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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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What's new in family medicine

What's new in family medicine
Literature review current through: Jan 2024.
This topic last updated: Feb 01, 2024.

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

High-dose glucocorticoid therapy not preferred in patients with sudden sensorineural hearing loss (January 2024)

Glucocorticoid therapy is the initial treatment for patients with sudden sensorineural hearing loss (SSNHL), but optimal dosing is uncertain. In a trial among 325 patients with SSNHL, five days of either high-dose intravenous prednisolone (250 mg/d) or high-dose oral dexamethasone (40 mg/d) did improve hearing more than low-dose oral prednisone (five days at 60 mg/d followed by five days of tapering doses), but increased adverse events [1]. In patients with SSNHL, we use a low-dose regimen of oral glucocorticoids. (See "Sudden sensorineural hearing loss in adults: Evaluation and management", section on 'Initial therapy'.)

Macular changes related to pentosan polysulfate sodium (November 2023)

Macular eye disease has been reported in patients who have taken pentosan polysulfate sodium (PPS), which is used for the treatment of interstitial cystitis. In a prospective cohort study of 26 eyes with PPS maculopathy and >3000 g cumulative PPS exposure, progression of macular changes continued 13 to 30 months after drug cessation [2]. Median visual acuity decreased slightly; most patients reported progression of symptoms, including difficulty in low-light environments and blurry vision. These results indicate that PPS maculopathy progresses despite drug discontinuation, underscoring the importance of regular screening for maculopathy in patients with current or prior PPS exposure. (See "Interstitial cystitis/bladder pain syndrome: Management", section on 'Pentosan polysulfate sodium as alternative'.)

Long distance effect of wildfire smoke on asthma symptoms (October 2023)

Wildfire fine particulate matter (PM2.5) has been shown to affect respiratory health; however, previous work has focused on populations residing near and directly affected by wildfires. In June 2023, smoke from wildfires in Canada drifted hundreds of miles to New York City, resulting in increased ambient PM2.5. During smoke waves, emergency department visits for asthma in both pediatric and adult patients increased to 261 per day (reference during nonsmoke periods, 181.5 per day; incidence rate ratio 1.4) [3]. Wildfires have health effects far from their source and are particularly hazardous to those with underlying lung disease. (See "Climate emergencies", section on 'Changing wildfire exposure'.)

Nurse-delivered brief behavioral treatment for insomnia (October 2023)

A growing body of evidence supports the use of brief, behaviorally-focused treatments for insomnia, which involve fewer sessions than traditional cognitive behavioral therapy and can be delivered by clinicians with varied levels of expertise. In an open-label randomized trial in England involving nearly 650 adults with insomnia disorder recruited from 35 general practices, four sessions of nurse-delivered sleep restriction therapy (table 1) improved patient-reported insomnia severity scores and six-month response rates compared with a sleep hygiene booklet alone (table 2) [4]. Training nurses or advanced practice providers to deliver brief behavioral treatments may be a feasible and cost-effective way to improve outcomes for insomnia. (See "Cognitive behavioral therapy for insomnia in adults", section on 'Brief behavioral treatment approaches'.)

Semaglutide in patients with heart failure with preserved ejection fraction and obesity (September 2023)

In patients with heart failure with preserved ejection fraction (HFpEF), weight loss is likely to improve functional status and quality of life, but achieving weight loss in this group of patients is difficult. In a recent trial of more than 500 patients with HFpEF, patients randomly assigned to treatment with semaglutide had greater improvement in exercise capacity (ie, six-minute walk distance), quality of life, and weight loss (-13 percent mean change in body weight versus -2.6 percent) at 52 weeks than patients assigned to placebo [5]. An exploratory analysis suggested a lower risk of urgent HF hospitalizations in those treated with semaglutide. Similar to other patients with obesity, patients with HFpEF and obesity should receive appropriate management to achieve weight loss. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Obesity'.)

Low awareness of meat allergy caused by "alpha-gal syndrome" (September 2023)

Allergy to galactose-alpha-1,3-galactose, a carbohydrate allergen found in all mammalian meat except that of primates, causes allergic reactions to meats like beef, pork, and lamb, as well as to an array of other products, medications, and medical devices made with mammalian tissues. This allergy, first reported in 2009 and termed "alpha-gal syndrome," develops following the bites of certain ticks and causes reactions that are uncharacteristically delayed (ie, several hours after ingestion). A common presentation is anaphylaxis developing in the middle of the night after a meat-containing evening meal. Although the prevalence is increasing worldwide, a web-based survey of 1,500 health care professionals in the United States revealed that 42 percent had never heard of the disorder [6]. This lack of awareness can delay diagnosis for decades. (See "Allergy to meats", section on 'In whom to suspect the diagnosis'.)

Over-the-counter opioid antagonist for opioid overdose (September 2023)

Drug overdose is a major public health problem; opioids were reported to be involved in nearly 80 percent of the 600,000 overdose deaths worldwide in 2019. The increasing rate of fatal overdose is driven by the presence of the synthetic opioid fentanyl. Naloxone 4 mg nasal spray rapidly reverses the effects of opioid overdose and is now the first opioid antagonist agent available for over-the-counter purchase in the United States [7]. The increased availability is part of an ongoing effort by the US Food and Drug Administration Overdose Prevention Framework to encourage harm reduction through developing and expanding access to novel overdose reversal products. (See "Prevention of lethal opioid overdose in the community", section on 'Community-based naloxone'.)

No benefit of opioids for acute low back pain (August 2023)

Opioid analgesics are often used to treat acute low back pain despite limited supporting evidence. In a randomized trial of 347 adults presenting to the emergency department or primary care clinic with acute, nonspecific low back pain, oxycodone (up to 20 mg daily for six weeks) was no more effective for pain relief or functional improvement than placebo [8]. There was a higher risk of potential opioid misuse in patients in the oxycodone group at one-year follow-up (20 versus 10 percent). These results support our recommendation against routine opioid use for acute low back pain, given the lack of benefit and potential for misuse. (See "Treatment of acute low back pain", section on 'Opioids'.)

Exercise and cardiovascular risk reduction (July 2023)

Current guidelines from the American Heart Association and World Health Organization recommend at least 150 minutes of moderate-to-vigorous physical activity weekly. Two recent studies suggest that how one exercises matters more than when. In one prospective cohort of over 500,000 individuals, combining twice-weekly muscle strengthening activity to at least 150 minutes of moderate-to-vigorous physical activity was associated with optimal reductions in all-cause and cardiovascular mortality [9]. In a separate study of nearly 90,000 individuals, among those who had at least 150 minutes of weekly physical activity, "weekend warrior" patterns of exercise (at least 50 percent of activity occurring over one to two days) and "regular" patterns (physical activity distributed more evenly during the week) were associated with similar reductions in the risk of myocardial infarction, stroke, heart failure, and atrial fibrillation compared with inactivity [10]. These findings provide support for recommending exercise whenever it is most feasible for patients and adding regular resistance training. (See "Exercise and fitness in the prevention of atherosclerotic cardiovascular disease", section on 'Type, intensity, and duration of exercise'.)

