Anaphylaxis in practice: A guide to the 2023 Practice Parameter Update.

This review will summarize new research developments and clinical practice recommendations for the diagnosis and management of anaphylaxis presented in the Joint Task Force on Practice Parameters' 2023 Anaphylaxis Practice Parameter Update. It is intended to serve as a high-level summary of the 2023 practice parameter, which makes clinically impactful recommendations based on new evidence that has emerged since the 2015 practice parameter. We invite clinicians to explore the full 2023 practice parameter to better understand the research methods and underlying evidence that have informed the recommendations summarized here. There are new and evolving diagnostic criteria for anaphylaxis, rules for defining elevated tryptase levels, and recognition of signs and symptoms particular to infants and toddlers. The administration of epinephrine should not be used as a surrogate to diagnose anaphylaxis. Risk factors for anaphylaxis should be assessed on a case-by-case basis. Patient counseling and shared decision making (SDM) are essential for supporting patients' treatment decisions and capacity to manage the risk of anaphylaxis at home and in other community settings. Activation of emergency medical services following home epinephrine administration may not be required in all cases, and patients should be engaged in SDM to determine when home management may be appropriate.

A systematic literature review of recommendations for referral to specialty care for patients with epilepsy.

OBJECTIVE: In epilepsy, patients who receive appropriate care receive treatment that differs substantially from those that do not. Given the need for a more detailed assessment of the role of specialty referral in the care of patients with epilepsy, this systematic literature review identified epilepsy care guidelines and recommendations that specifically address when and why people with epilepsy should be referred to specialty care. METHODS: This study identified recent (in the last 10 years) publications that made best-practice recommendations for referring people with epilepsy to a neurologist or epileptologist. We searched six databases in December 2018: MEDLINE (PubMed), Cochrane Library, ProQuest, Web of Science, CINAHL (Ebsco), Scopus (Elsevier). Search terms included "Epilepsy" OR "Seizures," "Guideline" OR "Practice Parameter," and "Referral." RESULTS: The 15 full-text articles identified included formal guidelines, summaries of these guidelines, or professional commentary that builds upon existing guidelines. Most of these publications came from the U.K and its National Institute for Health and Care Excellence. Overall, the included recommendations for referral varied considerably both for new-onset and refractory epilepsy. Although these recommendations were not consistent, it is reasonable to refer patients following the failure of 2 anti-seizure medication (ASM) trials. SIGNIFICANCE: Guidelines and informal recommendations are not consistent regarding best practices for specialty care referral for patients with epilepsy. These guidelines and recommendations should consider the context of care in real-world settings and suggest pragmatic approaches that optimize seizure control and functioning.

Peanut allergy diagnosis: A 2020 practice parameter update, systematic review, and GRADE analysis.

Given the burden of disease and the consequences of a diagnosis of peanut allergy, it is important that peanut allergy be accurately diagnosed so that an appropriate treatment plan can be developed. However, a test that indicates there is peanut sensitization present (eg, a "positive" test) is not always associated with clinical reactivity. This practice parameter addresses the diagnosis of IgE-mediated peanut allergy, both in children and adults, as pertaining to 3 fundamental questions, and based on the systematic reviews and meta-analyses, makes recommendations for the clinician who is evaluating a patient for peanut allergy. These questions relate to when diagnostic tests should be completed, which diagnostic tests to utilize, and the utility (or lack thereof) of diagnostic testing to predict the severity of a future allergic reaction to peanut.

Development of the Korean Practice Parameter for Adult Attention-Deficit/Hyperactivity Disorder.

