng / ml is a commonly used cutoff, but thresholds vary. lower thresholds will result in higher rates of false positives, overdiagnosis, and associated harms,
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guidelines
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3a5d3630ae1536f75091764c355e6198e56b9f20
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Prostate Cancer - Clinical Preventive Service Recommendation
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Prostate Cancer - Clinical Preventive Service Recommendation
while higher thresholds may minimize harms but potentially lower the mortality benefit. digital rectal exam does not improve detection of prostate cancer and should not be performed as a part of screening. table 1 : estimated effects of psa \ - based screening for prostate cancer in men aged 55 \ - 69 years after 13 years adapted from final recommendation statement : prostate cancer : screening. u. s. preventive services task force. may 2018 \. estimates based on benefits observed in the erspc trial for men aged 55 to 69 years and on treatment harms derived from pooled absolute rates in the treatment groups in the 3 treatment trials ( protect, pivot, spcg \ - 4 \ ). aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading.
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guidelines
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3841cd8e826c225200d2939299561bc7f877f337
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Management of Acute and Recurrent Gout
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Management of Acute and Recurrent Gout
management of acute and recurrent gout key recommendations corticosteroids, nonsteroidal anti \ - inflammatory drugs ( nsaids ), or low \ - dose colchicine should be prescribed for patients who have acute gout. long \ - term urate \ - lowering therapy should not be initiated in most patients after their first gout attack or in patients who have infrequent gout attacks. a discussion of the benefits, harms, costs, and individual preferences should be held with patients who have recurrent gout attacks before initiating urate \ - lowering therapy and concomitant prophylaxis. read the full recommendation
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guidelines
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8edd161da0fd7fa921552f05054dc4bfdb2a6082
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ADHD in Children and Adolescents
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ADHD in Children and Adolescents
adhd in children and adolescents key recommendations any child 4 through 18 years of age who presents with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity should be evaluated for adhd. the diagnosis of adhd should be based on the criteria from the diagnostic and statistical manual of mental disorders, 5th edition, with information obtained from parents / guardians, teachers, and other school and mental health clinicians involved in the child ’ s care. alternative causes of the behavior should be ruled out. a child being evaluated for adhd should also be assessed for other conditions that might coexist with adhd, including emotional, behavioral, developmental, and physical conditions. children with adhd should be managed following the principles of the chronic care model and the medical home. preschool \ - aged children ( 4 \ - 5 years of age ) should be treated with behavior therapy as the first line of treatment. methylphenidate may be prescribed if the behavior interventions do not provide significant improvement and there is moderate \ - to \ - severe continuing disturbance in the child ’ s function. elementary school \ - aged children ( 6 \ - 11 years of age ) should be treated with fda \ - approved medications for adhd and / or behavioral therapy. adolescents ( 12 \ - 18 years of age ) should be treated with fda \ - approved medications, with assent, for adhd and may be treated with behavioral therapy. medication doses should be titrated to achieve maximum benefit with minimum adverse effects. co \ - morbid conditions should be diagnosed and managed appropriately. access the article with full recommendation for more information on adhd : clinical practice guideline for the diagnosis, evaluation, and treatment of attention \ - deficit / hyperactivity disorder in children and adolescents. read the full recommendation
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guidelines
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6a308924a96d13e52c84ce488672060f9208971c
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Screening for Carotid Artery Stenosis
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Screening for Carotid Artery Stenosis
screening for carotid artery stenosis recommendation don ’ t screen for carotid artery stenosis ( cas ) in asymptomatic adult patients. there is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. screening could lead to non \ - indicated surgeries that result in serious harms, including death, stroke and myocardial infarction.
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guidelines
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e3ea099c2f2b1a82538f3b3ccc61144acadf9981
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Atrial Fibrillation - Clinical Practice Guideline
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Atrial Fibrillation - Clinical Practice Guideline
atrial fibrillation - clinical practice guideline key recommendations rate control is recommended in preference to rhythm control for the majority of patients who have atrial fibrillation. preferred options for rate control therapy include non \ - dihydropyridine calcium channel blockers and beta blockers. rhythm control may be considered for certain patients based on patient symptoms, exercise tolerance, and patient preferences. lenient rate control ( \ < 110 beats per minute resting ) is recommended over strict rate control ( \ < 80 beats per minute resting ) for patients who have atrial fibrillation. the risk of stroke and bleeding should be discussed with all patients considering anticoagulation. the continuous chads2 or continuous cha2ds2 \ - vasc should be considered for prediction of risk of stroke and the has \ - bled should be considered for prediction of risk for bleeding in patients who have atrial fibrillation. chronic anticoagulation is recommended for patients who have atrial fibrillation unless they are at low risk of stroke ( chads2 \ < 2 \ ) or have specific contraindications ( strong recommendation, high quality evidence ). choice of anticoagulation therapy should be based on patient preferences and patient history. options for anticoagulation therapy may include warfarin, apixaban, dabigatran, edoxaban, or rivaroxaban. dual treatment with anticoagulant and antiplatelet therapy is not recommended in most patients who have atrial fibrillation. see the full recommendation for further details.
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guidelines
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f9d3bfb389f03d0e5a86195beacd1b158b9695c3
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Screening for Testicular Cancer
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Screening for Testicular Cancer
screening for testicular cancer recommendation don ’ t screen for testicular cancer in asymptomatic adolescent and adult males. there is no benefit to screening for testicular cancer due to the low incidence of disease and high cure rates of treatment, even in patients who have advanced disease. there are potential harms associated with screening, which include false \ - positive results, anxiety, and harms from diagnostic tests or procedures.
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guidelines
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ba5dcd0fd10ecb027e9b7fb1f867fcef09bdac57
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DEXA for Osteoporosis
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DEXA for Osteoporosis
dexa for osteoporosis recommendation don ' t use dual \ - energy x \ - ray absorptiometry ( dexa ) screening for osteoporosis in women under age 65 or men under 70 with no risk factors. dexa is not cost effective in younger, low \ - risk patients, but is cost effective in older patients.
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guidelines
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56557e676cb43de51822ff607247621a18c7830b
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Imaging for Low Back Pain
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Imaging for Low Back Pain
imaging for low back pain recommendation don ' t do imaging for low back pain within the first six weeks, unless red flags are present. ( red flags include, but are not limited to, severe or progressive neurological deficits or when serious underlying conditions such as osteomyelitis are suspected. ) low back pain is the fifth most common reason for all physician visits. imaging of the lower spine before six weeks does not improve outcomes, but does increase costs.
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guidelines
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8d2178ecea51187bedab402eb30cb48ce26f1fdd
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Lung Cancer - Clinical Preventive Service Recommendations
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Lung Cancer - Clinical Preventive Service Recommendations
lung cancer - clinical preventive service recommendations clinical preventive service recommendation lung cancer screening, adult grade : b recommendation the aafp supports the united states preventive services task force ( uspstf ) recommendation for annual screening for lung cancer with low \ - dose computed tomography ( ldct ) in adults aged 50 to 80 years who have a 20 pack \ - year smoking history and currently smoke or have quit within the past 15 years. screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. the aafp has reviewed the evidence and has determined there is sufficient evidence to support a b recommendation for lung cancer screening in adults at increased risk. however, the aafp acknowledges that the harms from annual screening with ldct are not well documented at this time and that there are considerable barriers to screening for lung cancer in the community setting. future research is needed to determine the harms of annual screening with ldct including overdiagnosis, unnecessary procedures due to incidental findings, and barriers to care among communities of color. ( 2021 \ ) grade definition clinical considerations aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading. these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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e8a3aadfc35cdbe49d00e6d0715441fe622f83fe
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Diagnosis of Venous Thromboembolism - Clinical Practice Guideline
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Diagnosis of Venous Thromboembolism - Clinical Practice Guideline
diagnosis of venous thromboembolism - clinical practice guideline key recommendations pulmonary embolism ( pe ) for individuals with a low or intermediate pretest probability or prevalence, clinicians should use a d \ - dimer strategy to rule out pe followed by vq scan or ctpa in patients requiring additional testing. d \ - dimer testing alone should not be used to rule in a pe. for individuals with a high pretest probability or prevalence ( ≥50 % ), clinicians should start with ctpa to diagnose pe. if ctpa is not available, a vq scan be used with appropriate follow up testing. d \ - dimer testing alone should not be used to diagnose pe and should not be used as a subsequent test after ct scan in individuals with a high pretest probability / prevalence. for individuals who have a positive d \ - dimer or likely pretest probability, a ctpa should be performed. d \ - dimer testing can be used to exclude recurrent pe in individuals with unlikely pretest probability. use of an age \ - adjusted d \ - dimer cutoff in outpatients older than 50 years is safe and improves diagnostic yield. age \ - adjusted cutoff \ = age ( years ) x 10 µg / l ( using d \ - dimer assays with a cutoff of 500 µg / l ). lower extremity deep vein thrombosis ( dvt ) for individuals with a low pretest probability or prevalence, clinicians should use a d \ - dimer strategy to rule out dvt followed by proximal lower extremity ultrasound or whole \ - leg ultrasound in patients requiring additional testing. for individuals with low pretest probability or prevalence ( ≤10 % ), positive d \ - dimer alone should not be used to diagnose dvt and additional testing following negative proximal or whole \ - leg ultrasound should not be conducted. for individuals with an intermediate pretest probability or prevalence ( \ ~ 25 % ), whole \ - leg ultrasound or proximal lower extremity ultrasound should be used. serial proximal ultrasound testing is needed after a negative proximal ultrasound. no serial testing is needed after a negative whole leg ultrasound. for individuals with suspected dvt and high pretest probability or prevalence ( ≥50 % ), whole \ - leg ultrasound or proximal lower extremity ultrasound should be
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guidelines
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e8a3aadfc35cdbe49d00e6d0715441fe622f83fe
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Diagnosis of Venous Thromboembolism - Clinical Practice Guideline
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Diagnosis of Venous Thromboembolism - Clinical Practice Guideline
used. serial ultrasound should be used if initial ultrasound is negative and no alternative diagnosis is identified. upper extremity dvt for individuals with low prevalence / unlikely pretest probability, d \ - dimer testing should be used to exclude upper extremity dvt, followed by duplex ultrasound if positive. for individuals with high prevalence / likely pretest probability, either d \ - dimer testing followed by duplex ultrasound / serial duplex ultrasound, or duplex ultrasound / serial duplex ultrasound alone can be used for assessing patients suspected of having upper extremity dvt. a positive d \ - dimer alone should not be used to diagnose upper extremity dvt. see the full recommendation for more information. read the full recommendation
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guidelines
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54eec9722fa5dc31021885ed60e435e8fbd24619
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Elective, Non-medically Indicated Inductions of Labor or Cesarean Deliveries Before 39 Weeks
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Elective, Non-medically Indicated Inductions of Labor or Cesarean Deliveries Before 39 Weeks
elective, non - medically indicated inductions of labor or cesarean deliveries before 39 weeks recommendation don ’ t schedule elective, non \ - medically indicated inductions of labor or cesarean deliveries before 39 weeks, 0 days gestational age. delivery prior to 39 weeks, 0 days has been shown to be associated with an increased risk of learning disabilities and a potential increase in morbidity and mortality. there are clear medical indications for delivery prior to 39 weeks and 0 days based on maternal and / or fetal conditions. a mature fetal lung test, in the absence of appropriate clinical criteria, is not an indication for delivery. about choosing wisely® the choosing wisely® campaign was created as an initiative of the american board of internal medicine ( abim ) foundation to improve health care quality. more than 70 specialty societies have identified commonly used tests or procedures within their specialties that are possibly overused. learn more about the aafp support of the choosing wisely® campaign.
