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  • Clinical Pharmacy Specialist—Breast Medical Oncology, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, Texas

Containment Recommendations Work with clinical specimens from patients suspected of having melioidosis and of B symptoms rheumatoid arthritis generic thyroxine 50 mcg online. Organisms are isolated from stool specimens through the use of selective media symptoms after conception cheap thyroxine 25 mcg free shipping, reduced oxygen tension medicine abuse purchase thyroxine cheap, and elevated incubation temperature (43°C) medications 1 thyroxine 25 mcg. Natural Modes of Infection Numerous domestic and wild animals, including poultry, pets, farm animals, laboratory animals, and wild birds are known reservoirs and are a potential source of infection for laboratory and animal care personnel. While the infective dose is not firmly established, ingestion of as few as 500-800 organisms has caused symptomatic 49-51 infection. Natural transmission usually occurs from ingestion of organisms in contaminated food or water and from direct contact with infected pets, farm animals, or 52 infants. Chlamydiae are nonmotile, gram-negative bacterial pathogens with obligate intracellular life cycles. These three species of Chlamydia vary in host spectrum, pathogenicity, and in the clinical spectrum of disease. In cases reported before 1955, the majority of infections were psittacosis, and these had the highest case fatality rate of laboratory acquired infectious agents. The major sources of laboratory-associated psittacosis are contact with and exposure to infectious aerosols in the handling, care, or necropsy of naturally or experimentally infected birds. Early reports commonly attributed infections to exposure to aerosols formed during nasal inoculation of mice or inoculation of egg yolk Agent Summary Statements – Bacterial Agents sacs and harvest of chlamydial elementary bodies. Infections are associated with fever, chills, malaise, and headache; a dry cough is also associated with C. Seroconversion to chlamydial antigens is common and often striking although early antibiotic treatment may prevent an antibody response. The route of infection was attributed to inhalation of droplet aerosols created during procedures associated with culture and harvest of the agent from cell culture. With all species of Chlamydia, mucosal tissues in the eyes, nose, and respiratory tract are most often affected by occupational exposures that can lead to infection. Exposure to infectious aerosols and droplets, created during the handling of infected birds and tissues, are the primary hazards to laboratory personnel working with C. Infectious aerosols, including those that may be created as a result of centrifuge malfunctions, also pose a risk for infection. Wetting the feathers of infected birds with a detergent-disinfectant prior to necropsy can appreciably reduce the risk of aerosols of infected feces and nasal secretions on the feathers and external surfaces of the bird. Gloves are recommended for the necropsy of birds and mice, the opening of inoculated eggs, and when there is the likelihood of direct skin contact with infected tissues, bubo fluids, and other clinical materials. Agent: Clostridium botulinum Agent Summary Statements – Bacterial Agents Clostridium botulinum, and rare strains of C. The pathogenicity of these organisms results from the production of botulinum toxin, one of the most highly potent neurotoxins currently recognized. Purified botulinum neurotoxin is a 150 kDa protein that acts selectively on peripheral cholinergic nerve 55 endings to block neurotransmitter release. The principal site of action is the neuromuscular junction, where blockade of transmission produces muscle weakness or paralysis. The toxin also acts on autonomic nerve endings where blockade of transmission can produce a variety of adverse effects. Occupational Infections There has been only one report of botulism associated with handling of the toxin 56 in a laboratory setting. However, concerns about potential use of the toxin as an agent of bioterrorism or biological warfare have led to increased handling of the substance by investigators studying mechanism of action and/or developing countermeasures to 57 poisoning. Natural Modes of Infection Botulinum toxin occurs in seven different serotypes (A to G), but almost all 58 naturally-occurring human illness is due to serotypes A, B, E, and F. Poisoning is normally due to ingestion of toxin; however, animal studies show a significant inhalation risk. Using appropriate personal protective equipment should prevent potential exposure through mucus membranes. Although rare, botulism also can be caused by puncture wounds in which there is local