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CloseSociety guideline links: Lower spine disordersSociety guideline links: Lower spine disorders Introduction — This topic includes links to society and government-sponsored guidelines from selected countries and regions around the world. We will update these links periodically; newer versions of some guidelines may be available on each society's website. Some societies may require users to log in to access their guidelines.The recommendations in the following guidelines may vary from those that appear in UpToDate topic reviews. Readers who are looking for UpToDate topic reviews should use the UpToDate search box to find the relevant content.Links to related guidelines are provided separately. (See"Society guideline links: Spondylolysis and spondylolisthesis" and"Society guideline links: Chronic pain management".)International●International Federation of Ortho-paedic Manipulative Physical Therapists (IFOMPT): Position statement – International framework for red flags for potential serious spinal pathologies (2020)●American Society of Regional Anesthesia and Pain Medicine (ASRA), European Society of Regional Anaesthesia and Pain Therapy (ESRA), American Academy of Pain Medicine (AAPM), International Neuromodulation Society (INS), North American Neuromodulation Society (NANS), and World Institute of Pain (WIP): Guidelines on interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications, 2nd edition (2018)Canada●Choosing Wisely Canada: Canadian Spine Society (CSS) – Eight things physicians and patients should question (2021)●Choosing Wisely Canada: Don't do imaging for lower-back pain unless red flags are present (2020)●Choosing Wisely Canada: Don't order lumbosacral (low back) spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators (2020)United States●North American Spine Society (NASS): Guidelines●American College of Radiology (ACR): ACR Appropriateness Criteria on inflammatory back pain – Known or suspected axial spondyloarthritis (2021)●ACR: ACR Appropriateness Criteria on low back pain (2021)●American Physical Therapy Association (APTA): Clinical practice guidelines for interventions for the management of acute and chronic low back pain, revision (2021)●Choosing Wisely: American Chiropractic Association (ACA) – Five things physicians and patients should question (2021)●Choosing Wisely: Don't do a needle electromyography (EMG) test for isolated neck or back pain after a motor vehicle accident, as a needle EMG is unlikely to be helpful (reviewed 2021)●Choosing Wisely: Don't perform dermatomal somatosensory evoked potentials (SEPs) for a pinched nerve in the neck or back, as they are an unproven diagnostic procedure (reviewed 2021)●Choosing Wisely: Don't do nerve conduction studies without also doing a needle EMG for testing for radiculopathy, a pinched nerve in the neck or back (reviewed 2021)●Choosing Wisely: Don't do a magnetic resonance imaging (MRI) scan of the spine or brain for patients with only peripheral neuropathy (without signs or symptoms suggesting a brain or spine disorder) (reviewed 2021)●Choosing Wisely: North American Spine Society (NASS) – Five things physicians and patients should question (reviewed 2021)●American College of Occupational and Environmental Medicine (ACOEM): Practice guideline on diagnostic tests for low back disorders (2019)●Choosing Wisely: American Society of Anesthesiologists (ASA) – Five things physicians and patients should question (reviewed 2019)●ACR: Appropriateness Criteria on management of vertebral compression fractures (2018)●American Society of Regional Anesthesia and Pain Medicine (ASRA), European Society of Regional Anaesthesia and Pain Therapy (ESRA), American Academy of Pain Medicine (AAPM), International Neuromodulation Society (INS), North American Neuromodulation Society (NANS), and World Institute of Pain (WIP): Guidelines on interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications, 2nd edition (2018)●American College of Physicians (ACP): Clinical practice guideline on noninvasive treatments for acute, subacute, and chronic low back pain (2017)●US Department of Veterans Affairs (VA)/US Department of Defense (DoD): Clinical practice guideline for diagnosis and treatment of low back pain (2017)●Choosing Wisely: Don't do a four limb needle EMG/nerve conduction study (NCS) testing for isolated neck and back pain after trauma (2015)●ACOEM: Practice guidelines on opioids for treatment of acute, subacute, chronic, and postoperative pain (2014)●Choosing Wisely: Avoid lumbar spine imaging in the emergency department for adults with nontraumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis) (2014)●Choosing Wisely: Don't initially obtain X-rays for injured workers with acute non-specific low back pain (2014)●Choosing Wisely: Don't obtain imaging (plain radiographs, magnetic resonance imaging, computed tomography [CT], or other advanced imaging) of the spine in patients with non-specific acute low back pain and without red flags (2014)●Choosing Wisely: Don't prescribe opioids for treatment of chronic or acute pain for workers who perform safety-sensitive jobs such as operating motor vehicles, forklifts, cranes or other heavy equipment (2014)●American Society of Interventional Pain Physicians (ASIPP): Comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain, update (2013)●Choosing Wisely: Don't do imaging for low back pain within the first six weeks, unless red flags are present (2012)●Choosing Wisely: Don't obtain imaging studies in patients with non-specific low back pain (2012)Europe●American Society of Regional Anesthesia and Pain Medicine (ASRA), European Society of Regional Anaesthesia and Pain Therapy (ESRA), American Academy of Pain Medicine (AAPM), International Neuromodulation Society (INS), North American Neuromodulation Society (NANS), and World Institute of Pain (WIP): Guidelines on interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications, 2nd edition (2018)United Kingdom●National Institute for Health and Care Excellence (NICE): Interventional procedures guidance on neurostimulation of lumbar muscles for refractory non-specific chronic low back pain (2022)●NICE: Medical technologies guidance on iFuse for treating chronic sacroiliac joint pain (2018, updated 2022)●NICE: Guideline on low back pain and sciatica in over 16s – Assessment and management (2016, updated 2020)●Choosing Wisely UK: Royal College of Physicians (RCP): Patients with low back pain do not routinely need imaging (2018)●NICE: Interventional procedures guidance on transaxial interbody lumbosacral fusion for severe chronic low back pain (2018)●NICE: Interventional procedures guidance on lateral interbody fusion in the lumbar spine for low back pain (2017)●NICE: Interventional procedures guidance on minimally invasive sacroiliac joint fusion surgery for chronic sacroiliac pain (2017)●NICE: Quality standard on low back pain and sciatica in over 16s (2017)●NICE: Interventional procedures guidance on epiduroscopic lumbar discectomy through the sacral hiatus for sciatica (2016)●NICE: Interventional procedures guidance on percutaneous coblation of the intervertebral disc for low back pain and sciatica (2016)●NICE: Interventional procedures guidance on percutaneous electrothermal treatment of the intervertebral disc annulus for low back pain and sciatica (2016)●NICE: Interventional procedures guidance on percutaneous interlaminar endoscopic lumbar discectomy for sciatica (2016)●NICE: Interventional procedures guidance on percutaneous intradiscal radiofrequency treatment of the intervertebral disc nucleus for low back pain (2016)●NICE: Interventional procedures guidance on insertion of an annular disc implant at lumbar discectomy (2014)●NICE: Interventional procedures guidance on peripheral nerve-field stimulation for chronic low back pain (2013)●NICE: Interventional procedures guidance on non-rigid stabilisation techniques for the treatment of low back pain (2010)●NICE: Interventional procedures guidance on therapeutic endoscopic division of epidural adhesions (2010)Australia-New Zealand●Choosing Wisely Australia: Do not prescribe benzodiazepines for low back pain (2018)●Choosing Wisely Australia: Do not prescribe spinal orthotics or bed rest for patients with non-specific low back pain (2018)●Choosing Wisely Australia: Do not refer axial lower lumbar back pain for spinal fusion surgery (2018)●Choosing Wisely Australia: Do not undertake imaging for low back pain in patients without indications of a serious underlying condition (2018)●Choosing Wisely Australia: Do not order X-rays or other imaging for acute non-specific low back pain, unless there are red flags or other clinical reasons to suspect serious spinal pathology (2017)●Choosing Wisely Australia: Do not use imaging for diagnosing non-specific acute low back pain in the absence of red flags (2017)●Choosing Wisely Australia: Avoid using electrotherapy modalities in the management of patients with low back pain (2016)●Choosing Wisely Australia: Don't request imaging for patients with non-specific low back pain and no indicators of a serious cause for low back pain (2016)●Choosing Wisely Australia: Don't perform imaging for patients with non-specific acute low back pain and no indicators of a serious cause for low back pain (2015)Japan●[In Japanese] Japanese Orthopedic Association (JOA): Clinical practice guideline on lumbar disc herniation, 3rd edition (2021)●[In Japanese] JOA: Clinical practice guideline on lumbar spinal canal stenosis, 2nd edition (2021)●[In Japanese] JOA: Clinical practice guideline on backache treatment, 2nd edition (2019)●[In Japanese] Choosing Wisely Japan: Treatment of low back pain – What is the period of proper bed rest? (2018)Topic 115413 Version 25.0

