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What's new in family medicine
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What's new in family medicine
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2016. | This topic last updated: May 24, 2016.

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.

ADULT GENERAL INTERNAL MEDICINE

Clinical practice guideline for chronic insomnia in adults (May 2016)

The American College of Physicians has released a new clinical practice guideline for the management of chronic insomnia in adults [1]. The guideline recommends that all patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder. The guideline suggests that clinicians use a shared decision-making approach, including discussion of benefits, harms, and costs of short-term use of medications, to decide whether to add medication to CBT-I in patients with persistent symptoms. This approach is consistent with our preference for behavioral therapy over medication in most patients with chronic insomnia, particularly in older adults and patients with organ dysfunction, who are at increased risk for side effects from sedative-hypnotic drugs. (See "Treatment of insomnia", section on 'General approach'.)

Updated guidelines for the treatment of venous thromboembolism (March 2016)

The American College of Chest Physicians (ACCP) has published new guidelines on antithrombotic therapy for venous thromboembolic (VTE) disease that include guidance on choice of anticoagulant, indications for extended anticoagulation, and indications for thrombolytic therapy in patients with acute pulmonary embolism (PE) [2]. In addition to a preference for direct oral anticoagulants for the treatment of VTE, the ACCP suggests extending anticoagulation beyond three months (ie, no scheduled stop date) in patients with unprovoked VTE or active cancer. For most patients with small subsegmental pulmonary embolism (SSPE), anticoagulation is suggested; however, clinical surveillance with lower extremity Doppler ultrasound may be appropriate for select patients with a low burden of SSPE who have no evidence of thrombus elsewhere and in whom the risk of recurrence is low. The guidelines suggest administration of systemic thrombolytic therapy, rather than catheter-directed thrombolysis (CDT), for patients with hemodynamically-significant PE; CDT may be appropriate for those who fail systemic thrombolysis or who are at high risk of bleeding. (See "Fibrinolytic (thrombolytic) therapy in acute pulmonary embolism and lower extremity deep vein thrombosis", section on 'Indications' and "Venous thromboembolism: Anticoagulation after initial management", section on 'Selection of agent' and "Rationale and indications for indefinite anticoagulation in patients with venous thromboembolism", section on 'Patients likely to benefit' and "Overview of the treatment, prognosis, and follow-up of acute pulmonary embolism in adults", section on 'Patients with subsegmental PE'.)

Agent selection for anticoagulation in venous thromboembolism (March 2016)

Guidelines for the treatment of acute venous thromboembolism (VTE) were issued by The American College of Chest Physicians (ACCP) [2]. Compared with earlier versions of the guidelines, the direct oral anticoagulants (DOACs) apixaban, edoxaban, rivaroxaban, or dabigatran are now the preferred agents for long-term anticoagulation in patients who are not pregnant and do not have active cancer or severe renal insufficiency. This preference was based upon randomized trials that consistently reported similar efficacy, a lower bleeding risk, and improved convenience when compared with warfarin. We agree with this preference for DOACs in patients with acute VTE, understanding that choosing among anticoagulants frequently depends upon availability and cost as well as patient comorbidities and preferences. (See "Venous thromboembolism: Anticoagulation after initial management", section on 'Selection of agent'.)

Systemic exertion intolerance disease and association with suicide (March 2016)

The short-term prognosis for recovery of function is generally poor in systemic exertion intolerance disease (SEID), also known as chronic fatigue syndrome (CFS). The long-term prognosis may be better, although studies have been conflicting. SEID/CFS has not been associated with an increased risk of all-cause mortality but may be associated with an increased risk for suicide [3]. (See "Treatment of systemic exertion intolerance disease (chronic fatigue syndrome)", section on 'Prognosis'.)

Acupuncture ineffective for menopausal hot flashes (January 2016)

It is estimated that up to 75 percent of postmenopausal women use complementary therapies to treat their menopausal symptoms, despite little evidence of efficacy. Acupuncture is among the most frequently used, but results from clinical trials have been conflicting. The best evidence to date that acupuncture is no more effective than placebo (sham-acupuncture) comes from a trial in 327 peri- or postmenopausal women with moderate to severe hot flashes who were randomly assigned to 10 traditional Chinese acupuncture or noninsertive sham acupuncture treatments over eight weeks [4]. Hot flash (HF) scores, a calculated score based upon HF frequency and severity, were no different between the groups at the end of treatment (both showed approximately 40 percent improvement). Thus, like other nonhormonal and complementary therapies for hot flashes, acupuncture has an important placebo effect, but it has no additional benefit over sham acupuncture. (See "Menopausal hot flashes", section on 'Inconsistent evidence of efficacy'.)

Conception after miscarriage (January 2016)

Although data support the benefits of delaying conception after a live birth, it is not clear if such a delay benefits women after miscarriage. In a study of nearly 1100 women who had a miscarriage at less than 20 weeks of gestation, women who attempted conception within 0 to 3 months of the loss were more likely to achieve a live birth, had a faster time to pregnancy that resulted in a live birth, and had similar pregnancy complications compared with women who waited greater than 3 months to try to conceive [5]. We advise women who have completed a miscarriage that they may attempt conception as soon as they are psychologically ready. (See "Spontaneous abortion: Management", section on 'Interval to conception'.)

Normal-weight central obesity and mortality (December 2015)

Overall obesity, as defined by body mass index (BMI), has been thought to play the major role in the obesity-associated excess risk of cardiovascular morbidity and mortality, with abdominal or central obesity (as defined by an increased waist-to-hip ratio [WHR]) playing an independent but lesser role. However, data from the Third National Health and Nutrition Examination Survey suggest that normal-weight central obesity (normal BMI with increased WHR) is associated with higher mortality than BMI-defined obesity, particularly when compared with individuals without central obesity [6]. In a cross-sectional survey of over 15,000 individuals, men with a normal BMI but central obesity (WHR ≥0.90) had the highest total mortality risk when compared with men without central obesity who were normal weight, overweight, or obese (hazard ratio [HR] 1.87, 2.24, 2.42, respectively). A similar pattern was seen in normal weight women with central obesity, but the excess risk was not as great. A limitation of the study is that central obesity was determined by WHR only; no quantitative imaging studies of adipose tissue were performed. These data suggest that normal weight individuals with central obesity appear to have an increased mortality risk, and should be targeted for lifestyle modification strategies. (See "Obesity in adults: Health hazards", section on 'Normal weight central obesity'.)

GERIATRICS

Proton pump inhibitors and risk of dementia in older adults (February 2016)

A new study has identified a possible link between proton pump inhibitors (PPIs) and risk of dementia in older adults. In a prospective cohort study of >73,000 adults aged 75 years and older who were free of dementia at baseline, regular use of a PPI was associated with a 1.4-fold increase in the risk of incident dementia, independent of age, gender, depression, stroke, heart disease, and polypharmacy [7]. Possible factors that could contribute to this finding include PPI-induced vitamin B12 deficiency or an interaction between PPIs and amyloid beta deposition, although these factors were not examined in this study. On the other hand, the association may reflect residual confounding by factors related to both use of PPIs and the development of dementia, and more studies are needed to confirm or refute this association. (See "Epidemiology, pathology, and pathogenesis of Alzheimer disease", section on 'Medications'.)

2015 revised Beers criteria for potentially inappropriate medication use in older adults (November 2015)

The 2015 revised Beers criteria for potentially inappropriate medication use in older adults are available through the American Geriatrics Society website. The criteria include over 50 medications designated in one of three categories: those that should always be avoided (eg, barbiturates, chlorpropamide); those that are potentially inappropriate in older adults with particular health conditions or syndromes; and those that should be used with caution. New additions since 2012 are a table of non-anti-infective drug interactions and a table of non-anti-infective medications to avoid or adjust for decreased renal function [8]. Other notable changes in the 2015 listings are removal of loratadine from the list of medications with strong anticholinergic properties; a more liberal renal threshold for withholding nitrofurantoin (now creatinine clearance <30 rather than <60 mL/min); avoidance of long-term proton pump inhibitors because of risk of C. difficile infections and bone loss; and stricter guidelines to avoid antipsychotics for behavioral problems unless other options have failed and the older adult is threatening harm to self or others. (See "Drug prescribing for older adults", section on 'Beers criteria'.)

