Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.
The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
Routine prophylactic antibiotics do not improve clinically important outcomes in survivors of out-of-hospital cardiac arrest (April 2017)
Many survivors of out-of-hospital cardiac arrest (OHCA) go on to develop pneumonia, but the value of prophylactic antibiotics is unproven. In a single-center clinical trial involving 60 comatose OHCA patients without obvious evidence of tracheobronchial aspiration on admission, random assignment to prophylactic antibiotics versus clinically-driven antibiotic therapy reduced the number of positive broncho-alveolar lavage cultures on hospital day 3, but did not improve survival or other patient-important outcomes . We do not suggest routine prophylactic treatment with antibiotics in these patients. (See "Post-cardiac arrest management in adults", section on 'Antibiotic therapy and prophylaxis'.)
2016 sepsis guidelines (March 2017)
Updated sepsis guidelines were issued by the Surviving Sepsis Campaign/Society of Critical Care Medicine/European Society of Intensive Care Medicine . Major differences, compared with the 2012 iteration, include: the administration of intravenous antibiotics within one hour of presentation, with emphasis on source control and antibiotic stewardship; infusion of crystalloid solution at a rate at 30 mL/kg/hour within three hours for early fluid resuscitation; and movement away from previously recommended early goal-directed therapy targets (eg, central venous pressure) to use of dynamic predictors of fluid responsiveness, when feasible. Norepinephrine remains the vasopressor of first choice. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Hemodynamic'.)
The effect of tracheal intubation on in-patients with sudden cardiac arrest (February 2017)
The appropriate role for tracheal intubation during sudden cardiac arrest (SCA) remains a source of debate. In a large multicenter cohort study comparing outcomes between intubated patients and a propensity-matched group of non-intubated patients, all of whom sustained SCA while admitted to the hospital, intubated patients had lower rates of return of spontaneous circulation, survival, and survival with good functional outcome . This study provides additional evidence that tracheal intubation is best withheld until the return of spontaneous circulation following SCA, unless adequate ventilation cannot be maintained with bag-mask ventilation or a supraglottic airway. (See "Advanced cardiac life support (ACLS) in adults", section on 'Airway management while performing ACLS'.)
Emergency coronary catheterization following sudden cardiac arrest (February 2017)
Emergency coronary catheterization is indicated for patients who sustain sudden cardiac arrest (SCA) and manifest signs of an acute coronary syndrome (ACS), such as ST elevation on their electrocardiogram. However, whether coronary catheterization should be performed in SCA patients without such signs remains controversial. A meta-analysis of 11 heterogeneous, retrospective studies involving several thousand patients found that over 30 percent of post-arrest patients with no ST elevation had acute coronary artery occlusions regardless of their presenting rhythm . While randomized trials are needed to address this question, we believe it is reasonable to perform coronary catheterization in SCA patients without discrete signs of ACS, provided resources to do so are available. (See "Post-cardiac arrest management in adults", section on 'Coronary revascularization'.)
GENERAL ADULT EMERGENCY MEDICINE
Confirmatory data on idarucizumab for dabigatran reversal (July 2017)
Idarucizumab (pronounced "I-dare-you-cizumab") is a monoclonal antibody fragment against dabigatran that can reverse the anticoagulant effect within minutes. A preliminary report suggested good efficacy in patients with dabigatran-associated bleeding or those undergoing emergency surgery. In a new report of over 500 patients treated with idarucizumab, most had cessation of bleeding or underwent surgery without abnormal bleeding . We continue to suggest idarucizumab for clinically significant bleeding or truly emergent surgery in patients on dabigatran with a history or laboratory testing that suggest they are actively anticoagulated. (See "Management of bleeding in patients receiving direct oral anticoagulants", section on 'Dabigatran reversal'.)