GERIATRICS

Risk of fractures with benzodiazepine receptor agonists (January 2024)

Benzodiazepine receptor agonists (BZRAs), including benzodiazepines and nonbenzodiazepine BZRAs such as zolpidem, can cause excess drowsiness and imbalance leading to falls and fractures. In a recent meta-analysis of 20 observational studies in over six million individuals, BZRAs were associated with increased risk of osteoporotic fractures across a range of drug classes and fracture types, with odds ratios ranging from 1.2 to 1.4 [11]. Most but not all studies included adults 50 years of age or older. These data reinforce the need for caution in prescribing BZRAs for insomnia and other indications, particularly in older adults. (See "Pharmacotherapy for insomnia in adults", section on 'Special populations'.)

IMMUNIZATIONS

2024 immunization schedule for adults (January 2024)

The United States Centers for Disease Control and Prevention has published the 2024 immunization schedule for adults (figure 1 and figure 2) [12]. Respiratory syncytial virus (RSV) vaccine is a new addition to the schedule; it is recommended for pregnant people 32 to 36 weeks' gestation during RSV season and is an option for adults ≥60 years of age. Mpox vaccine has also been added and is recommended for adults of all ages who are at risk for infection. Other changes include updates to COVID-19, polio, and meningococcal vaccine recommendations. Our approach to immunization is largely consistent with these updated recommendations. (See "Standard immunizations for nonpregnant adults", section on 'Immunization schedule for nonpregnant adults'.)

Nirsevimab to prevent severe respiratory syncytial virus in infants (January 2024)

Nirsevimab is a new antibody that prevents severe respiratory syncytial virus (RSV) infection in infants. In a trial conducted in France, Germany, and the United Kingdom, more than 8000 otherwise healthy infants ≤12 months, born at ≥29 weeks' gestation, and entering their first RSV season were assigned to receive one dose of nirsevimab or no intervention [13]. The group who received nirsevimab had fewer hospitalizations for RSV-associated lower respiratory tract infection (0.3 versus 1.5 percent, efficacy 83.2 percent, 95% CI 67.8-92.0) and fewer infants with an oxygen saturation <90 percent (0.1 versus 0.5 percent, efficacy 75.7 percent, 95% CI 32.8-92.9). These findings further support the use of nirsevimab for RSV immunoprophylaxis in infants. (See "Respiratory syncytial virus infection: Prevention in infants and children", section on 'Immunoprophylaxis'.)

R21/Matrix-M vaccine to prevent malaria in children (November 2023)

In October 2023, the World Health Organization (WHO) approved the R21/Matrix-M vaccine for prevention of malaria in children [14]. In a placebo-controlled randomized trial of 4800 children (age 5 to 36 months) in four African countries, 12-month efficacy of a three-dose vaccine series against clinical malaria was 75 percent at sites with seasonal transmission and 68 percent at sites with year-round transmission; these data are under peer review prior to publication [15]. The vaccine was well tolerated. Injection site pain and fever were the most frequent adverse events. Together with the RTS,S/AS01 vaccine (recommended by the WHO in 2021), this approval is expected to facilitate sufficient vaccine supply to benefit all children living in areas where malaria is a public health risk. (See "Malaria: Epidemiology, prevention, and control", section on 'R21/Matrix-M vaccine'.)

ACIP recommendations for 2023-24 seasonal influenza vaccination (September 2023)

The Advisory Committee on Immunization Practices (ACIP) issued new recommendations for seasonal influenza vaccination in August 2023 (table 3) [16]. The antigenic composition has been updated. In addition, the ACIP now states that egg allergy alone no longer necessitates additional safety measures for influenza vaccination, including with egg-based vaccines, beyond those recommended for any recipient of any vaccine, regardless of severity of previous reaction to egg. All vaccines should be administered in settings where personnel and equipment needed for prompt recognition and treatment of acute hypersensitivity reactions are available. This is consistent with our previous guidance. (See "Seasonal influenza vaccination in adults", section on 'Antigenic composition'.)

Updated COVID-19 mRNA vaccine recommendations (September 2023)

The US Food and Drug Administration and Centers for Disease Control and Prevention have updated COVID-19 vaccine authorizations and recommendations [17,18]. Available COVID-19 vaccines have been updated to target Omicron variant XBB.1.5 (Moderna COVID-19 vaccine 2023-2024 formula, Pfizer COVID-19 vaccine 2023-2024 formula, and Novavax 2023-2024 formula); bivalent vaccines are no longer available. An updated 2023-2024 formula vaccine is recommended for all individuals aged six months and older. Immunocompetent individuals five years and older should receive one updated vaccine, regardless of prior vaccination history. For individuals who are four years or younger or have an immunocompromising condition (table 4), the number of recommended updated vaccines depends on their vaccination history. Our approach to COVID-19 vaccination is consistent with these recommendations. (See "COVID-19: Vaccines", section on 'Indications and vaccine selection' and "COVID-19: Vaccines", section on 'Benefits of vaccination'.)

PREVENTION

Immunoprophylaxis for severe respiratory syncytial virus in infants (October 2023)

Nirsevimab is a new monoclonal antibody that targets the prefusion conformation of the respiratory syncytial virus (RSV) F glycoprotein [19]. It has a longer half-life than palivizumab, an existing antibody that requires five monthly injections to provide immunoprophylaxis against severe RSV infection. The efficacy and safety of nirsevimab were demonstrated in two randomized placebo-controlled trials, one involving 1490 infants ≥35 weeks' gestation and the other involving >1400 preterm infants (29 to <35 weeks' gestation) [20,21]. In both trials, a single intramuscular dose of nirsevimab lowered rates of RSV-related medical evaluation and hospital admissions for RSV. In line with American Academy of Pediatrics and United States Centers for Disease Control and Prevention guidance, we now recommend that infants <8 months old receive one dose of nirsevimab during their first RSV season if the birthing parent did not receive RSV vaccination between 32 and 36 weeks of gestation and at least 14 days prior to delivery. Palivizumab may be used in high-risk infants if nirsevimab is not available. (See "Respiratory syncytial virus infection: Prevention in infants and children", section on 'Immunoprophylaxis'.)

SCREENING

Screening for major depressive disorder in adults (October 2023)

Major depressive disorder is a leading cause of disability in the United States, with a lifetime prevalence of approximately 20 percent; however, it remains underdetected and undertreated. Updated guidelines from the United States Preventive Services Task Force recommend screening for depression in adults (ages 19 years and above), including pregnant and postpartum women, based upon a systematic review that suggested a net benefit from screening [22]. These guidelines are consistent with our suggestion that primary care clinicians routinely screen adults for depression with diagnostic evaluation and treatment for those who screen positive. (See "Screening for depression in adults".)