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guidelines
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32d4c6a664fa16b78b9179f4ca7b3081a920a6b1
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Opioid Prescribing
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Opioid Prescribing
opioid prescribing key recommendations nonpharmacologic and nonopioid pharmacologic therapies are preferred for chronic pain. opioid therapy should be considered only when benefits for both pain and function are anticipated to outweigh the risks. if opioids are used, they should be combined with nonpharmacologic and nonopioid pharmacologic therapy as appropriate. realistic treatment goals for pain and function should be established before initiation of opioid therapy. opioid treatment should be continued only if there is meaningful improvement in pain and function that outweighs risk. when starting opioid therapy for chronic pain, the lowest effective dose of immediate \ - release opioids should be prescribed instead of extended \ - release / long \ - active ( er / la ) opioids. benefits and risks should be reassessed when increasing dosages to ≥50 morphine milligram equivalents ( mme ) / day. dosages ≥90 mme / day should be carefully justified or avoided if possible. for acute pain, the lowest effective dose of immediate \ - release opioids should be prescribed in no greater quantity than is needed for severe pain. benefits and harms should be evaluated with patients within one to four weeks of initiating or escalating dose of opioids for chronic pain and at least every three months thereafter. if benefits do not outweigh the harms, a plan to taper opioids and optimize other therapies should be developed. risk factors for opioid \ - related harms should be evaluated prior to initiation and periodically during treatment. strategies to mitigate risk should be developed, including offering naloxone to those at increased risk for overdose. a patient ’ s history of controlled substance prescriptions using a prescription drug monitoring program ( pdmp ). pdmp data should be reviewed when starting opioid therapy and periodically during treatment. urine drug testing may be used prior to initiating opioid therapy and periodically during treatment to assess for controlled prescription medications as well as illicit drugs. co \ - prescription of opioids and benzodiazepines should be avoided whenever possible. evidence \ - based treatment including medication \ - assisted treatment with buprenorphine or methadone and behavioral therapies should be offered to patients with opioid use disorder. see the full recommendation for additional details. the aafp uses the
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guidelines
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32d4c6a664fa16b78b9179f4ca7b3081a920a6b1
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Opioid Prescribing
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Opioid Prescribing
category of “ affirmation of value ” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. the primary reasons for not endorsing this guideline included : strong ( category a ) recommendations were made based on limited or insufficient evidence. none of the recommendations are based on high quality evidence. due to the poor evidence base, the recommendations are generally consensus and therefore are “ good practice points ” rather than category a recommendations. the methodology included inconsistent inclusion and exclusion criteria. these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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a684b5273b310340dd925a55ddcecc236da79e31
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Hypertension - Clinical Practice Guideline
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Hypertension - Clinical Practice Guideline
hypertension - clinical practice guideline key recommendations treat adults who have hypertension to a standard blood pressure target ( less than 140 / 90 mm hg ) to reduce the risk of all \ - cause and cardiovascular mortality ( strong recommendation ; high \ - quality evidence ). treating to a lower blood pressure target ( less than 135 / 85 mm hg ) does not provide additional benefit at preventing mortality ; however, a lower blood pressure target could be considered based on patient preferences and value. consider treating adults who have hypertension to a lower blood pressure target ( less than 135 / 85 mm hg ) to reduce risk of myocardial infarction ( weak recommendation ; moderate \ - quality evidence ). although treatment to a standard blood pressure target ( less than 140 / 90 mm hg ) reduced the risk of myocardial infarction, there was a small additional benefit observed with a lower blood pressure target. there was no observed additional benefit in preventing stroke with the lower blood pressure target.
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guidelines
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c44c6dfd88d5c44225a334db0fe563ebe51a679a
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Pap Smears
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Pap Smears
pap smears recommendation don ' t perform pap smears on women under the age of 21 or women who have had a hysterectomy for non \ - cancer disease. most observed abnormalities in adolescents regress spontaneously, therefore screening pap smears done in this age group can lead to unnecessary anxiety, additional testing, and cost. pap smears are not helpful in women after hysterectomy ( for non \ - cancer disease ) and there is little evidence for improved outcomes.
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guidelines
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49358cea69c7c164a99b7620e27cd9aba0e337ec
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Hoarseness
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Hoarseness
hoarseness key recommendations dysphonia ( hoarseness ) should be diagnosed in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice \ - related quality of life ( qol ). patients with hoarseness should be assessed by history and / or physical examination for underlying cause and factors that may modify management. factors that may indicate the need for expedited laryngeal evaluation include : recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, presence of concomitant neck mass, respiratory distress or stridor, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer. the patient ’ s larynx should be visualized when dysphonia fails to resolve or improve within 4 weeks or if a serious underlying cause is suspected. computed tomography or magnetic resonance imaging should not be obtained in patients with a primary complaint of dysphonia prior to visualizing the larynx. anti \ - reflux medications or corticosteroids should not be prescribed for patients with isolated dysphonia without prior visualization of the larynx. antibiotics should not be routinely prescribed to treat dysphonia. following diagnostic laryngoscopy : voice therapy should be recommended for patients who have dysphonia from a cause amenable to voice therapy. surgery should be considered for patients with suspected : 1 \ ) laryngeal malignancy, 2 \ ) benign laryngeal soft tissue lesions, 3 \ ) glottic insufficiency. botulinum toxin injections should be considered for treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. see full recommendation for further details. read the full article
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guidelines
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034fed9a1d1b8ce47d632dd7a3328997792f4735
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Unhealthy Drug Use: Screening
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Unhealthy Drug Use: Screening
unhealthy drug use : screening clinical preventive service recommendation grade : i recommendation the aafp concludes that the evidence is insufficient to assess the benefits and harms for screening adolescents and adults for unhealthy drug use. this statement does not include screening for opioid use disorder. the aafp emphasizes the importance of early diagnosis, treatment, and referral of individuals with substance use disorder ( sud ). the aafp recognizes that suds are complex health issues that have significant impacts on individuals, families, and communities. family physicians play a key role in the diagnosis, treatment, and prevention of substance use disorders. the aafp strongly urges its members to be knowledgeable of and utilize evidence \ - based strategies to diagnose and treat substance use disorders in the primary care setting. the aafp has reviewed the united states preventive services task force ’ s ( uspstf ) recommendation on unhealthy drug use screening for adolescents and adults. screening in this setting refers to asking patients who are asymptomatic questions about unhealthy use of illegal drugs and the nonmedical use of prescription psychoactive medications. the aafp agrees with the uspstf that there is insufficient evidence to assess the balance of benefits and harms for screening of unhealthy drug use in adolescents. however, the aafp disagrees with the uspstf regarding screening for unhealthy drug use in adults age 18 years or older and has found that the evidence presented by the uspstf does not support a " b " level recommendation. the aafp has issued a separate recommendation for screening for opioid use disorder. the primary evidence report utilized by the uspstf found that screening tools have acceptable sensitivity and specificity to identify drug use and substance use disorders in primary care. 1there were no direct studies on the benefits or harms of screening for unhealthy drug use. further, a second systematic review showed that psychosocial interventions and pharmacotherapy were only effective at improving opioid use outcomes for treatment \ - seeking populations, but not effective in screen detected populations. the aafp has concerns that there is an overreliance on indirect evidence to support the universal screening for all substance use, particularly on the use of medication assisted treatment ( mat ) for opioid use disorders. the studies included evaluated the use of medication assisted therapies in treatment seeking populations, predominantly recruited from inpatient settings, drug treatment programs
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guidelines
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034fed9a1d1b8ce47d632dd7a3328997792f4735
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Unhealthy Drug Use: Screening
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Unhealthy Drug Use: Screening
, and the criminal justice system. mat for opioid use disorders is effective at reducing drug use, reducing risk of relapse, and increasing the likelihood of retention in treatment. 2 substance use disorders are a heterogenous group of disorders and evidence for treatment outcomes with one substance use disorder may not be generalizable to all substance use disorders. many individuals who screen positive for substance use may not have a substance use disorder. the aafp is concerned about the potential for overdiagnosis and exposure to harms without beneficial interventions. harms include stigmatization and medicolegal consequences of labeling patients, particularly those who are pregnant. the aafp issues a strong call for more research on this topic, in addition to the reduction of administrative complexity and other barriers faced by patients to access treatment for unhealthy drug use. screening programs should only be implemented if services for accurate diagnosis, effective treatment, and psychosocial supports can be offered or referred.
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guidelines
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ce65fee64041b29e42c481d98177a64b791a5d57
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Pelvic Exam or Physical Exams to Prescribe Oral Contraceptive Medications
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Pelvic Exam or Physical Exams to Prescribe Oral Contraceptive Medications
pelvic exam or physical exams to prescribe oral contraceptive medications recommendation do not require a pelvic exam or other physical exam to prescribe oral contraceptive medications. hormonal contraceptives are safe, effective, and well tolerated for most women. data do not support the necessity of performing a pelvic or breast examination to prescribe oral contraceptive medications. hormonal contraception can be safely provided on the basis of medical history and blood pressure measurement.
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guidelines
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89e190b88ab131d9550f43aceadcdfc11243db8a
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Vertigo
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Vertigo
vertigo key recommendations posterior semicircular canal bppv should be diagnosed when vertigo associated with nystagmus is provoked by the dix \ - hallpike maneuver. if the patient has a history compatible with bppv and the dix \ - hallpike test is negative, a supine roll test should be performed to assess for lateral semicircular canal bppv. bppv should be differentiated from other causes of imbalance, dizziness, and vertigo. patients with bppv should be questioned for factors that modify management including impaired mobility or balance, cns disorders, lack of home support and increased risk for falling. radiographic imaging and / or vestibular testing should not be used in patients diagnosed with bppv, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to bppv that warrant testing. patients with posterior canal bppv should be treated with a canalith repositioning procedure ( crp ). post \ - procedural postural restrictions should not be recommended after repositioning procedure is performed. bppv should not be routinely treated with vestibular suppressant medications such as antihistamines or benzodiazepines. patients with persistent symptoms should be evaluated for unresolved bppv or underlying peripheral vestibular or cns disorders. patients should be educated regarding the impact of bppv on their safety, the potential for recurrence, and the importance of follow \ - up. see the full recommendation for further details, including specifics about the dix \ - hallpike maneuver and a treatment algorithm.
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guidelines
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4f12f09facc9b07226d0866052501377f159625d
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Allergic Rhinitis
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Allergic Rhinitis
allergic rhinitis key recommendations the diagnosis of allergic rhinitis ( ar ) should be made when history and physical findings are consistent with an allergic cause ( e. g., clear rhinorrhea, pale discoloration of nasal mucosa, and red and watery eyes ) and one or more of the following symptoms : nasal congestion, runny nose, itchy nose, or sneezing. individuals with ar should be assessed for the presence of associated conditions such as asthma, atopic dermatitis, sleep \ - disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. specific ige testing ( blood or skin ) should be performed for patients with a clinical diagnosis of ar who do not respond to empiric treatment, or when diagnosis is uncertain, or when determination of specific target allergen is needed. sinonasal imaging should not routinely be performed in patients presenting with symptoms consistent with allergic rhinitis. intranasal steroids should be prescribed for patients with ar whose symptoms affect quality of life. oral second \ - generation / less sedating antihistamines should be prescribed for patients with ar and primary complaints of sneezing and itching. intranasal antihistamines may be prescribed for patients with seasonal, perennial, or episodic ar. oral leukotriene receptor antagonists should not be prescribed as primary therapy for patients with ar. combination pharmacologic therapy may be prescribed for patients with ar who have inadequate response to monotherapy. the most effective combination therapy is an intranasal steroid and an intranasal antihistamine. immunotherapy should be prescribed for patients with ar who have inadequate response to pharmacologic therapy. avoidance of known allergens or environmental control may be considered in patients with ar who have identified allergens that correlate with their clinical symptoms. inferior turbinate reduction may be considered for patients with ar with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. see the full recommendation for further details, including a treatment flow chart and specific pharmacologic options. read the full recommendation
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guidelines
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e08bfc0e2217062877c7cabe8d603e8cd25f387d
|
Daily Home Glucose Monitoring for Type 2 Diabetes
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Daily Home Glucose Monitoring for Type 2 Diabetes
daily home glucose monitoring for type 2 diabetes recommendation don ’ t routinely recommend daily home glucose monitoring for patients who have type 2 diabetes mellitus and are not using insulin. self \ - monitoring of blood glucose ( smbg ) is an integral part of patient self \ - management in maintaining safe and target \ - driven glucose control in type 1 diabetes mellitus. however, daily finger glucose testing has no benefit in patients with type 2 diabetes mellitus who are not on insulin or medications associated with hypoglycemia, and small, but significant, patient harms are associated with daily glucose testing. smbg should be reserved for patients during the titration of their medication doses or during periods of changes in patients ’ diet and exercise routines.
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guidelines
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8ee831968548444d12e9d0f0fab28f8966953a6b
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Antibiotics for Sinusitis
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Antibiotics for Sinusitis
antibiotics for sinusitis recommendation don ' t routinely prescribe antibiotics for acute mild \ - to \ - moderate sinusitis unless symptoms last for ten or more days or symptoms worsen after initial clinical improvement. ( symptoms must include discolored nasal secretions and facial or dental tenderness to percussion. ) most sinusitis in the ambulatory setting is due to a viral infection that will resolve on its own. despite consistent recommendations to the contrary, antibiotics are prescribed in over 80 % of outpatient visits for acute sinusitis. sinusitis accounts for 16 million office visits and $ 5 \. 8 billion in annual health care.
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guidelines
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b93473986992739da905178b4975e694a4ed9b84
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Annual EKGs for Low-risk Patients
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Annual EKGs for Low-risk Patients
annual ekgs for low - risk patients recommendation don ' t order annual electrocardiograms ( ekgs ) or any other cardiac screening for low \ - risk patients without symptoms. there is little evidence that detection of coronary artery stenosis in asymptomatic patients at low \ - risk for coronary heart disease improves health outcomes. false \ - positive tests are likely to lead to harm through unnecessary invasive procedures, over \ - treatment, and misdiagnosis. potential harms of this routine annual screening exceed the potential benefit.