infection and in situ production of toxin. Risk to toxin exposure is dependent on both route of exposure and toxin molecular weight size. In healthy adults, it is typically the toxin and not the organism that causes disease. Vaccination is recommended for all personnel working in direct contact with cultures of C. Post-Exposure Treatment An equine antitoxin product is available for treatment of patients with symptoms consistent with botulism. However, due to the risks inherent in equine products, treatment is not provided as a result of exposure unless botulism symptoms are present. Agent: Clostridium tetani and Tetanus toxin Clostridium tetani is an anaerobic endospore-forming gram-positive rod found in the soil and an intestinal tract commensal. It produces a potent neurotoxin, tetanospasmin, that causes tetanus, an acute neurologic condition characterized by painful muscular contractions. Tetanospasmin is an exceedingly potent, high molecular weight protein toxin, consisting of a heavy chain (100kD) subunit that binds the toxin to receptors on neuronal cells and a light chain (50kD) subunit that blocks the release of inhibitory neural transmitter molecules within the central nervous system. The incidence of tetanus in the United States has declined steadily since the introduction of tetanus 62 toxoid vaccines in the 1940’s. Occupational Infections Agent Summary Statements – Bacterial Agents Although the risk of infection to laboratory personnel is low, there have been five 4 incidents of laboratory personnel exposure recorded. Natural Modes of Infection Contamination of wounds by soil is the usual mechanism of transmission for tetanus. Elevated incidence rates also were observed for persons aged over 60 years, diabetics, 63 and intravenous drug users. Accidental parenteral inoculation of the toxin is the primary hazard to laboratory personnel. Because it is uncertain if tetanus toxin can be absorbed through mucous membranes, the hazards associated with aerosols and droplets remain unclear. While the risk of laboratory-associated tetanus is low, the administration of an adult diphtheria-tetanus toxoid at 10-year intervals further reduces the risk to laboratory and animal care personnel of toxin exposures and wound 62 contamination, and is therefore highly recommended. Agent: Corynebacterium diphtheriae Cornebacterium diphtheriae is a pleomorphic gram-positive rod that is isolated from the nasopharynx and skin of humans. The organism is easily grown in the Agent Summary Statements – Bacterial Agents laboratory on media containing 5% sheep blood. Inhalation, accidental parenteral inoculation, and ingestion are the primary laboratory hazards. Natural Modes of Infection the agent may be present in exudates or secretions of the nose, throat (tonsil), pharynx, larynx, wounds, in blood, and on the skin. Travel to endemic areas or close 67 contact with persons who have returned recently from such areas, increases risk. Transmission usually occurs via direct contact with patients or carriers, and more rarely, with articles contaminated with secretions from infected people. Naturally occurring diphtheria is characterized by the development of grayish-white membranous lesions involving the tonsils, pharynx, larynx, or nasal mucosa. An effective vaccine has been developed for diphtheria and this disease has become a rarity in countries with vaccination programs. While the risk of laboratory-associated diphtheria is low, the administration of an adult diphtheria-tetanus toxoid at 10-year intervals may 67 further reduce the risk of illness to laboratory and animal care personnel. Agent: Francisella tularensis Francisella tularensis is a small gram-negative coccobacillus that is carried in numerous animal species, especially rabbits, and is the causal agent of tularemia (Rabbit Agent Summary Statements – Bacterial Agents fever, Deer fly fever, Ohara disease, or Francis disease) in humans. Type A and Type B strains are highly infectious, requiring only 10-50 organisms to cause disease. The incubation period varies with the virulence of the strain, dose and route of introduction but ranges from 1-14 days with most cases exhibiting symptoms in 3-5 68 days. Occupational Infections Tularemia has been a commonly reported laboratory-associated bacterial 4 infection. Most cases have occurred at facilities involved in tularemia research; however, cases have been reported in diagnostic laboratories as well. Occasional cases were linked to work with naturally or experimentally infected animals or their ectoparasites. Natural Modes of Infection Tick bites, handling or ingesting infectious animal tissues or fluids, ingestion of contaminated water or food and inhalation of infective aerosols are the primary transmission modes in nature.