Antibiotic therapy for skin abscess (July 2017)
Management of skin abscess consists of incision and drainage; the role of antibiotic therapy depends on individual clinical circumstances, including abscess size. In a randomized trial including more than 780 patients with skin abscess ≤5 cm (most were larger than 2 cm) who underwent incision and drainage, higher cure rates were observed among those who received antibiotic therapy with methicillin-resistant Staphylococcus aureus (MRSA) coverage (trimethoprim-sulfamethoxazole or clindamycin) than those who received placebo (82 or 83 percent versus 69 percent); MRSA was isolated in 49 percent of cases . These findings support our approach to management of patients with skin abscess, in which we suggest antibiotic therapy in addition to incision and drainage for patients with skin abscess ≥2 cm. (See "Cellulitis and skin abscess in adults: Treatment", section on 'Role of antibiotic therapy'.)
Delafloxacin for treatment of skin and soft tissue infections (July 2017)
Delafloxacin, a fluoroquinolone, has been approved by the US Food and Drug Administration for treatment of bacterial skin and soft tissue infections. It has activity against staphylococci (including methicillin-resistant strains), gram-negative bacteria (including Pseudomonas aeruginosa and Enterobacteriaceae), and some anaerobes (including Clostridium difficile) but does not have activity against enterococci. In two phase III clinical trials, the drug was statistically noninferior to the combination of vancomycin and aztreonam at the endpoint of early clinical response at 48 to 72 hours [7,8]. Given limited clinical experience with delafloxacin, at this time its use should be reserved for patients who do not respond to or do not tolerate first-line antimicrobial agents. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Treatment of skin and soft tissue infections", section on 'Delafloxacin'.)
Countering the high cost of epinephrine autoinjectors (June 2017)
Physicians and patients in the United States have been struggling with the high cost of epinephrine autoinjectors, and alternatives, as well as ways to maximize the utility of expensive devices, have begun to appear:
●A prefilled syringe (Symjepi) containing 0.3 mg epinephrine per dose was approved by the US Food and Drug Administration (FDA) in June 2017 and should offer a more affordable alternative to autoinjectors . It will be available in upcoming months in just one dose, labeled for use in patients weighing ≥30 kg (66 lbs). (See "Prescribing epinephrine for anaphylaxis self-treatment", section on 'Prefilled syringes'.)
●A study of 31 expired autoinjectors (EpiPens) found that devices as much as four years past the expiration date still contained 84 to 88 percent of the intended epinephrine dose . Thus, patients should understand that expired devices retain most of their potency and that if anaphylaxis develops, using an outdated device is preferable to not injecting epinephrine at all. (See "Prescribing epinephrine for anaphylaxis self-treatment", section on 'Use of expired autoinjectors'.)
YEARS algorithm for the diagnosis of pulmonary embolism (June 2017)
Algorithms that integrate pretest probability (PTP) assessment using Wells criteria with a fixed cutoff level for D-dimer (<500 ng/mL) are typically used to target which patients with suspected pulmonary embolism (PE) should undergo computed tomography pulmonary angiography (CTPA). Compared with this typical approach, an alternative strategy using the YEARS items (clinical signs of deep venous thrombosis, hemoptysis, and PE as the most likely diagnosis) together with varying cutoff levels of D-dimer resulted in a 14 percent reduction in the number of CTPA scans performed, without increasing the risk of PE during a three-month follow-up . While encouraging, this algorithm requires further validation before it is routinely used in practice. (See "Clinical presentation, evaluation, and diagnosis of the nonpregnant adult with suspected acute pulmonary embolism", section on 'D-dimer'.)
Treatment of nonpurulent cellulitis (June 2017)
Empiric antibiotic therapy for nonpurulent cellulitis (ie, with no purulent drainage and no associated abscess) should be active against beta-hemolytic streptococci and methicillin-susceptible Staphylococcus aureus (MSSA) but not necessarily methicillin-resistant S. aureus (MRSA). This approach is supported by a randomized trial of nearly 500 patients with nonpurulent cellulitis, in which cephalexin plus placebo (active against beta-hemolytic streptococci and MSSA) and cephalexin plus trimethoprim-sulfamethoxazole (TMP-SMX, which adds activity against MRSA) resulted in statistically similar clinical cure rates (69 versus 76 percent) . Although there was a trend toward higher cure rates with the addition of TMP-SMX, the results were likely skewed by a relatively large number of patients who did not complete the full course of therapy. (See "Cellulitis and skin abscess in adults: Treatment", section on 'Cellulitis'.)
