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 RESUSCITATION
Vascular access for cardiac life support (April 2025)
Few studies have directly compared intraosseous (IO) and intravenous (IV) vascular access in adults with cardiac arrest. A systematic review and meta-analysis identified three randomized trials that enrolled over 9300 patients with out-of-hospital cardiac arrest treated by emergency medical services and compared a strategy of IO-first with IV-first vascular access [1]. While successful placement was more common for IO-first participants (92 to 94 percent, proximal tibia or humerus placement) than for IV-first participants (58 to 80 percent), the time to first drug administration did not vary, and there was no significant difference in 30-day survival. However, in two studies (7545 participants), the rate of sustained return of spontaneous circulation was higher in the IV-first group (25 versus 23 percent). While IV access is preferred, when it cannot be readily established, IO lines are safe and effective. (See "Advanced cardiac life support (ACLS) in adults", section on 'Vascular access for medication administration'.)
Advanced respiratory support in COVID-19 (January 2025)
In patients with COVID-19 who need advanced respiratory support, choosing between high-flow oxygen delivered via nasal cannulae (HFNC) and noninvasive ventilatory (NIV) support is challenging. In a recent trial of 1800 patients with acute respiratory failure from COVID-19 randomized to HFNC versus NIV, similar rates of endotracheal intubation (approximately 30 percent) and death (12 percent) were reported at the end of one week [2]. Subgroup analyses were not helpful in modality selection. In patients with COVID-19 who need advanced respiratory support, we use the patient's comorbidities and the tolerability of the device to help choose between NIV and HFNC. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Choosing oxygen via high-flow nasal cannulae versus noninvasive ventilation'.)
Electronic alert systems for sepsis (January 2025)
Increasingly, hospitals are automatically screening patients for evidence of sepsis, but the effectiveness of this approach is unclear. In a recent cluster randomized trial of an electronic medical record (EMR) sepsis screening alert system in 5 hospitals and over 60,000 patients, adjusted 90-day mortality was lower in patients who were electronically screened (adjusted relative risk 0.85; 95% CI, 0.77-0.93) [3]. Screening reduced vasopressor therapy administration and new multidrug-resistant organisms but increased kidney replacement therapy and new C difficile (colonization or infection unknown). Automated EMR alerts for sepsis may impact provider behavior and patient outcomes; however, which factors should be used for screening, and the best way to alert providers to this information, require further study. (See "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Identification of early sepsis (qSOFA, NEWS)'.)
Extracorporeal life support for hypothermic cardiac arrest (January 2025)
Extracorporeal life support (ECLS) may improve overall survival and neurologically intact survival in select adults with hypothermic cardiac arrest. A multicenter registry study of 127 patients in hypothermic cardiac arrest treated with ECLS reported a survival rate of 49 percent, with 89 percent of survivors having good neurologic outcomes [4]. Lower age and lower serum potassium and lactate concentrations were associated with a higher likelihood of survival. This survival rate, compared with a historical survival rate of 10 to 37 percent without ECLS, supports our recommendation for treatment with ECLS in a salvageable patient with severe hypothermia and a non-perfusing cardiac rhythm. A Hypothermia Outcome Prediction after ECLS probability ≥10 percent is one reasonable criterion to determine salvageability. (See "Accidental hypothermia in adults: Management", section on 'Benefit of extracorporeal life support'.)
ENVIRONMENTAL EMERGENCIES
Predictors of lung injury after pediatric drowning (April 2025)
Children with nonfatal drowning often develop lung injury and require respiratory support; however, it is often difficult to determine the appropriate disposition for children with less severe presentations at initial evaluation in the emergency department (ED). In a multicenter, retrospective study of over 4200 children seen in a pediatric ED after drowning, risk factors associated with clinically significant lung injury included age >5 years, submersion duration >5 minutes, any resuscitation at the scene or during the ED evaluation, altered mental status or abnormal heart rate, respiratory rate, or lung auscultation. [5]. These findings provide guidance on which children who are not obviously critically ill following drowning may need admission for respiratory monitoring. (See "Drowning (submersion injuries)", section on 'Hypoxic and other severely ill patients'.)