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Humans and other de nitive hosts disseminate eggs into the envi ronment as long as worms remain in the intestine medications zoloft side effects buy thyroxine paypal, sometimes for many years medications given for bipolar disorder order thyroxine 125mcg visa. Preventive measures: Thorough heating of freshwater sh (56°C/133°F for 5 minutes) medications vitamins cheap thyroxine 75mcg otc, freezing for 24 hours at 18°C (0°F) treatment hepatitis c buy generic thyroxine on-line, or irradiation. Identi cation—An infection of the subcutaneous and deeper tis sues by a large nematode. A blister appears, usually on a lower extremity (especially the foot) when the gravid 60–100 cm long adult female worm is ready to discharge its larvae. Burning and itching of the skin in the area of the lesion and frequently fever, nausea, vomiting, diarrhea, dyspnoea, generalized urticaria and eosinophilia may accompany or precede vesicle formation. After the vesicle ruptures, the worm discharges larvae when ever the infected part is immersed in fresh water. The prognosis is good unless bacterial infection of the lesion occurs; such secondary infections may produce arthritis, synovitis, ankylosis and contractures of the involved limb and may be life-threatening. Diagnosis is made by visual recognition of the adult worm protruding from a skin lesion or by microscopic identi cation of larvae. In some locales, nearly all inhabitants are infected, in others, few, mainly young adults. Mode of transmission—Larvae discharged by the female worm into stagnant fresh water are ingested by minute crustacean copepods (Cyclops spp). People swallow the infected copepods in drinking water from infested step wells and ponds. The larvae are liberated in the stomach, cross the duodenal wall, migrate through the viscera and become adults. The female, after mating, grows and develops to full maturity, then migrates to the subcutaneous tissues (most frequently of the legs). Period of communicability—From rupture of vesicle until larvae have been completely evacuated from the uterus of the gravid worm, usually 2–3 weeks. After ingestion by copepods, the larvae become infective for people after 12–14 days at temperatures above 25°C (77°F), and remain infective in the copepods for about 3 weeks, the life span of an infected copepod. No acquired immunity; multiple and repeated infections may occur in the same person. Foci of disease formerly present in some parts of the Middle East and the Indian subcontinent have been eliminated in this manner. Preventive measures: 1) Provide health education programs in endemic communities to convey 3 messages: 1) that guinea worm infection comes from their drinking unsafe water; 2) that villagers with blisters or ulcers should not enter any source of drinking water; and 3) that drinking water should be ltered through ne mesh cloth (such as nylon gauze with a mesh size of 100 micrometers) to remove copepods. Construction of protected wells or rainwater catchments can provide noninfected water. Aseptic surgical extraction just prior to worm emergence is only possible on an individual basis but not applicable as a public health measure of eradication. Drugs, such as thiabendazole, al bendazole, ivermectin and metronidazole have no therapeu tic value. Epidemic measures: In hyperendemic situations, eld survey to determine prevalence, discover sources of infection and guide control/eradication measures as described under 9A. Identi cation—Severe acute viral illnesses, usually with sudden onset of fever, malaise, myalgia and headache, followed by pharyngitis, vomiting, diarrhea and maculopapular rash. Case-fatality rates for Ebola infections in Africa have ranged from 50% to nearly 90%; 25%–80% of reported cases of Marburg virus infection have been fatal. Postmortem diagnosis through immunohistochemical examination of formalin xed skin biopsy or autopsy specimens is possible. Infectious agents—Virions are 80 nanometers in diameter and 970 (Ebola) or 790 nanometers (Marburg) in length, and are respectively members of Ebolavirus and Marburgvirus genus in the family Filoviridae. Pleomorphic virions with branched, circular or coiled shapes are frequent on electron microscopy preparation and may reach micrometers in length. In the Republic of Congo, Co te d’Ivoire, the Democratic Republic of the Congo (formerly Zaire), Gabon, Sudan and Uganda, 3 different subtypes of Ebolavirus (Co te d’Ivoire, Sudan and Zaire) have been associated with human disease. A4th Ebola subtype, Reston, causes fatal hemorrhagic disease in nonhu man primates originated from the Philippines in Asia; few human infec tions have been documented and those were clinically asymptomatic. A new subtype of