Overdiagnosis of breast cancer in older women (October 2023)

Overdiagnosis, the detection of a disease that would not have caused morbidity or mortality if it had not been found, is a concern in breast cancer screening, particularly among older patients. In a 2023 study in over 54,000 women 70 years and older who had recently undergone screening, the percent of overdiagnosed breast cancer cases increased with age from 31 percent among women aged 70 to 74 years to 54 percent among women aged 85 years and older [23]. We utilize a shared decision-making framework for breast cancer screening in older women to balance potential risks and benefits. (See "Screening for breast cancer: Evidence for effectiveness and harms", section on 'Overdiagnosis'.)

ADULT CARDIOVASCULAR MEDICINE

Sport participation among athletes with increased risk of fatal arrhythmias (October 2023)

In patients who participate in competitive athletics and have a diagnosis that increases the risk of fatal arrhythmias, return to sport participation may provoke an arrhythmia or risk damage to an internal cardioverter-defibrillator (ICD). In a recent single-center report of 76 patients with a genetic cardiomyopathy that increased the risk of sudden death (32 percent with an ICD) who underwent tailored treatment and a shared decision-making process before returning to elite sport participation, there were four arrhythmic events and no fatalities during 200 patient-years of observation [24]. The small study size and nonstandardized approach to risk assessment and counseling limit the generalizability of these findings. In patients with an increased risk of fatal arrhythmias, we advise against participation in competitive sports, but some athletes may choose to participate based on their values and preferences following a shared decision-making process. (See "Athletes with arrhythmias: Treatment and returning to athletic participation", section on 'Athletes with ICDs'.)

Semaglutide in patients with heart failure with preserved ejection fraction and obesity (September 2023)

In patients with heart failure with preserved ejection fraction (HFpEF), weight loss is likely to improve functional status and quality of life, but achieving weight loss in this group of patients is difficult. In a recent trial of more than 500 patients with HFpEF, patients randomly assigned to treatment with semaglutide had greater improvement in exercise capacity (ie, six-minute walk distance), quality of life, and weight loss (-13 percent mean change in body weight versus -2.6 percent) at 52 weeks than patients assigned to placebo [5]. An exploratory analysis suggested a lower risk of urgent HF hospitalizations in those treated with semaglutide. Similar to other patients with obesity, patients with HFpEF and obesity should receive appropriate management to achieve weight loss. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Obesity'.)

ADULT GASTROENTEROLOGY

Mortality risk in alcohol-associated liver disease (January 2024)

Few studies have reported the long-term outcomes of patients with alcohol-associated liver disease (ALD). In a national registry study including over 23,000 patients with ALD diagnosed at median age 58 years, 67 percent died during >100,000 person-years of follow-up and liver disease was the primary cause of death in 45 percent [25]. The 5- and 10-year mortality rates due to liver disease were 26 and 31 percent, respectively. These data emphasize the importance of treating patients with alcohol use disorder and may inform strategies to prevent liver-related mortality in those with ALD. (See "Management of alcohol-associated steatosis and alcohol-associated cirrhosis", section on 'Mortality'.)

Clinical practice update on risk stratification for colorectal cancer screening and postpolypectomy surveillance (December 2023)

The American Gastroenterological Association (AGA) recently published nine statements of best practice advice on risk stratification for colorectal cancer (CRC) screening and postpolypectomy surveillance [26]. They advise basing risk stratification on an individual's age, a known or suspected predisposing hereditary CRC syndrome, other CRC predisposing conditions (eg, inflammatory bowel disease), and/or a family history of CRC. They also suggest that the decision to continue postpolypectomy surveillance for individuals older than 75 years should be individualized. Shared decision-making discussions should include an assessment of the risks of incident CRC, procedure-related risks, comorbidities, and life expectancy (>5 years). Our approach is consistent with this guidance. (See "Overview of colon polyps", section on 'Risk assessment for subsequent colorectal cancer'.)

Clinical practice update on exocrine pancreatic insufficiency (November 2023)

The American Gastroenterological Association (AGA) recently published best practice advice on exocrine pancreatic insufficiency (EPI) [27]. The AGA Clinical Practice Update advises considering a diagnosis of EPI in individuals with moderate-risk clinical conditions (eg, celiac disease, previous intestinal surgery, longstanding diabetes mellitus, Zollinger-Ellison syndrome). It emphasizes the importance of testing for EPI in patients with nonspecific symptoms and cautions against relying on a response to an empiric trial of pancreatic enzymes to diagnose EPI as this may be due to a placebo effect. Our approach is consistent with this guidance. (See "Exocrine pancreatic insufficiency", section on 'Diagnostic approach'.)

Clinical practice update on bloating and distention (November 2023)

The American Gastroenterological Association (AGA) recently published best practice advice on the evaluation and management of bloating and distention [28]. The AGA Clinical Practice Update endorses serologic evaluation for celiac disease and exclusion of carbohydrate enzyme deficiencies with dietary restriction and/or breath testing, but emphasizes reserving additional evaluation with abdominal imaging and upper endoscopy for patients with alarm features, recent worsening symptoms, or an abnormal physical examination. Our approach is consistent with this guidance. (See "Overview of intestinal gas and bloating", section on 'Evaluation'.)

Low-dose tricyclic antidepressants in irritable bowel syndrome (October 2023)

The efficacy of tricyclic antidepressants (TCAs) in the management of irritable bowel syndrome (IBS) has not been well established in the primary care setting. In a pragmatic randomized trial, 463 patients with IBS unresponsive to dietary advice and first-line therapies in primary care practices were assigned to titrated low-dose amitriptyline or placebo as a second-line therapy [29]. At six months, patients treated with low-dose amitriptyline had lower IBS-symptom severity scores and a higher rate of symptom relief. The most common side effects were related to the anticholinergic effects of amitriptyline, but the majority were mild. These data support current guidelines and our recommendation to use TCAs in the management of patients with IBS. (See "Treatment of irritable bowel syndrome in adults", section on 'Antidepressants'.)

ADULT HEMATOLOGY AND ONCOLOGY

Improvement in breast cancer mortality from 1975 to 2019 (January 2024)

Improvements in breast cancer screening and treatments are decreasing breast cancer mortality. In a study using four simulation models of breast cancer mortality rates in the United States (US), breast cancer screening and treatment in 2019 were associated with a 58 percent reduction in US breast cancer mortality compared with 1975 [30]. Approximately half of this reduction was due to treatment of early breast cancer, while the rest was divided roughly equally between treatment of metastatic breast cancer and breast cancer screening. We support breast cancer screening for appropriate candidates and incorporate novel, data-driven strategies into our treatment recommendations for breast cancer. (See "Overview of the treatment of newly diagnosed, invasive, non-metastatic breast cancer", section on 'Introduction' and "Screening for breast cancer: Strategies and recommendations".)