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guidelines
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be7f49008da97789532ca5027bbf811241b6b649
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Adult Sinusitis - Clinical Practice Guideline
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Adult Sinusitis - Clinical Practice Guideline
adult sinusitis - clinical practice guideline key recommendations acute bacterial rhinosinusitis ( abrs ) should be distinguished from acute rhinosinusitis due to viral respiratory infections and noninfectious conditions. abrs should be diagnosed when signs and symptoms of acute rhinosinusitis ( ars ) ( purulent nasal drainage plus nasal obstruction, facial pain \ - pressure or both ) persist without improvement for at least 10 days or if signs and symptoms worsen within 10 days after initial improvement. radiographic imaging should not be performed in patients with ars unless a complication or alternative diagnosis is suspected. analgesics, intranasal steroids and / or nasal saline irrigation may be recommended for symptomatic relief of viral or bacterial rhinosinusitis. adults with uncomplicated abrs should be either offered watchful waiting or prescribed antibiotic therapy. patients undergoing watchful waiting should be prescribed antibiotics if their symptoms fail to improve after 7 days or worsen at any time. if a decision is made to treat abrs with antibiotics, amoxicillin with or without clavulanate should be prescribed as first \ - line therapy for 5 \ - 10 days. amoxicillin with clavulanate should be prescribed for patients at high risk of being infected by an organism resistant to amoxicillin. patients with an allergy to penicillin should be prescribed doxycycline or a respiratory quinolone as first \ - line therapy. for patients who fail to improve or worsen by 7 days following initial treatment, they should be reassessed to confirm the diagnosis and to detect complications. if initial treatment involved watchful waiting, antibiotics should be prescribed. if initial treatment included an antibiotic, a different antibiotic should be prescribed. chronic rhinosinusitis ( crs ) and recurrent acute rhinosinusitis should be distinguished from isolated episode of abrs. the diagnosis of crs should be confirmed with documentation of sinonasal inflammation using anterior rhinoscopy, nasal endoscopy, or computed tomography. saline nasal irrigation, intranasal corticosteroids, or both should be prescribed for symptom relief in patients with crs. testing for allergy and immune function may be obtained when evaluating a patient with for crs or recurrent ars. read the full recommendation which includes a treatment algorithm and more information about antibiotic choices. read the full recommendation
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guidelines
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3a76930362eb5408f05a94b79bb1ce0c70747cec
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Prostate Cancer Screening
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Prostate Cancer Screening
prostate cancer screening recommendation do not routinely screen for prostate cancer using a prostate \ - specific antigen ( psa ) test or digital rectal exam. for men who desire psa screening, it should only be performed after engaging in shared decision making. screening for prostate cancer using psa may prevent mortality from prostate cancer for a small number of men, while putting many men at risk for long term harms, such as urinary incontinence and erectile dysfunction. whether this potentially small benefit in mortality outweighs the potential harms is dependent on the values and preferences of individual men. therefore, for men who express a desire for prostate cancer screening, it should only be performed following a discussion of the potential benefits and harms. routine screening for prostate cancer should not be done. psa \ - based prostate cancer screening should not be performed in men over 70 years of age.
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guidelines
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0859c0c5d89b1f8265a0aa1feebab2b5915a4797
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Low Back Pain
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Low Back Pain
low back pain key recommendations nonpharmacologic treatment, including superficial heat, massage, acupuncture, or spinal manipulation, should be used initially for most patients with acute or subacute low back pain, as they will improve over time regardless of treatment. when pharmacologic treatment is desired, nonsteroidal anti \ - inflammatory drugs ( nsaids ) or skeletal muscle relaxants should be used. nonpharmacologic treatment, including exercise, multidisciplinary rehabilitation, acupuncture, mindfulness \ - based stress reduction, tai chi, yoga, motor control exercise, progressive relaxation, biofeedback, low \ - level laser therapy, cognitive behavioral therapy, or spinal manipulation, should be used initially for most patients who have chronic low back pain. for patients who have chronic low back pain and do not respond to nonpharmacologic therapy, nsaids should be used. tramadol or duloxetine should be considered for those patients who do not respond to or do not tolerate nsaids. opioids should only be considered if other treatments are unsuccessful and when the potential benefits outweigh the risks for an individual patient. see full recommendation for further details.
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guidelines
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b221904800b2a61202aa8f8e46860e4ff5e2efc2
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Tonsillectomy
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Tonsillectomy
tonsillectomy key recommendations watchful waiting for recurrent throat infection is strongly recommended if there have been fewer than 7 episodes in the past year, fewer than 5 episodes per year in the past 2 years, or fewer than 3 episodes per year in the past 3 years. tonsillectomy may be considered for recurrent throat infection with a frequency of at least 7 episodes in the past year or at least 5 episodes per year for 2 years or at least 3 episodes per year for 3 years with documentation in the medical record for each episode of sore throat and 1 or more of the following : temperature \ > 38 \. 3°c, cervical adenopathy, tonsillar exudate, or positive test for group a beta \ - hemolytic streptococcus. the child with recurrent throat infection who does not meet the criteria above should be assessed for modifying factors that may nonetheless favor tonsillectomy, such as multiple antibiotic allergy / intolerance, pfapa ( periodic fever, aphthous stomatitis, pharyngitis and adenitis ), or history of \ > 1 peritonsillar abscess. caregivers of children with obstructive sleep \ - disordered breathing and tonsil hypertrophy should be asked about comorbid conditions that might improve after tonsillectomy, including growth retardation, poor school performance, enuresis, asthma, and behavioral problems. caregivers should be counseled about tonsillectomy as a means to improve health in children with abnormal polysomnography who also have tonsil hypertrophy and obstructive sleep \ - disordered breathing. caregivers should be counseled that sleep \ - disordered breathing may persist or recur after tonsillectomy and may require further management. perioperative antibiotics should not be administered or prescribed for children undergoing tonsillectomy. caregivers should be educated about the importance of managing and reassessing pain after tonsillectomy. postoperative pain should be managed with ibuprofen and / or acetaminophen. codeine should not be administered or prescribed for children under the age of 12 \. see the full recommendation for further details. read the full recommendation
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guidelines
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81ca67d5638d10e0f3ac99ac1a1e7f9d961c4c79
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Genomic Testing for Cardiovascular Disease - Clinical Preventive Service Recommendation
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Genomic Testing for Cardiovascular Disease - Clinical Preventive Service Recommendation
genomic testing for cardiovascular disease - clinical preventive service recommendation clinical preventive service recommendation cardiovascular disease, genomic testing the aafp recommends against genomics profiling to assess risk for cardiovascular disease. the net health benefit from the use of any genomic tests for the assessment of cardiovascular disease risk is negligible and there is no evidence that they lead to improved patient management or increased risk reduction. ( 2012 \ ) grade definition clinical consideration aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading.
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guidelines
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ab1a863d6e23fb656583a058a3d24aff08590696
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Immunizations - Clinical Preventive Service Recommendations
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Immunizations - Clinical Preventive Service Recommendations
immunizations - clinical preventive service recommendations clinical preventive service recommendation immunization, children grade : a recommendation the aafp recommends immunizing all children 0 \ - 6 years of age using the aafp recommendations unless contraindicated. ( 2010 \ ) grade definition recommended childhood immunization schedule immunization, children, catch \ - up grade : a recommendation the aafp recommends immunizing children 0 \ - 6 years of age who are between doses for vaccinations with the aafp recommendation unless contraindicated. ( 2010 \ ) grade definition recommended catch \ - up immunization schedule immunization, adolescent grade : a recommendation the aafp recommends immunizing all adolescents 7 \ - 18 years of age using the aafp recommendations unless contraindicated. ( 2010 \ ) grade definition recommended adolescent immunization schedule immunization, adolescent, catch \ - up grade : a recommendation the aafp recommends immunizing adolescents 7 \ - 18 years of age who are between doses for vaccinations with the aafp recommendation unless contraindicated. ( 2010 \ ) grade definition recommended adolescent immunization schedule immunizations, adults grade : a recommendation the aafp recommends immunizing all adults using the aafp recommendations unless contraindicated. ( 2010 \ ) grade definition recommended adult immunization schedule aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading. these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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94b7b24f0d060f986859ac4aabbfaba936ccf327
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Hepatitis B Virus Chronic Infection Screening - Clinical Preventive Service Recommendation
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Hepatitis B Virus Chronic Infection Screening - Clinical Preventive Service Recommendation
hepatitis b virus chronic infection screening - clinical preventive service recommendation clinical preventive service recommendation grade : d recommendation the aafp recommends against routinely screening the general asymptomatic population for chronic hepatitis b virus infection. ( 2014 \ ) grade definition clinical consideration aafp clinical recommendations view the criteria for aafp clinical preventive services recommendations and grading.
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guidelines
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efb7d43d7e12d3b784c24de72df09c6d239cca13
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United States Medical Eligibility Criteria for Contraceptive Use - Clinical Practice Guideline
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United States Medical Eligibility Criteria for Contraceptive Use - Clinical Practice Guideline
united states medical eligibility criteria for contraceptive use - clinical practice guideline key recommendations the 2016 u. s. medical eligibility criteria for contraceptive use ( u. s. mec ) comprises recommendations for the use of specific contraceptive methods in individuals with certain medical conditions. these recommendations can be used when consulting with women, men, and couples about their contraceptive choices. these recommendations should be used to inform contraceptive decisions, and may not apply to the use of contraceptives for other purposes. contraceptive methods are categorized for their appropriateness of use in a variety of medical conditions or circumstances. category 1 \ = method can be used without restriction category 2 \ = method generally can be used, follow up may be required category 3 \ = method not recommended unless other more appropriate methods are not available or acceptable category 4 \ = unacceptable health risk if method is used see the full recommendation for detailed guidance. read full recommendation
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guidelines
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3e1a4b3a2617536341c1a477d20f827b1a9eba48
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Diabetes Screening, Adults - Clinical Preventive Service Recommendation
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Diabetes Screening, Adults - Clinical Preventive Service Recommendation
diabetes screening, adults - clinical preventive service recommendation clinical preventive service recommendation type 2 diabetes, adults the aafp recommends screening for type 2 diabetes in adults aged 40 to 70 years who have overweight or obesity. ( 2021 \ ) b recommendation the aafp concludes that the evidence is insufficient to assess the benefits and harms for screening for type 2 diabetes in adults aged 35 \ - 39 years. ( 2021 \ ) i statement gestational diabetes, pregnant individuals the aafp supports the uspstf recommendation for screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after. ( 2021 \ ) b recommendation the aafp supports the uspstf statement that there is insufficient evidence to assess the balance of benefits and harms of screening for gestational diabetes in asymptomatic pregnant persons before 24 weeks of gestation. ( 2021 \ ) i statement rationale : the aafp has reviewed the u. s. preventive services task force evidence report and agrees that asymptomatic pregnant individuals should be screened for gestational diabetes at 24 weeks gestation or after. the aafp also agrees that there is insufficient evidence for screening prior to 24 weeks gestation. 1 the aafp has also reviewed the us preventive services task force evidence report and agrees that nonpregnant adults aged 40 to 70 who have obesity or overweight be screened for type 2 diabetes as part of risk assessment for cardiovascular disease. 2 screening in this setting refers to measuring fasting plasma glucose, hba1c level, or using an oral glucose tolerance test. a fasting plasma glucose level of 126 mg / dl ( 6 \. 99 mmol / l ) or greater, an hba1c level of 6 \. 5 % or greater, or a 2 \ - hour post \ - load glucose level of 200 mg / dl ( 11 \. 1 mmol / l ) or greater are considered to be consistent with the diagnosis of type 2 diabetes. patient preferences should be taken into account when determining which test is used and a diagnosis of type 2 diabetes should be confirmed before offering interventions. there is limited evidence on the best rescreening intervals for adults with normal results but screening every 3 years is a reasonable option. however, the aafp feels that there is currently insufficient evidence to recommend screening adults aged 35 to 39 \. almost all of the evidence that was presented looked at adults over the age of 40 and there were no subgroup
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guidelines
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3e1a4b3a2617536341c1a477d20f827b1a9eba48
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Diabetes Screening, Adults - Clinical Preventive Service Recommendation
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Diabetes Screening, Adults - Clinical Preventive Service Recommendation
analyses that specifically examined screening at younger ages. further, in contrast to individuals diagnosed with diabetes due to symptoms, there was no demonstrated improvement in mortality, cardiovascular events, or other health outcomes in individuals with screen \ - detected type 2 diabetes. the aafp does not agree that there is evidence to support screening for prediabetes. while aafp acknowledges that diabetes, like all chronic conditions, exists on a continuum and that insulin resistance is a risk factor for developing diabetes, the current evidence does not show improvement in long term health outcomes for screening for prediabetes in adults who have obesity or overweight. screening for prediabetes is neither sensitive nor specific and may result in false positives ( overdiagnosis ) or false negatives ( false reassurance ). the evidence did show a reduction in the incidence of diabetes in individuals at risk for diabetes who received intense lifestyle interventions or metformin, however there was not an associated improvement in health outcomes. the impact of the interventions was observed to be greatest at shorter lengths of follow up with the included trials providing data for 1 \ - 3 \. 9 years. lifestyle interventions to prevent progression for prediabetes to diabetes are effective in reducing weight, blood pressure and cholesterol and would likely be recommended and beneficial for these individuals, even in the absence of screening. moreover, the aafp is concerned that harms of screening and the resulting labeling or stigmatizing of individuals have not been adequately assessed and may lead to impacts on patient health and wellbeing. instead, there may be an increase in the number of individuals who are on medications as the provision or referral to intensive lifestyle interventions is not readily accessible in rural and underserved areas. there is also concern that persons of color will be disproportionately stigmatized and face additional barriers to care. increases in labeling is a great concern as there is stigma around diabetes both within and outside of the healthcare system as diabetes is routinely viewed as a disease resulting from “ poor life choices ” and “ lack of self \ - control ” rather than a combination of genetics and social determinants of health.