OBJECTIVES: Adult attention-deficit/hyperactivity disorder (ADHD) is an important mental health problem that needs resolution, especially considering the high rates of ADHD continuation from childhood to adolescence/adulthood and the high prevalence of ADHD in adults. Adults with ADHD have lifelong negative impacts and require close monitoring with long-term follow-up. Hence, the establishment of a Korean practice parameter for adult ADHD is necessary to minimize discontinuation of treatment and enable information sharing among Korean mental health professionals. METHODS: The Korean practice parameter was developed using an evidence-based approach consisting of expert consensus survey coupled with literature review. RESULTS: According to the expert consensus survey, the most commonly used diagnostic methods were clinical psychiatric interview (20.66%) and self-report scales (19.25%) followed by attention (14.71%) and psychological tests (14.24%). Key evaluation instruments currently available in Korea are the World Health Organization Adult ADHD Self-Report Rating Scale, Korean Adult ADHD Rating Scale, Diagnostic Interview for ADHD in Adults, Barkley Deficits in Executive Functioning Scale for adults, Comprehensive Attention Test, Conners' Continuous Performance Test, and the subtests of Wechsler Adult Intelligence Scale, Digit Span and Letter-Number Sequencing. Although pharmacotherapy is recommended as the first-line of treatment for adult ADHD, we recommend that it be followed by a multimodal and multidisciplinary approach including psychoeducation, pharmacotherapy, cognitive behavior therapy and coaching. CONCLUSION: The Korean practice parameter introduces not only general information for the diagnosis and treatment of adult ADHD on a global scale, but also the process of diagnosis and treatment options tailored to the Korean population.

Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis.

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.

Practice Parameter for the Assessment and Treatment of Psychiatric Disorders in Children and Adolescents With Intellectual Disability (Intellectual Developmental Disorder).

Intellectual disability (intellectual developmental disorder) (ID/IDD) is both a psychiatric disorder and a risk factor for co-occurring psychiatric disorders in children and adolescents. DSM-5 introduced important changes in the conceptualization and diagnosis of ID/IDD, and current research studies clarify assessment and treatment of co-occurring psychiatric disorders in this population. Optimal assessment and treatment of psychiatric illness in children and adolescents with ID/IDD includes modifications in diagnostic and treatment techniques, appreciation of variations in the clinical presentation of psychiatric disorders, an understanding of the spectrum of etiologies of behavioral disturbance, and knowledge of psychosocial and medical interventions.

Assessment and management of pediatric depression.

Pediatric depression is difficult to identify and manage because of complex nature of the disorder. Psychological and cognitive developments impact the clinical presentation and often make assessment tenuous. In addition, the disorder is often associated with multiple biological, psychological, and environmental risk factors, which need thorough assessment. Clinical presentation varies from subsyndromal depression to depression with psychotic features. Although diagnostic criteria for depression remain the same for children; deciphering symptoms need specialized clinical training. This article discusses identification and assessment of depression in the pediatric population. Specialized interviewing techniques pertaining to assessment in this unique population are discussed. Evidence-based guidelines for management of pediatric depression in terms of both pharmacotherapy and psychotherapy are also enumerated. Choice of medication based on multiple parameters with available evidence base is discussed. Treatment planning and continued evaluation on long-term basis are also elaborated.

Improving Folic Acid Supplementation Rates in Women of Childbearing Age With Epilepsy.

BACKGROUND: This study aims to improve the rate of folic acid supplementation to adolescent women with epilepsy on an antiepileptic drug (AED) regimen seen by the pediatric neurology providers at the Children's Hospital at Montefiore, in compliance with the 2009 American Academy of Neurology and American Epilepsy Society practice parameter. METHODS: We designed a quality improvement study with implementation of a series of interventions and compared folic acid supplementation rates before and after intervention. We made additional comparisons based on specific age groups (12 to 15 years and 16 to 21 years) and a diagnosis with or without developmental impairment. RESULTS: A review of 1850 charts from 2004 to 2015 showed an average folic acid prescription rate of 41%. Supplementation rates gradually increased to 52.2%, 58.5%, 60.3%, and finally up to 81.6% after this respective intervention: initial email reminder, provider education, posting signs in examination rooms, and implementation of an electronic medical record best practice advisory. There was improvement across all categories, in both age groups (12 to 15 years and 16 to 21 years) and in those with or without developmental impairment. There was a trend for higher compliance rates in adolescents without developmental impairment. CONCLUSIONS: Our interventions resulted in an increase in folic acid supplementation rates of adolescent women with epilepsy. These results are encouraging. We plan to extend education about the recommendations for folic acid supplementation to non-neurology providers, as well as expand to apply our interventions and assess adherence to other defined epilepsy quality measures.