PREVENTION

Fruit and vegetable consumption and cardiovascular outcomes in China (April 2016)

Studies suggest that fruit and vegetable consumption is associated with a lower risk of coronary heart disease and stroke, but most of these studies had been conducted in Western Caucasian populations. A prospective cohort study of over 450,000 adults aged 30 to 79 years in China found that compared with little or no fresh fruit consumption, those who ate fresh fruit daily had decreased risk for cardiovascular death (hazard ratio [HR] 0.6), major coronary events (HR 0.66), ischemic stroke (HR 0.75), and hemorrhage stroke (HR 0.64) [9]. There was a dose-response relationship between each outcome and the amount of fresh fruit consumed. Additionally, fresh fruit consumption was associated with decreased blood pressure and blood glucose levels. (See "Healthy diet in adults", section on 'Cardiovascular disease'.)

High-dose vitamin D may increase risk of falls (February 2016)

Evidence conflicts on the effectiveness of vitamin D for fall prevention in older adults, with emerging evidence that high-dose vitamin D administered monthly may increase fall risk. A randomized trial compared monthly high-dose vitamin D (60,000 international units of vitamin D3 in one group; 24,000 international units vitamin D3 plus 300 microg calcifediol in another) with a lower dose (24,000 units vitamin D3) in community-dwelling men and women age 70 and older who had a history of a prior fall [10]. Lower extremity function at 12 months did not differ among the groups, but there was a higher incidence of falls and mean number of falls in both groups that received high-dose vitamin D. Of note, there was no placebo group in this trial. (See "Falls: Prevention in community-dwelling older persons", section on 'Vitamin D supplementation' and "Vitamin D and extraskeletal health", section on 'Muscle function'.)

2015 US Dietary Guidelines (January 2016)

The 2015 US Dietary Guidelines for Americans have been released [11]. The new guidelines emphasize following a healthy eating pattern across the lifespan. Compared with the 2010 guidelines, the 2015 guidelines no longer restrict total cholesterol to 300 mg a day and recommend that <10 percent of calories should come from added sugars. (See "Healthy diet in adults", section on 'Carbohydrate' and "Dietary fat", section on 'Guidelines'.)  

SCREENING

Blood test for colorectal cancer screening (April 2016)

In 2016, the US Food and Drug Administration (FDA) approved a second-generation serum assay for the detection of circulating methylated Septin 9 (Epi proColon 2.0) for colorectal cancer screening [12]. This test detects Septin 9 DNA, which is hypermethylated in colorectal cancer but not in normal colon tissue. The test is intended for average-risk patients who refuse screening by guideline-recommended methods (eg, colonoscopy, sigmoidoscopy, fecal occult blood, or fecal DNA testing). A positive serum test should be followed up with a colonoscopy. However, there is no strong evidence of the effectiveness of screening for colorectal cancer with available serum markers. Until further evidence is available, we do not recommend serum tests for colorectal cancer screening. (See "Tests for screening for colorectal cancer: Stool tests, radiologic imaging and endoscopy", section on 'Serum markers'.)

Screening for ovarian cancer in average risk women (March 2016)

The UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) is the largest randomized trial evaluating the use of serum testing for CA 125 and transvaginal ultrasound (TVUS) for ovarian cancer screening in average risk women [13]. The trial compared three arms: no screening; screening with annual transvaginal ultrasound; and multimodal screening (MMS, consisting of annual CA 125 testing, followed by TVUS if the CA 125 was abnormal, using an algorithmic guideline). After a median of 11 years, cancers were detected in 0.7 percent of women in the MMS group and 0.6 percent of women in the control and TVUS-only groups. Compared with no screening, MMS detected cancer at an earlier stage and the primary analysis showed a nonsignificant trend toward a 15 percent reduction (95% CI -3 to 30) in mortality from ovarian cancer for MMS. When prevalent ovarian cancer cases were excluded, the mortality reduction with MMS was significant. The results of the UKCTOCS trial are not consistent with results from another randomized trial that did not show decreased mortality with MMS. Based on the available data, it is not clear that the benefits of screening for ovarian cancer outweigh the harms related to the adverse effects associated with false positive findings. UpToDate suggests not screening average risk women for ovarian cancer. (See "Screening for ovarian cancer", section on 'Multimodal screening'.)

2016 ACOG guidelines for cervical cancer screening (January 2016)

The 2016 American College of Obstetricians and Gynecologists (ACOG) guidelines for cervical cancer screening have been released [14]. ACOG continues to recommend screening for cervical cancer beginning at age 21 with cervical cytology, and co-testing (cervical cytology plus human papillomavirus [HPV] testing) for women age 30 and older. However, in agreement with the 2015 American Society for Colposcopy and Cervical Pathology guidelines, ACOG now also considers primary HPV testing as an option for screening in women age 25 years and older. Because HPV tests may be transiently positive in many younger women, UpToDate authors suggest that women age <30 years be screened with cervical cytology (Pap smear). (See "Screening for cervical cancer", section on 'Primary HPV testing'.)

Screening for diabetes mellitus (January 2016)

Although it has not been firmly established that screening for type 2 diabetes improves long-term outcomes, well-established treatments for diabetes can reduce progression to microvascular disease and early identification of diabetes allows interventions to prevent or limit cardiovascular disease. The US Preventive Services Task Force (USPSTF) has issued new recommendations for diabetes screening. Previously, the USPSTF only recommended screening for diabetes in adults with hypertension, but the new guideline recommends screening for diabetes as part of cardiovascular risk assessment in adults aged 40 to 70 years with body mass index (BMI) ≥25 kg/m2 [15]. The USPSTF suggests screening every three years based on limited evidence. We agree with the new USPSTF guideline and also suggest diabetes screening for adults with hypertension or hyperlipidemia. A fasting plasma glucose (FPG) and/or a glycated hemoglobin (A1C) are the preferred screening tests. (See "Screening for type 2 diabetes mellitus", section on 'A suggested approach'.)

ADULT CARDIOVASCULAR MEDICINE

Beta blocker therapy in patients with atrial fibrillation and heart failure (April 2016)

Randomized trials have shown that beta blocker therapy reduces mortality in patients with heart failure with reduced ejection fraction, but the effect of beta blocker therapy on prognosis in patients with atrial fibrillation and heart failure is uncertain. A meta-analysis that included 3066 patients with atrial fibrillation and heart failure found no reduction in mortality in this subgroup of patients, in contrast to the reduction in mortality seen in patients in sinus rhythm with heart failure. However, a subsequent observational study that included nearly 40,000 patients with atrial fibrillation and heart failure found that beta blocker therapy was associated with reduced mortality in this population [16]. Although a survival benefit from beta blocker therapy in patients with atrial fibrillation and heart failure with reduced ejection fraction has not been definitively established, beta blockers continue to serve as a primary therapy for rate control in these patients given their efficacy for rate control and the limitations of alternative therapies. (See "Use of beta blockers and ivabradine in heart failure with reduced ejection fraction".)

Duration of DAPT in patients treated with an everolimus-eluting stent (January 2016)

The optimal duration of dual antiplatelet therapy (DAPT) after coronary artery stenting is unknown; decisions whether to discontinue DAPT have been based on individual patient characteristics. The previously reported DAPT trial randomly assigned nearly 10,000 patients with different drug-eluting stents who had been treated successfully with DAPT for 12 months to receive DAPT or placebo for an additional 18 months. In a post hoc analysis of 4703 patients treated with the second-generation everolimus-eluting stent, continued DAPT therapy lowered the risk of major adverse cardiovascular events, similar to the results of the overall DAPT trial population [17]. Since this and other newer-generation stents are the preferred stenting options for most patients in 2016, confirmation of findings from the DAPT trial in this subgroup is of particular interest. (See "Long-term antiplatelet therapy after coronary artery stenting in stable patients", section on 'Drug-eluting stents'.)