CloseNormal visual behavior of infantsNormal visual behavior of infantsAge, months Behavior 0 to 1 Turns eyes and head to look at light sources Horizontal tracking Eye contact at 6 to 8 weeks 2 to 3 Intense eye contact Vertical and circular tracking Interested in mobiles Interested in "lip reading" 3 to 6 Watches own hands Reaches toward, later grasps, hanging objects Observes toys falling and rolling away Shifts fixation across midline Visual sphere of attention widens gradually 7 to 10 Notices small bread crumbs First touches them, then develops pincer grasp Interested in pictures Recognizes partially hidden objects 11 to 12 Visual orientation at home Looks through window and recognizes people, recognizes pictures, plays hide-and-seek133/28/2001 - perm requested - jm 4/24/2001 - perm granted - gave info to Nan & Chris - jm; 6/25/2001-will be used. ($150.00) 11/7/2001 - renewal requested -jm; 11/13/2001 - Lawley faxed back that we cannot renew, must rerequest. Faxed new request - jm 12/20/2001 -renewal granted (free). Did not say we have to renew.<a href="/Graphics/Pages/TableEditor.aspx?SPID=56936&Mode=Edit"></a>Reproduced with permission from: Hyvarinen L. Assessment of visually impaired infants. Ophthalmol Clin North Am 1994; 7:219. Copyright © 1994 WB Saunders.Graphic 73947 Version 4.0

ClosePrimary types of painful sensory neuropathyPrimary types of painful sensory neuropathyType Usual clinical setting Idiopathic small fiber neuropathyPrevalence increases with age Normal strength and deep tendon reflexes Normal position and vibration sensation Diminished pin sensation in lower extremities Normal electrodiagnostic testing Diminished sudomotor function Abnormal skin biopsyDiabetic peripheral neuropathyHistory or family history of diabetes Obesity, hypertension Diminished deep tendon reflexes Diminished distal sensation Usually abnormal electrodiagnostic testing Impaired glucose tolerance, impaired fasting glucose, elevated hemoglobin A1CHereditary neuropathiesFamily history Pes cavus or hammer toe Usually diminished deep tendon reflexes Diminished distal sensation Abnormal electrodiagnostic testingNeuropathy related to connective tissue diseaseHistory of rheumatoid arthritis, systemic lupus erythematosus, mixed connective tissue disease, Sjögren syndrome Diminished deep tendon reflexes Diminished distal sensation Abnormal electrodiagnostic testing Positive for autoimmune antibodiesVasculitic neuropathyKnown systemic vasculitis (but vasculitic neuropathy may occur in isolation) Multifocal examination findings Abnormal electrodiagnostic testing Positive for autoimmune antibodies, hepatitis B or C, cryoglobulins Abnormal nerve biopsyNeuropathy associated with monoclonal gammopathyPrevalence increases with age Variable examination findings depending upon mode of presentation (mononeuritis multiplex, distal polyneuropathy, radiculopathy, or plexopathy) Abnormal electrodiagnostic testing Monoclonal gammopathy (often IgM)Paraneoplastic sensory neuropathyTobacco smoking, family history, asbestos exposure Solid tumor cancer (mainly lung) Diminished deep tendon reflexes Diminished distal sensation Abnormal electrodiagnostic testing Anti-Hu antibodiesFamilial or acquired amyloid polyneuropathyFamily history or known plasma cell dyscrasia (acquired form) Diminished deep tendon reflexes Sensory loss Autonomic dysfunction (eg, postural hypotension, impotence, bladder dysfunction) Compressive mononeuropathy (mainly carpal tunnel syndrome) Abnormal electrodiagnostic testing Monoclonal gammopathy (acquired form) 105/5/2003 perm requested -em 5/7/2003 perm granted -em 9/30/2003 renewal requested 10/3/2003 granted 10/12/2004 renewal requested 12/6/2004 granted 11/9/2005 renewal requested 1/26/2006 granted 10/10/2006 renewal requested 10/13/2006 granted 11/29/2007--renewal requested. EM 1/9/2008--renewal granted. EM 1/2/2009--Requested renewal (JD). 1/9/2009--Renewal granted; invoice to Susan (JD). 2/3/2010--Renewal requested (JD). 4/2/2010--Renewal granted; invoice to Jo for payment (JD). The total fee of $"250.00"was originally charged to Painful_polyneuropathy_1 Painful_polyneuropathy_2<a href="/Graphics/Pages/TableEditor.aspx?SPID=41263&Mode=Edit"></a>NCS: nerve conduction study.Data from: Mendell JR, Sahenk Z. Clinical practice. Painful sensory neuropathy. N Engl J Med 2003; 348:1243.Graphic 74991 Version 7.0