Extracorporeal life support for hypothermic cardiac arrest (January 2025)
Extracorporeal life support (ECLS) may improve overall survival and neurologically intact survival in select adults with hypothermic cardiac arrest. A multicenter registry study of 127 patients in hypothermic cardiac arrest treated with ECLS reported a survival rate of 49 percent, with 89 percent of survivors having good neurologic outcomes [4]. Lower age and lower serum potassium and lactate concentrations were associated with a higher likelihood of survival. This survival rate, compared with a historical survival rate of 10 to 37 percent without ECLS, supports our recommendation for treatment with ECLS in a salvageable patient with severe hypothermia and a non-perfusing cardiac rhythm. A Hypothermia Outcome Prediction after ECLS probability ≥10 percent is one reasonable criterion to determine salvageability. (See "Accidental hypothermia in adults: Management", section on 'Benefit of extracorporeal life support'.)
GENERAL ADULT EMERGENCY MEDICINE
Catheter-directed therapies for intermediate-risk pulmonary embolism (June 2025)
The optimal catheter-directed therapy (CDT) for patients with an intermediate risk of death from pulmonary embolism (PE) is unclear. A recent randomized trial of 550 patients with intermediate-risk PE who were candidates for CDT compared catheter-directed thrombolysis with catheter-directed suction thrombectomy [6]. Suction thrombectomy resulted in lower rates of clinical deterioration/bailout therapy (1.8 versus 5.4) and intensive care use (46 versus 99 percent) than thrombolysis; patients were also less dyspneic and fewer patients had moderate or severe right ventricle dysfunction at 24 hours (42 versus 58 percent). However, at 30 days, mortality and dyspnea scores were similar. Although catheter-directed suction thrombectomy is our preference and has several advantages including faster resolution of thrombus, choosing among these modalities also depends upon local expertise. (See "Acute pulmonary embolism in adults: Reperfusion therapy in intermediate- and high-risk patients", section on 'Suction/mechanical embolectomy'.)
Anticoagulation for acute chest syndrome in sickle cell disease (June 2025)
Acute chest syndrome (ACS) is a potentially life-threatening complication of sickle cell disease that requires aggressive treatment. A new randomized trial in 172 adults with ACS and low bleeding risk evaluated adding therapeutic dose anticoagulation to standard treatments (analgesics, antibiotics, transfusions, oxygen), based on a possible role in reducing pulmonary microthrombi [7]. Compared with prophylactic dose anticoagulation (appropriate for venous thromboembolism [VTE] prophylaxis in all adults with ACS), therapeutic dose anticoagulation led to faster resolution of ACS and reduced opioid use without greater risk of bleeding. We are most likely to use therapeutic dose anticoagulation in a high-risk adult with prior life-threatening ACS; the decision is individualized. In children with ACS, therapeutic dose anticoagulation is reserved for documented VTE. (See "Acute chest syndrome (ACS) in sickle cell disease (adults and children)", section on 'Anticoagulation'.)
Nonsteroidal antiinflammatory drugs for pain control in patients with acute renal colic (May 2025)
Kidney stones often present with acute and intense abdominal and/or flank pain (ie, renal colic); we suggest nonsteroidal antiinflammatory drugs (NSAIDs) as the initial choice for pain control in most patients presenting with acute renal colic. A recent Cochrane systematic review of 29 randomized trials (nearly 3600 patients) found that NSAIDs are more effective than placebo in reducing pain (defined as the change in VAS-10 cm pain scores from baseline to 30 minutes after intervention; mean difference -3.84 cm, 95% CI -6.41 to -1.27) [8]. Patients receiving NSAIDs were also less likely to require rescue pain medication than those receiving placebo. These findings provide additional support for the use of NSAIDs as initial pain control in patients with acute renal colic. (See "Kidney stones in adults: Diagnosis and acute management of suspected nephrolithiasis", section on 'Pain control'.)