Omission of radiation in select patients with favorable-risk breast cancer (August 2023, Modified January 2024)

Trials are examining omission of radiation in early, favorable-risk breast cancer.

In a single-arm trial including 500 females ≥55 years with T1N0, grade 1 or 2, luminal A-breast cancer, breast-conserving surgery and endocrine therapy without radiation were associated with a low incidence of local recurrence at five years (2.3 percent) [31].

A prospective study found that patients ≥50 years with nontriple negative cT1N0 breast cancer that was unifocal on preoperative MRI and pT1N0 or N1mi at the time of surgery could omit adjuvant radiation and experience a low ipsilateral invasive recurrence rate (1 percent at five years) [32].

We consider omission of adjuvant radiation to be an option in women ≥65 years with clinically node-negative, small (tumor size <3 cm), hormone receptor-positive, HER2-negative breast cancer who are willing to take adjuvant endocrine therapy, but we await further data before omitting radiation in other patients. (See "Adjuvant radiation therapy for women with newly diagnosed, non-metastatic breast cancer", section on 'Possible omission of RT for select ER-positive, HER2-negative cancers'.)

ADULT INFECTIOUS DISEASES

Simnotrelvir-ritonavir for mild to moderate COVID-19 (January 2024)

Although nirmatrelvir-ritonavir reduces hospitalization and death from COVID-19, the many drug interactions make it difficult to use in some patients. Simnotrelvir-ritonavir is a similar protease inhibitor combination that inhibits viral replication but does not have as many drug interactions. In a randomized, double-blinded study of over 1000 patients with mild to moderate COVID-19 (majority fully vaccinated), 5 days of simnotrelvir-ritonavir reduced time to symptom resolution by 1.5 days [33]. Since no participant progressed to severe disease or died by day 29, it is unknown whether the drug prevents hospitalizations or death from COVID-19. Simnotrelvir-ritonavir has emergency use approval in China but is not yet approved for use in other countries. (See "COVID-19: Management of adults with acute illness in the outpatient setting", section on 'Therapies of limited or uncertain benefit'.)

Statins for primary prevention of cardiovascular disease in persons with HIV (September 2023)

HIV infection is associated with an excess risk of cardiovascular disease. A randomized trial evaluated the efficacy of lipid-lowering therapy with pitavastatin for primary prevention in over 7700 persons with HIV ≥40 years of age receiving antiretroviral therapy who had a 10-year atherosclerotic cardiovascular disease (ASCVD) risk score <15 percent [34]. Pitavastatin reduced the relative risk of major cardiovascular events (eg, myocardial infarction, stroke) by 35 percent compared with placebo; the trial was stopped early for this apparent benefit. Based on these data, we now advise statins in all persons ≥40 years of age with an ASCVD score ≥5 percent, particularly if the score is ≥7.5 percent; for those with lower baseline risk, we also discuss statin use, although the absolute benefit is smaller. For persons younger than 40 years of age, our approach is the same as in persons without HIV. (See "Management of cardiovascular risk (including dyslipidemia) in patients with HIV", section on 'Indications for statins'.)

ADULT NEPHROLOGY AND HYPERTENSION

Tenapanor for refractory hyperphosphatemia in patients on dialysis (November 2023)

Despite adequate dialysis, dietary restriction, treatment of hyperparathyroidism, and phosphate binders (PBs), hyperphosphatemia is common among patients on dialysis and associated with adverse outcomes. In a trial in which nearly 170 patients on hemodialysis with hyperphosphatemia despite PB therapy were randomly assigned to PBs plus either tenapanor (an inhibitor of intestinal sodium/hydrogen exchanger 3) or placebo for eight weeks, serum phosphorus levels were 1.76 mg/dL lower in the tenapanor group [35]. Diarrhea was more frequent among patients receiving tenapanor but was mild or moderate in all cases. These data, in conjunction with prior trial data, support our approach of using tenapanor as add-on therapy in patients on dialysis who have an inadequate response to PBs. (See "Management of hyperphosphatemia in adults with chronic kidney disease", section on 'Refractory hyperphosphatemia'.)

Novel aldosterone synthase inhibitor in the treatment of hypertension (October 2023)

Aldosterone synthase inhibitors may have the same antihypertensive benefit as mineralocorticoid receptor antagonists (such as spironolactone) without the associated hormonal adverse effects. Lorundrostat, an aldosterone synthase inhibitor, was tested in a trial of over 160 patients with a suppressed plasma renin activity and uncontrolled hypertension despite antihypertensive drug therapy (at least two medications) [36]. Compared with placebo, lorundrostat reduced automated office systolic blood pressure at eight weeks by 1.5 to 9.6 mmHg, depending upon the lorundrostat dose. Aldosterone synthase inhibitors such as lorundrostat may become useful in the treatment of resistant hypertension. (See "Treatment of resistant hypertension", section on 'Novel medications'.)

ADULT NEUROLOGY AND PSYCHIATRY

Time window to start dual antiplatelet therapy for high-risk TIA or minor ischemic stroke (January 2024)

There is evidence from several randomized trials that early initiation of short-term dual antiplatelet therapy (DAPT) for select patients with high-risk transient ischemic attack (TIA) or minor ischemic stroke reduces the risk of recurrent ischemic stroke. The evidence comes from trials that started DAPT within 12 to 24 hours of symptom onset. Results from the recent INSPIRES trial suggest that DAPT is still beneficial when started up to 72 hours after symptom onset [37]. Although the time window is extended by the results from INSPIRES, we start DAPT as soon as possible for patients with high-risk TIA or minor ischemic stroke. (See "Early antithrombotic treatment of acute ischemic stroke and transient ischemic attack", section on 'High-risk TIA and minor ischemic stroke'.)

Esketamine for treatment-resistant depression (December 2023)

Although esketamine has established efficacy for treatment-resistant depression, direct comparisons with other agents are limited. In a recent open label randomized trial in 676 adults with treatment-resistant major depression receiving baseline antidepressant therapy, addition of esketamine nasal spray for 32 weeks led to higher remission rates than addition of quetiapine extended release (XR, 49 versus 33 percent) [38]. Rates of discontinuation for adverse events were nearly three times lower with esketamine then quetiapine XR (4 versus 11 percent). Nevertheless, clinicians and patients considering esketamine need to weigh its benefits and disadvantages, including the need to administer it in a certified medical clinic. (See "Unipolar depression in adults: Choosing treatment for resistant depression", section on 'Initial approach'.)