"Warning" symptoms preceding sudden cardiac arrest (January 2016)

"Warning" symptoms may precede sudden cardiac arrest (SCA) in many patients, but symptoms are often unrecognized or minimized. In a community-based study of patients with SCA in whom symptom assessment could be ascertained (either from the surviving patient or from family members, witnesses at the scene of the event, or medical records from the four weeks leading up to the event), more than half of patients had warning symptoms within four weeks preceding SCA [18]. Chest pain and dyspnea were the most common symptoms, with chest pain being more common in men and dyspnea in women. Patients with symptoms concerning for cardiac disease, particularly new or unstable symptoms, should seek prompt medical care for potentially life-saving evaluation and treatment. (See "Overview of sudden cardiac arrest and sudden cardiac death", section on 'Warning symptoms'.)

ADULT ENDOCRINOLOGY AND DIABETES

Cardiovascular effects of early versus late menopausal hormone therapy (April 2016)

The Women's Health Initiative reported that menopausal hormone therapy is associated with an excess risk of coronary heart disease, but accumulating data suggest that estrogen therapy started soon after menopause does not increase risk. In The Early versus Late Intervention Trial with Estradiol (ELITE), 643 postmenopausal women, stratified according to time since menopause (<6 or >10 years; early versus late, respectively), received oral estradiol (with progesterone for women with a uterus) or placebo for a median of five years [19]. Progression of subclinical atherosclerosis (measured as carotid intima-medial thickness) was slower with hormone therapy than with placebo in the early intervention group, while rates of progression were similar to placebo in the late intervention group. Estradiol had no effect on computed tomography measures of coronary artery calcium in either the early or late intervention group. (See "Menopausal hormone therapy: Benefits and risks", section on 'Younger postmenopausal women'.)

Metformin use and reduced kidney function (April 2016)

The use of metformin is contraindicated in patients with factors predisposing to lactic acidosis, including impaired renal function. The precise renal thresholds for the safe use of metformin remain uncertain. Improved clinical outcomes with metformin have been reported in observational studies of patients with diabetes and renal impairment (estimated glomerular filtration rate [eGFR] 45 to 60 mL/min). On the basis of these studies, the US Food and Drug Administration (FDA) revised its labeling of metformin, which previously had identified metformin as contraindicated in women and men with serum creatinine levels ≥1.4 mg/dL (124 micromol/L) and ≥1.5 mg/dL (133 micromol/L), respectively [20]. The use of metformin is contraindicated in patients with an eGFR <30 mL/min, and the initiation of metformin is not recommended in patients with an eGFR between 30 and 45 mL/min. For patients taking metformin whose eGFR falls below 45 mL/min, the benefits and risks of continuing treatment should be assessed, whereas metformin should be discontinued if the eGFR falls below 30 mL/min. For patients with eGFR between 30 and 60 mL/min, we typically reduce the metformin dose by half (no more than 1000 mg per day), although there are no data to support this approach. (See "Metformin in the treatment of adults with type 2 diabetes mellitus", section on 'Contraindications'.)

Endocrine Society Statement: Bioidentical hormone therapy (April 2016)

The Endocrine Society has issued a Scientific Statement warning against the use of custom compounded "bioidentical hormone therapy" for managing menopausal symptoms [21]. This term refers to the use of custom-compounded, multi-hormone regimens (pills, gels, sublingual tablets, or suppositories) with dose adjustments based upon serial hormone monitoring. Compounded preparations typically include estradiol, estrone, estriol, progesterone, testosterone, and dehydroepiandrosterone (DHEA). Included among the key points were the absence of randomized trials demonstrating either efficacy or safety of compounded bioidentical hormone therapy for treating menopausal symptoms and the absence of regulatory oversight. When tested, potencies and patterns of absorption of compounded estrogens have been highly variable. Women who choose to take menopausal hormone therapy should be encouraged to use approved and regulated preparations of bioidentical hormones (for example, 17-beta estradiol and micronized progesterone). (See "Treatment of menopausal symptoms with hormone therapy", section on 'Bioidentical hormone therapy'.)

Diabetes as a coronary risk equivalent (March 2016)

Diabetes mellitus (DM) is frequently referred to as a "coronary risk equivalent," meaning that the risk of a coronary heart disease (CHD) event is similar between individuals with DM and individuals with known CHD. However, this “equivalency” averages together patients with widely varying CHD risks, and many patients with DM have much lower risks. This was examined in a prospective cohort study that followed more than 1.5 million adults (ages 30 to 90) for a median of 9.9 years [22]. The rate of new CHD events was lower in patients with DM than in those with a prior CHD event (12.2 versus 22.5 events per 1000 person-years); the risk of events was similar only in patients who had DM for more than 10 years. (See "Treatment of lipids (including hypercholesterolemia) in secondary prevention", section on 'Diabetes mellitus and CV risk'.)

ADULT GASTROENTEROLOGY

Progression from acute to chronic pancreatitis (December 2015)

There are limited data on the natural history of acute pancreatitis. In a meta-analysis that included over 8000 patients with acute pancreatitis, the pooled prevalence of recurrent acute pancreatitis and chronic pancreatitis were 22 and 10 percent, respectively [23]. The prevalence of chronic pancreatitis following the first episode and following recurrent acute pancreatitis were 10 and 36 percent, respectively. Among individuals with a history of smoking or alcohol use, the prevalence of chronic pancreatitis was 65 and 61 percent, respectively. The risk of progression to chronic pancreatitis was higher in men than in women after controlling for age and severity of acute pancreatitis. (See "Clinical manifestations and diagnosis of acute pancreatitis", section on 'Disease course'.)

Acute diverticulitis: Risk of recurrence (December 2015)

There are limited data on the natural history of acute diverticulitis. In a population-based study that included over 3000 patients with acute diverticulitis, recurrent diverticulitis in a 10-year period after the index and second diverticulitis episode occurred in 22 and 55 percent of patients, respectively [24]. The risk of recurrence was higher in younger individuals and in women. Increasing age was associated with a higher risk of both local and systemic complications. (See "Clinical manifestations and diagnosis of acute diverticulitis in adults", section on 'Disease course'.)

ADULT HEMATOLOGY AND ONCOLOGY

Zika virus and blood donation (March 2016, Modified April 2016)

The blood donor medical and travel history is used to identify and disqualify individuals who may be infected with Zika. Several agencies including the US Food and Drug Administration (FDA), World Health Organization (WHO), and AABB (an international organization) have issued guidance to reduce the risk of transmission in affected and unaffected areas [25-28]. These vary slightly but all include recommendations for deferral of individuals at risk of infection based on travel, symptoms, or sexual contacts, and recall and destruction of products if the donor develops symptoms of infection or diagnosis of Zika following donation. The WHO also recommends consideration of temporarily stopping collections and/or quarantining units until lack of symptoms can be confirmed. Currently used donor questionnaires are likely to identify individuals with symptomatic infection at the time of donation. (See "Blood donor screening: Medical history", section on 'Zika virus'.)

New guidance on blood donation deferral for men who have sex with men in the United States (December 2015)

The US Food and Drug Administration has updated its guidance on blood donation for men who have sex with men (MSM). The new guidance specifies a deferral period of 12 months since the last MSM sexual contact rather than indefinite deferral [29]. Prospective donors are instructed not to donate if they have other risk factors for human immunodeficiency virus (HIV) infection such as a recent needle stick injury or blood splash, and permanent deferral remains in place for individuals who have tested positive for HIV, used non-prescription injection drugs, or engaged in sex in exchange for money or drugs. The 12-month deferral has already been in place for other donors who have sex with at-risk individuals, and it aligns the US policy with that of Australia and the United Kingdom. Other countries have deferral periods ranging from six months to indefinite. (See "Blood donor screening: Medical history", section on 'Human immunodeficiency virus'.)

ADULT INFECTIOUS DISEASE

Nonoccupational postexposure prophylaxis to prevent HIV infection (April 2016)

A discrete course of antiretroviral therapy (ART) administered after a possible exposure to HIV may reduce the risk of HIV acquisition. The US Centers for Disease Control and Prevention (CDC) has issued updated guidelines on HIV prophylaxis following a nonoccupational exposure [30]. A 28-day course of a three-drug regimen (eg, tenofovir disoproxil fumarate-emtricitabine plus either raltegravir or dolutegravir) should be offered to patients who present within 72 hours of a high-risk exposure (eg, condomless receptive or insertive vaginal or anal intercourse or a percutaneous exposure to blood or bloody body fluids) from a source who is HIV-infected or is at high risk for HIV infection. Exposed patients should be educated about the signs and symptoms of acute HIV infection, and have follow up HIV testing. (See "Nonoccupational exposure to HIV in adults".)