No benefit of mechanical thrombectomy for acute stroke due to medium vessel occlusion (May 2025)
Data from multiple randomized clinical trials have established the benefit of mechanical thrombectomy (MT) for acute ischemic stroke due to large vessel occlusion (LVO). However, there was no high-quality evidence to support the use of MT for patients with acute stroke due to medium vessel occlusion (MeVO), generally defined as the middle cerebral artery beyond the proximal dominant M2 segment, the anterior cerebral artery beyond the A1 segment, and the posterior cerebral artery beyond the P1 segment. This situation has changed with new data from the recent ESCAPE-MeVO and DISTAL trials [9,10]. Both trials failed to demonstrate the benefit of MT for patients with acute ischemic stroke due to MeVO, and the ESCAPE-MeVO trial found that MT increased mortality [9]. Given these data, we recommend against routine treatment with MT for patients with acute ischemic stroke due to a MeVO. Regardless of whether they are candidates for MT, eligible patients should still receive standard treatment with intravenous thrombolysis. (See "Mechanical thrombectomy for acute ischemic stroke", section on 'Medium and distal vessel occlusion'.)
Outcomes associated with sepsis bundles (April 2025)
A "sepsis bundle" refers to a set of early interventions (eg, intravenous fluids, antibiotics, and laboratory tests) that improve the diagnosis, management, and survival of patients with sepsis; the time required to complete the "sepsis bundle" is widely used in hospitals as a pay-for-performance measure. A recent review analyzed 17 observational trials examining outcomes associated with compliance or implementation of a sepsis bundle [11]. Five studies demonstrated a mortality benefit from bundle compliance while seven did not. Only one study showed a mortality benefit from bundle implementation. High-quality data are needed to demonstrate a clear mortality benefit from sepsis bundles. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Early goal-directed therapy'.)
Procalcitonin and antibiotic duration in sepsis (April 2025)
While procalcitonin (PCT) has a clear role in determining antibiotic duration for patients with community-acquired pneumonia, its role in managing sepsis is less clear. A recent multicenter randomized trial of 2760 adults with sepsis, reported a reduction in antibiotic duration for patients in whom a daily PCT-guided protocol was implemented compared with standard care (9.8 versus 10.7 days) [12]. However, over half of study participants had lower respiratory tract infections which may have impacted the outcome. Based upon these and other accumulating data in patients with sepsis, we support measuring PCT to guide antibiotic duration. (See "Evaluation and management of suspected sepsis and septic shock in adults", section on 'Initial investigations'.)
Male partner treatment to prevent recurrence of bacterial vaginosis (March 2025)
Treatment of male sex partners to reduce bacterial vaginosis (BV) recurrence in females is an area of ongoing study. In a trial of 150 male-female monogamous couples with confirmed BV in the female, treatment of the male partner for one week with an oral and topical antibiotic (metronidazole tablet and clindamycin cream) in addition to standard antimicrobial treatment of the female patient reduced recurrences at 12 weeks compared with treating the female patient only (35 versus 63 percent; risk difference -2.6 recurrences per person-year) [13]. Based on these results, we now suggest dual topical and oral antimicrobial male partner therapy as an effective strategy to reduce BV recurrence in female patients. (See "Bacterial vaginosis: Initial treatment", section on 'Males'.)
Society of Critical Care Medicine guidelines on critical care ultrasonography use (March 2025)
The Society of Critical Care Medicine (SCCM) recently updated its guidelines on the use of bedside critical care ultrasonography (CCUS) [14]. The SCCM conditionally recommended CCUS use in patients with septic shock, acute respiratory failure, and acute cardiogenic shock as well as in patients with unclear volume status. It was unable to make a clear recommendation for CCUS use in patients undergoing cardiopulmonary resuscitation. We agree with these recommendations. (See "Indications for bedside ultrasonography in the critically ill adult patient", section on 'Introduction'.)
