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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'.)
Determining the futility of resuscitation following cardiac arrest (December 2016)
Based on data from almost 7000 out-of-hospital cardiac arrest patients from two large registries (Paris, France and King County, Washington State) and a major multicenter randomized trial, researchers identified three criteria (arrest not witnessed by emergency medical services personnel, non-shockable initial cardiac rhythm, and no return of spontaneous circulation prior to administration of third 1 mg dose of epinephrine) that, if all criteria were met, had a specificity and positive predictive value of essentially 100 percent for death prior to hospital discharge . Of the 2800 patients evaluated who met all three criteria, only one survived. Early identification of patients with no chance for survival may be helpful in family decisions about organ donation. (See "Advanced cardiac life support (ACLS) in adults", section on 'Termination of resuscitative efforts'.)
Iloprost therapy for severe frostbite (December 2016)
For years, no effective therapy was available to prevent tissue necrosis and subsequent amputation in patients with severe frostbite, but an increasing body of evidence suggests that treatment with iloprost, a prostacyclin analog (IV formulation not available in the United States) can prevent such injury in appropriately selected patients. According to one open-label randomized trial , a growing number of case reports , and revised management recommendations from wilderness medicine experts , treatment with iloprost is effective and safe. We suggest treatment with iloprost (where available), with or without tPA, for patients with severe frostbite (Grade 2-4) if given within 48 hours of the initial insult. (See "Frostbite", section on 'Prostacyclin therapy for severe injury presenting within 48 hours'.)
GENERAL ADULT EMERGENCY MEDICINE
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 [13,14]. 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
Safety and efficacy of nonoperative treatment of pediatric appendicitis (March 2017)
In a meta-analysis of 10 studies that provided outcomes for over 400 children undergoing nonoperative treatment (antibiotics without immediate surgery) of early, uncomplicated appendicitis, initial treatment was effective in 97 percent of patients and was associated with no appendectomy at reported follow-up in 82 percent of patients . Complications and total length of hospital stay appeared similar during follow-up for nonoperative treatment and appendectomy. Although appendectomy remains the treatment of choice for most children with early, uncomplicated appendicitis, nonoperative management is an alternative option in selected patients based upon caregiver preference. Additional studies are 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'.)
FDA issues warning about anesthesia for pregnant patients and children under three years of age (December 2016)
The US Food and Drug Administration has warned about potential negative effects on the developing brain from administration of anesthetics and sedatives to pregnant women and children under age three, especially for repeated exposures or procedures lasting more than three hours . However, the degree of risk remains unclear. A single, brief exposure to anesthesia probably does not cause neurotoxicity in healthy young children. Further study is required to determine the effects of prolonged or repeated anesthetics, variability among anesthetic agents and combinations of drugs, and patient factors that may confer vulnerability to anesthetic neurotoxicity. At present, there is no compelling evidence that any specific anesthetic agent should be avoided during pregnancy or in young children, or that necessary surgery should be delayed because of concerns about neurotoxicity. (See "Management of the pregnant patient undergoing nonobstetric surgery", section on 'Fetal brain development'.)
Tracheal intubation and survival following in-hospital pediatric cardiac arrest (November 2016)
In a retrospective observational study of over 2200 United States children younger than 18 years of age with in-hospital cardiac arrest reported to a centralized registry from 2000 to 2014, tracheal intubation during cardiac arrest was associated with a significantly lower adjusted survival to hospital discharge compared with a propensity-matched cohort of patients who were not intubated (36 versus 41 percent, respectively) . There was no significant difference in return of spontaneous circulation or favorable neurologic outcome between the groups. Although confounding cannot be fully excluded given the study design, this evidence suggests that the emphasis on early tracheal intubation during pediatric in-hospital cardiac arrest warrants re-examination and further study. (See "Pediatric basic life support for health care providers", section on 'Epidemiology and survival'.)
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'.)
Ketofol versus propofol for procedural sedation (December 2016)
Ketofol, a combination of ketamine and propofol, is purported to provide good conditions while reducing harmful side effects during procedural sedation and analgesia (PSA) performed outside the operating room, but studies to date have failed to identify clinically significant differences between ketofol and propofol alone. These findings were confirmed in a randomized, multicenter trial involving over 500 patients receiving PSA that reported no significant differences in the rate of adverse respiratory events (oxygen desaturation, apnea, or hypoventilation) between those managed with ketofol or propofol . While multiple studies confirm that ketofol is safe and effective, there is no convincing evidence that it improves clinically significant outcomes or reduces important (albeit rare) complications during PSA compared with propofol. (See "Procedural sedation in adults outside the operating room", section on 'Ketamine and propofol (ketofol)'.)
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'.)
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'.)
Early physical activity following acute concussion in children and adolescents (January 2017)
Although physical rest is routinely recommended after concussion, there are few data to determine whether avoidance of physical activity hastens recovery. In a prospective, multicenter cohort study of over 2400 children who were diagnosed with an acute concussion during an emergency department visit, early physical activity (within seven days of injury) compared with physical rest was associated with a significantly reduced risk of persistent postconcussive symptoms (PPCS) at 28 days . However, the difference in PPCS may be the result of confounding, and clinical trials are needed to confirm this result. We suggest that children and adolescents with concussions adhere to full physical rest until they have no symptoms of concussion (table 1) and normal balance or return to baseline on standardized testing. In the minority of patients with prolonged symptoms beyond seven days after injury, we introduce light, subsymptom threshold aerobic exercise (eg, light stationary bicycling), which can often be tolerated and may improve symptoms. (See "Concussion in children and adolescents: Management", section on 'Physical rest'.)
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