Indications for antibiotics in the management of skin abscess (March 2016)

The emergence of methicillin-resistant Staphylococcus aureus (MRSA) has raised uncertainty regarding the role of antimicrobial therapy for treatment of skin abscess following incision and drainage. In a randomized trial including 1220 patients >12 years of age (median 35 years) with drained skin abscess (≥2 cm in diameter) comparing trimethoprim sulfamethoxazole (TMP-SMX, 320 mg/1600 mg twice daily) with placebo, the cure rate 7 to 14 days after treatment was higher in the TMP-SMX group (80.5 versus 73.6 percent); wound cultures were positive for MRSA in 45 percent of cases [31]. Based on these findings, abscess size ≥2 cm in diameter is a useful threshold for guiding decisions regarding use of antibiotic therapy for adjunctive treatment of skin abscess.

Additional factors for which we recommend antibiotic therapy include the presence of multiple lesions, extensive surrounding cellulitis, associated comorbidities or immunosuppression, signs of systemic infection, or inadequate clinical response to incision and drainage alone; we suggest antibiotic therapy for patients with an indwelling device or high risk for transmission of S. aureus to others. For otherwise healthy patients with none of these factors, we suggest not administering antimicrobial therapy. (See "Skin abscesses, furuncles, and carbuncles", section on 'Role of antibiotics'.)

Zika virus and Guillain-Barre syndrome (March 2016)

Zika virus has been associated with Guillain-Barre syndrome (GBS), although a direct causal relationship has not been definitively established. A case-control study in French Polynesia evaluated the association between GBS and Zika virus infection during the 2013 to 2014 outbreak [32]. Cases included 42 patients diagnosed with GBS; one control group included 98 patients with nonfebrile illnesses and a second control group included 70 patients with Zika virus infection in the absence of neurological complications. Zika IgM was positive in 93 percent of GBS cases (versus 17 percent of patients in the first control group); serologic evidence of past dengue infection was similar among all three groups. Antiglycolipid IgG antibodies were detected in fewer than 50 percent of GBS cases, raising the possibility of direct viral neurotoxicity. Results of nerve conduction studies were consistent with the acute motor axonal neuropathy type of GBS; clinical improvement during follow-up suggested reversible conduction failure. Symptoms of Zika virus infection occurred in 88 percent of patients with GBS; the median interval between viral syndrome and onset of neurological symptoms was six days. All GBS cases received intravenous immune globulin, 38 percent required intensive care, and 29 percent needed respiratory care; all survived. The incidence of GBS during the outbreak was estimated to be 0.24 cases per 1000 Zika virus infections. (See "Zika virus infection: An overview", section on 'Guillain-Barré syndrome'.)

Oral fluoroquinolone use and serious arrhythmia (March 2016)

QT interval prolongation and torsades de pointes have been associated with fluoroquinolone use, but the degree to which fluoroquinolones block cardiac potassium channels and thereby cause QT prolongation varies by agent. The risk of serious arrhythmia during fluoroquinolone therapy was evaluated in a cohort of adults aged 40 to 79 years of age in Denmark and Sweden; arrhythmic events were compared for 909,656 courses of fluoroquinolones (ciprofloxacin in 83 percent, norfloxacin in 12 percent, ofloxacin in 3 percent, moxifloxacin in 1 percent, other in 1 percent) and 909,656 courses of penicillin, an antibiotic not associated with arrhythmia [33]. There was no increase in the risk of serious arrhythmia with fluoroquinolones compared with penicillin. This finding conflicts with results from earlier studies, and may be explained in part by the predominant use of ciprofloxacin in this cohort, with its smaller impact on QT prolongation. (See "Fluoroquinolones", section on 'QT interval prolongation and arrhythmia'.)

Behavioral interventions to decrease inappropriate antibiotic prescribing (February 2016)

Behavioral interventions may decrease inappropriate antibiotic prescribing for upper respiratory tract infections (URIs). A randomized trial among primary care practices compared provider education with antibiotic prescribing guidelines (control group) with behavioral interventions to decrease antibiotic prescribing for patients with nonspecific URIs, acute bronchitis, or influenza [34]. The interventions were: (1) suggesting nonantibiotic alternative treatments (eg, decongestants, cough suppressants, ipratropium) via electronic order sets; (2) prompting clinicians to justify prescribing; and (3) peer comparison. Rates of inappropriate prescribing decreased in all groups, including the control group, but the decrease in the groups using prompting to justify prescribing and peer comparison was greater than in the control group. (See "Acute bronchitis in adults", section on 'Lack of efficacy of routine antibiotic therapy'.)

Updated adult immunization schedule in the United States (February 2016)

Updates to the adult immunization schedule for 2016 have been issued by the United States Advisory Committee on Immunization Practices (ACIP) (figure 1 and figure 2) [35]. Changes from the 2015 schedule include updates to the recommendations for pneumococcal vaccine, serogroup B meningococcal (MenB) vaccine, and human papillomavirus (HPV) vaccine. The interval between administration of the 23-valent pneumococcal polysaccharide (PPSV23) and the 13-valent pneumococcal conjugate (PCV13) vaccines has been changed from '6 to 12 months' to 'at least one year' for immunocompetent adults aged ≥65 years. In addition, the MenB vaccine series should be administered to individuals age ≥10 years who are at increased risk for serogroup B meningococcal disease. Finally, the nine-valent HPV vaccine has been added to the schedule as an option for routine HPV vaccination for females and males. (See "Approach to immunizations in healthy adults", section on 'Immunization schedule for healthy adults'.)

Azithromycin versus doxycycline for uncomplicated chlamydia (January 2016)

The first-line regimens for uncomplicated urogenital chlamydial infection are azithromycin administered as a single dose or a seven-day course of doxycycline administered twice daily. There is emerging evidence that the efficacy of doxycycline may be marginally greater than that of azithromycin, although the reasons for this are unknown. In a trial of 310 adolescents and young adults who screened positive for urogenital Chlamydia trachomatis upon entrance into a correctional facility, microbial cure rates at 28 days were high for both doxycycline and azithromycin (each administered as directly-observed therapy), but were numerically higher for doxycycline (100 versus 97 percent) [36]. Adherence is the main challenge with the doxycycline regimen, and direct observation of the full course is unrealistic in most situations; thus, it is uncertain that doxycycline would achieve a similarly superior cure rate in the community. Given the very high efficacy of azithromycin, we continue to favor directly-observed single-dose azithromycin for treatment of uncomplicated urogenital C. trachomatis infection. (See "Treatment of Chlamydia trachomatis infection", section on 'First-line agents'.)

Tenofovir alafenamide as part of a coformulated antiretroviral regimen (November 2015)

Tenofovir is a preferred nucleoside to use in a combination antiretroviral regimen for the treatment of HIV infection. Until recently, tenofovir was available only as tenofovir-disoproxil fumarate (TDF), which has been associated with renal toxicity and decreased bone mineral density. In November 2015, a newer formulation, tenofovir alafenamide (TAF) became available in the United States as part of a single tablet coformulation, elvitegravir-cobicistat-emtricitabine-TAF (ECF-TAF) [37]. This combination agent is as effective as elvitegravir-cobicistat-emtricitabine-TDF (ECF-TDF) in suppressing HIV RNA with fewer adverse renal and bone effects [38]. ECF-TAF can be used for patients with reduced kidney function (estimated glomerular filtration rate [eGFR] ≥30 mL/min/m2), unlike ECF-TDF, which should only be used in patients with an eGFR >70 mL/min/m2. ECF-TAF is considered a recommended regimen by the United States Department of Health and Human Services [39]. In March 2016, TAF also became available as part of the coformulated tablet rilpivirine-emtricitabine-tenofovir alafenamide. (See "Selecting antiretroviral regimens for the treatment-naïve HIV-infected patient", section on 'Preferred regimens'.)