Botulinum toxin injections for essential head tremor (November 2023)

Botulinum toxin (BoNT) injections have been used for refractory head tremor in patients with essential tremor (ET) based on limited data. In a randomized trial of 117 patients with essential or isolated head tremor, BoNT type A injections into each splenius capitis muscle improved subjective and objective head tremor severity measurements compared with placebo injections, with expected waning of response by 12 weeks after each injection [39]. Adverse effects were more frequent with BoNT (47 versus 16 percent), most commonly headache or neck pain, dysphagia, and posterior neck weakness. BoNT type A injections are an option for patients with bothersome head tremor due to ET who do not tolerate oral medications or whose tremor does not respond, but side effects are common and may outweigh potential benefits in some patients. (See "Essential tremor: Treatment and prognosis", section on 'Administration and efficacy'.)

Early use of ubrogepant to abort migraine headache (November 2023)

Acute migraine treatments, including calcitonin gene-related peptide (CGRP) antagonists, are typically given at headache onset, but the benefit of earlier dosing is uncertain. In a trial of 477 patients with migraine who were treated at the onset of prodromal symptoms (prior to headache), ubrongepant improved the proportion of patients who remained free of moderate to severe headache at 24 hours compared with placebo (46 versus 29 percent) [40]. Enrolled patients had migraines that consisted of prodromal symptoms (eg, photophobia, fatigue, neck pain) occurring one to six hours before headache onset in at least 75 percent of attacks. These results support our practice to administer acute migraine treatments, such as ubrogepant, early in the course of migraine symptoms. (See "Acute treatment of migraine in adults", section on 'CGRP antagonists'.)

Screening for major depressive disorder in adults (October 2023)

Major depressive disorder is a leading cause of disability in the United States, with a lifetime prevalence of approximately 20 percent; however, it remains underdetected and undertreated. Updated guidelines from the United States Preventive Services Task Force recommend screening for depression in adults (ages 19 years and above), including pregnant and postpartum women, based upon a systematic review that suggested a net benefit from screening [22]. These guidelines are consistent with our suggestion that primary care clinicians routinely screen adults for depression with diagnostic evaluation and treatment for those who screen positive. (See "Screening for depression in adults".)

Psilocybin for treatment-resistant depression (October 2023)

The psychedelic psilocybin is being evaluated for treatment-resistant unipolar major depression and may provide a relatively rapid and durable response. In a trial of 104 patients, a single dose of psilocybin resulted in greater improvements in depressive symptoms than a single dose of niacin (the active placebo control); this effect occurred as early as day 8 and persisted until the end of the trial, at day 43 [41]. In addition, anxiety, psychosocial functioning, and quality of life improved more with psilocybin. However, it resulted in more frequent adverse events. Additional trials are necessary to determine who is most likely to benefit from psychedelics, the optimal dose and number of psilocybin sessions, type of patient preparation, whether and what type of accompanying psychotherapy should be administered, and how long the benefit persists. (See "Unipolar depression in adults: Choosing treatment for resistant depression", section on 'Psilocybin'.)

ADULT PULMONOLOGY

Guidelines for primary spontaneous pneumothorax (December 2023)

The British Thoracic Society (BTS) has recently issued new guidelines for the management of primary spontaneous pneumothorax (PSP) [42]. Major changes since 2010 include a symptom- rather than size-based approach. For patients with mild symptoms who are stable following adequate analgesia, monitored observation is preferred, while those with significant dyspnea should undergo a drainage procedure (eg, aspiration or catheter/chest tube thoracostomy). Also promoted was ambulatory management in select patients with adequate outpatient support. We agree with these recommendations. (See "Treatment of primary spontaneous pneumothorax in adults", section on 'Initial evaluation and management'.)

ADULT RHEUMATOLOGY

Phosphodiesterase type 5 inhibition for Raynaud phenomenon (January 2024)

Phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil and tadalafil are widely used to treat digital ischemia from Raynaud phenomenon. In an updated meta-analysis of nine randomized trials comprising 411 patients with Raynaud phenomenon (most of whom had scleroderma), treatment with PDE5 inhibition resulted in three fewer attacks weekly and a reduction in the average duration of the attacks by five minutes [43]. However, PDE5 inhibition led to minimal to no reduction in the pain associated with Raynaud phenomenon. This study implies that while PDE5 inhibition has a modest impact on the duration and frequency of Raynaud attacks, it might not be adequate to address all symptoms experienced by patients with severe disease. (See "Treatment of Raynaud phenomenon: Initial management", section on 'Phosphodiesterase type 5 inhibitor'.)

GYNECOLOGY

Risk of subsequent hysterectomy after endometrial ablation (January 2024)

Endometrial ablation is an alternative to hysterectomy in selected premenopausal patients with heavy menstrual bleeding. Most ablations are performed using a non-resectoscopic technique; however, the long-term efficacy of this approach is unclear. In a meta-analysis of 53 studies including over 48,000 patients managed with non-resectoscopic endometrial ablation (NREA), the rates of subsequent hysterectomy were 4 percent at 12 months, 8 to 12 percent at 18 to 60 months, and 21 percent at 120 months [44]. Hysterectomy rates were similar for the different NREA devices (eg, thermal balloon, microwave, radiofrequency). These findings are useful for counseling patients about the long-term risk for hysterectomy after NREA. (See "Endometrial ablation: Non-resectoscopic techniques", section on 'Efficacy'.)

Use of vaginal estrogen in breast cancer patients taking aromatase inhibitors (October 2023)

Use of vaginal estrogen to manage symptoms of genitourinary syndrome of menopause (GSM) may be harmful in patients with breast cancer on aromatase inhibitors (AIs). In a claims-based analysis, vaginal estrogen therapy was associated with a higher rate of breast cancer recurrence in patients taking versus not taking an AI [45]. Time to recurrence in the AI group was approximately 140 days. While this study had many limitations, these data support our general practice of avoiding vaginal estrogen for the management of GSM in most patients with breast cancer taking AIs. (See "Genitourinary syndrome of menopause (vulvovaginal atrophy): Treatment", section on 'Patients with breast cancer'.)

Mifepristone for treatment of adenomyosis (August 2023)

Symptomatic uterine adenomyosis is typically treated with nonsteroidal anti-inflammatory drugs, the 52 mg levonorgestrel-releasing intrauterine device, or surgery, but use of other hormonal medications (eg, oral contraceptive pills, gonadotropin-releasing hormone analogs, mifepristone) has been described. In a randomized trial including over 130 premenopausal patients with adenomyosis based on imaging, mifepristone (10 mg orally daily) resulted in greater improvement in dysmenorrhea, blood loss, and uterine volume compared with placebo after 12 weeks of treatment [46]. Further studies are needed to determine the long-term efficacy of mifepristone in such patients before it can be used routinely for this indication. (See "Uterine adenomyosis", section on 'Alternative hormone strategies'.)

