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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.
ABDOMINAL WALL AND HERNIA SURGERY
Mesh in incisional hernia repair (October 2016)
Mesh is widely used in incisional hernia repair, but the balance of risks versus benefits remains controversial. A registry-based cohort study including over 3000 elective incisional hernia repairs compared the outcomes of open and laparoscopic mesh repair with open nonmesh repair . At five years, mesh repair was associated with fewer reoperations for recurrences, but more reoperations for mesh-related complications. Based on this and other studies, we use mesh for repairing moderate- to large-sized hernias to reduce recurrences. For smaller hernias (<4 cm) where the risk of recurrence is low, mesh can be omitted to avoid potential complications. (See "Incisional hernia", section on 'Suture repair versus mesh repair'.)
ANESTHESIA AND PERIOPERATIVE CARE
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'.)
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)'.)
Transfusion outcomes with "fresh" versus "old" blood (November 2016)
The INFORM trial (Informing Fresh versus Old Red Cell Management) is the largest trial to compare clinical outcomes with "fresh" versus "old" blood . In INFORM, over 20,000 hospitalized adults who required transfusion were randomly assigned to receive "old" red blood cells (RBCs; stored for a mean of 24 days) or "fresh" RBCs (stored for a mean of 13 days). There were no differences in mortality or hospital length of stay. Smaller trials in adults, children, and neonates have also concluded that outcomes are unaffected by RBC storage duration. (See "Red blood cell transfusion in adults: Storage, specialized modifications, and infusion parameters", section on 'Clinical relevance of storage time'.)
Updated guideline and meta-analysis on hemoglobin thresholds for blood transfusion (November 2016)
An updated systematic review and meta-analysis of randomized trials involving over 12,000 patients has provided more support for the use of a restrictive transfusion strategy (giving less blood, transfusing at a lower hemoglobin level, typically 7 to 8 g/dL) for most hemodynamically stable medical and surgical patients who are not actively bleeding or symptomatic from anemia . An updated 2016 guideline from the AABB (an international organization) also supports the use of restrictive thresholds . The major exception is patients with acute coronary syndromes (ACS), for whom data from large randomized trials are not available and for whom pilot trials suggest a more liberal threshold may be associated with better outcomes. We continue to use an individualized approach to transfusion in patients with ACS. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult", section on 'Society guidelines'.)
Safety of magnetic resonance imaging and gadolinium in pregnancy (September 2016)
Magnetic resonance imaging (MRI) may be used for diagnostic imaging in pregnancy when ultrasound examination is inadequate; however, fetal safety has not been conclusively established. Recently, the largest study of MRI in pregnancy (over 1700 exposed and 1.4 million unexposed births) reported that first-trimester MRI was not associated with significantly increased risks for stillbirth, neonatal death, congenital anomaly, neoplasm, or vision or hearing loss in children followed up to age four years, when adjustments were made for differences between exposure groups . The study also found that gadolinium exposure at any time during pregnancy was associated with an increased risk for stillbirth and neonatal death. Children exposed in utero were at increased risk for rheumatological, inflammatory, or infiltrative skin conditions, but not congenital anomalies or nephrogenic systemic fibrosis (NSF). This study is a major addition to the body of evidence supporting the safety of MRI in pregnancy when medically indicated. It also provides the first data supporting existing recommendations to avoid use of gadolinium-based contrast agents in pregnant women, when possible. (See "Diagnostic imaging procedures during pregnancy", section on 'Magnetic resonance imaging'.)
Outcomes after PCI in patients with MI after noncardiac surgery (August 2016)
Mortality in patients who sustain a myocardial infarction (MI) after noncardiac surgery is known to be high. Outcomes were evaluated in a cohort of such individuals who were referred for coronary angiography and possible percutaneous coronary intervention (PCI) within seven days of surgery . Among those who ultimately underwent PCI, the 30-day death rate was 31.2 percent in those with ST-elevation MI and 8.5 percent in those with non-ST elevation MI. The optimal management strategy for those patients who sustain an MI in the perioperative period is unknown. (See "Perioperative myocardial infarction after noncardiac surgery", section on 'Prognosis after MI'.)
Aspirin does not prevent acute respiratory distress syndrome in adults (July 2016)
Preclinical and clinical observational studies have suggested a potential role for aspirin in the prevention of acute respiratory distress syndrome (ARDS). The ability of aspirin to prevent ARDS was tested in a randomized trial of 390 patients who were assessed upon presentation to an emergency department to be at risk of developing ARDS . Aspirin, administered at 325 mg orally followed by 81 mg daily for seven days, had no effect on the incidence of ARDS at one week (approximately 10 percent in each group). However, the lower than expected rate of ARDS in this study may have limited the potential to detect a study drug effect. (See "Acute respiratory distress syndrome: Investigational or ineffective pharmacotherapy in adults", section on 'Aspirin'.)