Statins and influenza vaccine immunogenicity and effectiveness (November 2015)

Statins are used commonly in older adults with hyperlipidemia and are known to have immunomodulatory effects, which could affect vaccine responses. In an observational study conducted in the context of a randomized trial that evaluated influenza vaccines in individuals >65 years of age, hemagglutination inhibition (HAI) geometric mean titers to various influenza strains were substantially lower in those receiving chronic statin therapy than in those not receiving it [40]. In addition, in the adjusted analysis of a large retrospective cohort study, statin use was associated with reduced influenza vaccine effectiveness against medically attended acute respiratory illness [41]. The observed associations between statin use and vaccine effectiveness could be due to confounding, as patients receiving statins are likely to be at differing baseline risk of influenza from those not receiving statins. Although these studies raise the possibility that older patients receiving statins are less likely to be protected by the influenza vaccine, such individuals should still receive statins, when indicated, as well as an influenza vaccine annually. (See "Seasonal influenza vaccination in adults", section on 'Efficacy'.)

ADULT NEPHROLOGY AND HYPERTENSION

Antihypertensive therapy in patients not at high cardiovascular risk (April 2016)

The benefit of antihypertensive therapy in patients at low or moderate cardiovascular risk, including those who are normotensive, is unclear. The Third Heart Outcomes Prevention Evaluation trial (HOPE-3) randomly assigned 12,705 patients at moderate risk for cardiovascular disease (only 38 percent were hypertensive at baseline) to receive a fixed-dose combination of candesartan plus hydrochlorothiazide or placebo [42]. At 5.6 years, there was no significant difference in cardiovascular events. However, among a hypertensive subgroup (ie, those whose initial systolic pressure was in the highest tertile, or greater than 143 mmHg), antihypertensive therapy significantly reduced the incidence of major cardiovascular events (5.7 versus 7.5 percent, absolute benefit of 1.8 percent). Thus, antihypertensive therapy reduced cardiovascular events in patients with mild hypertension and low overall cardiovascular risk. (See "What is goal blood pressure in the treatment of hypertension?", section on 'Benefit in those with mild hypertension'.)

ADULT NEUROLOGY AND PSYCHIATRY

Safety of smoking cessation medications in patients with and without mental health disorders (May 2016)

Reports of newly emergent depression, suicidal ideation, and suicidal behavior among patients receiving bupropion or varenicline for smoking cessation raised questions about the safety of these drugs in smokers with mental health disorders. In a recent trial examining the safety of these medications, more than 8000 motivated adult smokers, approximately half with clinically stable mental disorders, were randomly assigned to varenicline, bupropion, transdermal nicotine, or placebo for 12 weeks [43]. Compared with patients without mental health disorders, patients with such disorders were more likely to experience neuropsychiatric adverse events (including anxiety, depression, agitation, or hostility) during treatment (2.1 versus 5.8 percent). However, in both patients with and without mental health disorders, the rate of events did not differ for patients assigned to varenicline or bupropion compared with placebo. Rates of smoking abstinence were higher for each of the three drugs compared with placebo, and higher with varenicline compared with bupropion or transdermal nicotine. The findings are consistent with previous, smaller trials supporting carefully monitored use of smoking-cessation medications in smokers with stable mental health disorders. (See "Pharmacotherapy for co-occurring schizophrenia and substance use disorder", section on 'Safety'.)

Stenting versus surgery for carotid artery stenosis (March 2016)

Two recent studies have compared carotid artery stenting (CAS) and carotid endarterectomy (CEA) for treatment of carotid artery stenosis. Accumulating evidence suggests that both CAS and CEA provide similar long-term outcomes for patients with asymptomatic and symptomatic carotid occlusive disease, although the periprocedural risk of stroke and death is higher with CAS.

In a meta-analysis of older adult patients with symptomatic carotid disease, pooled patient-level data from four trials found that the periprocedural risk of stroke and death increased with age (hazard ratio [HR] 2.2 for ages 65 to 69 and 4.2 for age ≥80 years) for patients assigned to CAS, while there was no increase in periprocedural risk by age for CEA [44]. The periprocedural risk of stroke and death was significantly increased with CAS compared with CEA for patients age 70 and older. (See "Management of symptomatic carotid atherosclerotic disease", section on 'Effect of age'.)

The ACT I randomized trial in patients with asymptomatic 70 to 99 percent carotid stenosis assigned 1453 patients to either CAS or CEA [45]. For the primary composite endpoint (death, stroke, or myocardial infarction within 30 days of the procedure or ipsilateral stroke within one year), the prespecified statistical margin for noninferiority of stenting compared with endarterectomy was met. The cumulative five-year rates of stroke-free survival at CAS and CEA were 93.1 and 94.7 percent, respectively. (See "Management of asymptomatic carotid atherosclerotic disease", section on 'Stenting trials'.)

Because of higher rates of short-term complications with CAS, we continue to prefer CEA for most medically stable patients who have symptomatic carotid stenosis or who have a life expectancy of at least five years and high grade (≥80 percent) asymptomatic carotid stenosis at baseline or progression to ≥80 percent stenosis despite intensive medical therapy.

Growing concern over herb used in self-treatment of opioid withdrawal (March 2016)

Kratom (Mitragyna speciosa), an herb with opioid and stimulant-like properties used in self-treatment of opioid withdrawal, has been subject to international attention due to an increase in overdose-associated hospital visits and deaths [46]. Published investigation of kratom's efficacy and toxicity has been limited to case reports/series. Frequent and prolonged ingestion for pain or recreational use has been associated with anorexia, weight loss, seizures, and psychosis. In the United States, kratom is not regulated by the Food and Drug Administration, though individual states and some countries prohibit its use. (See "Medically supervised opioid withdrawal during treatment for addiction", section on 'Alternative treatments'.)

Declining incidence of dementia (February 2016)

A growing number of studies indicate that the incidence of dementia may be declining in high-income countries, concomitant with a decline in the prevalence of many vascular risk factors. As an example, using data from over 5000 patients enrolled in the Framingham Heart Study in the United States, the five-year cumulative hazard rate for dementia fell from 3.6 per 100 persons during the late 1970s to 2.0 per 100 persons in the late 2000s [47]. The risk reduction was only found among individuals with at least a high school diploma, and the magnitude of the change was higher for vascular dementia than for Alzheimer disease. Rates of hypertension, stroke, and atrial fibrillation also fell over the same time period, while rates of obesity and type 2 diabetes rose, and it is not certain what factors account for the decreased incidence of dementia. Despite these trends, the global total burden of dementia is expected to continue rising as the population ages. (See "Treatment and prevention of vascular dementia", section on 'Risk factor management'.)

Naloxone intranasal spray for community-based reversal of opioid overdose (January 2016)

Naloxone is an opioid antagonist that rapidly reverses the effects of opioid overdose. Take-home naloxone, along with education and training on its use for overdose, is increasingly provided to opioid-dependent patients and members of their households, making ease of administration a priority. The US Food and Drug Administration recently approved an intranasal naloxone spray (Narcan nasal spray) in a dispenser that delivers a premeasured 4 mg dose [48]. The nasal spray adds to treatment options, which include another easy-to-use device, a handheld naloxone auto-injector (Evzio) that was approved in 2014. Caregivers should contact emergency services as soon as the first dose is given; additional doses may be needed before first responders arrive. (See "Prevention of lethal opioid overdose in the community", section on 'Administration'.)

ADULT PULMONOLOGY

Combination inhaled glucocorticoid/long-acting beta agonists in patients with COPD and cardiovascular risk factors or disease (May 2016)

While the evidence has been generally reassuring about the safety of combination inhaled glucocorticoid plus long-acting beta agonist (ICS-LABA) inhalers in patients with chronic obstructive pulmonary disease (COPD), patients with known cardiovascular disease (CVD) were excluded from previous clinical trials. In the three-year randomized trial, Study to Understand Mortality and MorbidITy (SUMMIT), the effect of the fluticasone furoate-vilanterol combination inhaler was compared with the individual components and placebo in almost 17,000 patients with moderate COPD (FEV1 between 50 and 70 percent of predicted) and known or increased risk of CVD [49]. Relative to placebo, the combination inhaler did not affect all-cause mortality or composite cardiovascular events. Thus, the presence of CVD should not affect the role of ICS-LABA inhalers in COPD. (See "Management of the patient with severe COPD and cardiovascular disease", section on 'Combination inhaled bronchodilator plus glucocorticoid'.)