OBSTETRICS

Fetoplacental GDF15 linked to nausea and vomiting of pregnancy (February 2024)

Almost all pregnant people experience nausea with or without vomiting in early pregnancy; however, the pathogenesis of the disorder has been unclear. Previous studies have shown that GDF15 is expressed in a wide variety of cells, with the highest expression in placental trophoblast, and that its protein (GDF15) appears to regulate appetite. A recent study confirmed the fetoplacental unit as a major source of GDF15 and also found that higher GDF15 levels correlated with more severe nausea and vomiting of pregnancy [47]. In the future, drugs targeting the production or action of GDF15 are a potential novel pathway for treating nausea and vomiting of pregnancy, if safety and efficacy are established. (See "Nausea and vomiting of pregnancy: Clinical findings and evaluation", section on 'Pathogenesis'.)

Use of cerebroplacental ratio at term does not reduce perinatal mortality (February 2024)

Cerebral blood flow may increase in chronically hypoxemic fetuses to compensate for the decrease in available oxygen and can be assessed by the cerebroplacental ratio (CPR; middle cerebral artery pulsatility index divided by the umbilical artery pulsatility index). However, increasing evidence indicates that use of the CPR does not reduce perinatal mortality in low-risk pregnancies. In a randomized trial comparing fetal growth assessment plus revealed versus concealed CPR in over 11,000 low-risk pregnancies at term, knowledge of CPR combined with a recommendation for delivery if the CPR was <5th percentile did not reduce perinatal mortality compared with usual care (concealed group) [48]. We do not perform umbilical artery Doppler surveillance, including the CPR, in low-risk pregnancies. (See "Doppler ultrasound of the umbilical artery for fetal surveillance in singleton pregnancies", section on 'Low-risk and unselected pregnancies'.)

Intrauterine postpartum hemorrhage control devices for managing postpartum hemorrhage (February 2024)

Intrauterine balloon tamponade and vacuum-induced uterine compression are the most common devices used for intrauterine postpartum hemorrhage (PPH) control in patients with atony, but it is unclear which device is superior as few comparative studies have been performed. In a retrospective study including nearly 380 patients with PPH, quantitative blood loss after placement, rate of blood transfusion, and discharge hematocrit were similar for both devices [49]. Based on these and other data, in the setting of ongoing uterine bleeding, rapid use of one of these devices is likely to be more important than the choice of device when both devices are available. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Choice of method'.)

Low- versus high-dose calcium supplements and risk of preeclampsia (January 2024)

In populations with low baseline dietary calcium intake, the World Health Organization recommends 1500 to 2000 mg/day calcium supplementation for pregnant individuals to reduce their risk of developing preeclampsia. However, a recent randomized trial that evaluated low (500 mg) versus high (1500 mg) calcium supplementation in over 20,000 nulliparous pregnant people residing in two countries with low dietary calcium intake found low and similar rates of preeclampsia in both groups [50]. These findings suggest that a 500 mg supplement is sufficient to reduce the risk of preeclampsia in these populations. For pregnant adults in the United States, we prescribe 1000 mg/day calcium supplementation, which is the recommended daily allowance to support maternal calcium demands without bone resorption. (See "Preeclampsia: Prevention", section on 'Calcium supplementation'.)

Respectful maternity care (January 2024)

Respectful maternity care is variably defined but broadly involves both absence of disrespectful conduct and promotion of respectful conduct toward pregnant individuals. A systematic review found that validated tools to measure respectful maternity care were available, but the optimal tool was unclear and high quality studies were lacking on the effectiveness of respectful maternity care for improving any maternal or infant health outcome [51]. Respectful maternal care is a basic human right, but how to best implement and monitor it and assess outcomes requires further study. (See "Prenatal care: Initial assessment", section on 'Effectiveness'.)

Outcome of a multifaceted intervention in patients with a prior cesarean birth (January 2024)

Patients with a pregnancy after a previous cesarean birth must choose between a trial of labor (TOLAC) and a planned repeat cesarean. The optimal care of such patients is unclear. In a multicenter, cluster-randomized trial including over 20,000 patients with one prior cesarean birth, a multifaceted intervention (patient decision support, use of a calculator to assess chances of a vaginal birth after cesarean [VBAC], sonographic measurement of myometrial thickness, clinician training in best intrapartum practices during TOLAC) reduced perinatal and major maternal morbidity composite outcomes compared with usual care [52]. VBAC and uterine rupture rates were similar for both groups. Further study is needed to identify the most useful component(s) of the intervention for reducing morbidity. (See "Choosing the route of delivery after cesarean birth", section on 'Person-centered decision-making model'.)

Labor epidural analgesia and risk of emergency delivery (December 2023)

It is well established that contemporary neuraxial labor analgesia does not increase the overall risk of cesarean or instrument-assisted vaginal delivery. However, a new retrospective database study of over 600,000 deliveries in the Netherlands reported that epidural labor analgesia was associated with an increased risk of emergency delivery (cesarean or instrument-assisted vaginal) compared with alternative analgesia (13 versus 7 percent) [53]. Because of potential confounders and lack of detail on epidural and obstetric management, we consider these data insufficient to avoid neuraxial analgesia or change the practice of early labor epidural placement to reduce the potential need for general anesthesia in patients at high risk for cesarean delivery. (See "Adverse effects of neuraxial analgesia and anesthesia for obstetrics", section on 'Effects on the progress and outcome of labor'.)

Delayed cord clamping in preterm births (December 2023)

Increasing evidence supports delaying cord clamping in preterm births. In an individual participant data meta-analysis of randomized trials of delayed versus immediate cord clamping at births <37 weeks (over 3200 infants), delaying cord clamping for >30 seconds reduced infant death before discharge (6 versus 8 percent) [54]. In a companion network meta-analysis evaluating the optimal duration of delay, a long delay (≥120 seconds) significantly reduced death before discharge compared with immediate clamping; reductions also occurred with delays of 15 to <120 seconds but were not statistically significant [55]. For preterm births that do not require resuscitation, we recommend delayed rather than immediate cord clamping. We delay cord clamping for at least 30 to 60 seconds as approximately 75 percent of blood available for placenta-to-fetus transfusion is transfused in the first minute after birth. (See "Labor and delivery: Management of the normal third stage after vaginal birth", section on 'Preterm infants'.)