Suzetrigine, a first-in-class nonopioid analgesic, now available for acute pain (March 2025)
Suzetrigine, a first-in-class nonopioid oral analgesic, has been approved by the US Food and Drug Administration for management of acute pain in adults and is now available. Suzetrigine is a selective inhibitor of the Nav 1.8 voltage-gated sodium channel, which is expressed in the dorsal root ganglia and is involved in transmission of nociceptive signals to the spinal cord. In randomized trials of 303 patients who had acute pain after abdominoplasty and 274 patients after bunionectomy, suzetrigine (100 mg orally followed by 50 mg orally every 12 hours) reduced pain scores compared with hydrocodone/acetaminophen (5 mg/325 mg orally every six hours) or placebo [15]. Further study is required to determine the role of suzetrigine in acute pain management. (See "Nonopioid pharmacotherapy for acute pain in adults", section on 'Suzetrigine, a novel Nav1.8 inhibitor'.)
Buprenorphine initiation by emergency clinicians (February 2025)
Initiating buprenorphine in emergency department (ED) patients with opioid use disorder (OUD) is feasible and increases treatment engagement, but barriers to routine use remain. In a retrospective study of a California program involving more than 80 percent of the state’s acute care hospital EDs, buprenorphine initiations in the ED increased from 0.1 percent of total buprenorphine initiations to 5 percent over five years [16]. Buprenorphine use continued in approximately one in three patients at 40 days and one in nine patients at one year. Strategies that directly engage emergency clinicians can help increase buprenorphine prescribing and lead to continued OUD treatment for many individuals. (See "Acute opioid intoxication in adults", section on 'Prevention of recurrent opioid overdose'.)
Trial of emergency clinician palliative care educational program (January 2025)
Emergency department (ED) patients with chronic, severe, or life-threatening conditions may benefit from palliative interventions, but the benefit of such care provided by ED clinicians is unclear. In a cluster randomized trial conducted in almost 30 EDs and including 99,000 visits, a palliative care educational intervention for emergency physicians, nurses, and advanced practice providers resulted in fewer hospital admissions in the post-intervention period (61 versus 64 percent), but the findings did not achieve statistical significance [17]. While ED-based palliative care interventions may have the potential to accomplish important goals, the optimal approach is still unknown. (See "Palliative care for adults in the ED: Concepts, presenting complaints, and symptom management", section on 'Why the integration of palliative care in the ED is important'.)
GENERAL PEDIATRIC EMERGENCY MEDICINE
Duration of observation for children treated with epinephrine for anaphylaxis (June 2025)
Consensus does not exist regarding the optimal observation period for a child successfully treated for anaphylaxis; concern for biphasic reactions results in significant practice variation and potentially unnecessary hospital observation. In a retrospective study of over 5600 children with acute allergic reactions that were treated with epinephrine before or shortly after presentation to the emergency department (ED), there was a minimal (<2 percent) hourly increase in receiving additional epinephrine after four hours, even in patients who presented with cardiovascular involvement [18]. These findings support our recommendation for discharging patients, including children, from the ED after an appropriate observation period following resolution of anaphylaxis signs and symptoms. (See "Anaphylaxis: Emergency treatment", section on 'Duration of observation'.)
C-reactive protein and procalcitonin in febrile young infants (April 2025)
For well-appearing febrile infants 29 to 60 days of age, current guidance from the American Academy of Pediatrics and commonly used clinical prediction rules support use of procalcitonin (PCT), absolute neutrophil count, and urine testing to detect patients at low risk of invasive bacterial illness (IBI; ie, bacteremia or meningitis); C-reactive protein is optional but not required if PCT results are rapidly available (algorithm 1). In a new study of over 2000 febrile young infants (8 to 60 days old) with a prevalence of IBI of 1.4 percent, the combination of PCT ≤0.5 ng/mL and C-reactive protein (CRP) ≤20 mg/L had 100 percent sensitivity and negative predictive value with no patients misclassified as low risk for IBI regardless of age [19]. Study limitations include small sample size and limited generalizability. These findings suggest that measuring both PCT and CRP in all febrile young infants may be the optimal approach to guide further evaluation and treatment. (See "The febrile infant (29 to 90 days of age): Outpatient evaluation", section on 'Inflammatory markers'.)