ARTERIAL AND VENOUS ACCESS
Regional anesthesia for hemodialysis arteriovenous fistula creation (November 2016)
Regional anesthesia during the creation of hemodialysis arteriovenous fistulas causes arterial and venous dilation, which may improve early fistula patency. In a trial that randomly assigned 126 adults receiving primarily radiocephalic or brachiocephalic fistulas to brachial plexus block or local anesthesia, brachial plexus block resulted in a higher rate of primary fistula patency and a trend toward a higher rate of functional patency at three months . Based upon these findings, we suggest brachial plexus block for the creation of arteriovenous fistulas, rather than using local anesthesia alone. (See "Creating an arteriovenous fistula for hemodialysis", section on 'Type of anesthesia'.)
Locking solutions for preventing hemodialysis catheter malfunction (July 2016)
Heparin is commonly used as a locking solution to prevent hemodialysis catheter malfunction. Alternative locking solutions (eg, citrate, recombinant tissue plasminogen activator, various antimicrobial agents) and systemic anticoagulation (eg, warfarin) have also been tried. In a recent metaanalysis of randomized trials of alternative agents for preventing central venous hemodialysis catheter malfunction, the incidence of malfunction was not significantly different with use of alternative locking solutions or systemic agents compared with usual care, which was typically instillation of heparin 5000 units into each catheter port . The results of this systematic review confirm our practice of using heparin to minimize catheter malfunction, given its ease of use, availability, and relatively low cost compared with alternative agents. (See "Central catheters for acute and chronic hemodialysis access", section on 'Anticoagulant locking solutions'.)
Surgical margin in breast conserving surgery for ductal carcinoma in situ (October 2016)
For women undergoing breast conserving therapy for ductal carcinoma in situ (DCIS), surgical resection margins have a significant impact on local recurrence, but the optimal margin has been controversial. A meta-analysis found a 2 mm margin was associated with a twofold reduction in local recurrence rates compared with a positive margin, and equivalent recurrence rates compared with wider margins . A multidisciplinary consensus guideline advises that 2 mm be the standard for an adequate margin in DCIS treated with breast conserving surgery followed by whole breast irradiation . Clinical judgment is advised when determining whether patients with a negative but <2 mm margin require re-excision. (See "Breast conserving therapy", section on 'Margins for DCIS'.)
Conventional hemorrhoidectomy versus stapled hemorrhoidopexy for internal hemorrhoids (November 2016)
Conventional hemorrhoidectomy and stapled hemorrhoidopexy are the surgical procedures most commonly used to treat symptomatic or prolapsing internal hemorrhoids. In a large randomized trial comparing the two procedures, stapled hemorrhoidopexy resulted in less postoperative pain in the initial six weeks, but more recurrences and worse symptoms and quality of life at 12 and 24 months . Thus, we suggest conventional hemorrhoidectomy for most patients seeking surgical treatment for symptomatic or prolapsing internal hemorrhoids. Patients who prefer to minimize pain and “downtime” after surgery may benefit from stapled hemorrhoidopexy. (See "Surgical treatment of hemorrhoidal disease", section on 'Conventional versus stapled'.)
Hemorrhoidal artery ligation not superior to rubber band ligation for internal hemorrhoids (August 2016)
Doppler-guided transanal hemorrhoidal artery ligation (HAL) is a relatively new procedure that uses Doppler ultrasound to identify and ligate the hemorrhoidal arterial blood supply. In a recent trial of 337 patients with grade II or III internal hemorrhoids randomly assigned to treatment with HAL or rubber band ligation (RBL), HAL resulted in greater pain, more serious adverse events requiring hospitalization, and higher costs, but fewer recurrences within 12 months of the procedure . However, the additional recurrences in the RBL group were largely attributable to repeated procedures in patients with multiple hemorrhoids. Repeat RBL is common in this group since typically only one hemorrhoid column is banded at each RBL session. Given its low morbidity and cost, RBL remains the first-line treatment for symptomatic internal hemorrhoids. (See "Surgical treatment of hemorrhoidal disease", section on 'Hemorrhoidal artery ligation'.)