Vacuum-induced intrauterine tamponade for postpartum hemorrhage (November 2023)

Intrauterine tamponade (with a balloon, packing, or vacuum) may be used to manage patients with postpartum hemorrhage (PPH) resulting from uterine atony that is not controlled by uterotonic medications and uterine massage. However, outcome data regarding vacuum-induced tamponade are limited. A study of data from a postmarketing registry of over 500 patients with PPH and isolated atony treated with vacuum-induced tamponade reported that the device controlled bleeding without treatment escalation or bleeding recurrence in 88 percent following cesarean birth and 96 percent following vaginal birth, typically within five minutes [56]. These data are consistent with previously published outcomes. Given its efficacy and ease of use, vacuum-induced tamponade is an important option for managing PPH in centers where this device is available. (See "Postpartum hemorrhage: Use of an intrauterine hemorrhage-control device", section on 'Vacuum-induced tamponade'.)

Early metformin treatment of gestational diabetes mellitus (November 2023)

Usual initial gestational diabetes mellitus (GDM) care (ie, medical nutritional therapy, exercise) may result in a few weeks of hyperglycemia before a need for pharmacotherapy is established. In a randomized trial evaluating whether initiating metformin at the time of GDM diagnosis regardless of glycemic control improves clinical outcomes compared with usual care, the metformin group had a lower rate of insulin initiation and favorable trends in mean fasting glucose, gestational weight gain, and excessive fetal growth, but more births <2500 grams [57]. Rates of preeclampsia, neonatal intensive care unit admission, and neonatal hypoglycemia were similar for both groups. Given these mixed results, we recommend not initiating metformin at the time of GDM diagnosis except in a research setting. (See "Gestational diabetes mellitus: Glucose management and maternal prognosis", section on 'Does early metformin initiation improve glycemic control and reduce need for insulin?'.)

Valacyclovir for prevention of congenital cytomegalovirus infection (October 2023)

Emerging evidence suggests that maternal administration of valacyclovir for primary cytomegalovirus (CMV) infection substantially reduces the risk of congenital CMV infection, especially if begun prior to 14 weeks of gestation and within 8 weeks of the maternal infection. In a 2023 individual patient data meta-analysis (one randomized trial, two observational studies), maternal valacyclovir administration upon diagnosis of periconception or first-trimester primary CMV infection was associated with a 66 percent reduction in congenital CMV (11 versus 25 percent) [58]. We suggest high-dose oral valacyclovir (8g per day) for patients with a primary CMV infection in early pregnancy after a comprehensive discussion of the potential benefits and risks (eg, 2 percent risk of reversible maternal kidney failure). (See "Cytomegalovirus infection in pregnancy", section on 'Antiviral medication'.)

Respiratory syncytial virus vaccination in pregnancy (April 2023, Modified October 2023)

Respiratory syncytial virus (RSV) is a major cause of morbidity and mortality in infants. In October 2023, the United States Centers for Disease Control and Prevention, along with guidelines from other expert groups, endorsed RSV vaccination of pregnant individuals to reduce severe RSV infections in their infants [59-62]. Nirsevimab, a monoclonal antibody that can be given to infants postnatally to reduce the risk of severe RSV, has also been recently approved and endorsed by expert guidance panels. In settings where nirsevimab is not available, we suggest vaccination of pregnant individuals between 32 0/6 and 36 6/7 weeks of gestation in September through January (in the northern hemisphere) with inactivated nonadjuvanted recombinant RSV vaccine (RSVPreF; Abrysvo). In settings where both maternal vaccination and nirsevimab are available, the optimal preventive strategy remains uncertain, and, in most cases, it will not be possible to use both. For such patients, both options should be discussed and shared decision-making undertaken. (See "Immunizations during pregnancy", section on 'Choosing the optimal strategy'.)

Respectful, equitable, supportive maternity care (August 2023)

Respectful, equitable, and supportive maternity care is a basic human right that is not always achieved. In a recent survey of mothers in the United States, 90 percent of respondents were satisfied with the care they received during pregnancy, but 20 percent overall reported mistreatment, including requests for help refused or not responded to, physical privacy violated, and verbal abuse [63]. Approximately 30 percent of all respondents and 40 percent of Black, Hispanic, and multiracial respondents reported discrimination during maternity care. Multiple organizations have developed strategies that encourage a culture of respectful, equitable, and supportive maternity care. These strategies can be useful to providers, patients, and health care systems. (See "Prenatal care: Second and third trimesters", section on 'Respectful, equitable, and supportive maternity care'.)

Zuranolone for severe postpartum depression (August 2023)

For patients with severe postpartum depression who prioritize rapid improvement, we suggest initial therapy with brexanolone; however, the agent requires continuous intravenous infusion for 60 hours in an inpatient facility. Recently, the US Food and Drug Administration approved zuranolone for postpartum depression; clinical availability is anticipated by the end of 2023 [64,65]. Zuranolone is an oral agent that is administered over 14 days, has a similar mechanism of action to brexanolone, and can also result in rapid remission of symptoms. We expect that some patients will prefer zuranolone over the infusion required for brexanolone. (See "Severe postpartum unipolar major depression: Choosing treatment", section on 'Treatment that is approved but not yet available'.)

Pessary placement for short cervical length does not reduce preterm birth (July 2023)

Previous meta-analyses of randomized trials comparing use of a cervical pessary versus no pessary (with or without vaginal progesterone) for asymptomatic patients at high risk for preterm birth (PTB) have found that a pessary did not result in a statistically significant reduction in spontaneous PTB; however, the trials had many limitations. In a recent well-designed randomized trial of over 500 patients with cervical length <20 mm, placement of an Arabin pessary at 16 to 23 weeks of gestation also demonstrated no benefit over usual care; the rate of PTB or fetal death <37 weeks was nearly the same for both groups [66]. Strengths of this trial were inclusion of a very high-risk population, exclusion of patients with a history of PTB, and routine use of vaginal progesterone in both groups. These findings further support our practice of not using a pessary to reduce PTB in patients with a short cervix. (See "Cervical insufficiency", section on 'Pessary'.)

PEDIATRICS: GENERAL PEDIATRICS

Cannabinoids and mental health in adolescents (December 2023)

Cannabis use is associated with an increased risk of mental health disorders. However, little is known about the effects of cannabidiol (CBD), a nonpsychoactive component of cannabis used for anorexia and childhood epilepsy, or of recreational synthetic cannabinoids. In a school-based survey from the United Kingdom that included over 6500 adolescents ages 13 to 14 years, reported use of cannabis, CBD, or synthetic cannabinoids were each associated with probable depression, anxiety disorder, or conduct disorder, as well as with auditory hallucinations [67]. For each disorder, the risk appeared greatest with synthetic cannabinoids. This study highlights the need for further investigation into the association between mental health effects in youth and the different types of cannabinoids. We advise adolescents (and younger children) to avoid cannabis consumption, including CBD. (See "Substance use disorder in adolescents: Epidemiology, clinical features, assessment, and diagnosis", section on 'Cannabis, cannabidiol, and synthetic cannabinoids'.)