Time to treatment and mortality in sepsis (May 2017)
Timely administration of fluids and antibiotics is the cornerstone of therapy for patients with sepsis and septic shock. A recent database study of patients with sepsis reported increased mortality in association with the delayed administration of antibiotics (greater than three hours) but not with a longer time to completion of a fluid bolus (greater than six hours) . This study further validates international guideline recommendations that antibiotics be administered within the first three hours, and preferably within the first hour after presentation in patients with sepsis and septic shock. We also continue to recommend infusion of intravenous fluids within the first three hours of presentation. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Initial resuscitative therapy'.)
Glucocorticoids not necessary for simple acute urticaria (May 2017)
Although patients with urticaria and symptoms involving other organ systems are treated with epinephrine given the likelihood of anaphylaxis, H1 antihistamines are the initial treatment for those with isolated urticaria. For such patients, the additive benefit of glucocorticoids is not well defined. In a randomized trial of 100 adults presenting to the emergency department with isolated urticaria (without angioedema, anaphylaxis, or fever) of ≤24 hours duration, patients received the H1 antihistamine levocetirizine plus either prednisone or placebo for four days . There was no significant difference in the rate of symptom resolution, and most patients were symptom-free within two days. This study supports our suggestion to reserve glucocorticoids for those patients with new urticaria who have prominent angioedema or whose symptoms persist despite antihistamines. (See "New-onset urticaria", section on 'Glucocorticoids'.)
Differences in anaphylaxis treatment by age (February 2017)
Epinephrine given by intramuscular (IM) injection is the treatment of choice for anaphylaxis, but clinicians are sometimes reluctant to administer it, particularly to older adults. In a retrospective study of nearly 500 children and adults with anaphylaxis presenting to the emergency department, patients >50 years of age were less likely to receive epinephrine (36 versus 61 percent) compared with younger patients . In addition, among patients who were given epinephrine, older adults were more likely to receive excessive doses when epinephrine was administered intravenously (IV). IM epinephrine was well-tolerated by patients of all ages, while IV administration was associated with a higher rate of cardiovascular complications. These findings support our recommendations to administer epinephrine by IM injection whenever possible and reserve IV administration for refractory cases. (See "Anaphylaxis: Emergency treatment", section on 'Situations requiring caution'.)
Treatment of acute diverticulitis without antibiotics (February 2017)
Acute diverticulitis is typically treated with antibiotics. However, in a Dutch trial (DIABOLO) that randomly assigned over 500 low-risk patients with first-episode, acute, uncomplicated diverticulitis confirmed with computed tomography to either observation or antibiotic therapy, outcomes were similar for both groups . Because almost all of the patients were admitted to the hospital for one or more days, this trial did not establish the safety of avoiding antibiotic therapy in low-risk outpatients. Thus, until further data become available, UpToDate continues to recommend antibiotic treatment of acute diverticulitis in patients meeting criteria for outpatient management. (See "Acute colonic diverticulitis: Medical management", section on 'Outpatient treatment' and "Acute colonic diverticulitis: Medical management".)
Rapidly progressive acute chest syndrome in sickle cell disease (February 2017)
Acute chest syndrome (ACS) in individuals with sickle cell disease (SCD) encompasses a variety of clinical presentations and severities. A distinct phenotype of ACS has been characterized, referred to as rapidly progressive ACS, in which respiratory failure occurs within 24 hours of initial respiratory symptoms . In a cohort of 97 children and 76 adults with SCD and at least one prior ACS episode, rapidly progressive ACS occurred more commonly in adults than children (21 versus 2 percent). Adults with rapidly progressive ACS were more likely to have multiorgan failure compared with adults without this phenotype. The only laboratory predictor of rapidly progressive ACS was a decline in platelet count on presentation. (See "Evaluation of acute pain in sickle cell disease", section on 'Acute systemic illness, diffuse pain, or both'.)