American College of Radiology-American Brachytherapy Society practice parameter for electronically generated low-energy radiation sources.

BACKGROUND: This collaborative practice parameter technical standard has been created between the American College of Radiology and American Brachytherapy Society to guide the usage of electronically generated low energy radiation sources (ELSs). It refers to the use of electronic X-ray sources with peak voltages up to 120 kVp to deliver therapeutic radiation therapy. MAIN FINDINGS: The parameter provides a guideline for utilizing ELS, including patient selection and consent, treatment planning, and delivery processes. The parameter reviews the published clinical data with regard to ELS results in skin, breast, and other cancers. CONCLUSIONS: This technical standard recommends appropriate qualifications of the involved personnel. The parameter reviews the technical issues relating to equipment specifications as well as patient and personnel safety. Regarding suggestions for educational programs with regard to this parameter,it is suggested that the training level for clinicians be equivalent to that for other radiation therapies. It also suggests that ELS must be done using the same standards of quality and safety as those in place for other forms of radiation therapy.

The Revised Korean Practice Parameter for the Treatment of Attention-Deficit Hyperactivity Disorder (II): Diagnosis and Assessment

Attention-deficit hyperactivity disorder (ADHD) is a highly prevalent, impairing, and comorbid disorder that persists into adulthood. ADHD should be diagnosed in the same manner as other common adult mental health disorders. The three most important components in the comprehensive evaluation of patients with ADHD are the clinical interview, medical examination, and completion and scoring of behavior rating scales. The diagnostic evaluation of ADHD should include questions about the symptoms, family history, prior evaluation and treatment of ADHD, as well as other problems including alcohol and drug use. Screening interviews or rating scales, as well as interviews, should be used. When it is feasible, clinicians may wish to supplement these components of the evaluation with the objective assessments of the ADHD symptoms, such as through psychological tests. These tests are not essential to reaching a diagnosis, however, or to treatment planning, but may yield further information about the presence and severity of cognitive impairments that could be associated with some cases of ADHD. As comorbidity is the rule rather than the exception, clinicians should carefully screen for comorbid disorders as part of a comprehensive assessment of ADHD. To receive a diagnosis of ADHD, the person must be experiencing significant distress or impairment in his or her daily functioning, and must not meet the criteria for other mental disorders which might better account for the observed symptoms, such as mental retardation, autism or other pervasive developmental disorders, mood disorders and anxiety disorders. This report aims to suggest practice guidelines for the assessment and diagnosis of children, adolescents and adults with ADHD in Korea.

The Revised Korean Practice Parameter for the Treatment of Attention-Deficit Hyperactivity Disorder (IV): Non-Pharmacologic Treatment

Attention-deficit hyperactivity disorder (ADHD) is a neuropsychiatric disorder that begins in early childhood and can persist throughout adulthood. ADHD causes difficulties in various area of life, such as academic achievement, peer relationships, family functioning, employment and marriage. Although ADHD is known to respond well to medication, such treatment is more effective when combined with psychosocial (non-pharmacologic) therapy in terms of alleviating the core symptoms and improving appropriate functions. Psychosocial treatment interventions are divided into psychoeducation, behavioral parent training, school intervention, cognitive behavior therapy, social skill training, parent-child interaction therapy, play therapy, other treatments (coaching, complementary and alternative medicine), neurofeedback and Cogmed. Adult ADHD cognitive behavioral therapy is described separately. These practice parameters summarize the evidence for psychosocial treatment. Based on this evidence, specific recommendations are provided for psychosocial interventions.