Safety of fluticasone-salmeterol combination therapy in asthma (March 2016)

In early studies, a small increase in asthma-related deaths associated with salmeterol led the US Food and Drug Administration to place a boxed warning on the use of salmeterol in asthma. While concerning, the number of events was small, and the magnitude of the risk was unclear. In addition, it could not be determined if the potential risk of salmeterol could be mitigated by combining it with an inhaled glucocorticoid. The safety of salmeterol in combination with fluticasone has been assessed in a multicenter trial, in which almost 12,000 adolescents and adults with persistent asthma were randomly assigned to take inhaled fluticasone or the combination of inhaled fluticasone-salmeterol (in a single inhaler) for 26 weeks [50]. The rate of serious asthma-related adverse events was similar in the two groups, and no deaths occurred in either group. In addition, no difference was noted in the rate of asthma-related hospitalizations. Thus, for patients over age 12 who do not have a history of life-threatening asthma events, data are reassuring about the safety of fluticasone-salmeterol in a fixed-dose inhaler. (See "Beta agonists in asthma: Controversy regarding chronic use", section on 'Potential risk mitigation'.)

Mandibular advancement devices lower blood pressure in sleep apnea (December 2015)

Improved blood pressure control is a benefit associated with continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA) and hypertension. However, it is unclear whether therapeutic modalities other than CPAP result in the same benefit. One meta-analysis of 51 studies of patients with hypertension and OSA reported that compared with patients on placebo or not receiving therapy, mandibular advancement devices (MADs) were associated with a significant reduction in systolic and diastolic blood pressure [51]. The level of reduction was similar to that reported in patients treated with CPAP. While this study does not alter the indications for either therapy, it suggests that patients with OSA who are treated with MADs may derive similar positive effects on blood pressure control as those treated with CPAP. (See "Obstructive sleep apnea and cardiovascular disease", section on 'Impact of treatment'.)

ADULT RHEUMATOLOGY

Vitamin D ineffective for osteoarthritis (March 2016)

Low vitamin D levels have been associated with osteoarthritis (OA) in observational studies, but randomized trials of vitamin D for the treatment of OA have had mixed results. In the largest of the randomized trials, involving over 400 patients with symptomatic knee OA and low levels of 25-hydroxyvitamin D, compared with placebo, monthly treatment for two years with cholecalciferol did not improve knee pain and did not reduce tibial cartilage volume loss or bone marrow lesions as assessed by MRI [52]. We do not recommend dietary supplementation with vitamin D for the treatment of OA. (See "Nonpharmacologic therapy of osteoarthritis", section on 'Diet and vitamins'.)

Oral glucocorticoids for acute gout flare (March 2016)

The use of oral glucocorticoids as first-line therapy in patients with an acute gout flare, rather than nonsteroidal antiinflammatory drugs or colchicine, is a matter of debate. In a randomized trial, over 400 patients with acute gout presenting to an emergency department within three days of symptom onset were treated with either prednisolone or indomethacin for five days [53]. There was no significant difference between the groups in the degree of pain reduction, and no serious adverse events occurred with either therapy. Although effective in this trial, glucocorticoid use in acute gout is associated with an increased risk of rebound attacks, especially in patients with frequent flares and those not receiving prophylactic therapy, in whom tapering over 10 days or longer may be advisable. (See "Treatment of acute gout", section on 'Oral glucocorticoids'.)

GYNECOLOGY

Atypical glandular cells on cervical cytology associated with immediate and long-term risks of cervical cancer (March 2016)

Women with atypical glandular cells (AGC) on cervical cytology appear to be at increased risk for cervical cancer in both the short and long term. A recent study used data from Swedish national registries to analyze outcomes of over 14,000 women with AGC on their first recorded cervical cancer screening test [54]. Immediately following an AGC result, adenocarcinoma was identified in 0.99 percent of women and squamous carcinoma in 0.30 percent. Compared with women with normal cytology at their first recorded cervical cancer screening test, women with AGC continued to be at higher risk of cervical cancer for up to 15.5 years. The highest risk of cervical cancer was in the first 3.5 years, and then decreased over time. (See "Cervical cytology: Evaluation of atypical and malignant glandular cells", section on 'Histology and site of lesion'.)

Acupuncture ineffective for menopausal hot flashes (January 2016)

It is estimated that up to 75 percent of postmenopausal women use complementary therapies to treat their menopausal symptoms, despite little evidence of efficacy. Acupuncture is among the most frequently used, but results from clinical trials have been conflicting. The best evidence to date that acupuncture is no more effective than placebo (sham-acupuncture) comes from a trial in 327 peri- or postmenopausal women with moderate to severe hot flashes who were randomly assigned to 10 traditional Chinese acupuncture or noninsertive sham acupuncture treatments over eight weeks [4]. Hot flash (HF) scores, a calculated score based upon HF frequency and severity, were no different between the groups at the end of treatment (both showed approximately 40 percent improvement). Thus, like other nonhormonal and complementary therapies for hot flashes, acupuncture has an important placebo effect, but it has no additional benefit over sham acupuncture. (See "Menopausal hot flashes", section on 'Inconsistent evidence of efficacy'.)

OBSTETRICS

Antenatal steroids at 34 to 37 weeks for pregnancies at high risk of preterm birth (February 2016)

Antenatal corticosteroid therapy at 23 to 34 weeks of gestation for women at risk for preterm delivery reduces the incidence and severity of respiratory distress syndrome in offspring delivered within seven days of administration. Steroids have not been administered after 34 weeks because studies have not demonstrated a benefit, although data have been sparse. Recently, the Antenatal Late Preterm Steroids (ALPS) Trial randomly assigned women at 340/7ths to 365/7ths weeks of gestation at high risk for late preterm birth to receive a first course of antenatal betamethasone or placebo and found that the frequency of a composite outcome of neonatal respiratory problems was reduced in the betamethasone group [55]. Based on these data, we believe offering a first course of antenatal corticosteroids to patients scheduled for cesarean delivery at 340/7ths to 366/7ths weeks is reasonable. We would not administer a first course of steroids to women at 340/7ths to 366/7ths weeks planning vaginal delivery as transient tachypnea of the newborn is less common after labor and vaginal birth. For women in whom delivery at 340/7ths to 366/7ths is uncertain (eg, threatened preterm labor), we would not administer a course of steroids because of the potential for long-term harm with no benefit if the patient does not deliver preterm. For women at 340/7ths to 366/7ths weeks who received a course of antenatal corticosteroids earlier in pregnancy, we would not administer a second course as the benefits and risks have not been studied in this population. This approach limits late preterm in utero steroid exposure to pregnancies certain to deliver preterm and with neonates at most risk for experiencing serious respiratory problems from transient tachypnea of the newborn. We do not administer steroids to women undergoing scheduled cesarean delivery at ≥37 weeks: the overall risk of respiratory illness at this gestational age is low and rarely serious. (See "Antenatal corticosteroid therapy for reduction of neonatal morbidity and mortality from preterm delivery", section on 'After 34 weeks'.)

Screening for perinatal depression (February 2016)

Up to 15 percent of pregnant women experience depression either during pregnancy or in the postpartum period. Perinatal depression is under-recognized and associated with adverse outcomes including preterm birth, impaired fetal growth, lower birth weight, and impaired maternal-infant bonding. A systematic review, comparing usual care with a program for depression screening during pregnancy (one trial) or postpartum (four trials), found that screening reduced the prevalence of depression at three- to five-month follow-up (absolute reduction 2.1 to 9.1 percent) [56,57]. We suggest routine screening for depression during pregnancy and at the six-week postpartum visit, with services available to ensure follow-up for diagnosis and treatment. The most widely used screening instrument is the 10-item Edinburgh Postnatal Depression Scale (figure 3A-B), which also can be used for prenatal depression. This approach is consistent with practice guidelines issued by the US Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the United Kingdom National Institute for Health and Care Excellence. (See "Unipolar major depression in pregnant women: Clinical features, consequences, assessment, and diagnosis" and "Postpartum blues and unipolar depression: Epidemiology, clinical features, assessment, and diagnosis".)