Ebola virus was recovered from one person probably infected while dissecting an infected chimpanzee in Co te-d’Ivoire in 1994. In 1995, a major Ebola outbreak with 315 cases and 244 deaths was centered on Kikwit (Democratic Republic of the Congo, formerly Zaire). Between the end of 1994 and the third trimester of 1996 three outbreaks reported in Gabon resulted in 150 cases and 98 deaths. Between August 2000 and January 2001 an epidemic (425 cases, 224 deaths) occurred in northern Uganda. From October 2001 to April 2003, several outbreaks were reported in Gabon and the Republic of Congo with a total of 278 cases and 235 deaths; high numbers of deaths were reported among wild animals in the region, particularly non-human primates. Antibodies have been found in residents of other areas of sub-Saharan Africa; their relation to the Ebola virus is unknown. End 2003, an outbreak in the Republic of Congo, with high case-fatality and thought to be related to contact with non-human primates, was rapidly controlled. In Reston, 4 animal handlers with daily exposure to these monkeys in 1989 developed speci c antibodies. Marburg disease has been recognized on 5 occasions: in 1967, in Germany and what was then the Federal Republic of Yugoslavia, 31 humans (7 fatalities) were infected following exposure to African green monkeys (Cercopithecus aethiops) imported from Uganda; in 1975, the fatal index case of 3 cases diagnosed in South Africa had been infected in Zimbabwe; in 1980, 2 linked cases, 1 of which fatal, were con rmed in Kenya; in 1987, a fatal case occurred in Kenya. From 1998 to 2000, in the Democratic Republic of the Congo, at least 12 cases were con rmed among more than 145 suspected cases (case-fatality rate 80%) of Marburg viral hemorrhagic fever. In Africa, Ebola infections of human index cases were linked to contact with gorillas, chimpanzees, monkeys, forest duikers and porcupines found dead or killed in the rainforest. So far, Ebola virus has been detected in the wild in carcases of chimpanzees (in Co te-d’Ivoire and Republic of Congo), gorillas (Gabon and Republic of Congo) and duikers (Republic of Congo), found dead in the rainforest. Person-to-person transmission occurs through direct contact with infected blood, secretions, organs or semen. Risk is highest during the late stages of illness when the patient is vomiting, having diarrhea or hemorrhaging, and during funerals with unprotected body preparation. Under natural conditions, airborne transmission among humans has not been documented. Nosocomial infections have been frequent; virtually all patients who acquired infection from contaminated syringes and needles died. Period of communicability—Not before the febrile phase and increasing with stages of illness, as long as blood and secretions contain virus. Ebola virus was isolated from the seminal uid on the 61st, but not on the 76th, day after onset of illness in a laboratory acquired case. Methods of control—No vaccine and no speci c treatment avail able as yet for either Ebola or Marburg. See control measures for Lassa fever: 9B, C, D and E; plus protection of sexual intercourse for 3 months or until semen can be shown to be free of virus. Cysts usually develop in the liver but also in other viscera, nervous tissue or bone. Identi cation—Larval stages of the tapeworm Echinococcus granulosus, the most common Echinococcus, cause cystic echinococcosis or hydatid disease. Infections may be asymptomatic until cysts cause notice able mass effect; signs and symptoms will vary according to location, cyst size, cyst type and numbers. Ruptured or leaking cysts can cause severe anaphylactoid reactions and may release protoscolices that can produce secondary echinococcosis. Cysts are typically spherical, thick-walled and unilocular, most frequently found in the liver and lungs, although they may occur in other organs. Clinical diagnosis is based on signs and symptoms compatible with a slowly growing tumour, a history of residence in an endemic area, along with association with canines. Differential diagnoses include malignancies, amoebic abscesses, congenital cysts and tuberculosis. Radiography, com puterized tomography and sonography along with serological testing are useful for laboratory diagnosis. De nitive diagnosis in seronegative patients, however, requires microscopic identi cation from specimens obtained at surgery or by percutaneous aspiration; the potential risks of this (anaphylaxis, spillage) can be avoided by ultrasound guidance and anthelmintic cover age. Species identi cation is based on nding thick laminated cyst walls and protoscolices as well as on the structure and measurements of protoscolex hooks. Infectious agent—Echinococcus granulosus, a small tapeworm of dogs and other canids.