CloseBaseline probabilities for thrombolytic decision tree (example for decision analysis)Baseline probabilities for thrombolytic decision tree (example for decision analysis)For illustration purposes onlyParameterPercentProbability that the patient is having a myocardial infarction (MI)83If the patient is having an MI, probability of death29If the patient is not having an MI, probability of death2Probability of a patient having a severe or fatal complication of thrombolytic therapy0.40In a patient having an MI, relative reduction in mortality from treatment with thrombolytic therapy1316.0000000000000Table2/23/99-Perm requested. 5/6/99-Perm granted. 11/13/99-perm requested for 8.1-8.3. 11/30/99-perm granted 8.1-8.3. 11/14/2000-renewal request sent. 11/16/2000-9.1-9.3 granted. Two_way_sensitivity_analysis (Figure 1 in article, not renewed, graph) 10/15/2001 -faxed renewal request - jm; 10/29/2001 -renewal granted -jm 10/2/2002 Mailed renewal request -em 11/19/2002 renewal granted -em 9/30/2003 renewal requested 10/3/2003 granted 10/12/2004 renewal requested 12/6/2004 granted 11/9/2005 renewal requested 1/26/2006 granted 10/10/2006 renewal requested 10/13/2006 granted 11/29/2007--not using any more, no renewal. EM<a href="/Graphics/Pages/TableEditor.aspx?SPID=60681&Mode=Edit"></a>Data from: Krumholz HM, Pasternak RC, Weinstein MC, et al, N Engl J Med 1992; 327:7.Graphic 81073 Version 6.0

CloseRadiation toxicity: Gastrointestinal systemRadiation toxicity: Gastrointestinal systemSymptom Degree 1 Degree 2 Degree 3 Degree 4 Stool (number/day) 2 to 3 4 to 6 7 to 9 ≥10 Stool consistency Bulky Loose Loose Watery GI bleeding Occult Intermittent Persistent Persistent large amount Abdominal cramps or pain Minimal Moderate Intense Excruciating78/26/2004 Perm requested Pull if no perm by 12.3 9/7/2004 Perm granted 6/3/2005 renewal requested 6/17/2005 they emailed for more info 6/28/2005 granted - need to note in each renewal the waselenko is the author since they don't carry over this info 7/24/2006 Renewal Requested 8/21/2006 bugged - informed that they only grant for one version at a time 8/21/2006 renewal granted (renew 15.1) 10/6/2006 renewal requested 10/11/2006 renewal granted for one year 11/28/2007--renewal requested. EM 1/8/2008--renewal granted. EM 12/30/2008--Requested renewal (JD). 1/14/2009--Renewal invoice recevied, to Susan; awaiting formal grant of permission (JD). 1/22/2009--Grant of permission received (JD). 2/4/2010--Renewal requested (JD). 2/12/2010--Renewal granted, paid on my AMEX (JD). The total fee of $"120.00"was originally charged to Radiation_tox_gastrointest Radiation_tox_hematopoietic Radiation_tox_cerebrovascular Radiation_biodosimetry Rx_guide_radiation_exposure Cytokines_radiation_exposure Military_triage_radiation<a href="/Graphics/Pages/TableEditor.aspx?SPID=26436&Mode=Edit"></a>GI: gastrointestinal.Modified with permission from: Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management of the acute radiation syndrome: Recommendations of the strategic national stockpile radiation working group. Ann Intern Med 2004; 140:1037. Copyright © 2004 American College of Physicians.Graphic 70498 Version 19.0

ClosePrimary vagin*l carcinoma: distribution by stage of diseasePrimary vagin*l carcinoma: distribution by stage of diseaseStageNPercentI35826II51137.2III33124.1IV17512.7Total1375100.019.0000000000000Table4/14/00-perm requested. 4/21-perm granted. 12/6/2000-citation in gold gives 3rd ed and 2000. 2/16/2001 - renewal requested -jm 3/14/2001-perm granted 9.2-10.2. 2/12/2002 - renewal requested -jm 4/2/2002-Sent reminder about renewals to A. Queen. -kw; 4/16/2002-renewal perm received. -jm 10/4/2002 - renewal requested (arnetta)-jm; 12/11/2002-emailed followup-jm; 12/24/2002- renewal granted, gave to ajeah-jm 1/31/2003 renewal requested 3/13/2003 renewal granted 9/30/2003 renewal requested should be no fee 11/17/2003 granted 10/12/2004 renewal requested 11/19/2004 granted 11/9/2005 renewal requested 12/7/2005 granted 10/10/2006 renewal requested 1/5/2007 renewal granted 11/29/2007--renewal requested. EM 1/11/2008--bug to arnetta. EM 1/18/2008--permission granted. EM 1/2/2009--Requested renewal (JD). 1/21/2009--Renewal granted; mailed copy back to Arnetta (JD). 1/7/2010--Figure removed from Gold, to Terrence to archive; permission expired with 17.3 (JD).<a href="/Graphics/Pages/TableEditor.aspx?SPID=24468&Mode=Edit"></a>vagin*l_CA_stage_distributi.htmReproduced with permission by Berek JS, Hacker NF. Practical Gynecologic Oncology. 3rd ed, Williams and Wilkins, Baltimore, 2000. Copyright © 2000 Lippincott Williams & Wilkins.http://www.lww.comGraphic 79926 Version 6.0