Expanded approval for intranasal glucagon for hypoglycemia in young children with diabetes (April 2025)
The US Food and Drug Administration (FDA) has expanded regulatory approval for intranasal glucagon for the treatment of severe hypoglycemia in patients with type 1 and type 2 diabetes; while previously it was approved for those aged ≥4 years old, approval now includes those aged ≥1 year old. This expanded approval was based on a phase 1 single-arm study of seven patients age 1.8 to 4 years with type 1 diabetes [20]. All patients experienced an increase in blood glucose ≥20 mg/dL from baseline within 30 minutes of administration of 3 mg of intranasal glucagon. No serious adverse events were reported, although several minor events occurred (eg, vomiting, epistaxis, nasal discomfort and eye irritation). Based on these data, we consider intranasal glucagon to be a safe and effective alternative to intramuscular glucagon for the treatment of severe hypoglycemia in patients with diabetes aged 1 year and older. (See "Type 1 diabetes in children and adolescents: Prevention and management of hypoglycemia", section on 'Glucagon'.)
Nonoperative management of appendicitis in children (January 2025)
For children with early appendicitis, the role of nonoperative management with antibiotics (NOM) has been debated. In a multicenter trial of 846 children with appendicitis, 34 percent of children assigned to NOM required an appendectomy within one year. Approximately one-half of these patients required appendectomy at the index admission, of whom 35 percent had perforated appendicitis [21]. For children assigned to prompt appendectomy, 7 percent had normal pathology and 6 percent had perforation. Based on this first randomized trial of NOM in children with early appendicitis, we continue to perform appendectomy for most of these patients. However, NOM may be an option for selected children after shared decision-making (algorithm 2). (See "Acute appendicitis in children: Management", section on 'Nonoperative management'.)
Pediatric opioid use-associated neurotoxicity with cerebellar edema (POUNCE) syndrome (January 2025)
The pediatric opioid use-associated neurotoxicity with cerebellar edema (POUNCE) syndrome occurs rarely following an opioid overdose in young children (typically ≤3 years old). In a recent case report, a 31-month-old girl presented with coma, miosis, bradypnea, right gaze deviation, and shaking of the extremities following an accidental methadone overdose; naloxone improved alertness and miosis [22]. Brain imaging showed bilateral cerebellar edema typical of POUNCE syndrome. Clinicians should consider this rare syndrome in a young child with persistent neurologic findings after treatment of opioid overdose; some children may require neurosurgical intervention for tonsillar herniation or obstructive hydrocephalus. (See "Opioid intoxication in children and adolescents", section on 'Physical examination'.)
Laparoscopic repair of intestinal malrotation without volvulus in children (January 2025)
Laparoscopic repair is an option for children who have malrotation without volvulus, but, compared with laparotomy, it has been associated with a higher risk of postoperative volvulus. However, in a retrospective study of 226 such children with malrotation, laparoscopic repair and laparotomy were both associated with a low rate of postoperative volvulus (≤1 percent) [23]. These data suggest that laparoscopic repair in these patients may have fewer postoperative complications than previously believed, particularly when performed by an experienced surgeon in an older child without comorbidities. (See "Intestinal malrotation in children", section on 'Laparoscopic repair'.)