The qSOFA prediction score and in-hospital mortality (January 2017)
Two recent studies have evaluated the quick sepsis-related organ failure assessment score (qSOFA) as a simple bedside tool to facilitate early identification of patients at risk of dying from sepsis [18,19]. In one study of patients presenting to the emergency department with suspected infection, the predictive validity of qSOFA for in-hospital mortality was similar to that of the full SOFA score . In contrast, qSOFA was inferior to SOFA in a retrospective analysis of intensive care unit (ICU) patients with an infection-related diagnosis . We believe that qSOFA is a valuable bedside tool in predicting death from sepsis outside the ICU. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Identification of early sepsis (qSOFA)'.)
No benefit of hypothermia in convulsive status epilepticus (January 2017)
Convulsive status epilepticus is prolonged and refractory to standard first-line medications in approximately one-third of patients, and outcomes associated with refractory status epilepticus are often poor. Induced hypothermia has been proposed as a potential neuroprotective strategy. However, in a randomized trial of 250 critically ill adults with convulsive status epilepticus, induced hypothermia did not improve 90-day mortality, functional outcomes, or rate of progression to refractory status epilepticus when added to standard first-line therapies . (See "Convulsive status epilepticus in adults: Treatment and prognosis", section on 'Others'.)
GENERAL PEDIATRIC EMERGENCY MEDICINE
Delay of appendectomy up to 24 hours not related to appendiceal perforation in children with appendicitis (June 2017)
In the past, appendicitis has been considered a surgical emergency that requires prompt appendectomy to avoid perforation and other complications. In a multicenter, prospective observational study of 955 children 3 to 18 years of age, all of whom were treated with appendectomy for appendicitis within 24 hours of arrival to the emergency department, duration of time between initial evaluation and operation was not associated with an increase in appendiceal perforation . This study adds to a growing body of evidence that suggests that adverse outcomes are not increased for children who receive timely administration of antibiotics and undergo appendectomy less than 24 hours after diagnosis. (See "Acute appendicitis in children: Management", section on 'Timing of operation'.)
Safety and efficacy of nonoperative treatment of pediatric appendicitis (March 2017)
In a systematic review of 10 studies that provided outcomes for over 400 children undergoing nonoperative treatment (NOT, antibiotics without immediate surgery) of early, uncomplicated appendicitis, initial treatment was effective in 88 to 99 percent of patients and was associated with no appendectomy at reported follow-up in 62 to 92 percent of patients . Complications and total length of hospital stay appeared similar during follow-up for NOT and appendectomy. Pooled estimates were performed by the investigators but, given the underlying variation in methodology of the included studies, may be misleading, particularly given subsequent evidence suggesting that patient selection strongly influences outcomes of NOT for appendicitis [23-25]. Although appendectomy remains the treatment of choice for most children with early, uncomplicated appendicitis, NOT is an alternative for selected patients based upon caregiver preference. Additional research is needed to determine which patients are least likely to fail nonoperative treatment. (See "Acute appendicitis in children: Management", section on 'Nonoperative management'.)
Early initiation of heated humidified high-flow nasal cannula therapy in children with bronchiolitis (February 2017)
In an open randomized trial comparing heated humidified high-flow nasal cannula (HFNC) with standard low-flow oxygen therapy in 200 children with moderately severe bronchiolitis, early initiation of HFNC did not shorten the median duration of oxygen therapy (approximately 22 hours in both groups) . However, HFNC was associated with avoidance of intensive care unit admission when it was used as a rescue therapy for clinical deterioration in children treated with standard therapy. No serious adverse effects occurred. These findings provide additional support for HFNC as a rescue therapy in children with bronchiolitis, although the efficacy of this approach remains unproven. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention", section on 'HFNC and CPAP'.)