CloseTreatment guidelines for radiation exposureTreatment guidelines for radiation exposureVariable Cytokines Antibiotics HCTLess than 100casualtiesHealthy, no other injuries3 to 10*2 to 10Allo: 7 to 10Auto: 4 to 10Multiple injuries or burns2 to 62 to 6NAMorethan 100 casualtiesHealthy, no other injuries 3 to 72 to 7Allo: 7 to 10Auto: 4 to 10Multiple injuries or burns2 to 62 to 6NA7.00000000000000Table8/26/2004 Perm requested Pull if no perm by 12.3 9/7/2004 Perm granted 6/3/2005 renewal requested 6/17/2005 they emailed for more info 6/28/2005 granted - need to note in each renewal the waselenko is the author since they don't carry over this info 7/24/2006 Renewal Requested 8/21/2006 bugged - informed that they only grant for one version at a time 8/21/2006 renewal granted (renew 15.1) 10/6/2006 renewal requested 10/11/2006 renewal granted for one year 11/28/2007--renewal requested. EM 1/8/2008--renewal granted. EM 12/30/2008--Requested renewal (JD). 1/14/2009--Renewal invoice recevied, to Susan; awaiting formal grant of permission (JD). 1/22/2009--Grant of permission received (JD). 2/4/2010--Renewal requested (JD). 2/12/2010--Renewal granted, paid on my AMEX (JD). The total fee of $"120.00"was originally charged to Radiation_tox_gastrointest Radiation_tox_hematopoietic Radiation_tox_cerebrovascular Radiation_biodosimetry Rx_guide_radiation_exposure Cytokines_radiation_exposure Military_triage_radiation<a href="/Graphics/Pages/TableEditor.aspx?SPID=26606&Mode=Edit"></a>Rx_guide_radiation_exposure.htmHCT: hematopoietic cell transplantation; Allo: allogeneic HCT; Auto: autologous HCT; NA: not applicable; G-CSF: granulocyte colony-stimulating factor; GM-CSF: granulocyte-macroplage colony-stimulating factor. * This table provides a consensus guideline for treatment with cytokines (eg, G-CSF, GM-CSF), antibiotics, and consideration for hematopoietic cell transplantation based upon whole body or significant partial body exposure doses, given in Gy units. See text for treatment details.Modified with permission from: Waselenko JK, MacVittie TJ, Blakely WF, et al. Medical management of the acute radiation syndrome: Recommendations of the strategic national stockpile radiation working group. Ann Intern Med 2004; 140:1037. Copyright © 2004 American College of Physicians.Graphic 57598 Version 16.0

CloseTreatable conditions associated with cardiac arrestTreatable conditions associated with cardiac arrestConditionCommon associated clinical settingsAcidosisDiabetes, diarrhea, drug overdose, renal dysfunction, sepsis, shockAnemiaGastrointestinal bleeding, nutritional deficiencies, recent traumaCardiac tamponadePost-cardiac surgery, malignancy, post-myocardial infarction, pericarditis, traumaHyperkalemiaDrug overdose, renal dysfunction, hemolysis, excessive potassium intake, rhabdomyolysis, major soft tissue injury, tumor lysis syndromeHypokalemia*Alcohol abuse, diabetes mellitus, diuretics, drug overdose, profound gastrointestinal lossesHypothermiaAlcohol intoxication, significant burns, drowning, drug overdose, elder patient, endocrine disease, environmental exposure, spinal cord disease, traumaHypovolemiaSignificant burns, diabetes, gastrointestinal losses, hemorrhage, malignancy, sepsis, traumaHypoxiaUpper airway obstruction, hypoventilation (CNS dysfunction, neuromuscular disease), pulmonary diseaseMyocardial infarctionCardiac arrestPoisoningHistory of alcohol or drug abuse, altered mental status, classic toxidrome (eg, sympathomimetic), occupational exposure, psychiatric diseasePulmonary embolismImmobilized patient, recent surgical procedure (eg, orthopedic), peripartum, risk factors for thromboembolic disease, recent trauma, presentation consistent with acute pulmonary embolismTension pneumothoraxCentral venous catheter, mechanical ventilation, pulmonary disease (eg, asthma, chronic obstructive pulmonary disease), thoracentesis, thoracic trauma27/27/2001-perm requested. 8/2/2001-perm granted. 10/15/2001 -faxed renewal request - jm; 10/26/2001 -renewal granted - jm 10/2/2002 Mailed renewal request -em; 12/11/2002 - emailed followup-jm; 12/11/2002- Jen is mailing today-jm; 12/24/2002 -renewal granted, gave to ajeah-jm 9/30/2003 renewal requested 10/3/2003 granted 10/12/2004 renewal requested 12/7/2004 granted 11/9/2005 renewal requested 1/26/2006 granted 10/10/2006 renewal requested 10/13/2006 granted 11/29/2007--renewal requested. EM 1/9/2008--renewal granted. EM 1/2/2009--Requested renewal (JD). 1/9/2009--Renewal granted; invoice to Susan (JD). 2/3/2010--Renewal requested (JD). 4/2/2010--Renewal granted; invoice to Jo for payment (JD). The total fee of $"250.00"was originally charged to Treatable_conditions_SCD_I Treatable_conditions_SCD_II<a href="/Graphics/Pages/TableEditor.aspx?SPID=8783&Mode=Edit"></a>CNS: central nervous system.* Hypomagnesemia should be assumed in the setting of hypokalemia, and both should be treated.Adapted from: Eisenberg MS, Mengert TJ. Cardiac resuscitation. N Engl J Med 2001; 344:1304.Graphic 52416 Version 8.0