Review of Select Practice Parameters, Evidence-Based Treatment Algorithms, and International Guidelines for Hereditary Angioedema.

Hereditary angioedema (HAE) is a rare bradykinin-mediated disease that is characterized by recurrent attacks of subcutaneous or submucosal edema, which can be life threatening. HAE affects all ethnic groups equally and does not differentiate between age, sex, or race. However, the availability of therapies varies amongst countries resulting in a lack of uniformity of care. Not only is there a disparity of medication availability, but since HAE is a rare disease, it is frequently overlooked and the diagnosis is missed. Even with diagnosis, treatment and management is often less than optimal. For these reasons, it is essential to have practice parameters and guidelines. In this chapter, we focus on recent guidelines. These guidelines deal with recognition, diagnosis, medical care, patient management, and assessment, all which are essential to provide optimal care to people with a rare and orphan disease. The intent of the guidelines, and thus this chapter, is to reduce morbidity and mortality, and restore a normal quality of life for the patient with HAE. We will review the guidelines from various regions of the world as well as international group recommendations. In addition, specific patient populations such as the pregnant, elderly, and juvenile require modified treatment regimens, and for this reason, we have included these data as well. The intent of this chapter is to aid the practitioner in holistic care of the patient with HAE in order to ultimately provide the best standard of care possible.

Practice parameter for the assessment and treatment of children and adolescents with tic disorders.

Tic disorders, including Tourette's disorder, present with a wide range of symptom severity and associated comorbidity. This Practice Parameter reviews the evidence from research and clinical experience in the evaluation and treatment of pediatric tic disorders. Recommendations are provided for a comprehensive evaluation to include common comorbid disorders and for a hierarchical approach to multimodal interventions.

The Korean Practice Parameter for the Treatment of Attention-Deficit Hyperactivity Disorder(I): Introduction, Clinical Features and Course

Based on the broad and in-depth literature review, the dedicated members of the committee for the development of Korean attention-deficit hyperactivity disorder(ADHD) practice parameter develop the Korean practice parameter for ADHD. Members of the Korean Academy of Child and Adolescent Psychiatry(KACAP) had reviewed the drafts through off-line and on-line access to the drafts. Feedbacks from the members of KACAP were carefully integrated into the current practice parameter. This article presents the state of the art knowledge regarding the assessment and the management of ADHD. Recommendations in the end of the practice parameter may help clinician to make decisions in clinical practice, but are not likely to override the clinician's decision in natural settings. Future directions to complement the limitation of the current practice parameter is suggested.

The Korean Practice Parameter for the Treatment of Attention-Deficit Hyperactivity Disorder(II): Diagnosis and Assessment

Probably the three most important components to a comprehensive evaluation of patients with attention-deficit hyperactivity disorder(ADHD) are the clinical interview, the medical examination, and the completion and scoring of behavior rating scales. Teachers and other school personnel are often the first to recognize that a child or adolescent might have ADHD, and often play an important role in the help-seeking/referral process. A diagnostic evaluation for ADHD should include questions about ADHD symptoms, other problems including alcohol and drug use, family history of ADHD, prior evaluation and treatment for ADHD. Screening interview or rating scales as well as interviews should be used. When it is feasible, clinicians may wish to supplement these components of the evaluation with objective assessments of the ADHD symptoms, such as psychological tests. These tests are not essential to reaching a diagnosis, however, or to treatment planning, but they may yield further information about the presence and severity of cognitive impairments that could be associated with some cases of ADHD. Screening for intellectual ability and academic achievement skills is also important in determining the presence of comorbid developmental delay or learning disabilities. The number and type of symptoms required for a diagnosis of ADHD vary depending on the specific subtype. To receive a diagnosis of ADHD, the person must be experiencing significant distress or impairment in daily functioning, and must not meet criteria for other mental disorders which might better account for the observed symptoms such as mental retardation, autism or other pervasive developmental disorders, mood disorders, anxiety disorders. This report aims to suggest a practice guideline of assessment and diagnosis for children and adolescents with ADHD in Korea.