Serum test for prediction of preeclampsia (January 2016)

The ratio of soluble fms–like tyrosine kinase 1 (sFlt-1) to placental growth factor (PlGF) is increased in the serum of women with preeclampsia; however, the clinical application for this observation remains unclear. A prospective international observational study (PROGNOSIS) attempted to derive and validate a serum sFlt-1:PlGF ratio that would predict the absence or presence of preeclampsia in women who had signs suggestive of the disease, but who did not meet standard criteria for preeclampsia [58]. An sFlt-1:PlGF ratio cutoff of 38 using a specific automated commercial assay had a negative predictive value (no preeclampsia in the next seven days) of 99.3 percent. Few women in the cohort ultimately developed preeclampsia, resulting in a positive predictive value of only 36.7 percent for preeclampsia diagnosis in the next four weeks. Further study is warranted, including determining whether the cut-off varies among laboratories and patient populations, the best interval for repeat testing, and how this information affects clinical decisions, outcomes and costs. (See "Preeclampsia: Clinical features and diagnosis", section on 'Measurement of angiogenic factors'.)

Zika virus infection in the Americas (January 2016)

Zika virus is a member of the flavivirus family that is spread via mosquito bites. Outbreaks have occurred in Africa, Southeast Asia, and the Pacific Islands; more recently Zika virus has spread to the Americas. More than 20 countries in Latin America have confirmed circulation; cases of Zika virus infection in the United States have occurred among returning travelers. The illness is usually mild; typical symptoms include fever, rash, joint pain, and conjunctivitis. However, Zika virus infection has also been associated with perinatal complications (congenital microcephaly and fetal losses) and Guillain-Barre syndrome [59]. In 2015-2016, more than 5000 cases of microcephaly were reported among newborns in Brazil; this represents a >20-fold increase in the number of cases compared with years prior to the circulation of Zika virus [60]. A number of authorities have advised that pregnant women consider postponing travel to areas below 6500 feet (2000 meters) where mosquito transmission of Zika virus is ongoing [61]. Sexual transmission have been described [62]. It is prudent for individuals with Zika virus infection/exposure to abstain from sexual activity (vaginal, anal, and oral sex) or use barrier protection; men who have a pregnant partner should follow such guidance for the duration of the pregnancy. Zika virus is also transmissible via blood products; deferral of blood donors for one month following Zika virus infection/exposure is advised [63]. (See "Zika virus infection: An overview", section on 'Geographic distribution'.)

Membrane sweeping in GBS-colonized women (January 2016)

Some practitioners choose not to sweep/strip fetal membranes to induce labor in group B Streptococcus (GBS)-colonized women because of theoretical concerns of bacterial seeding during the procedure. The first prospective study to compare maternal and neonatal outcomes following membrane sweeping among GBS-positive (n = 135), GBS-negative (n = 361), and GBS-unknown (n = 46) women found no significant difference in adverse maternal or neonatal outcomes between groups [64]. There was no difference in the rate of possible early-onset neonatal infection between the GBS-positive and GBS-negative groups and no cases of neonatal sepsis in the entire cohort. Most GBS-positive women received intrapartum GBS antibiotic prophylaxis. Although these results are reassuring about the safety of membrane sweeping in GBS-positive women, the study did not have adequate power to detect modest differences in outcome and is subject to the limitations of an observational design. We believe GBS colonization is not a contraindication to membrane sweeping as there is no direct evidence of harm, but given the paucity of safety data for the procedure in known GBS carriers, we weigh the potential risks and benefits before performing the procedure in known carriers. (See "Induction of labor", section on 'Membrane stripping'.)

Miscarriage risk with oral fluconazole (January 2016)

The pregnancy effects of oral azoles for treatment of vulvovaginal candidiasis is unclear. Studies have reported an increased risk of birth defects after exposure to high-dose azole therapy (400 to 800 mg/day), but not for the low dose therapy used to treat vulvovaginal infections (eg, fluconazole 150 mg). Prior studies have not reported an increased risk of miscarriage with oral fluconazole. However, a recent cohort study of over 3300 women who received 150 to 300 mg of oral fluconazole between 7 and 22 weeks of pregnancy reported an approximately 50 percent increased risk of miscarriage in exposed women compared with either unexposed women or with women treated with vaginal azole therapy [65]. We continue to offer topical azole treatment during pregnancy and prefer to avoid oral therapy until more data on reproductive outcomes are available. (See "Candida vulvovaginitis", section on 'Pregnancy'.)

Neonatal and maternal outcomes for planned out-of-hospital birth (January 2016)

In the United States (US), the safety of non-hospital births is unclear. Several studies have reported that women who deliver at home or at a birth center have equal or improved neonatal and maternal outcomes compared with those who deliver in a hospital; however, outcomes of women transferred to the hospital intrapartum or postpartum because of complications were often included with the hospital delivery group, which could have impacted results. In a US study that analyzed birth outcomes by planned birth location rather than actual delivery site, approximately 16 percent of women planning out-of-hospital births (combined home births and freestanding birth centers) required hospital transfer and their infants had higher rates of perinatal death, neonatal seizures, and neonatal ventilator support compared with infants of planned in-hospital births [66]. Mothers who planned out-of-hospital births but delivered in a hospital had fewer obstetric interventions and a higher rate of blood transfusion. For women in the United States, this study provides a more accurate understanding of the outcomes associated with planned out-of-hospital versus planned in-hospital birth. (See "Planned home birth", section on 'Retrospective studies'.)

PEDIATRICS: GENERAL PEDIATRICS

BMI during adolescence and cardiovascular mortality during adulthood (April 2016)

A variety of studies have shown associations between obesity during adolescence and multiple cardiovascular risk factors (eg, hypertension, dyslipidemia, diabetes). Now, a large population-based study from Israel found that higher body mass index (BMI) during late adolescence is associated with cardiovascular mortality in mid-adulthood [67]. Of note, this association was seen even within the range of BMIs considered to be normal in adolescents, with a graded increase in risk of death as adolescent BMI rose above the 50th percentile (figure 4). This study supports and expands the body of evidence suggesting that the processes causing coronary heart disease begin during adolescence. (See "Comorbidities and complications of obesity in children and adolescents", section on 'Adult coronary heart disease'.)

Increasing vegetable consumption in children (April 2016)

Vegetables are an important component of a healthy diet, but national surveys indicate that vegetable consumption by young children falls short of the recommended 2.5 cup-equivalents per day. In a longitudinal study, six-year old children who had been offered a variety of vegetables at the initiation of complementary feedings were more willing to try new vegetables, ate more new vegetables, and liked new vegetables more than children who were offered little or no variety of vegetables [68]. Offering a vegetable that was initially disliked at eight subsequent meals was associated with increased acceptance of that vegetable and continuing to like and eat that vegetable at three and six years of age. These findings support recommendations to offer vegetables at least once per day, to offer a variety of vegetables, and to offer vegetables that are initially refused at subsequent meals. (See "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'Puréed foods'.)

Early introduction of highly allergenic foods in infancy (March 2016)

The Enquiring about Tolerance (EAT) trial examined whether early introduction of six highly allergenic foods (peanut, hen’s egg, cow's milk, sesame, whitefish, and wheat) beginning at three months of age, compared with exclusive breastfeeding until approximately 6 months of age, protected against the development of food allergy in over 1300 breastfed infants recruited from the general population [69]. Early food introduction did not reduce breastfeeding, although caregivers found the feeding regimen to be challenging, with only 43 percent of the participants in the early-introduction group adhering to the protocol. No difference was seen in the prevalence of food allergy at one and three years of age between the two groups in the intention-to-treat (ITT) analysis. However, in the per-protocol analysis, the prevalence of any food allergy, and peanut and egg allergy in particular, was lower in the early-introduction group compared with the standard-introduction group (2.4 versus 7.3 percent, respectively, for any food allergy). Thus, although the more rigorous ITT analysis did not show a benefit of introduction at three months and further research is needed, the results are consistent with our current recommendation to not withhold allergenic foods, and to introduce them as early as 4 to 6 months of age. (See "Introducing highly allergenic foods to infants and children", section on 'Introduction in the general population'.)