CloseACCF/AHA/SCAI expert consensus document requirements for off-site surgical backupACCF/AHA/SCAI expert consensus document requirements for off-site surgical backup1. Interventional cardiologists establish a working relationship with cardiac surgeons at the receiving facility 2. Cardiac surgeon must have privileges at the referring facility to allow review of treatment options as time allows 3. Cardiac surgeon and receiving hospital agree to provide cardiac surgical backup for urgent cases at all hours and for elective cases at mutually agreed hours 4. Surgeon and receiving facility ensure that patients will be accepted based on medical condition, capacity of surgeon to provide services at the time of request, and availability of resources. If this cannot be ensured before the start of an elective procedure, the case should not be done at this time. 5. Interventional cardiologists must review with surgeons the immediate needs and status of any patient transferred for urgent surgery 6. Hospital administrations from both facilities endorse transfer agreement 7. Transferring and receiving facilities establish a rigorous protocol for rapid transfer of patients, including the proper personnel with appropriate experience 8. A transport provider is available to begin transport within 20 min of the request and provide vehicle/helicopter with necessary life-sustaining equipment, including IABP and monitoring capability 9. Transferring physician obtains consent for surgery from patient or appropriate surrogate 10. Initial informed consent for PCI discloses that the procedure is being done without on-site surgical backup and acknowledges the possibility of risks related to transfer. The consent process should include the risk of urgent surgery (approximately 0.3 percent) and state that a written plan for transfer exists. 11. As part of the local continuous quality improvement program, a regular review of all patients transferred for emergency surgery with the outcome of surgery and identification of any improvement opportunities2<a href="/Graphics/Pages/TableEditor.aspx?SPID=99344&Mode=Edit"><img alt="" border=0 src="/_layouts/IMAGES/ICGEN.gif">Edit Table</a>IABP: intra-aortic balloon pump; PCI: percutaneous coronary intervention; SCAI: Society for Cardiovascular Angiography and Interventions.From: Levine GN, Bates ER, Blankenship JC, et al. 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol 2011; 58:e44. Table used with the permission of Elsevier Inc. All rights reserved.Graphic 68713 Version 2.0

ClosePrognosis of renal cell carcinoma according to University of California Los Angeles Integrated Staging System (UISS) categorizationPrognosis of renal cell carcinoma according to University of California Los Angeles Integrated Staging System (UISS) categorizationUISS stage1997 TNM stageFurman's gradeECOG PSTwo-year survival (percent)Five-year survival (percent)II1, 2096 94III1, 21 or more8967I 3, 4AnyIIAnyAnyIIIAny0III11 or moreIIIIII2 to 41 or more6639IV1, 20IVIV3, 4042231 to 31 or moreVIV41 or more9 011.0000000000000Table10/12/2001-perm requested (from David OBrien) -kw11/26/2001-need au permission first-requested permission from A. Pantuck (@UCLA), could not find A. Zisman (no longer at UCLA)12/17/2001-sent a follow-up.12/19/2001-perm granted from author (A. Pantuck) -kw1/8/2002-invoice from LWW paid -kw10/4/2002 - renewal requested-jm; 12/11/2002- followup emailed to d Obrien-jm; 1/3/2003 -emailed followup to new contact - fran -jm 1/16/2003 emailed again Renewal granted -em10/1/2003 renewal requested10/29/2003 They asked me to submit a request form11/5/2003 Granted10/13/2004 renewal requested 10/18/2004 granted11/10/2005 renewal requested 11/18/2005 granted10/6/2006 renewal requested 11/1/2006 granted11/28/2007--renewal requested. EM1/10/2008--renewal granted, no fee, per email from 12/11/07, this permission is good for future editions and no more renewals on this figure are needed. EM<a href="/Graphics/Pages/TableEditor.aspx?SPID=47822&Mode=Edit"></a>ECOG PS: Eastern Cooperative Oncology Group performance status.Modified with permission from: Zisman A, Pantuck A, Dorey F, et al. Improved prognostication of renal cell carcinoma using an integrated staging system. J Clin Oncol 2001; 19:1649. Copyright ©2001 American Society of Clinical Oncology.Graphic 77502 Version 2.0

ClosePelvic organ prolapse stagingPelvic organ prolapse stagingStage 0No prolapseAa, Ba, Ap, Bp are -3 cm and C or D≤ -(tvl - 2) cmStage 1Most distal portion of the prolapse -1 cm (above the level of hymen)Stage 2Most distal portion of the prolapse ≥ -1 cm but ≤ +1 cm (≤1 cm above or below the hymen)Stage 3Mostdistal portion of the prolapse > +1 cm but < +(tvl - 2) cm(beyond the hymen; protrudes no farther than 2 cm less thanthe total vagin*l length)Stage 4Complete eversion; most distal portion of the prolapse ≥ + (tvl - 2) cm19.0000000000000Table8/2/2001-perm requested.8/27/2001-refaxed w/status request.9/14/2001 -perm granted, gave to lisa and chris -jm (figs $210 each)5/14/2002-Renewal requested (M. Gracey). -kw6/19/2002 Renewal granted.To Ajeah -em6/2/2003 renewal requested7/15/2003 renewal granted<a href="/Graphics/Pages/TableEditor.aspx?SPID=24033&Mode=Edit"></a>Stage_of_pelvic_organ_prola.htmAa: Point A of anterior wall; Ba: point B of anterior wall; Ap: point A of posterior wall; Bp: point B of posterior wall; -: above the hymen; +: beyond the hymen; tvl: total vagin*l length.Reproduced with permission from Harvey, M-A, Versi, E. Urogynecology and pelvic floor dysfunction. In: Kistner's Gynecology and Women's Health, 7th ed, Ryan, KJ, Berkowitz, RS, Barbieri, RL, Dunaif, A (Eds), St. Louis, Mosby 1999. Copyright © 1999 Elsevier.Graphic 72477 Version 1.0