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Factory pretreated nets are now available medicine zolpidem cheap 100 mcg thyroxine otc, but achieving high re treatment coverage rates is a major challenge to symptoms 4dpo order thyroxine 50 mcg free shipping public health programs medicine man gallery cheap thyroxine 125mcg with amex. One brand of pretreated nets is impreg nated by a technique allowing the insecticide to treatment naive discount 200mcg thyroxine otc remain effective for about 5 years despite washing; others (such as nets treated with two insecticides to prevent resistance) are under development. This method is most effective where mosquitoes rest indoors on sprayable surfaces, where peo ple are exposed in or near the home, and when it is applied before the transmission season or period of peak transmis sion. The most important constraints are operational: dif culty of managing the operations once or twice a year, year after year, in areas with low human density and dif cult terrain, as spraying often becomes less and less popular over time. Their duration of action is generally shorter, and thus they carry a lesser risk of environmental side-effects. The same goes for chemical and biological (larvivorous sh) control methods applied to impounded water bodies—it is rarely possible to obtain the necessary level of coverage to reduce transmission in tropical areas. Nonetheless, these methods may be useful adjuncts in some situations such as arid, coastal and urban areas and refugee camps. This is promoted in Africa, but of limited use in other parts of the world, partly because transmission there is often less intense, partly because of widespread parasite resistance to the only drug that has been fully validated for this purpose, sulfadoxine-pyrimethamine. The case de nition for surveillance recommended within the national malaria con trol program should be used; as a minimum, con rmed cases must be distinguished from non-con rmed (probable) cases. In non-endemic areas, blood donors should be ques tioned for a history of malaria or a history of travel to, or residence in, a malarious area. Long-term (over 6 months) visitors to malarious areas who have been on antimalarials and have not had malaria, or persons who have immigrated or are visiting from an endemic area may be accepted as donors 3 years after cessation of prophylac tic antimalarial drugs and departure from the endemic area, if they have remained asymptomatic. Such areas include malaria endemic coun tries of the Americas, tropical Africa, southwestern Paci c, and south and southeastern Asia. Personal protective measures for non-immune travellers Because of the resurgence of malaria, the following guide lines are presented in detail. Travellers to malarious areas must realize that: protection from biting mosquitoes is of paramount importance; no antimalarial prophylactic regimen gives com plete protection; prophylaxis with antimalarial drugs should not automatically be prescribed for all travellers to malarious areas; and “standby” or emergency self-treatment is recommended when a febrile illness occurs in a falciparum malaria area where professional medical care is not readily available. Manufacturers’ recommendations for use must not be exceeded, particularly with small children (not to ex ceed 10% of active product in the latter case). Im pregnating the net with synthetic pyrethroid insecti cides will increase protection. Medical help must be sought promptly if malaria is suspected; a blood sample must be examined on more than one occasion and a few hours apart. There are limited data, but so far no rm evidence, for embryotoxic/teratogenic effects: in situations of inadvertent pregnancy, prophylaxis with me oquine is not considered an indication for preg nancy termination. Most non-immune individuals exposed to or infected with malaria should be able to obtain prompt medical attention when malaria is suspected. A minority will be exposed to a high risk of infection while at least 12–24 hours away from competent medical attention. Persons prescribed standby treatment must receive precise instruc tions on recognition of symptoms, complete treatment regimen to be taken, possible side-effects and action to be taken in the event of drug failure. They must be made aware that self-treatment is a temporary measure and medical advice is to be sought as soon as possible. The possible side-effects of long-term (up to 3 to 5 months) use of the drug or drug combination recommended for use in any particular area should be weighed against the actual likelihood of being bitten by an infected mosquito. The risk of exposure for visitors or residents in most urban areas in many malarious countries, including southeastern Asia and South America may be negligible, and suppressive drugs may not be indicated. In some urban centers, notably in Indian subcontinent countries, there may be a risk of exposure. The drug must be continued on the same schedule for 4 weeks after leaving endemic areas. Minor side-effects may occur at prophylactic doses and may be alleviated by