Risk of recurrence in anaphylaxis in children (January 2017)
Individuals who experience an initial episode of anaphylaxis are at risk for subsequent episodes. In the first prospective study to assess the risk of recurrent anaphylaxis, nearly 300 children treated for anaphylaxis (mostly food-induced) in the emergency department were followed for one year, during which 18 percent suffered another episode . Concomitant asthma and treatment of the initial episode with epinephrine were associated with an increased risk of recurrence. These results highlight the importance of prompt intervention (equipping patients/caregivers with epinephrine autoinjectors and referring to an allergist) after the initial episode. (See "Anaphylaxis: Emergency treatment", section on 'Risk of recurrence'.)
Duration of treatment for acute otitis media in children younger than two years (January 2017)
Methodologic limitations in previous studies evaluating duration of treatment for acute otitis media (AOM) in young children were addressed in a trial that randomly assigned more than 500 infants and young children (age 6 through 23 months) with strictly defined AOM to treatment with amoxicillin-clavulanate for 10 days or 5 days; those assigned to 5 day treatment received an additional 5 days of placebo . The 10-day group had lower rates of clinical failure (16 versus 34 percent) without more adverse events. These findings support a standard 10-day course of antimicrobial therapy for AOM in children <2 years. (See "Acute otitis media in children: Treatment", section on 'Duration of therapy'.)
Ultrasound to improve the success rate of lumbar puncture in young infants (February 2017)
Ultrasound has been proposed as a means to increase the success rate of lumbar puncture (LP) in infants. In a small, unblinded trial of 43 young infants undergoing LP in the emergency department, ultrasound-assisted LP was associated with a significantly higher rate of success compared with the landmark technique . We suggest that when equipment and properly trained providers are available, ultrasound guidance be used to identify the best site and safest depth for LP in young infants. (See "Lumbar puncture: Indications, contraindications, technique, and complications in children", section on 'Ultrasound guidance'.)
Medical use of prescription opioid medications and misuse in adolescents (May 2017)
Surveys of high school seniors in the United States over 40 years show that the use of prescription opioids is strongly correlated with misuse in adolescents and that misuse typically follows medical use by the patient . Thus, health care providers should follow safe prescribing guidance for prescription opioids, including use of alternatives (eg, acetaminophen or ibuprofen) to control pain whenever possible, using the lowest effective dose and minimum quantity of prescription opioid medications when they are needed, and utilizing prescription drug monitoring programs, where available, to identify patients or caregivers who might be misusing (ie, abusing or diverting) prescription opioid medications. (See "Opioid intoxication in children and adolescents", section on 'Safe prescribing'.)
Safe storage of prescription opioids (May 2017)
Although safe storage of prescription opioid medications (eg, locked cabinet) is recommended, it infrequently occurs. In a United States nationally representative survey of over 1000 adults with prescription opioid use in the past 12 months, only 9 percent reported safe storage of their medications . In further analysis of those adults with children younger than 18 years of age in the household, safe storage was reported in less than one-third of households with young children and 12 percent of households with children older than six years of age . These results support the need for anticipatory guidance by health care providers, emphasizing opioid safe storage and how it may limit opioid misuse and overdose, especially in households with children and adolescents. Further research should focus on developing and implementing effective means of secure storage in households. (See "Opioid intoxication in children and adolescents", section on 'Safe storage'.)
Persistence of neurotoxicity of childhood lead poisoning into adulthood (May 2017)
Detectable blood lead levels (BLLs) are associated with irreversible neurocognitive deficits in children and a BLL lower limit for this toxicity has not been established. Previous studies had shown that this effect persists into adolescence. In a longitudinal cohort study of over 1000 patients, lead exposure, based upon BLLs obtained at 11 years of age, was associated in a dose-dependent fashion with lower intelligence quotient (IQ) and lower socioeconomic status at age 38 years after adjustment for maternal IQ, child IQ, and childhood socioeconomic status . Thus, childhood lead exposure causes neurotoxicity that persists into adulthood. Primary prevention of lead exposure, including in pregnant women, can prevent these effects. (See "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Neurologic'.)