CloseRisk factors for morbidity and mortality in patients with cirrhosis undergoing surgeryRisk factors for morbidity and mortality in patients with cirrhosis undergoing surgeryType of surgeryAbdominal (especially cholecystectomy, gastric resection or colectomy)CardiacEmergencyHepatic resectionPatient characteristicsAnemiaAscitesChild's class (C>B)EncephalopathyHypoalbuminemiaHypoxemiaInfectionJaundiceMalnutritionPortal hypertensionProlonged prothrombin time (>2.5 seconds above control that does not correct with vitamin K)6.00000000000000Table8/9/99-perm requested. 8/25/99-need au perm first. 9/21/99-perm granted by Saunders for one year for CD.; 3/22/2000-Internet perm req, ar. 4/17-Internet perm granted for 1 year.;1/31/2001-renewal perm requested, 9.2-10.1.;4/5/2001-Faxed Sharon Boone.;5/15/2001-Perm granted.2/12/2002 -renewal requested -jm4/2/2002-Reminder sent to S. Keomany. -kw4/23/2002-Renewal sent by C. Harris, no extra charge. -kw2/3/2003 renewal request sent 2/12/2003 renewal granted<a href="/Graphics/Pages/TableEditor.aspx?SPID=28080&Mode=Edit"></a>Risk_factors_surg_in_cirrho.htmReproduced with permission from Friedman LS. The risk of surgery in patients with liver disease. Hepatology 1999; 29:1617. Copyright © 1999 Elsevier Science.Graphic 61787 Version 2.0

CloseProposed (1998 draft) ICD-10 criteria for cancer-related fatigueProposed (1998 draft) ICD-10 criteria for cancer-related fatigue Six (or more) of the following symptoms have been present every day or nearly every day during the same two-week period in the past month, and at least one of the symptoms is (A1) significant fatigue. A1. Significant fatigue, diminished energy, or increased need to rest, disproportionate to any recent change in activity level A2. Complaints of generalized weakness or limb heaviness A3. Diminished concentration or attention A4. Decreased motivation or interest to engage in usual activities A5. Insomnia or hypersomnia A6. Experience of sleep as unrefreshing or nonrestorative A7. Perceived need to struggle to overcome inactivity A8. Marked emotional reactivity (eg, sadness, frustration, or irritability) to feeling fatigued A9. Difficulty completing daily tasks attributed to feeling fatigued A10. Perceived problems with short-term memory A11. Postexertional malaise lasting several hours B. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning C. There is evidence from the history, physical examination, or laboratory findings that the symptoms are a consequence of cancer or cancer therapy D. The symptoms are not primarily a consequence of comorbid psychiatric disorders such as major depression, somatization disorder, somatoform disorder, or delirium 11.0000000000000Table7/23/2004 perm requested 7/26/2004 CMP Media doesn't own the copyright for this table - - it is owned by NCCN, 500 Old York Road, Suite 250 , Jenkintown, PA 19046 Fax: 515-690-0300 - - resent request 8/2/2004 granted 6/9/2005 renewal requested 6/24/2005 granted 7/26/2006 rewewal requested 8/21/2006 bugged 8/21/2006 granted 8/6/2007 - renewal requested.mn 8/7/2007 - resubmitted using the online form at NCCN.org 8/10/2007 -granted.mn 8/15/2008--Requested renewal (JD). 10/17/2008--Figure removed from Gold because our renewal was not granted in time for 16.3. Pursuing permission for 17.1 (JD). 11/12/2008--Requested permission from WHO because Diane believes that they own the copyright, if there is one, because these are only proposed (JD). 2/4/2009--Permission granted (JD).<a href="/Graphics/Pages/TableEditor.aspx?SPID=47650&Mode=Edit"></a>Propose_ICD10_crit_CA_fatig.htmReproduced with permission from: World Health Organization. The ICD-10 classification of mental and behavioral disorders: Diagnostic criteria for research. Copyright © World Health Organization.Graphic 61574 Version 2.0

CloseToxicity of commonly used complementary and alternative medicationsToxicity of commonly used complementary and alternative medicationsCAMIndicationToxicitySt. John's wortDepressionNausea, hypersensitivity reactionsEphedra alkaloidsWeight reductionHypertension, tachycardia, stroke, seizuresKavaAnxietyYellow discoloration of skin/nails, hepatic dysfunction, stupor, visual disturbances, dizzinessEchinaceaRespiratory infectionsHypersensitivity reactions (including anaphylaxis)Saw palmettoBenign prostatic hypertrophyDiarrhea, constipation, headache, hypertension, nausea,urinary retentionGinsengSedativeDiarrhea, headache, hypertension, insomnia, nauseaGinkgoDementiaEmesis, headacheGreen teaProstate cancer Emesis, insomnia, diarrhea, confusionHydrazine sulfate Appetite stimulantHepatorenal failureShark cartilage CancerEmesis, constipation, hepatitisLaetrileCancerEmesis, headache, dizziness, obtundation, dermatitisAntineoplastonsGliomasSomnolence, confusion11.0000000000000Table1/22/2003 perm requested -em2/3/2003 perm granted1/30/2004 renewal requested2/2/2004 granted2/2/2005 renewal requested 3/9/2005 granted2/24/2006 renewal requested 3/9/2006 granted3/15/2007 -renewal requested.mt 3/22/2007 -granted.mt4/21/2008--Requested renewal (JD).4/24/2008--Permission granted, no future renewal required (JD).<a href="/Graphics/Pages/TableEditor.aspx?SPID=48453&Mode=Edit"></a>Toxicity_complement_altern.htmCAM: complementary and alternative medicine.Reproduced with permission from: Markman M. Safety issues in using complementary and alternative medicine. J Clin Oncol 2002; 20:39. Copyright © 2002 American Society of Clinical Oncology.Graphic 81493 Version 3.0