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guidelines
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1865731eec0175d9e98f20094895e9840eaef26c
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High Blood Pressure in Children and Adolescents - Clinical Practice Guideline
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High Blood Pressure in Children and Adolescents - Clinical Practice Guideline
high blood pressure in children and adolescents - clinical practice guideline key recommendations : children and adolescents three years of age or older should have their blood pressured measured annually. blood pressure checks should be performed at every health care encounter for children and adolescents who are obese, take medications that raise blood pressure, have renal disease, diabetes or a history of aortic arch obstruction or coarctation. hypertension should be diagnosed in children and adolescents who have auscultatory \ - confirmed blood pressure readings greater than the 95th percentile, based on sex, age, and height tables, at three different visits. children and adolescents being evaluated for high bp should have a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history recorded and a physical examination to identify findings suggestive of secondary causes of hypertension. electrocardiography should not be used for initial evaluation. children and adolescents who have been diagnosed with hypertension should be counseled regarding lifestyle modifications including diet and physical activity. children and adolescents who fail lifestyle modifications should be prescribed pharmacologic therapy. treatment options may include an ace inhibitor, arb inhibitor, long \ - acting calcium channel blocker, or thiazide diuretic. treatment goals for children and adolescents who have been diagnosed with hypertension should be a reduction in blood pressure to less than the 90th percentile and less than 130 / 80 in adolescents aged 13 years or older. see the full guideline for more recommendations, blood pressure tables, and treatment algorithms. read the full recommendation the aafp uses the category of “ affirmation of value ” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. the primary reasons for not endorsing this guideline included : there was a lack of transparency in the methodology used for study evaluation. while recommendations based on expert opinion were identified, it was unclear how those recommendations were developed. the management of conflicts of interest was not well described. there was inadequate discussion of the potential harms of medications for long \ - term use in children.
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guidelines
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4da80909f98f245f1e88d20ad6970fda0d3a8244
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Screening Pelvic Exams in Asymptomatic Non-pregnant Women
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Screening Pelvic Exams in Asymptomatic Non-pregnant Women
screening pelvic exams in asymptomatic non - pregnant women recommendation don ’ t perform pelvic exams on asymptomatic nonpregnant women, unless necessary for guideline \ - appropriate screening for cervical cancer. screening pelvic examinations, except for the purpose of performing cervical cancer screening at recommended intervals, have not led to reduction in mortality or morbidity, and expose asymptomatic women to unnecessary invasive testing. noninvasive options to screen for sexually \ - transmitted infections are now available as alternatives to endocervical cultures. screening pelvic examinations also add unnecessary costs to the health care system, included expenses from evaluations of false \ - positive findings. these pelvic exams can even lead to unnecessary surgery.
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guidelines
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97ffe94e1c019e6ad18b5f9453ff40288a2f4751
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Vaginal Birth After Cesarean
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Vaginal Birth After Cesarean
vaginal birth after cesarean key recommendations counseling, encouragement and facilitation for a planned vaginal birth after cesarean ( pvbac ) should be provided so that women can make informed decisions. if pvbac is not locally available, then women desiring it should be offered referral to a facility or clinician who can offer the service. indications for and circumstances surrounding the prior cesarean birth ( s ) should be discussed. induction of labor after cesarean is appropriate for women who have a medical indication for induction of labor and who are planning a lac / vbac. misoprostol should not be used for cervical preparation or induction of labor in the third trimester of pregnancy for women with a prior cesarean birth. at time of labor and presentation to the hospital, the plan for labor and vaginal birth should be reassessed with consideration of factors on admission that may affect the risks of labor and likelihood of vaginal birth. any changes in status during labor should be discussed. patients should be informed of the specific short \ - term and long \ - term benefits and harms of planned lac / vbac for the patient, her fetus / infant, and future pregnancies. all women desiring planned lac / vbac should be counseled about the capabilities of their specific delivery setting and women at high risk for complications should be referred as necessary to facilities with capabilities to effectively treat problems as they develop. hospitals should have guidelines to promote access to lac / vbac and actively monitor and improve quality of care for women who choose labor after cesarean. read the full recommendation for further details. read the full recommendation
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guidelines
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9caf76e034a7d1495819072180a1d196a40431a3
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Antibiotics for Otitis Media
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Antibiotics for Otitis Media
antibiotics for otitis media recommendation don ' t routinely prescribe antibiotics for otitis media in children aged 2 \ - 12 years with non \ - severe symptoms where the observation option is reasonable. the “ observation option ” refers to deferring antibacterial treatment of selected children for 48 to 72 hours and limiting management to symptomatic relief. the decision to observe or treat is based on the child ’ s age, diagnostic certainty, and illness severity. to observe a child without initial antibacterial therapy, it is important that the parent or caregiver has a ready means of communicating with the clinician. there also must be a system in place that permits reevaluation of the child.
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guidelines
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72cb26f60da4a93266ee12b3626ec6640b801a68
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Human Immunodeficiency Virus (HIV) - Clinical Preventive Service Recommendation
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Human Immunodeficiency Virus (HIV) - Clinical Preventive Service Recommendation
human immunodeficiency virus ( hiv ) - clinical preventive service recommendation clinical preventive service recommendation the aafp supports the united states preventive services task force ( ustspf ) recommendation that clinicians screen adolescents and adults ages 15 to 65 years for hiv infection. younger adolescents and older adults who are at increased risk should also be screened. the evidence base for the new recommendations for hiv screening for adults is solid. however, the prevalence of hiv infection and rate of new infection are very low among individuals who are 13 \ - 14 and 15 \ - 17 years old. although hiv testing has excellent sensitivity and specificity, the false positive rate will be higher in these populations. the benefits of detecting hiv in a low risk 15 \ - 17 year old versus detecting the infection in the same adolescent at age 18 is unknown, but this detection may reduce further infection. ( 2019 \ ) grade definition clinical considerations hiv infection, pregnant persons grade : a recommendation the aafp supports the ustspf recommendation that clinicians screen for hiv infection in all pregnant persons, including those who present in labor or at delivery whose hiv status is unknown. ( 2019 \ ) grade definition clinical considerations these recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. as such, they cannot substitute for the individual judgment brought to each clinical situation by the patient ' s family physician. as with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. these recommendations are only one element in the complex process of improving the health of america. to be effective, the recommendations must be implemented.
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guidelines
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619feac0abc2988b6a4e62f14889e27565f84cfa
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Voiding Cystourethrogram (VCUG) for First Febrile Urinary Tract Infection in Young Children
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Voiding Cystourethrogram (VCUG) for First Febrile Urinary Tract Infection in Young Children
voiding cystourethrogram ( vcug ) for first febrile urinary tract infection in young children recommendation do not perform voiding cystourethrogram ( vcug ) routinely in first febrile urinary tract infection ( uti ) in children aged 2 \ - 24 months. the risks associated with radiation ( plus the discomfort and expense of the procedure ) outweigh the risk of delaying the detection of the few children with correctable genitourinary abnormalities until their second uti.
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guidelines
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ca0b4f29f5641744107f304509d70fbeed157c8f
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children with asplenia or hyposplenia are at risk of developing overwhelming sepsis. health care providers caring for children with asplenia should ensure the best outcomes by using preventive strategies that focus on parent and patient education, immunization, antibiotic prophylaxis, and aggressive management of suspected infection. this updated position statement replaces a prior document from 2014 because new vaccines have become available and information on epidemiology has evolved. keywords : * antibiotic prophylaxis ; immunization ; sepsis ; splenectomy * children can have absent or defective splenic function as a result of congenital anatomical absence of a spleen, surgical removal of the spleen, or medical conditions that result in poor or absent splenic function. sickle cell anemia is a common cause of this condition in canada. absent or defective splenic function is associated with a high risk of fulminant bacterial sepsis, especially with encapsulated bacteria. splenectomized children younger than 15 years of age and congenitally asplenic infants are at greater risk of developing overwhelming postsplenectomy sepsis than adults. \ ] individuals with underlying blood disorders, such as hemoglobinopathies ( e. g., sickle cell disease, thalassemia major ) or hereditary spherocytosis, are at greater risk than those who have undergone a splenectomy because of trauma. \ ] asplenic patients are at risk of overwhelming sepsis throughout their life span, with the highest frequency of sepsis reported in the first three years postsplenectomy or in the first three years of life, if congenitally asplenic. \ ] asplenic patients with sepsis from encapsulated organisms have a 50 % to 70 % mortality rate, with the highest mortality rate reported in children younger than two years of age. \ ] \ ] most fulminant sepsis in asplenic patients is due to bacteria encapsulated by a polysaccharide capsule. * streptococcus pneumoniae * is the most common organism causing sepsis and is isolated in at least 50 % of cases. other encapsulated bacteria ( e. g., * haemophilus influenzae * type b ( hib ), * neisseria meningitidis *, and salmonella species are less common than pneumoco
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guidelines
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ca0b4f29f5641744107f304509d70fbeed157c8f
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##cci. \ ] sepsis associated with cat and dog bites due to * capnocytophaga * species carry high morbidity. \ ] other causes of sepsis, such as * escherichia coli - or, more recently, * bordetella holmesii - infection, have been described. \ ] asplenic patients are also more susceptible to severe or fatal malaria \ ] and to infection by the protozoan * babesia. * \ ] health care providers caring for children with asplenia should ensure the best outcomes with preventive strategies : parent and patient education, immunization, antibiotic prophylaxis, and the aggressive management of suspected infection. parent and patient education although immunization and prophylactic antibiotics are effective, they do not provide complete protection. children with asplenia and their families must be educated about the risk of sepsis and instructed to seek medical attention promptly when the child is ill or has a fever. heightened infection risk continues into adulthood. recognizing postsplenectomy sepsis can be difficult and death may occur in a matter of hours. the importance of using prophylactic antibiotics and vaccines should be emphasized repeatedly. vulnerable patients should wear a medicalert bracelet. when travelling, they should carry a note from their physician stating their diagnosis, associated risks, and a suggested medical management plan should they become ill. they should be aware of their increased risk of infection after animal bites, especially with * capnocytophaga canimorsus * from dog bites, and must be given appropriate antibiotics, such as amoxicillin \ - clavulanic acid, if they are bitten. all patients should receive the standard childhood and adolescent immunizations at the recommended age. however, due to the risk of fulminant sepsis from encapsulated bacteria, supplementary immunizations against * s pneumoniae *, hib and * n meningitidis - should be ensured, and may be administered on an earlier schedule than is routine ( ). all asplenic or hyposplenic patients should receive both the conjugated 13 \ - valent pneumococcal vaccine and the 23 \ - valent polysaccharide vaccine. \ ] \ ] - the immunization schedule for pneumococcal conjugate vaccine ( pcv13 ( prevnar \ - 13 \ ) ) should be a primary series of four doses
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guidelines
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ca0b4f29f5641744107f304509d70fbeed157c8f
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at two, four, six, and 12 to 15 months of age. children between 12 and 24 months of age without previous doses of pcv13 should receive two doses * at least * eight weeks apart. patients \ > 24 months of age need only one dose of pcv13 \. even when children have received all the required doses of pcv7 or pcv10 in the past, they should be given one dose of pcv13 as soon as possible. - the pneumococcal polysaccharide vaccine ( ppv23 ( pneumovax ) ) should be administered about 8 weeks after receipt of the appropriate number of pcv13 doses for supplemental protection. this interval will ensure ‘ priming ’ with the conjugated protein vaccine, followed by the broader spectrum, though less immunogenic, polysaccharide vaccine. a booster dose of ppv23 should be given five years after the first dose. - if asplenic patients have previously received only ppv23, they should receive one dose of pcv13 one year after receiving the ppv23 vaccine. all asplenic or hyposplenic patients should receive conjugate quadrivalent meningococcal vaccine ( mcv4 \ ) ) against serogroups a, c, w, and y as well as vaccine to prevent serogroup b meningococcus as per the schedule that coincides with the age at diagnosis of asplenia or hyposplenia. \ ] vaccines licensed in canada against the acwy serogroups include menveo ( glaxosmithkline, canada ), which can be administered under license starting at two months of age ), menactra ( sanofi pasteur, canada ) ( licensed starting at nine months of age ), and nimenrix ( pfizer, canada ) ( licensed starting at 6 weeks of age ). - infants should receive mcv4 as a primary series of four doses at two, four, six, and 12 to 15 months of age or on a three \ - dose schedule ( 2, 4, 12 months, if using nimenrix ). children identified as asplenic or hyposplenic from 12 months to 23 months of age should receive two doses of mcv4, eight weeks apart. patients identified after two years of age should receive two doses of mcv4, eight weeks apart.