Prevention of graft reinfection in HCV-infected patients undergoing liver transplantation (December 2016)
In the absence of viral suppression or clearance of chronic hepatitis C virus (HCV) in patients who undergo liver transplantation, the new liver is almost always reinfected. In an open-label study, 16 HCV genotype 1-infected patients undergoing their first liver transplantation from an uninfected donor received a single dose of ledipasvir-sofosbuvir the day they arrived at the hospital for transplantation and once daily for four weeks postoperatively . The sustained virologic response rate 12 weeks after completion of treatment was 88 percent, suggesting that an abbreviated perioperative course of direct-acting antiviral (DAA) treatment can prevent reinfection of the graft. Additional studies are warranted to confirm the efficacy and safety of this approach in other HCV-infected populations and with other DAA regimens. (See "Recurrence of hepatitis C virus infection following liver transplantation", section on 'Perioperative therapy'.)
Screening for cardiovascular disease before kidney transplantation (October 2016)
Cardiovascular disease is the leading cause of mortality in kidney transplant recipients. Although pretransplant cardiac evaluation is recommended for potential transplant candidates, the optimal screening strategy has not yet been identified. In a prospective study comparing clinical risk factor assessment with coronary artery calcium (CAC) scores among 138 pretransplant patients, CAC scores were not superior to risk factor assessment in identifying patients who would benefit from noninvasive testing for coronary heart disease (CHD) . Both clinical risk factor assessment and CAC scores had a poor positive predictive value but a high negative predictive value for identifying patients with CHD. (See "Evaluation of the potential renal transplant recipient", section on 'Coronary heart disease'.)
Perioperative complications in minimally invasive live donor nephrectomy (September 2016)
Minimally invasive donor nephrectomies account for more than half of live donor nephrectomies performed for kidney transplantation. A systematic review of over 32,000 minimally invasive live donor nephrectomies demonstrated a low operative mortality rate of 0.01 percent and low rates of intraoperative and postoperative complications (primarily bleeding and infections) . Comparison of the different minimally invasive techniques found similar complication rates between hand-assisted versus non-hand-assisted, laparoscopic versus retroperitoneoscopic, and multiport versus single-port procedures. (See "Benefits and complications of minimally invasive live-donor nephrectomy", section on 'Donor morbidity'.)
TRAUMA AND BURN SURGERY
Oxandrolone to treat moderate-to-severe burns (August 2016)
Many pharmacological therapies have been tried to reverse the damaging effects of the hypermetabolic response to severe injury. Trials evaluating anabolic steroids, which improve protein balance, have reported inconsistent outcomes. A recent systematic review included 15 randomized trials of adults and children with severe burns (>20 percent total body surface area) treated with oxandrolone, a testosterone analog, versus placebo or blank controls . Meta-analyses of individual outcome measures in the acute phase, intermediate phase, and long term showed significant improvements in metabolic parameters (eg, less nitrogen loss, less weight loss, increased lean body mass, improved wound healing), shortened length of stay, and no significant differences in adverse events (mortality, infection, liver dysfunction). These results support our recommendation to treat all patients with moderate-to-severe burns with oxandrolone (10 mg twice daily in adults; 5 mg twice daily in children and patients >65 years of age). (See "Hypermetabolic response to severe burn injury".)
New guidelines for the management of Stevens-Johnson/toxic epidermal necrolysis syndrome (August 2016)
The British Association of Dermatologists released new guidelines for the management of Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), a severe and potentially fatal mucocutaneous drug reaction . The guidelines provide evidence-based recommendations for the diagnosis, severity assessment, and management of SJS/TEN. Specific areas covered include initial management, supportive care, and therapies intended to reduce mortality, such as intravenous immune globulins, systemic corticosteroids, and cyclosporine. The treatment of eye involvement, including systemic therapies and amniotic membrane transplantation to prevent permanent ocular sequelae, as well as the management of oral, urogenital, and airway mucosal involvement are also addressed. (See "Stevens-Johnson syndrome and toxic epidermal necrolysis: Management, prognosis, and long-term sequelae", section on 'General principles'.)
Thromboelastography-guided transfusion in trauma patients (July 2016)
Coagulopathy associated with trauma is evident in 25 to 35 percent of severely injured civilian patients and is associated with increased morbidity and mortality. Thromboelastography (TEG) is a point-of-care testing method that rapidly provides information on the properties of clot formation, detects hyperfibrinolysis, and may offer an advantage over standard coagulation assays. The results of a randomized trial are consistent with observations suggesting that TEG-parameter-guided resuscitation may improve outcomes . Following initial transfusion triggered by activation of a massive transfusion protocol, 111 injured patients were randomly assigned to subsequent transfusions based upon TEG parameters or conventional coagulation assays. Mortality rates were significantly lower for the TEG group compared with the conventional group at 6 hours and 28 days (7.1 versus 21.8 percent, and 19.6 versus 36.4 percent, respectively). Although there were no differences in the overall volume of transfusion at 24 hours, the standard assay group received more plasma and platelets during the first several hours of resuscitation. Where TEG is available, we suggest TEG-based goal-directed resuscitation for trauma patients requiring massive transfusion. (See "Coagulopathy associated with trauma", section on 'Thromboelastography-based transfusion'.)