CloseFrequency of adverse drug events by typeFrequency of adverse drug events by typeTypeTotal adverse drug events (n = 815) N (percent) Preventable adverse drug events (n = 338) N (percent)Neuropsychiatric 199 (24) 97 (29) Hemorrhagic 159 (20) 53 (16) Gastrointestinal 140 (17) 55 (16) Renal/electrolytes 80 (10) 40 (12) Metabolic/endocrine 64 (8) 35 (10) Cardiovascular 36 (4) 15 (4) Dermatologic 36 (4) 4 (1) Extrapyramidal symptoms 30 (4) 7 (2) Fall with injury 21 (3) 17 (5) Fall without injury 21 (3) 11 (3) Infection 19 (2) 1 (<1) Syncope/dizziness 16 (2) 8 (2) Anticholinergic 9 (1) 3 (1) Ataxia/difficulty with gait 9 (1) 5 (2) Hematologic 8 (1) 3 (1) Respiratory 6 (1) 4 (1) Anorexia 3 (<1) 2 (<1) Functional decline 3 (<1) 2 (<1) Hepatic 1 (<1) 1 (<1)163/14/2006 perm requested should be no fee 4/14/2006 granted<a href="/Graphics/Pages/TableEditor.aspx?SPID=58907&Mode=Edit"></a>Adverse drug events could manifest as more than one type. Neuropsychiatric events include oversedation, confusion, hallucinations, and delirium. Anticholinergic effects include dry mouth, dry eyes, urinary retention, and constipation.Reproduced with permission from: Gurwitz, MD, Field, T, Judge, J, Rochon, P, et al. The incidence of adverse drug events in two large academic long-term care facilities. Am J Med 2005; 118:251. Copyright © 2005 Excerpta Media.Graphic 72518 Version 3.0

CloseThe role of endomyocardial biopsy in fourteen clinical scenariosThe role of endomyocardial biopsy in fourteen clinical scenariosScenario numberClinical scenarioClass of recommendation (I, IIa, IIb, III)Level of evidence (A,B,C)1New onset heart failure of less than 2 weeks duration associated with a normal size or dilated left ventricle and hemodynamic compromiseIB2New onset heart failure of 2 weeks to 3 months duration associated with a dilated left ventricle, and new ventricular arrhythmias, second or third degree heart block, or failure to respond to usual care within 1 to 2 weeksIB3Heart failure of greater than 3 months duration associated with a dilated left ventricle and new ventricular arrhythmias, second or third degree heart block, or failure to respond to usual care within 1 to 2 weeksIIaC4Heart failure associated with a dilated cardiomyopathy of any duration associated with suspected allergic reaction and/or eosinophilia IIaC5Heart failure associated with suspected anthracycline cardiomyopathyIIaC6Heart failure associated with unexplained restrictive cardiomyopathy IIaC7Suspected cardiac tumors IIaC8Unexplained cardiomyopathy in children IIaC9New onset heart failure of 2 weeks to 3 months duration associated with a dilated left ventricle, without new ventricular arrhythmias, or second or third degree heart block, and that responds to usual care within 1 to 2 weeks IIbB10Heart failure of greater than 3 months duration associated with a dilated left ventricle, without new ventricular arrhythmias, or second or third degree heart block, and that responds to usual care within 1 to 2 weeks IIbC11Heart failure associated with unexplained hypertrophic cardiomyopathyIIbC12Suspected arrhythmogenic right ventricular dysplasia/cardiomyopathyIIbC13Unexplained ventricular arrhythmias IIbC14Unexplained atrial fibrillationIIIC2.00000000000000Table1/15/2008--permission not requested holding on LWW for now, author is the same as original. EM 2/7/2008--sent request to Laura Lee. EM 2/8/2008--permission granted. EM 1/2/2009--Renewal requested (JD). 1/17/2009--Renewal granted, mailed back agreement (JD).<a href="/Graphics/Pages/TableEditor.aspx?SPID=4558&Mode=Edit"></a>Endo_biopsy_recs.htmReproduced with permission from: Cooper, LT, Baughman, KL, Feldman, AM, et al. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Circulation 2007; 116:2216. Copyright ©2007 Lippincott Williams and Wilkins.Graphic 78022 Version 3.0

Neonatal diabetes mellitus (DM) is characterized by the onset of persistent hyperglycemia within the first six months of life due to impaired insulin function and is frequently caused by a mutation in a single gene affecting pancreatic beta cell function.The presentation, clinical manifestations, di