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guidelines
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ca0b4f29f5641744107f304509d70fbeed157c8f
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- vaccinated patients should be revaccinated with mcv4 every five years pending further information on duration of immunity. - vaccines licensed in canada for protection against serogroup b include a four \ - component vaccine, bexero ( glaxosmithkline, canada ), which can be administered under license starting at two months of age ), and a bivalent recombinant lipoprotein ( rlp2086 \ ), trumenba ( pfizer, canada ) ( licensed starting at 10 to 25 years of age ). - infants and and children should be given 4cmenb ( bexsero ). infants 2 to 11 months of age should receive a two \ - or three \ - dose schedule administered 8 weeks apart. children 12 months to 10 years of age should receive two doses at least 8 weeks apart. - children 11 to 18 years of age can be given 4cmenb ( bexsero ) or bivalent recombinant vaccine ( trumenba ) in a two \ - dose series, six months apart ( with a minimum interval of four weeks ). # * haemophilus influenzae * type b ( hib ) - the recommended vaccination schedule for hib is a primary series of three doses given at two, four, and six months of age, with a booster dose at 18 months. - all patients ≥5 years of age who have never received hib immunization or have missed one or more doses should receive one dose. some experts recommend one additional dose of hib vaccine for all asplenic patients older than five years of age, even if they were fully immunized previously. - children with asplenia who present with a life \ - threatening hib infection should receive hib vaccine because the infection itself does not confer lifelong protection. - yearly seasonal influenza vaccine is recommended, starting at six months of age, to lower the risk of secondary bacterial infections. - all asplenic patients travelling to countries with less stringent food safety and water supply standards than canada may be at risk for * salmonella * infection, and should be immunized for * s typhi *. \ ] # household contacts - household contacts of asplenic patients should receive all age \ - appropriate vaccines and the yearly influenza vaccine. timing of immunizations in elective splenectomy when a patient is undergoing an elective or semiele
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guidelines
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ca0b4f29f5641744107f304509d70fbeed157c8f
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##ctive splenectomy, there is some evidence that the best responses occur when vaccines are administered at least two weeks before the surgery is performed. when this timing is not possible, it is optimal to begin immunizations at least two weeks postsplenectomy. \ ] however, in situations for which vaccines are not administered before splenectomy, the benefit of waiting two weeks postsplenectomy must be carefully weighed against the possibility that the patient may not be vaccinated at all ; sometimes the best choice is to vaccinate the child before discharge from hospital. antibiotic prophylaxis for children with asplenia or hyposplenia immunizations do not fully protect against infections with encapsulated bacteria, making antibiotic prophylaxis a second, vital aspect of care. provides dosing information for antibiotic prophylaxis. because * s pneumoniae - is the most common cause of severe infections in children with asplenia or hyposplenia, with significant associated mortality, patients younger than five years of age should all receive antibiotic prophylaxis. \ ] \ ] controversies exist with respect to duration of antibiotic prophylaxis. issues include the underlying disease and the effect of prophylaxis on the emergence of penicillin \ - resistant pneumococci. the single prospective controlled study that showed an 84 % reduction in infection was conducted in a population of patients with sickle cell disease ; these findings may not apply to all patients with poor splenic function. the age at which antibiotic prophylaxis should be discontinued is the most controversial topic. the 2018 red book from the american academy of pediatrics recommends prophylaxis until the child is five years of age and a minimum of one year of prophylaxis for children older than five years of age postsplenectomy, provided the child has received all the appropriate pneumococcal vaccinations. \ ] the 2011 british committee for standards in haematology and australian 2017 guidelines recommend that prophylactic antibiotics be continued, especially if : children are younger than 16 years of age ; have a history of invasive pneumococcal disease ; underwent a splenectomy for a hematological malignancy. they further recommend prophylactic antibiotics for all age groups in the first two years postsplenectomy or when there is an underlying immune function impairment. \
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guidelines
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ca0b4f29f5641744107f304509d70fbeed157c8f
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] \ ] because most postsplenectomy sepsis occurs within the first two to three years after surgery, the canadian paediatric society ’ s infectious diseases and immunization committee recommends antibiotic prophylaxis for a minimum of two years postsplenectomy and for all children \ < 5 years of age. furthermore, because fulminant septicemia has been reported in adults up to 65 years postsplenectomy, and invasive infection with penicillin \ - resistant pneumococci has not emerged as a problem for patients on long \ - term penicillin prophylaxis, lifelong prophylaxis in all cases is ideally recommended. however, the patient ’ s or family ’ s compliance and degree of access to medical care, current pneumococcal resistance rates, and previous episodes of life \ - threatening sepsis must be considered when making or reviewing this decision. children who have had or are believed to have had an anaphylactic \ - type reaction to penicillin should be referred immediately to an allergist to verify the diagnosis and for challenge or desensitization as warranted. \ ] clarithromycin is a recommended alternative ; however, this antibiotic is less successful at preventing invasive disease because of higher rates of pneumococcal resistance. the optimal duration of antibiotic prophylaxis for children who undergo partial splenectomy or who have functional asplenia or polysplenia is unclear from the literature. until there are recommendations to the contrary, following the guidelines described for children undergoing total splenectomy appears to be the most prudent course. asplenic and hyposplenic children must be advised of their increased risk of severe malaria and should always seek travel advice. they should also take malaria prophylaxis as appropriate for their age and the type of malaria found in the area to which they are travelling. preventive measures should be taken, including sleeping under an insecticide \ - treated bed net or in air \ - conditioned accommodations, and using insect repellent. within the first month of returning from a malaria endemic area, and for up to a year afterward, the patient with fever should inform their health care provider and malaria should be included in the differential diagnosis. \ ] \ ] initial treatment of suspected sepsis : a medical emergency children with asplenia must be seen by a physician immediately if there
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is a sudden fever or concern about a non \ - specific febrile illness, or after an animal bite. sepsis in individuals with asplenia or hyposplenia is a medical emergency because they can die within several hours of fever onset despite appearing well initially. unless there is an obvious nonbacterial source, a blood culture should be performed but should not delay the administration of antibiotic therapy. all patients should receive ceftriaxone ( 100 mg / kg / dose, maximum 2 g / dose ). where intermediate or high penicillin \ - resistant pneumococci are prevalent, administer both ceftriaxone and vancomycin ( 60 mg / kg / day in divided doses every 6 h ). if the patient is being treated in a clinic or office setting, refer immediately to the nearest emergency department. clinical deterioration can be rapid even after antibiotic administration. antibiotics should be modified once blood culture results become available. if the patient has a serious penicillin or cephalosporin allergy, vancomycin and ciprofloxacin can be used. antibiotics should be modified once blood culture results become available. to prevent and treat infections in children with asplenia or hyposplenia, the canadian paediatric society recommends that : - physicians educate patients and families about the risks associated with asplenia and hyposplenia. - children with asplenia and hyposplenia should receive all routine childhood immunizations, and some routine vaccinations should be administered on an accelerated schedule with extra doses. all children with these conditions, regardless of age, should receive vaccines to protect against * s pneumoniae *, * n meningitidis *, hib, and seasonal influenza. - prophylactic antibiotics should be administered until patients are at least 60 months of age, and longer for children who experience an episode of invasive pneumococcal disease. consideration should be given to lifelong prophylaxis. - patients with asplenia or hyposplenia must be considered at high risk of serious bacterial infection ( i. e., as presenting with a medical emergency ). they should wear a medic alert bracelet, be promptly assessed whenever fever occurs and started on antimicrobial therapy immediately unless a nonbacterial source is apparent.
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counselling couples facing the birth of an extremely preterm infant is a complex and delicate task, entailing both challenges and opportunities. this revised position statement proposes using a prognosis \ - based approach that takes the best estimate of gestational age into account, along with additional factors, including estimated fetal weight, receipt of antenatal corticosteroids, singleton versus multiple pregnancy, fetal status and anomalies on ultrasound and place of birth. this statement updates data on survival in canada, long \ - term neurodevelopmental disability at school age and quality of life, with focus on strategies to communicate effectively with parents. it also proposes a framework for determining the prognosis \ - based management option ( s ) to present to parents when initiating the decision \ - making process. this statement replaces the 2012 position statement. early preterm birth poses medical, social and ethical challenges and opportunities. although extremely preterm infants have high mortality and morbidity rates compared with term infants, prognostic uncertainty exists in each individual case. this uncertainty accounts, in part, for the ethical challenges associated with determining what course of action is in the best interests of a particular newborn. some argue that extremely preterm infants deserve the same aggressive intensive care offered to older children with comparable risks of morbidity and mortality. every infant, situation and family is unique and decisions regarding management can vary substantially among families \ -. there is no universal agreement on approach and management. parents and health care professionals ( hcps ) each have their own personal and professional experiences, value systems and interpretations of relevant medical data shaping moral judgments regarding best interests. hcps rank the quality of life ( qol ) of adolescents born extremely preterm lower than parents and children with related disabilities rank it themselves. recent research has put emphasis on the role of the family in decision making, how to communicate with families and the importance of sharing qol information with parents. also, the survival of infants born at 22 weeks gestational age ( ga ) has been increasingly reported in the last few years. hcps must remember that most births involve the opportunity for a family to welcome a child into the world with hope, even one born extremely preterm. this position statement provides updated recommendations to help hcps, together with families, guide management of the anticipated birth of an extremely preterm infant. statement objectives are to : review factors to consider in the decision \ - making process,
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provide a framework for engaging parents in the decision \ - making process and suggest levels of care based on the estimated risks of mortality and neurodevelopmental disability ( ndd ). it does not address obstetrical care of the mother in detail. for present purposes, the terms ‘ parent ’ and ‘ family ’ can refer to any person or couple expecting the birth of an infant or to those whose child has been born. recommendations focus on infants to be born between 220 and 256 weeks ga. cases exist at any ga where a devastating congenital lesion, clinical situation or family circumstance leads to the consideration of palliative care. nationally, palliative care is accepted as the usual approach when an infant is born ≤21 weeks ga. search strategies were conducted between 2013 and 2015, using medline, embase, cochrane database of systematic reviews and central. search terms included : outcomes ( ndd at 4 to 8 years of age and qol ) for infants born extremely preterm ; antenatal corticosteroid ( ancs ) use and risks of maternal morbidity related to delivering preterm ; and shared decision making and communication with parents. regarding studies related to ndd, the age range of 4 to 8 years is more predictive of long \ - term disability than follow \ - up at an earlier age. to ensure sufficient breadth of expertise, national stakeholders provided input through a consultation process, which included the use of validated tools. definitions ( ga, ndd, early intensive care and palliative care ) can be found in the appendix. # care of the mother at risk for extremely preterm birth # # assessing ga ultrasound is the most accurate method for establishing ga ( aside from in vitro fertilization ). first trimester crown \ - rump length is the most accurate for dating within 3 to 8 days. the degree of imprecision increases with advancing ga ( ± 10 days at 16 to 22 weeks and ± 2 weeks at 24 weeks ) \ -. despite these limitations, establishing an accurate ga is crucial for counselling, management and support of the family. # # place of care rates of neonatal mortality and morbidity decrease when extremely preterm infants are born at tertiary perinatal centres rather than at nontertiary centres. transferring women at risk for extremely preterm birth to tertiary perinatal centres improves maternal care and offers opportunities for counselling by maternal – fetal medicine specialists and neon
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##atologists. when transfer is not possible and delivery at a nontertiary centre is expected, management decisions for mother and infant need to consider availability of resources and the possible limitations of setting and local expertise when determining the infant ’ s prognosis. # # antenatal corticosteroids debate continues concerning the benefits of administering ancs to mothers during pregnancies before 24 weeks ga because they were excluded from studies reported in the national institutes of health ’ s consensus statement. since then, animal data and several large retrospective cohort studies have suggested that ancs use improves survival rates for infants \ < 24 weeks ga \ -. ancs should be offered to women at risk for extremely preterm birth at ≥22 weeks ga when early intensive care is a management option. the timing of ancs administration can be a challenge because the chance of delivering extremely preterm is difficult to estimate and the maximal period of efficacy for ancs is reached within 7 days of the last dose. although some trials of repeated ancs have suggested potential for harm to the fetus and mother, one recent systematic review showed lower risk for respiratory distress syndrome and other neonatal morbidities in infants born after mothers received one or more courses of ancs, without evidence of harm in later childhood. # # mode of delivery three recent statements concluded that current evidence does not consistently support routine caesarean sections to improve neonatal outcome in extremely preterm births. caesarean sections at an extremely early ga carry significant risks for the mother, particularly when they involve a classical incision \ -. parents and obstetrical hcps should decide jointly on optimal mode of delivery by carefully weighing the potential short \ - and long \ - term risks ( including that of in utero fetal demise ) against benefits. # factors to consider in decision making around management many medical and nonmedical factors inform the management of extremely preterm infants. relying on ga alone to predict outcome and generate recommendations for management is erroneous. medical considerations include the risk estimates for infant mortality and ndd and qol in the longer term. explaining the limitations of current data clearly and truthfully to expectant parents is necessary. one systematic review of survival focused on infants weighing \ < 1000 g or \ < 28 weeks ga at birth. out of 51 studies, large variation in survival rates was found, particularly depending on the denominator used. variation was also possibly caused by differences in baseline risk, antenatal and post