The Korean Practice Parameter for the Treatment of Attention-Deficit Hyperactivity Disorder(III): Pharmacologic Treatment

The objective of this review is to propose the Korean practice guideline for pharmacological treatment of attentiondeficit hyperactivity disorder(ADHD). For making the guideline, the authors used the evidence-base approaches derived from a detailed review of literature including wide range of controlled clinical trials, studies of side effects of drugs, toxicological reports, and meta-analyses published in United States and Europe, as well as inside Korea. The review committee composed of experts in ADHD in Korea has reviewed the parameter. The practice parameter for pharmacological treatment describes the use of stimulants, atomoxetine, modafinil, bupropion, tricyclic antidepressants, and alpha-adrenergic agonists and their side effects. The recommendations of pharmacological treatment are proposed at the end of the article.

The Korean Practice Parameter for the Treatment of Attention-Deficit Hyperactivity Disorder(IV): Non-Pharmacologic Treatment

This practice parameter for non-pharmacological treatment for attention-deficit hyperactivity disorder(ADHD) review the domestic and international literature on the psychosocial treatment of children and adolescents with ADHD. This parameter include the parental training & education, cognitive behavior therapy(group or individual), social skill training, family therapy, play therapy(individual psychotherapy) and non-traditional therapy(art therapy, herbal therapy et al). Among them, there is some proven evidence only in parental training & education and cognitive behavior therapy. So, this parameter describes some details only in the field of parental training & education and cognitive behavior therapy. The efficacy or effectiveness, especially, cost-effectiveness of specific psychosocial treatment method for ADHD cannot be fairly assessed due to the scarcity of controlled clinical data. Based on the clinical expert consensus and limited evidence, we cautiously suggest the practice recommendations about the non-pharmacological psychosocial treatment for children and adolescents with ADHD.

The Korean Practice Parameter for the Treatment of Pervasive Developmental Disorders: Development and Implications

The new research data and rapid development of psychotropic drugs over the past few years have warranted the development of clinical practice guidelines for managing pervasive developmental disorder(PDD). These guidelines are urgently needed due to the recent changes in social circumstances and clinical situations in Korea. Despite the many limitations and problems surrounding the development of these guidelines, the Korean Academy of Child and Adolescent Psychiatry(KACAP) has decided to develop the Korean Practice Parameters for the Treatment of PDD. The goal, basic principles, organization, and implications of this development project are introduced in this special paper. We expect these practice parameters to be a useful reference not only for child psychiatrists and other healthcare professionals in clinical practice, but also for the autistic patients themselves and their caregivers. The practice parameters shall be revised and improved in the near future.

The Korean Practice Parameter for the Treatment of Pervasive Developmental Disorders: Clinical Manifestation, Epidemiology, Course, Causes, and Comorbidity

Pervasive developmental disorders are characterized by lifelong impairments in fundamental social and/or communication skills and by the presence of seemingly purposeless and repetitive behaviors, interests, or activities. A number of possible biological etiologies, including genetic, structural and functional brain abnormalities, have been identified in patients with pervasive developmental disorders. In addition, clinicians should take the possibility of comorbid psychiatric conditions into consideration when making the differential diagnosis of pervasive developmental disorders.

The Korean Practice Parameter for the Treatment of Pervasive Developmental Disorders: Diagnosis and Assessment

Multiple areas of development are affected in pervasive developmental disorders(PDD), and assessments of various aspects of behavior and development are essential for diagnosis. The object of this review is to provide the practical guidelines for the assessment of core features of PDD, including abnormalities in communication, social interaction, and repetitive and stereotyped behavior. It covers the issues of differential diagnosis within and outside the PDD category, standardized diagnostic tools, assessment of intellectual and language functions, and the early diagnosis of PDD in infancy. This guideline also stresses the process of medical and neurological evaluation for proper diagnosis of PDD.