High blood lead levels in US children after eating cinnamon applesauce pouches (November 2023)

The Centers for Disease Control and Prevention have issued a health alert following reports of high blood lead levels from several states for a total of 22 children who were fed cinnamon-containing applesauce pouches that were subsequently found to contain extremely high concentrations of lead [68]. Children who have eaten a recalled product should undergo blood lead testing. Clinicians should advise parents, primary caregivers, and guardians to not buy specific cinnamon-containing apple puree or applesauce products named in the US Food and Drug Administration announcement and to discard any recalled products that they have purchased. (See "Childhood lead poisoning: Exposure and prevention", section on 'Food' and "Childhood lead poisoning: Clinical manifestations and diagnosis", section on 'Laboratory evaluation' and "Childhood lead poisoning: Management".)

Testing for hepatitis C virus infection in infants with perinatal exposure (November 2023)

Perinatally acquired hepatitis C virus (HCV) infection in the United States has increased sharply since 2010. New guidance from the Centers for Disease Control and Prevention recommends early testing for infants with perinatal exposure to HCV (algorithm 1) [69]:

● Test for HCV RNA during early infancy after two months of age, and ideally before six months of age.

● After 18 months of age, test any infant who has not previously been tested by measuring anti-HCV antibodies, with reflexive testing for HCV RNA.

A negative HCV RNA result at any time point after two months of age virtually excludes HCV infection and further testing is not required. Children with a positive HCV RNA test before three years of age should have repeat testing for HCV RNA before initiating antiviral therapy to determine whether they have spontaneously cleared the infection. This new guidance is consistent with our previous recommendations for early testing for infants with perinatal exposure to HCV. (See "Hepatitis C virus infection in children", section on 'How to test'.)

Avulsion fractures of hip and pelvis in children (October 2023)

There are few large-scale studies of pelvic avulsion fractures in children. A retrospective review of over 700 children with pelvic or hip avulsion fractures from a single tertiary care hospital reported the average patient age was just over 14 years and nearly 80 percent were sustained by males [70]. The anterior-superior and inferior iliac spines and ischial tuberosity were the most common sites, accounting for over 80 percent of fractures. Most injuries were sustained while the patient was running or kicking during sport, most often football (soccer). The incidence of avulsion fracture rose substantially during the study period, 2005 to 2020. (See "Pelvic trauma: Initial evaluation and management", section on 'Epidemiology and mechanism'.)

Updated guidance for pneumococcal vaccination in children in the Unites States (October 2023)

The Centers for Disease Control and Prevention (CDC) has provided updated guidance for pneumococcal vaccination, endorsing use of either the 15-valent or 20-valent pneumococcal conjugate vaccine (PCV15 or PCV20) for routine vaccination in infancy and childhood [71]. The primary vaccine schedule otherwise remains unchanged. For infants who previously received the 13-valent vaccine (PCV13), the series may be completed with PCV15 or PCV20; restarting the series is not necessary. Children with high-risk conditions(table 51) may require additional pneumococcal vaccination with either PCV20 or the polysaccharide vaccine (PPSV23) after age two years if their primary series did not include at least one dose of PCV20. We agree with the updated CDC guidance. Guidelines for pneumococcal vaccination in other countries may differ. (See "Pneumococcal vaccination in children", section on 'In the United States'.)

Ultrasound guidance for lumbar puncture in children (August 2023)

Previous studies suggest that ultrasound guidance for lumbar puncture (LP) in children increases the chance of success. In a meta-analysis of seven randomized trials (over 700 infants and children), overall LP success rate was higher with ultrasound guidance compared with the use of external landmarks and palpation alone, but the difference was not significant [72]. Subgroup analysis of five studies (over 520 children) demonstrated significantly higher first attempt success in infants undergoing ultrasound guidance, but not in older children. The overall quality of the evidence was considered low. Based on these findings, when performed by a trained provider, ultrasound guidance prior to LP may be useful in infants. Ultrasound guidance in older children is also reasonable, but evidence of benefit in these patients is lacking. (See "Lumbar puncture in children", section on 'Ultrasound guidance'.)

Invasive bacterial illness in febrile young infants with COVID-19 (July 2023)

Evidence is limited for the risk of invasive bacterial illness (IBI) in febrile young infants <60 days old with SARS-CoV-2 infection. In one cohort study of 163 well-appearing febrile infants ≤60 days old (36 neonates) who were diagnosed with COVID-19 by multiplex viral panel testing, none had IBI compared with 0.5 percent of 448 infants with other viral infection (none had meningitis) and 1.3 percent of 320 infants with no viral infection on testing (one with meningitis) [73]. For well-appearing febrile infants ≤60 days old with a positive test for SARS-CoV-2, the risk of IBI appears to be low. For well-appearing infants 29 to 60 days, we suggest, at minimum, urinalysis and urine culture. It is also reasonable to obtain additional studies according to the American Academy of Pediatric Clinical Practice Guideline (algorithm 2). Evidence is insufficient to change the recommended evaluation for well-appearing neonates. (See "The febrile infant (29 to 90 days of age): Outpatient evaluation", section on 'COVID-19' and "The febrile neonate (28 days of age or younger): Outpatient evaluation and initial management", section on 'Well-appearing'.)

PEDIATRICS: DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS

Infertility and autism spectrum disorder (December 2023)

Patients with infertility often ask about the impact of the disorder and its treatment on risk of autism spectrum disorder (ASD) in offspring. In a large population-based cohort study comparing ASD risk among children whose parents had subfertility (an infertility consultation without treatment), infertility treatment, or neither (unassisted conception), children in the subfertility and infertility treatment groups had a small increased risk of ASD compared with unassisted conception but the absolute risk was low (2.5 to 2.7 per 1000 person-years versus 1.9 per 1000 person-years with unassisted conception) [74]. The increased risk was similar in the subfertile and infertility treatment groups, suggesting that infertility treatment was not a major risk factor. Obstetrical and neonatal factors (eg, preterm birth) appeared to mediate a sizeable proportion of the increased risk for ASD. (See "Assisted reproductive technology: Infant and child outcomes", section on 'Confounders'.)

SURGERY

Pregnancy and childbirth after urinary incontinence surgery (January 2024)

Patients with stress urinary incontinence (SUI) have historically been advised to delay midurethral sling (MUS) surgery until after childbearing because of concerns for worsening SUI symptoms following delivery. In a meta-analysis of patients with MUS surgery who were followed for a mean of nearly 10 years, similar low SUI recurrence and reoperation rates were reported for the 381 patients with and the 860 patients without subsequent childbirth [75]. Birth route did not affect the findings. Although the total number of recurrences and reoperations was small, this study adds to the body of evidence suggesting that subsequent childbirth does not worsen SUI outcomes for patients who have undergone MUS. (See "Surgical management of stress urinary incontinence in females: Retropubic midurethral slings", section on 'Subsequent pregnancy'.)

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Topic 8349 Version 12473.0

References

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