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##natal therapies and / or approaches to withholding or withdrawing life \ - sustaining interventions. the last two variables depend on individual hcps and / or variation in approved practices in a particular society. such potential for selection bias underlines the need for hcps to understand the limitations of survival data and acknowledge them during discussions with parents. the most relevant data for parents in canada are population \ - specific ( i. e., canadian ) and, ideally, based on local institution rates. between 2010 and 2015, the units providing data to the canadian neonatal network ( cnn ) recorded a total of 3830 live births at \ < 26 weeks ga. shows survival data to time of discharge from the neonatal intensive care unit ( nicu ) ( stillbirths excluded ). cnn reports data for babies born at ≤22 weeks ga as a group. survival at \ < 22 weeks ga is extremely rare, with four reported survivors at \ < 22 weeks ga within the stated time frame ( p. chan, * personal communication * ). the cnn website ( ) provides up \ - to \ - date data. # # neurodevelopmental disability at school age one recent systematic review and meta \ - analysis included nine high quality cohorts. summarizes the findings. while there was no statistically significant difference in the risk for severe ndd by week of ga, there was a statistically significant reduction of 6 % in the risk of moderate \ - to \ - severe ndd with each increasing week of ga. the most commonly observed condition is cognitive impairment, followed by cerebral palsy. vision and hearing deficits occur less frequently. the limitations of these data must be understood by hcps and parents. they include : small sample sizes with wide confidence intervals at 22 and 23 weeks ga, an unknown number of children with one versus multiple impairments, variation in the definition and labelling of ndd by hcps ( especially ‘ severe ’ versus ‘ moderate ’ ) that may not reflect parents ’ views or reality, no information on mild or other types of impairment ( e. g., behavioural ) and the lack of correlation between degree of ndd and qol. one example demonstrates such limitations clearly : a child with severe cognitive impairment and severe cerebral palsy and a child with isolated uncorrectable deafness would both be classified as having severe ndd. # # health status and qol a systematic review performed in 2013 assessed the self \ - reported q
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##ol of adolescents and adults who were extremely low birth weight ( elbw ) or very low birth weight ( vlbw ) infants \ -. nearly all studies showed no significant difference in self \ - rated qol scores for former elbw / vlbw infants compared with full \ - term counterparts. both groups rated their qol as good. however, using self \ - reported data prevented severely disabled individuals from participating in some studies. two additional limitations are that no studies focused solely on infants born at 22 to 25 weeks ga and the data drawn from vlbw / elbw infants born in the 1970 to 1995 time period are probably inapplicable to babies born today. one study providing a breakdown by ga found no significant difference in qol scores among adolescents born at 23 to 27 weeks ga. while the broad results suggest that most former vlbw / elbw infants rate their qol as ‘ good ’ in adolescence / young adulthood, the individual qol measures vary considerably. # # parental qol a systematic review performed in 2013 used different reporting time frames and tools to evaluate qol in the caregivers of children born vlbw or elbw \ -. the time frames ranged from 1 to 25 years after delivery, with mothers completing the vast majority of evaluations. most studies reported increased levels of parent stress and a negative impact on family functioning and finances for parents of children born as vlbw / elbw infants compared with parents of children born at term. some effects did improve over time. one study following these children into early adulthood found that parents felt that their experience improved family bonds, enhanced parental self \ - perception and improved their parenting abilities. the effects of having a vlbw / elbw infant on divorce rate are equivocal. despite finding an overall negative impact compared with term controls, many parents of these children did not report distress or an additional burden of care. overall, the qol of parents appears to be highly individualized and dependent on specific family situations and characteristics. # # prognostic uncertainty although survival rates are improving and the chances of surviving without moderate \ - to \ - severe ndd increase with each incremental week of ga, such benefits can be off \ - set by other prognostic factors. these variables include : birth weight ( in 100 g increments ), singleton ( versus multiple ) birth, the provision of ancs therapy, and gender ( with male infants
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disadvantaged ). each of these factors can alter outcome by as much as an additional week of gestation. one canadian graphic tool uses a combination of birth weight and ga to predict survival, without short \ - term morbidity, to hospital discharge. other prognostic factors include the number of days into the week of gestation ( e. g., 231 versus 236 ) and birth outside a tertiary perinatal centre. finally, the clinical course of the extremely preterm infant in the nicu also influences long \ - term outcomes. intracranial bleeding, periventricular leukomalacia, retinopathy of prematurity, bronchopulmonary dysplasia, sepsis, days on mechanical ventilation and nutrition ( feeding human milk ) appear to influence outcomes \ -. other clinical diagnoses, parental socioeconomic status and post \ - discharge interventions can also influence outcomes but a detailed review of such factors is beyond the scope of this statement. # antenatal counselling and decision making # # communicating with parents parents facing the birth of an extremely preterm infant should, ideally, have several opportunities to meet with hcps to share information and consider a care plan, particularly as pregnancy progresses or new information becomes available. many parents report feeling distressed, disempowered and grief \ - stricken when faced with the possibility of delivering extremely preterm. qualitative studies report a degree of ‘ disconnect ’ between the information hcps provide and what parents recall. providing written information improves parental understanding and recall. consistency and accuracy in provided information is crucial for expectant parents. communication between obstetrical and neonatal teams concerning consultations, along with clear documentation of the joint plan in the mother ’ s medical chart, promotes consistency and adherence to the plan. communicating with parents about periviability, potential outcomes and difficult decisions requires specialized training \ - : trainees must demonstrate expert competence before performing consultations without supervision. involving trained peer counsellors may provide further support to parents. # # shared decision making shared decision making ( sdm ) is the best approach for preference \ - sensitive decisions, which include those made when no clear evidence supports one treatment over another, options have different inherent benefits / risks, or parental values are involved. sdm can mitigate parental grief around end \ - of \ - life decisions, enhance knowledge of and satisfaction with care, aid decision making that is consistent with parental values
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and foster collaboration with medical teams \ -. key steps in the sdm process include : identifying the decision to be made ( choice talk ), reviewing the options ( option talk ), and providing support for deciding what matters most to the parents ( decision talk ). the hcp ’ s expertise lies in recognizing major biological and medical factors influencing survival and long \ - term prognosis, while the family knows most about the socioenvironmental and familial characteristics that will influence their infant ’ s outcomes ( e. g., finances, resource availability, support from extended family ). such characteristics are difficult to measure but must all be considered in the sdm process. most parents wish for an sdm ‘ model ’ during antenatal consultations, a practice strongly recommended in the perinatal setting. some parents prefer a more directive approach or recommendation. the approach with each family should be individualized and based on their expressed needs and wishes. formal training in sdm helps hcps to optimize parental engagement in an informed decision \ - making process. the parents ’ expectations regarding their own role in decision making can never be assumed. some parents are reluctant to carry the burden of decision making, while others want to be involved but do not know how. decision aids for parents facing imminent preterm birth have been developed. decision ‘ coaching ’, where a trained hcp provides parents with individualized, nondirective guidance, is often used in conjunction with other decision aids to facilitate sdm. lists strategies for communicating effectively with parents, engaging parents in decision making, clarifying their values and preferences and guiding the prenatal consultation \ -. sdm is the goal but may not always be possible due to clinical circumstances ( e. g., a rapidly progressing labour, or when narcotics or a prescribed medication heavily alter a mother ’ s level of consciousness ). # management decisions, including ethical considerations depending on an infant ’ s prognosis, hcps usually present parents with one or two broad management options during a prenatal consultation : early intensive care ( with ongoing re \ - evaluation ) and / or palliative care. prognosis is based on all available information at the time of consultation and helps determine what management options are proposed. when the hcp determines that both early intensive and palliative care are options, parents should be engaged in sdm and their decisions regarding appropriate care for their infant supported. when there is a typical approach
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to care, present it to parents together with the reasons why other options may ( or may not ) apply to their particular circumstances. throughout the process, parents should be encouraged to express their thoughts and opinions. listen, be sure that parents understand the information provided, and seek consent to proceed. ideally, the decision \ - making process occurs over time, with hcps and parents able to acknowledge, articulate and manage varying degrees of prognostic uncertainty. some difficult clinical issues have no universal answers, which is why parental involvement, ethics \ - based discussion and personal reflection are such important aspects of care. what factors initially determine whether to offer parents both early intensive or palliative care options or recommend one option over another? what outcomes are relevant to this decision? what predicted likelihood of death justifies the noninitiation of intensive care? what severity and / or predicted likelihood of ndd could justify noninitiation of intensive care? what predicted likelihood of survival justifies over \ - ruling a family ’ s request for palliative care? clearly, these and other difficult questions exist in many cases. the clinical picture, hcp experience and parental involvement all inform the decision \ - making process, and suggests a framework for key deliberations. a lower limit where palliative care will be recommended by hcps is typical practice, just as there is an upper limit where they will recommend early intensive care. a parent may disagree with the option that is recommended. given the lack of a moral authority regarding standard of care in this complex area, a ‘ non \ - recommended ’ option is sometimes instituted after further informed discussion, time to think and conflict resolution. there are also cases where parents and hcps cannot reach consensus about an infant ’ s care management. while hcps are responsible for exploring management options with parents, this obligation does not necessarily extend to offering treatments that are clearly outside the usual local level of care. in such situations, consider seeking a second opinion from a colleague and / or support from an ethics consultation, or applying for an institutional board review to determine the infant ’ s and family ’ s best interests. when extremely preterm infants are born outside of a tertiary care centre, consultation via phone or video with a neonatologist can help to focus management options and care planning based on setting, resources and local expertise. when the care plan is uncertain or when the plan is to provide early intensive care, a neonatal team capable of caring for the infant and facilitating
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management decisions should be present at the birth. after the birth of an extremely preterm infant, there are often several opportunities to learn more about the infant ’ s prognosis and to re \ - evaluate care plans. the provision of palliative care ( chosen before or after birth ) mandates the presence of hcps who can oversee individualized comfort measures, including keeping the infant warm and minimizing discomfort and pain. give parents opportunities to hold and spend as much time with their infant as desired. also, be sure they are aware of the possibility that their infant may survive despite noninitiation or discontinuation of life \ - sustaining therapies, although such cases are extremely rare. comfort measures are essential for any dying infant, and bereavement care and options to create memories ( e. g., footprints, handprints, photographs ) should always be provided for parents in such situations. the quality of evidence reviewed for this statement is nearly all low or very low, such that almost all recommendations stem from expert opinion and consensus. with the exception of research on ancs, the literature provides relatively indirect evidence to support recommendations. recommendations have not been graded for evidence. difficult, preference \ - sensitive and value \ - based decisions are often made in this area of care. - when a pregnant woman is at risk of giving birth between 220 and 256 weeks ga, the primary hcp should consult with a maternal – fetal medicine specialist. transfer to a tertiary perinatal centre is recommended. - parents facing the birth of an extremely preterm infant should have the opportunity for face \ - to \ - face discussions with their obstetrical hcp as well as a consultation with a neonatologist or paediatrician. when circumstances permit, parents should be able to meet with these hcps on more than one occasion. - parents must receive individualized, accurate information about their infant ’ s anticipated likelihood of survival and potential long \ - term outcomes. for each case, the hcp must explain the degree of prognostic uncertainty and the limitation of data. - when both early intensive care and palliative care are considered to be equal care options, the management plan should be decided upon after engaging in a sdm process with parents. the sdm process should be ongoing as the pregnancy continues. - hcps should consider using a decision aid, decision coaching and parent information handouts to facilitate parental involvement and understanding throughout the sdm process
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. - the maternal – fetal medicine specialist, neonatologist, nurse caring for the mother and other hcps involved in the circle of care, must communicate directly with each other and with parents to ensure clear understanding of the management plan, avoid conflicting information and enhance care. ideally, such conversations should take place at the bedside to allow all pertinent information to inform the decision \ - making process. the plan must be clearly documented and revised if the plan changes. - ancs should be given between 220 and 256 weeks ga when early intensive care is a management option and, in the opinion of the obstetrical hcp, the risk of extremely preterm birth is high. - the hcp and team most capable of managing an extremely preterm infant should attend delivery, regardless of the management plan chosen. - when prenatal maternal transfer is not possible, the hcp at the referring centre should initiate a consultation with a neonatologist ( by phone or via telemedicine ) to review management options and receive guidance about the decision \ - making process with the parents. early intensive care or palliative care should be offered, based on estimation of prognosis and the resources available. the management plan should be finalized after discussion between hcp at the referring centre and parents. - when an extremely preterm infant is born but no decision has been reached regarding the management plan ( e. g., circumstances prevented sdm antenatally or parents could not yet decide ), the infant should usually receive early intensive care until sdm or further discussion with the parents can occur. this recommendation does not apply for infants considered extremely likely to die or to experience severe ndd, or when the setting, resources ( including personnel ) or local expertise do not allow for the adequate provision of early intensive care. - all extremely preterm infants who do not receive early intensive care, or for whom early intensive care is not successful, must receive compassionate palliative care, including warmth and pain relief.