VASCULAR AND ENDOVASCULAR SURGERY
Long-term follow-up of percutaneous femoropopliteal angioplasty for claudication (January 2017)
Whether minimally invasive vascular intervention improves the clinical status of patients with claudication due to peripheral artery disease (PAD) is debated. The early outcomes of a trial comparing femoropopliteal percutaneous transluminal angioplasty (PTA), a supervised exercise program (SEP), or combined treatment (PTA + SEP) found combined treatment produced a greater improvement in some clinical outcome measures than PTA or SEP alone. However, longer-term follow-up (mean 5.2 years) is now available and showed no significant differences between the groups for observed treadmill walking distances, restenosis rates, or quality-of-life outcomes . These results support our recommendation to treat claudication with a medical therapy regimen that includes risk factor modification and exercise therapy (and possibly pharmacologic therapy), rather than any form of vascular intervention. (See "Management of claudication", section on 'Initial therapy'.)
Angioplasty in renal artery stenosis (November 2016)
In patients with atherosclerotic renal artery stenosis, a meta-analysis of trials comparing percutaneous transluminal renal angioplasty (PTRA) with stent placement plus medical therapy with medical therapy alone found no benefit from PTRA on mortality, end-stage renal disease, major cardiovascular events, or blood pressure control . One or more major periprocedural complications occurred in 7.1 percent of patients who underwent PTRA. Thus, in patients with renal artery stenosis and clinical characteristics similar to those enrolled in these trials, we suggest not revascularizing and instead treating with medical therapy alone. (See "Treatment of unilateral atherosclerotic renal artery stenosis", section on 'Revascularization versus medical therapy alone'.)
Long-term outcomes of endovascular versus open abdominal aneurysm repair (November 2016)
For intact aneurysms, endovascular repair of abdominal aortic aneurysms (EVAR) results in lower perioperative mortality than open repair, but data on long-term risks and benefits are sparse. In the longest follow-up study, the endovascular aneurysm repair trial (EVAR 1) reported that the early benefit of EVAR was lost beginning about eight years after randomization due to late fatal secondary aneurysm ruptures, and that total mortality was the same for EVAR or open repair by the end of the follow-up period (mean 12.7 years) . The EVAR group also had higher cancer mortality, which was not reported in similar studies and may have been related to more frequent surveillance in EVAR 1. This study affirms previous data that EVAR does not result in a long-term survival advantage over open repair. (See "Management of asymptomatic abdominal aortic aneurysm", section on 'EVAR 1 trial'.)
Bioresorbable drug-eluting iliac artery stenting for PAD (July 2016)
Metal stents are commonly used to treat suboptimal transluminal angioplasty, but restenosis remains a problem. Bioresorbable scaffolds have been used in the coronary circulation, but may increase stent thrombosis. A recent feasibility study reported the first clinical use of a drug-eluting (everolimus) bioresorbable vascular scaffold to treat 66 patients with symptomatic peripheral artery disease in the iliac or femoral arteries . At one and two years follow-up, binary restenosis rates (>50 percent) were 12.1 and 16.1 percent, respectively, and freedom from target lesion revascularization was 91.2 and 88.2 percent, respectively. There were no procedure-related amputations or deaths at two years follow-up. Although these results are encouraging, direct comparisons with drug-eluting balloons and drug-eluting polymer-coated metal stents are needed. (See "Percutaneous interventional procedures in the patient with lower extremity claudication", section on 'Aortoiliac occlusive disease'.)
Ticagrelor in patients with peripheral artery disease (July 2016)
Patients with a history of myocardial infarction and concomitant lower extremity peripheral artery disease (PAD) are at increased risk for both systemic and limb ischemic events. Long-term antiplatelet therapy with aspirin is recommended for these patients. Whether adding a second agent offers additional benefits in this population is unclear. A recent large multicenter trial randomly assigned over 21,000 patients with prior myocardial infarction (MI) to ticagrelor 90 mg twice daily, ticagrelor 60 mg twice daily, or placebo in addition to low-dose aspirin . Among the subset of patients with previously identified PAD (n = 1143), compared with placebo, use of ticagrelor reduced the absolute rate of major adverse cardiovascular events (MACE) by 4.1 percent and reduced the risk for peripheral revascularization for limb ischemia (hazard ratio [HR] 0.63; 95% CI 0.43-0.93), with a 0.12 percent absolute excess of major bleeding. Given methodologic issues with data ascertainment, further trials are needed to determine if the benefits of dual therapy outweigh the bleeding risk. We do not use dual antiplatelet therapy in patients with PAD in the absence of other indications (eg, drug-eluting stent). (See "Overview of lower extremity peripheral artery disease", section on 'Antithrombotic therapy'.)