Standardized evaluation and management plan for children with syncope (February 2016)

Although the etiology of syncopal events in children is most often benign, syncope can also occur as the result of more serious (usually cardiac) disease with the potential for sudden death. The goal of the evaluation of a child with syncope is to identify life-threatening conditions, as well as conditions that are associated with the risk of significant injury. In most children, cardiac syncope is suggested by a careful history, physical examination, and electrocardiogram (ECG). In a prospective, multicenter observational study of over 1200 children with syncope evaluated by a pediatric cardiologist using a standardized outpatient evaluation and management plan (based upon history, physical examination, and ECG), 85 percent of patients were diagnosed with typical (vasovagal) syncope [70]. One patient with cardiac syncope caused by hypertrophic cardiomyopathy was identified using the standardized evaluation plan. This patient had exercise-induced syncope and abnormal findings on ECG. This study suggests that cardiac causes for syncope are rare in children and can usually be identified by clinical findings and an ECG (table 1). (See "Emergent evaluation of syncope in children and adolescents", section on 'Evaluation and decision'.)

Nonoperative management for children with uncomplicated appendicitis (February 2016)

Urgent appendectomy is routine practice for children with appendicitis. However, preliminary evidence suggests that nonoperative management (observation and intravenous antibiotics for 24 hours) may be safely performed in selected patients at low risk for perforation. In a prospective, observational study of 102 older children (median age 12 years) with acute uncomplicated appendicitis who were offered surgery or nonsurgical management at a children’s hospital, 28 of the 37 patients who with their families chose nonoperative management had not required appendectomy at one year [71]. When compared with children who underwent immediate appendectomy, children who received nonoperative management had a longer length of stay at initial hospitalization (median difference 17 hours) but, at one year, fewer days not participating in normal activities (median 13 fewer days) and lower appendicitis-related healthcare costs (median savings USD $810). Although these preliminary findings indicate potential benefits for selected children with acute, uncomplicated appendicitis who undergo nonoperative management, more information regarding longer-term outcomes in a much larger cohort of patients is needed before this option can be routinely offered. (See "Acute appendicitis in children: Management", section on 'Nonoperative management'.)

Evaluation of genetic testing to predict progression in adolescent idiopathic scoliosis (February 2016)

Determining the risk of progression is a crucial factor in the management of adolescent idiopathic scoliosis (AIS). Clinical factors used to predict the risk of progression include radiologic markers of skeletal maturity, age, sex, sexual maturity rating, and location and type of curve. However, accurate prediction of progression using clinical factors is limited. The AIS prognostic test (AIS-PT, marketed as ScoliScore) is an algorithm that incorporates saliva-based DNA testing to predict the risk of scoliosis progression in skeletally immature Caucasian patients with mild scoliosis. In an independent evaluation, AIS-PT scores did not differ between patients with and without curve progression [72]. Independent studies in other populations have also failed to validate the AIS-PT. Lack of validation of the AIS-PT in independent cohorts may be related to differences in the test population, genetic variability, or loss to follow-up of patients with nonprogressive scoliosis [72,73]. Until these issues are resolved, we continue to use clinical factors to predict the risk of progression in patients with AIS. (See "Adolescent idiopathic scoliosis: Management and prognosis", section on 'Genetic testing'.)

Updated guidelines for evaluation of the visual system in children (January 2016)

The American Academy of Pediatrics has issued a policy statement with updated guidelines to aid pediatricians in the assessment of the visual system in infants, children, and adolescents [74]. Changes from previous guidelines include recommendations for instrument-based screening beginning at age 12 months and preference of HOTV or LEA charts over other charts for assessment of visual acuity in young children. Our approach is consistent with these new guidelines. (See "Visual development and vision assessment in infants and children", section on 'Overview of vision assessment'.)

Timing of appendectomy (January 2016)

Whether emergent appendectomy is required in all patients with early appendicitis has been debated. In many institutions, children with early appendicitis receive antibiotics and undergo appendectomy based upon operative and professional resources with a preference for performance of the procedure during daytime or evening hours. In a prospective, observational study that evaluated 230 children who underwent appendectomy, patients with symptoms greater than 48 hours had a significantly higher rate of perforation when compared with patients with symptoms ≤48 hours (46 versus 12 to 18 percent) [75]. When evaluated according to time from diagnosis, the perforation rate, length of stay, and operating time were not significantly different. Thus, limiting the total time from symptom onset to surgery rather than from diagnosis to surgery appears to be of greatest importance in preventing adverse outcomes of appendicitis. (See "Acute appendicitis in children: Management", section on 'Timing of operation'.)

Use of azithromycin to prevent or shorten the duration of symptoms in young children with recurrent wheeze/asthma (December 2015, Modified January 2016)

The potential utility of macrolide antibiotics in the treatment of recurrent wheezing/asthma is under investigation, given their antiinflammatory properties and antimicrobial effects against Mycoplasma pneumonia and Chlamydia pneumonia.

A multicenter trial examined whether the early use of azithromycin prevented lower respiratory tract illness (LRTI) in 607 preschool children with a history of severe recurrent wheezing [76]. Children were randomly assigned to oral azithromycin or placebo for five days in addition to albuterol. Treatment was initiated at the onset of respiratory illness in conjunction with signs/symptoms that usually preceded the development of a severe LRTI, specific to each child. The risk of progressing to severe LRTI was lower in the treatment group compared with the control, although there was no difference in urgent care utilization, emergency department visits, or hospitalizations.

A second trial randomly assigned 72 children one to three years of age with recurrent asthma-like symptoms to three days of oral azithromycin or placebo for each episode of asthma-like symptoms lasting at least three days [77]. Treatment with azithromycin significantly decreased the duration of the episode, with a greater response seen with earlier initiation of treatment.

These studies provide some evidence for the early use of azithromycin. However, given concerns regarding antibiotic resistance and adverse effects with widespread use, further study is warranted to define subpopulations who could most benefit from preventive therapy before recommendations can be made. (See "Treatment of recurrent virus-induced wheezing in young children", section on 'Antibiotics'.)

PEDIATRICS: DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS

Screening for autism spectrum disorder (March 2016)

Autism spectrum disorder (ASD) is common, with a prevalence of 1 in 50 to 1 in 500 children. Symptoms of ASD often are present before 18 months of age, but the average age of diagnosis is >4 years. Early identification is hampered by the heterogeneous presentation and the difficulty of differentiating symptoms of ASD from those of other developmental disorders. In February 2016, the United States Preventive Services Task Force concluded that there is insufficient evidence to adequately assess the balance of benefits and harms of universal screening of children 18 to 30 months of age for ASD [78]. Pending additional evidence, we continue to suggest universal screening for ASD in children at 18 and 24 months of age. In our estimation, the potential benefits of early detection outweigh the potential harms of screening (eg, time, effort, anxiety). (See "Autism spectrum disorder: Surveillance and screening in primary care", section on 'Our screening recommendations'.)

PEDIATRIC IMMUNIZATIONS

Nonmedical vaccine exemptions and risk of measles and pertussis (March 2016)

Despite universal childhood vaccination programs in the United States, the incidence of measles and pertussis has increased since the early 2000s. A systematic review evaluated the association between vaccine refusal and measles or pertussis infection in the United States between 2000 and 2015 [79]. Nearly 60 percent of 1416 measles cases occurred in people who were not vaccinated against measles. Among the 574 unvaccinated cases who were old enough to have received measles vaccine, 71 percent refused it for nonmedical reasons (eg, religious or philosophic beliefs). Nonmedical exemptions also were prevalent among unvaccinated cases of pertussis (ranging from 59 to 93 percent in eight outbreaks). These findings confirm that nonmedical exemptions increase the risk of vaccine-preventable illness in the unvaccinated individual and, by reducing overall community immunity, increase the risk of illness in children too young to be vaccinated, people with medical contraindications to vaccination, and vaccinated people with waning immunity [80]. (See "Standard childhood vaccines: Parental hesitancy or refusal", section on 'For the individual'.)

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