taking the drug with meals or changing to hydroxychlo roquine. Psoriasis may be exacerbated particularly in Africans and Americans of African origin; chloroquine may interfere with the immune response to intradermal rabies vaccine. Suppressive drug treatment must be continued weekly, starting 1–2 weeks before travel and continued during travel or residence in malarious area and for 4 weeks after returning to non-malarious areas. It is not recommended for women in the rst trimester of pregnancy nor for individuals with cardiac arrhythmias, a recent history of epilepsy or severe psychiatric disorders. Data show no increased risk of serious side-effects with long-term use of me o quine, but in general, for those with prolonged resi dence in high-risk areas, the seasonality of transmission and improved protective measures against mosquito bites should be weighed against the long-term risk of drug reactions. Doxycycline may precipitate Candida vaginitis, oesophageal irritation and photosensitivity. Doxycycline prophylaxis can begin 1–2 days before travel to malarious areas and be continued daily during travel and for 4 weeks after leaving the malarious area. Atovaquone/proguanil offers an alternative prophylaxis for travellers who are making short trips to areas where there is chloroquine-resis tance and who cannot take me oquine or doxycycline. The daily adult dose is one tablet containing 250 mg atovaquone plus 100 mg proguanil, to be started 1 day before departure and continued for 7 days after return. The most common side-effect was epigas tric or abdominal pain and vomiting in less than 10% of recipients. Longer term exposure, up to 50 weeks of daily administration of primaquine, showed a slight increase of methemoglobin level to 5. In the event of a febrile illness, if professional care is not available, they must take the complete antimalarial dosage and obtain medical consultation as soon as possible. Such presump tive self-treatment is only a temporary measure and early medical evaluation is imperative. The decision to administer primaquine is made on an individual basis, after consideration of the potential risk of adverse reactions, and this drug is generally indicated only for persons with prolonged exposure. Larger daily doses (30 mg base) are generally required for southwestern Paci c and some strains from southeastern Asia and South America. Primaquine should not be administered during preg nancy; chloroquine chemosuppression should instead be continued weekly for the duration of the pregnancy. In non-endemic areas where malaria transmission is possible, patients should be in mosquito-proof areas from dusk to dawn, until microscopy shows that they have no gameto cytes in the blood. If a history of sharing needles is obtained from the patient, investigate and treat all persons who shared the equipment. In transfusion-induced malaria, all donors must be located and their blood examined for malaria parasites and for antimalarial antibodies; parasite-positive donors must re ceive treatment. Malaria cases in non-endemic areas are usually imported, but some cases with no travel history have been reported from areas near airports in recent years. If the area is receptive to malaria (effective vectors present), household contacts should be screened, and persons living in the same community as well as health services should be advised about the risk of malaria; anybody developing malaria-like symptoms must be examined by blood microscopy or rapid diagnostic tests. The ight range of anopheline mosquitoes may reach 2 km, but in most cases it is only a few hundred meters. Identifying suitable antimalarial drug policies poses a major challenge to national programs. The following is mainly designed for the management of malaria in travellers (during and after travel), taking into account the need for highly effective treatment for these patients, who generally have no immunity to the disease, and the products which may be available to them. If no improvement within 48 hours, each dose should be reduced to 5–7 mg/kg; hypoglycaemia is a common side-effect, so plasma glucose should be monitored. Artemether and artesunate should be given for no more than 7 days, or until the patient can take another effective antimalarial drug, such as me oquine, 25 mg/kg, by mouth. Oral arte mether and artesunate and other artemisinin com pounds should be used only in combination with other antimalarials. They are not recommended in the rst trimester of pregnancy; and should be used later in pregnancy only if suitable alternatives are not available. Where parenteral quinine and artemisinin com pounds are not available, quinine can be substituted by parenteral quinidine, equally effective in the treatment of severe malaria. All parenteral drugs should be discontinued as soon as oral drug administration can be initiated. In extremely severe falciparum infections, particu larly with a parasitaemia approaching or exceeding 10%, exchange transfusion should be considered. De tails on the management of severe malaria can be found in: Management of severe malaria.