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- current : harm reduction : an … harm reduction : an approach to reducing risky health behaviours in adolescents # principal author ( s ) km leslie ; canadian paediatric society, paediatr child health 2008 ; 13 ( 1 \ ) : 53 \ - 6 harm reduction is a public health strategy that was developed initially for adults with substance abuse problems for whom abstinence was not feasible. harm reduction approaches have been effective in reducing morbidity and mortality in these adult populations. in recent years, harm reduction has been successfully applied to sexual health education in an attempt to reduce both teen pregnancies and sexually transmitted diseases, including hiv. programs using a harm reduction philosophy have also successfully lowered risky alcohol use. the target patient population and the context in which harm reduction strategies are delivered influence the specific interventions used. health care practitioners ( hcps ) who provide care to adolescents should be aware of and familiar with the types of harm reduction strategies aimed at reducing the potential risks associated with normative adolescent health behaviours. the goal of the present statement is to provide hcps with a background and definition of harm reduction as a public health policy, and to describe how hcps can effectively use harm reduction with their adolescent patients. harm reduction can be described as a strategy directed toward individuals or groups that aims to reduce the harms associated with certain behaviours. when applied to substance abuse, harm reduction accepts that a continuing level of drug use ( both licit and illicit ) in society is inevitable and defines objectives as reducing adverse consequences. it emphasizes the measurement of health, social and economic outcomes, as opposed to the measurement of drug consumption \ -. harm reduction has evolved over time, from its initial identification in the 1980s, as an alternative to abstinence \ - only focused interventions for adults with substance abuse disorders. at the time, it was recognized that abstinence was not a realistic goal for those with addictions. in addition, those individuals who were interested in reducing, but not eliminating, their use were excluded from programs that required abstinence. there is persuasive evidence from the adult literature that harm reduction approaches greatly reduce morbidity and mortality associated with risky health behaviours. for example, areas that have introduced needle \ - exchange programs have shown mean annual decreases in hiv seroprevalence compared with those areas that have not introduced needle \ - exchange programs. access to and use of methadone maintenance programs are strongly related to decreased mortality, both from natural
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causes and overdoses, which suggests that these programs have an impact on overall sociomedical health. the most recent addition to the harm reduction continuum is that of supervised injecting facilities, which have been successfully implemented in switzerland and the netherlands, and more recently in vancouver, british columbia. hcps play important roles in many of these harm reduction initiatives. how can this concept of harm reduction be applied to adolescents? the majority of adolescents are not going to require the kind of harm reduction strategies mentioned above. however, a harm reduction approach is congruent with what we know about adolescent development and decision \ - making. adolescence is a time of experimentation and risk \ - taking. adolescents also tend to reject authority and strive for autonomy in their decision \ - making. young people engage in behaviours that have potentially negative outcomes. in one study, more than two \ - thirds of high school students in ontario reported having used alcohol at least once over the previous year, and one \ - third reported cannabis use over the previous year. alcohol ingestion presents the potential for intoxication and overdosing ( particularly when binge drinking occurs ). alcohol disinhibits an individual, which may promote aggressive behaviour and fighting, or which may be associated with unwanted sexual advances or experiences. between 8 % and 10 % of teens reported that using drugs or alcohol was the reason that they had intercourse for the first time. unprotected sexual activity is associated with a higher incidence of sexually transmitted infections ( stis ) and can lead to unintended pregnancy. in fact, the highest rates of stis in canada are in the 15 \ - to 24 \ - year age group, with girls 15 to 19 years of age having the highest rates for chlamydia and gonorrhea. the 2002 canadian youth, sexual health and hiv / aids study reported that while the age at initiation of intercourse is decreasing gradually over time, the median age for first intercourse has not changed in over a decade and remains around 17 years of age. almost 30 % of boys and girls in grade 9 reported having had oral sex. overall, long \ - term trends have shown some changes in these behaviours over time ; however, it is highly unlikely that any interventions will eliminate these behaviours from adolescence. it is conceivable, however, that enhanced strategies will be developed, with the aim of slowing down some of the trends seen over the past decade. this would include trends of decreasing age
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at first use of substances such as cannabis and earlier ages of onset of sexual activity. there are several possible approaches to substance use and other risky behaviours : - discourage the behaviour ( ie, recommend that the teen stop the behaviour completely ) ; - encourage the teen to reduce the behaviour ; and - provide the teen with information aimed at reducing the harmful consequences of the behaviour when it occurs. some studies from the substance use literature have identified that the perceived risk of harm is inversely related to the level of use. the provision of education about the potential risks and ways of reducing them may impact on these behaviours. it is important to acknowledge that programs aimed at the primary prevention of a particular behaviour need to differ in focus from those aimed at secondary prevention in groups of adolescents in which the behaviour is already established. this requires careful consideration of the intended target population and the context in which the approach is used. primary prevention of risky behaviour is a reasonable focus for the young adolescent or preteen. this may be achieved by discouraging the behaviour ( using sexual behaviour as an example – by encouraging the delay of initiation of sexual activity ). for an adolescent who is already engaging in potentially risky sexual behaviour, he or she can be encouraged to reduce the behaviour, and can also be provided with information and education about condom use, additional contraception, and discussion about the pros and cons of sexual activity. for a street \ - involved young woman who is engaging in prostitution, providing free condoms, as well as regular access to sti testing and emergency contraception ( in addition to other biopsychosocial care ), may be the most appropriate intervention at the time. this would, however, not preclude the discussion of the option of reduction or elimination of the risky behaviour. there is a growing literature supporting the efficacy of harm reduction strategies in both the prevention and intervention of behaviour with potential health risks. marlatt and witkiewitz published a comprehensive review of harm reduction approaches to alcohol use, and summarized the relevant literature on health promotion prevention and treatment. they discussed the data on a program that was widely implemented in the united states, a program known as drug abuse resistance education ( dare ), which focused on zero tolerance ( the ‘ just say no ’ concept ). several studies have demonstrated that this program was nonefficacious in reducing substance use. two examples of programs that have been successfully implemented and evaluated based on a harm reduction philosophy are the alcohol misuse prevention study ( amp
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##s ) in the united states, and the school health and alcohol harm reduction project ( shahrp ) in australia. the amps program is a curriculum aimed at grade 5 and grade 6 students, and includes information about the harms of alcohol abuse and how to deal with social pressures to misuse alcohol. in a randomized, controlled study, participants in the amps program had significantly fewer alcohol problems than controls. the program has also demonstrated reductions in the normative increases in alcohol use and misuse in early to late adolescence. the shahrp program has similar components to the amps program, and consists of active learning incorporating skills training and alcohol education. evaluation of this program has demonstrated significant reductions in alcohol consumption and alcohol \ - related harms in those students participating in the program compared with controls. these prevention programs have not been effective in changing behaviour in those teens that are already engaged in harmful drinking. the concept of learning how to drink more safely is consistent with the fact that many adolescents see drinking as normative. it is also developmentally congruent that adolescents are less likely to engage in a program or treatment that ‘ requires ’ them to behave in a certain way, and may rebel against anything they see as being judgemental. strategies that incorporate motivational interviewing and acknowledge the adolescent ’ s individual goals are being developed for use with adolescents. motivational interviewing includes guidelines for addressing resistance, and addressing ambivalence or resistance to change ( ). it emphasizes self \ - responsibility in changing or modifying one ’ s behaviour. the use of these types of strategies with slightly older participants ( 17 to 20 years of age ) have led to reductions in alcohol \ - related problems. monti et al reported on a brief intervention with 18 \ - and 19 \ - year \ - olds who presented to the emergency room with an alcohol \ - related event. they demonstrated that those randomly assigned to the 35 min to 40 min motivational interviewing style session, had significantly lower incidences of drinking and driving, alcohol \ - related injuries and alcohol \ - related problems after six months of follow \ - up. harm reduction has also been used in primary and secondary prevention programs aimed at reducing unintended pregnancies. a recent review demonstrated that programs that incorporate messages about both delayed abstinence and the use of condoms and contraception were more effective than those delivering abstinence \ - only messages. there are many other examples of harm reduction strategies that have been implemented successfully. these include condom machines in
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high schools, seat belt legislation and programs promoting safe participation in sports ( eg, wearing bike helmets, life vests for boating and hockey visors ). the basic premise of harm reduction holds for all of these programs ( ie, there are inherent risks involved with any behaviour, and there are interventions that, when followed, reduce these risks for those who choose to engage in the behaviours ). hcps routinely incorporate information about many harm reduction strategies into their everyday clinical work with patients, without explicitly realizing that they are harm reduction strategies. examples of these are promoting the use of bike helmets, encouraging patients to wear protective gear while skateboarding and promoting the use of sunscreen. this is a significant component of preventive health care. harm reduction is a developmentally congruent approach to the primary and secondary prevention of risky behaviour in the adolescent population. hcps are well positioned to deliver harm reduction messages to their adolescent patients. surveys of adolescents have supported the fact that adolescents identify hcps as credible sources of health information. acknowledging the adolescent ’ s role in decision \ - making about his or her health behaviour is an important component to the provision of this education. avoiding judgment about potentially risky behaviours enhances the ability of the hcp to deliver important messages about risk reduction. the canadian paediatric society recommends that hcps working with adolescents : - screen all preadolescent and adolescent patients for potentially risky behaviours at regular health care visits. - provide messages that encourage delay in initiation of potentially risky behaviours, and at the same time, promote risk \ - reduction strategies if adolescents choose to engage or are already engaging in the behaviour. - use principles of motivational interviewing in the assessment and discussion of risky health behaviours with adolescent patients \ -. - become familiar with the resources in their communities that provide harm reduction programs for substance abuse, pregnancy prevention and injury prevention. - advocate for the introduction, further development and evaluation of evidence \ - based prevention and treatment programs that use a harm reduction philosophy in schools and communities. # adolescent health committee members : franziska baltzer md ; april elliott md ; debra katzman md ; jorge pinzon md ( chair ) ; koravangattu sankaran md ( board representative ) ; danielle taddeo md liaison : sheri m findlay md, adolescent health section, canadian paediatric society principal author : karen mary leslie md 1. bellis ma, hughes k, lowey h. healthy nightclubs and recreational
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substance use : from a harm minimisation to a healthy settings approach. addict behav 2002 ; 27 : 1025 \ - 35 \. 2. cheung yw. substance abuse and developments in harm reduction. cmaj 2000 ; 162 : 1697 \ - 700 \. 3. parker h, egginton r. adolescent recreational alcohol and drugs careers gone wrong : developing a strategy for reducing risks and harms. int j drug policy 2002 ; 13 : 419 \ - 32 \. 4. roche am, evans kr, stanton wr. harm reduction : roads less traveled to the holy grail. addiction 1997 ; 92 : 1207 \ - 12 \. 5. wodak a. what is this thing called harm reduction? int j drug policy 1999 ; 10 : 169 \ - 71 \. 6. bonomo y, bowes g. putting harm reduction into an adolescent context. j paediatr child health 2001 ; 37 : 5 \ - 8 \. 7. amundsen ej. measuring effectiveness of needle and syringe exchange programmes for prevention of hiv among injecting drug users. addiction 2006 ; 101 : 911 \ - 2 \. 8. langendam mw, van brussel gh, coutinho ra, van ameijden ej. the impact of harm \ - reduction \ - based methadone treatment on mortality among heroin users. am j public health 2001 ; 91 : 774 \ - 80 \. 9. centre for addiction and mental health. drug use among ontario students, 1977 \ - 2007 : osduhs highlights. version current at july 5, 2007 \. 10. council of ministers of education, canada. canadian youth, sexual health and hiv / aids study : factors influencing knowledge, attitudes and behaviours. 11. public health agency of canada. 2004 canadian sexually transmitted infections surveillance report. version current at november 21, 2007 \. 12. resnicow k, smith m, harrison l, drucker e. correlates of occasional cigarette and marijuana use : are teens harm reducing? addict behav 1999 ; 24 : 251 \ - 66 \. 13. toumbourou jw, stockwell t, neighbors c, marlatt ga, sturge j, rehm j. interventions to reduce harm associated with adolescent substance use. lancet 2007 ; 369 : 1391 \ - 401 \. 14. marlatt ga, witkiewitz
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k. harm reduction approaches to alcohol use : health promotion, prevention, and treatment. addict behav 2002 ; 27 : 867 \ - 86 \. 15. beck j. 100 years of “ just say no ” versus “ just say know ” : reevaluating drug education goals for the coming century. eval rev 1998 ; 22 : 15 \ - 45 \. 16. lynam dr, milich r, zimmerman r, et al. project dare : no effects at 10 \ - year follow \ - up. j consult clin psychol 1999 ; 67 : 590 \ - 3 \. 17. masterman pw, kelly ab. reaching adolescents who drink harmfully : fitting intervention to developmental reality. j subst abuse treat 2003 ; 24 : 347 \ - 55 \. 18. mcbride n, farringdon f, midford r, meuleners l, phillips m. harm minimization in school drug education : final results of the school health and alcohol harm reduction project ( shahrp ). addiction 2004 ; 99 : 278 \ - 91 \. ( erratum in 2004 ; 99 : following 527 \ ). 19. miller wr. motivational interviewing : research, practice, and puzzles. addict behav 1996 ; 21 : 835 \ - 42 \. 20. sindelar ha, abrantes am, hart c, lewander w, spirito a. motivational interviewing in pediatric practice. curr probl pediatr adolesc health care 2004 ; 34 : 322 \ - 39 \. 21. erickson sj, gerstle m, feldstein sw. brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings : a review. arch pediatr adolesc med 2005 ; 159 : 1173 \ - 80 \. 22. borelli b. using motivational interviewing to promote patient behaviour change and enhance health. 23. baer js, kivlahan dr, blume aw, mcknight p, marlatt ga. brief intervention for heavy \ - drinking college students : 4 \ - year follow \ - up and natural history. am j public health 2001 ; 91 : 1310 \ - 6 \. 24. monti pm, colby sm, barnett np, et al. brief intervention for harm reduction with alcohol \ - positive older adolescents in a hospital emergency department. j consult clin psycho
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##l 1999 ; 67 : 989 \ - 94 \. 25. kirby d. do abstinence \ - only programs delay the initiation of sex among young people and reduce teen pregnancy? version current at november 21, 2007 \. 26. boekeloo bo, schamus la, cheng tl, simmens sj. young adolescents ’ comfort with discussion about sexual problems with their physician. arch pediatr adolesc med 1996 ; 150 : 1146 \ - 52 \. ( erratum in 1997 ; 151 : 128 \ ). 27. klein jd, wilson km. delivering quality care : adolescents ’ discussion of health risks with their providers. j adolesc health 2002 ; 30 : 190 \ - 5 \. 28. malik r, oandason i, yang m. health promotion, the family physician and youth : improving the connection. fam pract 2002 ; 19 : 523 \ - 8 \. disclaimer : the recommendations in this position statement do not indicate an exclusive course of treatment or procedure to be followed. variations, taking into account individual circumstances, may be appropriate. internet addresses are current at time of publication.