Immunoassay for acetaminophen-induced liver injury (May 2017)
Establishing the diagnosis of acetaminophen (APAP) poisoning in patients who present greater than 24 hours to several days after ingestion, when a serum APAP level may no longer be detectable, can be difficult. However, a recent observational cohort study found excellent performance for a rapid immunoassay that measures serum APAP-protein adducts in identifying patients with APAP-induced acute liver injury (ALI) . In this study, a point of care immunoassay (AcetaSTAT) had 100 percent sensitivity and 100 percent negative predictive value, compared with results of high performance liquid chromatography as a reference standard, for identifying patients with such injury. If these results are validated in future clinical trials, this assay may provide a rapid means to distinguish APAP-induced ALI from other causes, and to begin appropriate management quickly. (See "Acetaminophen (paracetamol) poisoning in adults: Pathophysiology, presentation, and diagnosis", section on 'Evaluation following delayed presentation'.)
Mass intoxication with unusual clinical effects after exposure to a unique synthetic cannabinoid (January 2017)
Based upon reports to regional poison control centers, the most common effects after inhalation or insufflation of synthetic cannabinoids include vomiting, tachycardia, and agitation. However, mass exposure of 33 adults to burning incense containing methyl 2-(1-(4-fluorobenzyl)-1H-indazole-3-carboxamido)-3-methylbutanoate (AMB-FUBINACA, street name AK-47 24 Karat Gold) caused intoxication characterized by lethargy, blank staring, “zombie-like” groaning, and slow mechanical movements of the arms and legs . This report emphasizes that synthetic cannabinoids have a wide spectrum of clinical effects that vary according to the compound used. Furthermore, this is the first report of mass intoxication caused by burning of adulterated incense. (See "Synthetic cannabinoids: Acute intoxication", section on 'Clinical manifestations'.)
Focused Assessment with Sonography for Trauma (FAST) does not change outcomes in hemodynamically stable children with blunt torso trauma (June 2017)
Focused Assessment with Sonography for Trauma (FAST) is routinely used to rapidly identify pericardial effusion or intraabdominal hemorrhage in hemodynamically unstable pediatric patients with blunt trauma. Its utility in hemodynamically stable children after trauma is less clear. In an unblinded, randomized trial of 925 hemodynamically stable children evaluated for blunt torso trauma, FAST combined with standard emergency assessment, compared with standard care alone, did not lower missed intraabdominal injury (IAI) rates, frequency of abdominal computed tomography (CT), mean emergency department length of stay, or hospital charges . Negative results on ultrasonography did lower the managing physician's clinical suspicion for IAI but did not decrease the use of abdominal CT. Thus, routine use of FAST in stable trauma patients does not appear to alter important clinical outcomes.(See "Trauma management: Approach to the unstable child", section on 'FAST (Focused Assessment with Sonography for Trauma)' and "Approach to the initially stable child with blunt or penetrating injury", section on 'Abdominal trauma'.)
CT to rule out cervical spine injury following blunt trauma (February 2017)
Although patients who have sustained major trauma or are at high risk for cervical spinal column injury routinely undergo computed tomography (CT) scan of the entire cervical spine, the appropriate role for CT in patients with less severe trauma who cannot be cleared clinically of cervical spine injury and require imaging remains unclear. In a prospective, multicenter observational study involving over 10,000 patients with blunt trauma who did not meet the NEXUS criteria for clinical clearance of the cervical spine, CT was found to be highly sensitive and specific for clinically significant injury of the cervical spine . Of the three false negative CT studies, all involved patients with focal neurologic findings identified during their initial examination that were consistent with central cord syndrome. CT is an accurate and useful method for assessing patients at risk for cervical spine injury following less severe trauma, particularly if plain radiographs are expected to be difficult to interpret. (See "Evaluation and acute management of cervical spinal column injuries in adults", section on 'CT for cervical spinal column injury'.)
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