OTHER SURGICAL SPECIALTIES
Vertebroplasty for osteoporotic compression fractures (November 2016)
The indications for and timing of vertebroplasty for the treatment of osteoporotic compression fractures are controversial. In a trial comparing vertebroplasty or simulated vertebroplasty (sham) in 120 patients with acute (less than six weeks) vertebral fracture and back pain, more patients in the vertebroplasty group achieved clinically significant lower pain scores at 14 days . Two previous sham-controlled trials, however, did not show a significant reduction in pain with vertebroplasty, likely due to differences in study design, including different sham procedures for the control arm and varying definitions of acute vertebral fracture. (See "Osteoporotic thoracolumbar vertebral compression fractures: Clinical manifestations and treatment", section on 'Vertebroplasty'.)
Alpha-1-blocker therapy for symptoms from benign prostate hyperplasia (November 2016)
Drug treatment can reduce symptoms from benign prostatic hyperplasia (BPH), but the comparative effectiveness of different drug treatments has not been well studied. A meta-analysis commissioned by the Agency for Healthcare Research and Quality (AHRQ) compared drugs or combinations of drugs developed in the past 10 years for treatment of BPH with monotherapy using older drugs . Treatment with a newer alpha-1-blocker (AB) (silodosin), a combination of an anticholinergic drug (fesoterodine, tolterodine, or solifenacin) with an AB, or a phosphodiesterase type 5 (PDE-5) inhibitor (tadalafil) resulted in similar short-term symptom relief but a greater risk of adverse effects compared with treatment with an older AB (primarily tamsulosin). There was insufficient evidence to draw conclusions about other newer drugs. Thus, we suggest initial treatment of BPH symptoms with an AB alone, and choose the AB based upon cost, side effects (particularly hypotension), and potential medication interactions (especially with PDE-5 inhibitors). (See "Medical treatment of benign prostatic hyperplasia", section on 'Efficacy and administration'.)
M. chimaera infections associated with cardiac surgery (October 2016)
Clusters of disseminated infection with Mycobacterium chimaera in the United States and Europe have been linked to exposure to contaminated Stockert 3T heater-cooler devices during cardiac surgery . In the United States, the Food and Drug Administration recommends retiring 3T heater-cooler devices and accessories that have tested positive for M. chimaera or that have been linked to known infections and refraining from using any 3T heater-cooler device manufactured before September 2014 except in emergency situations. Providers of patients who have undergone cardiac surgery should be aware of the possibility of M. chimaera infection, even months to years following the procedure. (See "Overview of nontuberculous mycobacterial infections in HIV-negative patients", section on 'Disseminated disease'.)
Thymectomy for myasthenia gravis (August 2016)
Lacking evidence from randomized trials, thymectomy for patients with nonthymomatous myasthenia gravis (MG) had been controversial. Now, the benefit of thymectomy is supported by the results of the multicenter, assessor-blinded MGTX trial, which enrolled 126 subjects with generalized acetylcholine receptor (AChR) antibody-associated MG and randomly assigned them to thymectomy plus alternate-day prednisone or alternate-day prednisone alone . Over a three-year period, thymectomy improved multiple clinical outcomes, including quantitative strength testing, average alternating-day prednisone requirements (44 versus 60 mg), need for azathioprine immunosuppression (17 versus 48 percent), and hospitalization for acute exacerbations (9 versus 37 percent). Based on these results and prior observational data, we recommend thymectomy for patients age <60 years with nonthymomatous, generalized acetylcholine receptor (AChR) antibody-associated MG. Thymectomy is also indicated in all patients with thymoma if resection is feasible. (See "Thymectomy for myasthenia gravis", section on 'Efficacy'.)
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- Ferguson I, Bell A, Treston G, et al. Propofol or Ketofol for Procedural Sedation and Analgesia in Emergency Medicine-The POKER Study: A Randomized Double-Blind Clinical Trial. Ann Emerg Med 2016; 68:574.
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- Gonzalez E, Moore EE, Moore HB, et al. Goal-directed Hemostatic Resuscitation of Trauma-induced Coagulopathy: A Pragmatic Randomized Clinical Trial Comparing a Viscoelastic Assay to Conventional Coagulation Assays. Ann Surg 2016; 263:1051.
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