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early \ - onset neonatal bacterial sepsis ( eos ) is sepsis occurring within the first seven days of life. this statement provides updated recommendations for the care of term ( ≥37 weeks ’ gestational age ) newborns at risk of eos, during the first 24 h of life. maternal group b streptococcal ( gbs ) colonization in the current pregnancy, gbs bacteruria, a previous infant with invasive gbs disease, prolonged rupture of membranes ( ≥18 h ), and maternal fever ( temperature ≥38oc ) are the factors most commonly associated with eos. these risk factors are additive ; the presence of more than one factor increases the likelihood of eos. at present, there is no laboratory test, including white blood cell indices, that has sufficient sensitivity to allow clinicians to safely rule out eos. all unwell infants with clinical signs suggesting sepsis must be treated empirically with antibiotics, once cultures have been taken. the management of well \ - appearing, at \ - risk term infants depends on the number of risk factors ( including maternal gbs colonization ) and whether maternal intrapartum antibiotic prophylaxis for gbs was used. in some cases, management should be individualized. careful assessment and observation of these at \ - risk infants are a fundamental component of appropriate care. key words : * chorioamnionitis ; early \ - onset sepsis ; group b streptococcus ; newborn * early \ - onset neonatal bacterial sepsis ( eos ) has been defined as sepsis occurring within the first seven days of life ; most infants become symptomatic within 24 h of birth. \ - eos usually results from vertical transmission and, consequently, is associated with organisms that colonize the birth canal. organisms can ascend to the amniotic fluid, colonizing the infant, or the infant may become colonized during passage through the birth canal. invasive infection may occur if the skin barrier is broached. aspiration of infected fluid or transplacental passage of organisms may also result in invasive infection. following implementation of universal maternal screening for group b streptococcus ( gbs ) and intrapartum antibiotic prophylaxis ( iap ), the incidence of early onset gbs ( eogbs ) infection has decreased without concomitant decrease in the incidence of other pathogens. the net result has been an overall
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decrease in the incidence of eos. in 2013, 0 \. 5 % of infants admitted to canadian neonatal intensive care units had eos. in the united states, the overall incidence of eos has been estimated at 0 \. 77 cases per 1000 live births, with a case fatality rate of 10 \. 9 %. incidence and case fatality rates decrease with increasing gestational age ( ga ). in 2007, the canadian paediatric society published recommendations for management of infants at increased risk of eos. subsequently, guidelines were published by the united states centers for disease control and prevention ( cdc ) and the american academy of pediatrics ( aap ). \ - as the incidence of eos is declining, new questions are being raised about the utility of predictive tools and the exposure of well \ - appearing newborns to antibiotics. this statement provides updated recommendations for the care of term ( ≥37 weeks ’ ga ) newborns with risk factors for eos, during the first 24 h of life. a search of medline and the cochrane database was undertaken and updated in 2015 \. search terms included “ early \ - onset sepsis ”, “ neonatal sepsis ”, “ neonatal meningitis ”, “ chorioamnionitis ”, “ intrapartum fever ” and “ prolonged rupture of membranes ”. reference lists of published guidelines and articles were reviewed. chosen articles focused on term populations ; those restricted to late \ - onset sepsis were excluded. a modification of the grade ( grading of recommendations, assessment, development and evaluation ) system was used to describe the recommendations. # maternal and neonatal risk factors for early onset sepsis # # risk factors the risk factors associated most frequently with eos in term infants are summarized in. \ - the presence of more than one factor increases the likelihood of eos. \ - recent case \ - control studies have shown “ dose \ - dependent ” rather than dichotomous relationships between the degree of maternal fever, duration of ruptured membranes and lower ga with increasing risk of eos. puopolo and colleagues have developed a calculator which considers maternal gbs status, intrapartum antibiotic exposure, ga, highest maternal temperature and duration of membrane rupture to estimate the probability of eos for asymptomatic babies. validation of this algorithm is in progress. # # gbs colonization and intrapartum antibiotic prophylaxis in
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the absence of iap, approximately 1 % to 2 % of infants born to mothers colonized with gbs develop eogbs sepsis. current guidelines recommend screening pregnant women for gbs colonization at 35 weeks ’ to 37 weeks ’ ga and providing iap for those who screen positive as well as for those with gbs bacteruria or a previous gbs \ - infected infant. if gbs status is unknown, iap should be offered if any other risk factors ( ) are present. adequate iap consists of at least one dose given at least 4 h before birth of : - iv penicillin g ( initial dose 5 million units ) or ampicillin ( initial dose 2 grams ) - iv cefazolin ( initial dose 2 grams ) if the mother is allergic to penicillin but at low risk for anaphylaxis penicillin \ - allergic women with a high risk of anaphylaxis should be treated with iv clindamycin when the gbs isolate is sensitive to clindamycin and erythromycin or with iv vancomycin when the isolate is resistant to clindamycin or susceptibilities are unknown. because the efficacy of the latter two regimes has not been confirmed in clinical trials, they should be considered inadequate iap when managing the neonate. iap is not recommended when a caesarean section is performed before onset of labour when membranes are intact, regardless of gbs status. it should be noted that iap does not reduce the incidence of late \ - onset gbs disease. # investigations for early onset sepsis # # bacterial cultures a positive neonatal blood culture remains the gold standard for diagnosing neonatal sepsis, recognizing that maternal antimicrobial therapy may inhibit bacterial growth. blood may be drawn by peripheral venous or arterial puncture or from a newly inserted catheter, using aseptic technique. an in vitro study showed that at least 1 ml of blood is required for optimal recovery of micro \ - organisms in low \ - colony \ - count sepsis. drawing blood cultures from multiple sites does not appear to improve the yield of pathogens. meningitis is uncommon in newly born infants ( incidence 0 \. 25 – 1 / 1000 live births ) and it remains controversial whether a lumbar puncture ( lp ) should be performed routinely as part of the initial investigation for eos, particularly for term infants. in asymptoma
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##tic term infants investigated for eos, no cases of meningitis were reported in three large observational studies. meningitis was similarly very uncommon ( 0 % to 0 \. 3 % ) in preterm infants investigated for eos because of respiratory distress. however, newborns with positive blood cultures are more likely to have meningitis. \ - furthermore, 8 % to 40 % of infants with early onset meningitis are reported to have negative blood cultures. \ - these data suggest that an lp should be performed at the outset when there is a strong clinical suspicion of eos or when signs of meningitis ( seizures, bulging fontanelle, irritability, altered neurological status ) are present. the lp can be deferred in unstable infants until their condition improves. for term newborns with respiratory distress only, the lp could also be deferred if the infant is monitored closely. an lp must be done whenever the blood culture is positive. the csf culture may be negative when the lp is performed after antibiotics have been started but pleocytosis, low glucose and / or elevated protein concentration may be observed with meningitis. in term infants, a cerebrospinal fluid ( csf ) white blood cell ( wbc ) count of \ > 20 \ - 25 cells / mm3 is considered abnormal ; this value has a sensitivity of 79 % and specificity of 81 % for diagnosing bacterial meningitis. culture \ - positive bacterial meningitis may be present with a normal csf wbc count. cultures of urine, gastric aspirates and body surface have limited value in the evaluation for eos and are not recommended for newly born infants. a complete blood count ( cbc ) is the most readily available, rapid and economical investigative test for sepsis. studies have examined individual wbc indices, including total wbc count, absolute neutrophil count ( anc ), and ratio of immature to total neutrophils ( i : t ratio ), as well as combinations. following birth, the neutrophil count of healthy term neonates rises, peaking between 6 h to 8 h of age ; higher counts are associated with labour and duration of labour, likely because increasing catecholamine levels stimulate demargination of neutrophils. \ - four recent studies examined large cohorts of term and late preterm infants, many of whom were asympt
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##omatic but investigated because of septic risk factors. \ - a low total wbc count ( \ 0 \. 2 \ ) or high total wbc ( \ > 30 x 109 / l ). the positive predictive accuracies of all wbc indices were low, as were the sensitivities, the latter drawing into question the tests ’ role in allowing clinicians to confidently rule out sepsis. the predictive abilities of wbc indices improve with time after birth. after 4 h, the likelihood ratio in detecting sepsis for a wbc count \ 0 \. 6 was 10 \. 7 \. this means that in newborns with an abnormal test, the post \ - test probability of sepsis increased significantly. however, for most asymptomatic infants, who have a low pre \ - test probability for sepsis, wbc indices demonstrate only modest likelihood ratios which are not helpful for confidently ruling in or ruling out sepsis. when there is clinical uncertainty in well infants ( eg, multiple risk factors, chorioamnionitis ), wbc indices, particularly in combination, may be of some help if obtained after 4 h of age. waiting to obtain a cbc should never delay investigation and starting antibiotics when clinical signs of sepsis are present. reported sensitivities for eos of c \ - reactive protein ( crp ), an acute \ - phase protein synthesized in response to tissue injury, vary widely ; sensitivity is lowest early in the infectious process. the diagnostic accuracy of a single crp at the time of initial investigation is poor, and a normal result should not delay initiation of antibiotics for a symptomatic infant. crp measured serially may be helpful in determining duration of empiric antibiotic therapy. however, multiple conditions can be associated with the inflammatory response and a single elevated crp should not be used to prolong antibiotic therapy. although procalcitonin, a peptide precursor of calcitonin, has shown moderate to good accuracy in the diagnosis of eos, \ - it is not readily and rapidly available. the utility of other biomarkers, including interleukin \ - 6, interleukin \ - 8, tumour necrosis factor and neutrophil cd64, on their own or combined with wbc indices, requires confirmation. # # unwell infants initial signs of sepsis may be subtle and include respiratory distress, temperature instability, ta
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