CloseOur approach to the initial treatment of pediatric patients with newly diagnosed immune thrombocytopenia (ITP) based on severity of bleeding symptoms and other risk factorsOur approach to the initial treatment of pediatric patients with newly diagnosed immune thrombocytopenia (ITP) based on severity of bleeding symptoms and other risk factorsThis algorithm summarizes our suggested approach to treating pediatric patients with newly diagnosed ITP (ie, within 3 months from diagnosis). Management is not standardized, and practice may vary from center to center. Our suggested approach is based chiefly on the severity of bleeding symptoms. Other important considerations include degree of thrombocytopenia, other risk factors (eg, activity level, use of antiplatelet or anticoagulant medications), quality of life, and values and preferences of the patient/caregivers. This algorithm is intended for use in conjunction with additional UpToDate content on ITP in children. Refer to UpToDate topics on the management of ITP in children for additional details of our approach, including the evidence supporting the efficacy of these treatments. For details on the management of persistent ITP (ongoing ITP between 3 and 12 months from the initial diagnosis) and chronic ITP (ie, ITP lasting >12 months), refer to separate UpToDate content on these issues.ITP: immune thrombocytopenia; PLT: platelet; IV: intravenous; IVIG: intravenous immune globulin; anti-D: anti-D immune globulin (also known as anti-Rho immune globulin); NSAID: nonsteroidal antiinflammatory drug; DAT: direct antiglobulin test.* Anti-D may be used instead of or in addition to IVIG in Rh-positive, DAT-negative, non-splenectomized patients. Anti-D should not be given if the patient's DAT status is unknown, which is often the case in emergency situations. If DAT is negative and Rh is positive, our practice is to include anti-D as part of combination therapy in patients with life-threatening bleeding. IV anti-D can be a useful component of therapy even in splenectomized patients despite its relative lack of efficacy when used as the sole agent in these patients. Other experts may not use ant-D in this setting. In non-emergency situations, anti-D is generally used as an alternative to IVIG rather than an additive therapy.¶ Additional interventions that have been used patients with severe or life-threatening bleeding based upon limited data include: recombinant human factor VIIa, vincristine, adjunctive antifibrinolytic agents (eg, epsilon aminocaproic acid or tranexamic acid), and emergency splenectomy. For patients with severe menorrhagia, hormonal therapy may be warranted. In addition, we often administer a high dose of a thrombopoietin receptor agonist (eg, romiplostim) in patients with severe bleeding. This practice is not standardized. PLT transfusions are generally reserved for patients with active, life-threatening bleeding. However, PLT transfusions may be necessary for patients with non-life-threatening bleeding who require surgery and for those who do not achieve an adequate response with other treatments (eg, if the response is too slow or if the PLT count does not increase to an acceptable level). Refer to separate UpToDate content on ITP for additional details regarding these therapies.Δ For severe bleeding that is not life-threatening (gastrointestinal bleeding without hemodynamic instability, pulmonary hemorrhage without cardiopulmonary compromise, severe prolonged epistaxis, muscle or joint hemorrhage), the components of treatment are similar to those used for life-threatening bleeding; however, rather than giving all 3 agents (IVIG, IV anti-D, and methylprednisolone) for up to 4 days, a measured approach using only 1 or 2 of these agents for fewer days may be sufficient. The choice of agents can be guided by the patient's previous treatment response if such experience exists. The choice and duration of therapy also depends upon the response to treatment.◊ Target platelet counts for patients undergoing surgery or invasive procedures are higher than thresholds to prevent spontaneous bleeding and depend on the nature of the procedure. Refer to UpToDate topics on ITP and platelet transfusion therapy for further details.§ For children with substantially impaired quality of life due to symptoms (especially fatigue) or anxiety about bleeding risks, pharmacologic therapy may be a reasonable option (after discussing with the patient and/or caregivers and carefully weighing the potential risks and benefits).¥ IVIG and anti-D are our preferred agents for most patients deemed to be at moderate to high risk of bleeding in whom a rapid rise in platelet count is desired. In addition, in our practice, we typically treat these patients concomitantly with a single dose of high-dose methylprednisolone to augment the platelet response and ameliorate the side effects of IVIG and anti-D. This practice is not standardized, and others do not routinely treat with methylprednisolone. Glucocorticoids alone are a reasonable alternative in this setting; however, glucocorticoids generally have more delayed onset compared with IVIG. Refer to UpToDate content on management of ITP in children for further details.Source:Table reproduced from: Schoettler ML, Graham D, Tao W, et al. Increasing observation rates in low-risk pediatric immune thrombocytopenia using a standardized clinical assessment and management plan (SCAMP®). Pediatr Blood Cancer 2017; 64:10.1002/pbc.26303. https://onlinelibrary.wiley.com/doi/10.1002/pbc.26303. Copyright © 2017 John Wiley & Sons Ltd. Reproduced with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department either via email: permissions@wiley.com or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library (https://onlinelibrary.wiley.com/).Graphic 115184 Version 2.0

CloseCommon causes of macrocephaly in children according to time of clinical presentationCommon causes of macrocephaly in children according to time of clinical presentationEarly infantile (birth to 6 mo of age) Hydrocephalus (progressive or "arrested") Induction disorders Spina bifida cystica, cranium bifidum, Chiari malformations (types I, II, and III), aqueductal stenosis, holoprosencephaly Mass lesions Neoplasms, atrioventricular malformations, congenital cysts Intrauterine infections Toxoplasmosis, cytomegalic inclusion disease, syphilis, rubella Perinatal or postnatal infections Bacterial, granulomatous, parasitic Perinatal or postnatal hemorrhage Hypoxia, vascular malformation, trauma Hydranencephaly   Subdural effusion Hemorrhagic, infectious, cystic hygroma   Normal variant (often familial) Late infantile (6 mo to 2 yr of age) Hydrocephalus (progressive or "arrested") Space-occupying lesions Tumors, cysts, abscess Postbacterial or granulomatous meningitis   Posthemorrhagic Trauma or vascular malformation Dandy-Walker syndrome Subdural effusion Increased intracranial pressure syndrome Pseudotumor cerebri Lead, tetracycline, hypoparathyroidism, corticosteroids, excess or deficiency of vitamin A, cyanotic congenital heart disease Primary skeletal cranial dysplasias (thickened or enlarged skull) Osteogenesis imperfecta, hyperphosphatemia, osteopetrosis, rickets   Megalencephaly (increase in brain substance) Metabolic central nervous system diseases Leukodystrophies (eg, Canavan, Alexander), lipidoses (Tay-Sachs), histiocytosis, mucopolysaccharidoses Proliferative neurocutaneous syndromes von Recklinghausen tuberous sclerosis, hemangiomatosis, Sturge-Weber Cerebral gigantism Sotos syndrome Achondroplasia Primary megalencephaly May be familial and unassociated with abnormalities of cellular architecture, or associated with abnormalities of cellular architecture Early to late childhood (older than 2 yr of age) Hydrocephalus (progressive or "arrested") Space-occupying lesions   Preexisting induction disorder Aqueductal stenosis Postinfectious   Hemorrhagic   Chiari type I malformation   Megalencephaly Proliferative neurocutaneous syndromes   Familial   Pseudotumor cerebri Normal variant1310/28/2008--Requested permission (JD). 11/17/2008--Permission granted; figure to Terrence, mailed invoice back to Arnetta (JD). 2/4/2010--Renewal requested (JD). 3/26/2010--Renewal granted; agreement mailed back to Arnetta (JD).<a href="/Graphics/Pages/TableEditor.aspx?SPID=52213&Mode=Edit"></a>Reproduced with permission from: Child Neurology, 7th ed, Menkes JH, Sarnat HB, Maria BL (Eds), Lippincott Williams & Wilkins, New York 2005. Copyright © 2005 Lippincott Williams & Wilkins. www.lww.com.Graphic 74157 Version 16.0

The postpartum period is an ideal time to access contraception services, as patients are known to not be pregnant, they may be motivated to initiate contraception, and are under the care of clinicians with the appropriate expertise. Counseling involves understanding a patient's wishes regarding futu