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Author/Year Score Sample Comparison Results Conclusion Comments Study Type (0-11) Size Group Thordarson 6 symptoms mono thyroxine 25 mcg sale. Control decrease in device is elevation group: change in preoperative effective in © Copyright 2016 Reed Group medicine used for anxiety effective thyroxine 25mcg, Ltd symptoms gallbladder cheap 100mcg thyroxine with mastercard. All fractures outcome fractures rest with patients had before measures elevation mean surgery (shorter (C) treatment 6 month old cough discount thyroxine 25mcg with amex. Strength of Evidence – Moderately Not Recommended, Evidence (B) Level of Confidence Moderate Rational for Recommendation There is one high-quality trial comparing interferential current therapy with sham before and after ankle surgery that demonstrated no difference in foot or ankle volumetric measures. Author/Y Sco Sample Comparison Results Conclusion Comments ear re Size Group Study (0 Type 11) Christie 8. Strength of Evidence – No Recommendation, Insufficient Evidence (I) Level of Confidence Low Rationale for Recommendation There are no quality trials for the use of electric stimulation of ankle or foot fractures. There is no recommendation for the use of electrical stimulation devices for ankle and foot fractures. Evidence for the Use of Electrical Stimulation for Ankle and Foot Fractures There are no quality studies incorporated into this analysis. Recommendation: Physical or Occupational Therapy for Patients with Functional Debilities after Cast Removal © Copyright 2016 Reed Group, Ltd. Recommendation: Manual Therapy as Part of a Post-ankle Fracture Rehabilitation Program Manual therapy is not recommended as part of an active post-ankle fracture rehabilitation program. Recommendation: Passive Stretching for Contractures after Immobilization of Ankle Fractures Passive stretching is moderately not recommended for contractures after immobilization of ankle fractures. Strength of Evidence – Moderately Not Recommended, Evidence (B) Level of Confidence Moderate Rationale for Recommendations There is one moderate-quality trial of supervised physical therapy compared to usual care that demonstrated subjective and objective improvement in the supervised therapy group in persons under age 40. The study may have been underpowered, but the observed effect was likely of small clinical benefit. A high-quality trial comparing exercises alone, exercise with short-duration passive stretches, and exercise with long-duration passive stretches demonstrated no differences among groups when considering outcomes of passive dorsiflexion, pain, return to usual work, or participation in sports and leisure activities. Other patients may benefit from formal physical or occupational therapy after removal of a cast or splint to address disabilities. The number of appointments is dependent on the degree of debility, with 1 or 2 educational appointments appropriate for mildly affected patients. Patients with severe debility or those unable to return to work may benefit from 8 to 12 appointments that include assignment of and guidance with progressive stretching and strengthening exercises. Strength of Evidence – Moderately Not Recommended, Evidence (B) Level of Confidence Moderate Rationale for Recommendation There is one high-quality trial for the use of ultrasound stimulation of ankle or foot fractures. Ultrasound stimulation is non-invasive, is of moderate to high cost depending on frequency and duration of treatment, and has low adverse effects. Author/Y Sco Sample Comparison Results Conclusion Comments ear re Size Group Study (0 Type 11) Handolin 9. No mineral density or baseline le poly-L ultrasound difference in clinical outcome in characteristics lactide daily for 20 Olerud bioabsorbable screw presented. It has been recommended for crush injuries of the upper extremity, although no quality evidence is available for the lower extremity. Therefore, there is no recommendation for the use of hyperbaric oxygen for routine patients for bone healing or prevention of avascular necrosis. In select patients with moderate to severe crush injuries or compartment syndrome, hyperbaric oxygen may be indicated as risks of these conditions are outweighed by potential benefits. Evidence for the Use of Hyperbaric Oxygen for Ankle and Foot Fractures There are no quality studies incorporated into this analysis. Strength of Evidence – No Recommendation, Insufficient Evidence (I) Level of Confidence Low Rationale for Recommendation There is one moderate-quality trial of hypnosis for promotion of fracture healing compared to a no hypnosis group that demonstrated no significant differences as it was underpowered. Author/Year Score Sample Comparison Results Conclusion Comments Study Type (0-11) Size Group Ginandes 4. If clinically suspected in the setting of negative radiographs, follow-up radiographs may be helpful; after approximately 7 days there will be resorption at the fracture line, which will then be more easily visible. Evidence for the Use of X-ray for Hindfoot Fractures There is 1 high and 1 moderate-quality study incorporated into this analysis. Author/Y Sco Sample Compariso Results Conclusion Comments ear re Size n Group Study (0 Type 11) Knight 8. Indications – Generally reserved for suspicion of occult fracture of the talus neck or lateral process. Indications – Non-acute fracture patient with persistent pain more than 4 months after injury. Author/Year Score Sample Comparison Results Conclusion Comments Study Type (0-11) Size Group Zeiss 5. It could be identifying both bone more helpful in possible pain and soft evaluation of generating tissue. Strength of Evidence – Recommended, Insufficient Evidence (I) Level of Confidence High Rationale for Recommendation There are no quality studies on bone scanning and bone scans are not required for evaluation of the majority of patients with calcaneus fractures. Technetium scanning may be positive for occult or stress fracture within 6 to 72 hours of the onset of pain. Author/Y Sco Sample Compari Results Conclusion Comments ear re Size son Study (0 Group Type 11) Ebrahei 7. This sign, visible in the anterior-posterior view, is indicative of viability at 6 to 8 weeks post-fracture indicating that avascular necrosis is unlikely to develop. Initial Care Talus Fractures Because of its key position, diagnosis and treatment of talus fractures is critical for foot and ankle function. Referral to specialist is indicated for all injuries due to the high potential for poor outcomes. Non-displaced, non-rotated talar neck fractures can be treated with short-leg, non weight-bearing cast in neutral position for 6 to 12 weeks or until there is radiographic evidence that union has been achieved, followed by weight bearing in walker boot for 1 to 2 more months. Recommendation: Non-operative Management of Non-displaced Talar Fractures There is no recommendation for or against non-operative management of non-displaced talar fractures (head, neck, body). Strength of Evidence – No Recommendation, Insufficient Evidence (I) Level of Confidence Low 2. Recommendation: Operative Management of Displaced Talar Fractures Operative management is recommended for all displaced talar fractures (head, neck, body, lateral process). Referral to specialist is indicated for all injuries due to the high potential for poor outcomes of these injuries. Because of the key role the talus plays in locomotion, and the risk for significant disability and complication with these fractures, most are managed aggressively with open reduction and internal fixation. Evidence for the Management of Talar Fractures There are no quality studies incorporated into this analysis. Recommendation: Non-operative Management of Osteochondral Lesions of the Talus Non-operative management of osteochondral lesions of the talus is recommended for select patients. Indications – A non-operative approach is indicated for initial management of lateral lesions that radiographically appear to be a compression lesion with no visible fragment or there is a fragment but it is still attached. Recommendation: Operative Intervention for Osteochondral Lesions of the Talus Operative intervention for osteochondral lesions of the talus is recommended for after an initial course of conservative management. A systematic review of 32 lesser quality studies describing clinical outcomes reported a 45% success rate with non-operative treatment. Author/Y Sco Sample Comparis Results Conclusion Comments ear re Size on Group Study (0 Type 11) © Copyright 2016 Reed Group, Ltd. Calcaneus Injuries Both non-surgical and surgical interventions are described to help regain anatomical reduction and alignment. Recommendation: Cast Immobilization for Select Calcaneus Fractures Non-operative cast immobilization is recommended for select calcaneus fractures. Indications – Non-displaced fracture, displaced extra-articular, displaced intra-articular. Recommendation: Operative Management for Select Calcaneus Fractures Operative management is recommended for select calcaneus fractures. Indications – Displaced, non-reducible extra-articular fractures, displaced intra-articular fractures. Upon stratification, females, patients not receiving workers’ compensation, younger males, patients with a higher Bohler angle, patients with a lighter workload, and those with a single simple displaced intra-articular calcaneus fracture were demonstrated to have better results after operative treatment than after non-operative treatment.

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