PRIMARY CARE ORTHOPEDICS AND SPORTS MEDICINE
Management of nondisplaced tibial spiral (toddler's) fractures in children (June 2025)
Toddler's fractures of the tibia (image 1) are common injuries in ambulatory infants and young children; the best approach to management is debated. In the largest randomized trial of 129 toddlers (mean age 2.2 years), the majority of whom had toddler's fractures of the distal two-thirds of the tibia on radiograph, more patients assigned to a pediatric walking boot (WB) had returned to baseline activities at three weeks compared with those assigned to a long- or short-leg cast (77 versus 41 percent) [24]. Caregivers in the WB group also reported fewer challenges with home care tasks than the cast group. There was a nonsignificant trend towards more pressure sores in the WB group, which appeared to be mitigated by placement of a stockinette prior to WB application. Based on this and other studies, we suggest a WB rather than a cast for children with these fractures on imaging. (See "Tibial and fibular shaft fractures in children", section on 'Tibial spiral (toddler's) fractures'.)
High rate of iron deficiency in athletes (January 2025)
High-intensity athletics can cause iron deficiency by several mechanisms including reduced iron intake, gastrointestinal blood loss, iron loss in sweat, and traumatic hemolysis. A new meta-analysis including over 17,000 college athletes and military recruits reported iron deficiency in 31 percent, using a ferritin cutoff of 30 ng/mL [25]. Female athletes are more likely than male athletes to have iron deficiency; younger and older athletes are equally affected. These observations confirm that high-intensity athletics is a significant risk factor for iron deficiency and support a role for screening in this population. (See "Diagnosis of iron deficiency and iron deficiency anemia in adults", section on 'Epidemiology'.)
PROCEDURES
Securing central venous catheter dressings (May 2025)
A central venous catheter (CVC) must be secured to the skin to stabilize it, but the optimal dressing is unclear. In a randomized trial of patients undergoing jugular CVC insertion, application of medical liquid adhesive (MLA) under the standard CVC dressing border resulted in fewer dressing failures due to lifting edges at seven days compared with a standard dressing alone (28 versus 50 percent) [26]. Skin complications were similar between the groups. While MLA improved catheter securement and dressing integrity, a larger trial is needed to evaluate clinically important outcomes such as infection, catheter loss, and other complications. (See "Routine care and maintenance of intravenous devices", section on 'Device securement'.)
Reduction of radial head subluxation ("pulled elbow") in children (March 2025)
Radial head subluxation (RHS) commonly occurs in young children (<5 years old) when a parent or caregiver grabs the arm to prevent falling or pulling away (figure 1); the best method for reduction of an RHS is debated. In a meta-analysis of 11 randomized trials (almost 1200 children with RHS undergoing reduction), the pooled first-attempt success rate was higher following the use of the hyperpronation method (figure 2) compared with the supination/flexion method (figure 3) (91 versus 75 percent, respectively) [27]. Limitations of this analysis include the high risk of bias in most of the included studies and interstudy differences in the definition of a successful reduction. These findings support our suggestion for the hyperpronation method rather than the supination/flexion method to reduce an RHS; however, the supination/flexion method is a reasonable alternative if the clinician is more familiar and skilled with this technique. (See "Radial head subluxation (pulled elbow): Evaluation and management", section on 'Radial head subluxation reduction'.)
Crystallization of mixtures of drugs used for regional anesthesia (February 2025)
Regional anesthesia often involves the use of two different local anesthetics (with or without adjuvant drugs) to speed onset, improve block quality, and/or prolong the block effect. A new laboratory study found that even commonly used combinations may precipitate in the syringe; many of the tested combinations precipitated immediately, and most precipitated after one hour [28]. The safety of perineural injection of crystallized solutions and the potential for in situ crystallization after injection have not been determined. Whenever possible, compatibility of drug combinations should be confirmed prior to the use of admixtures. (See "Clinical use of local anesthetics in anesthesia", section on 'Combinations of local anesthetics'.)
TOXICOLOGY
Two-bag acetylcysteine dosing protocol for acetaminophen poisoning (April 2025)
There are many acetylcysteine (N-acetylcysteine) dosing protocols for acetaminophen poisoning, including the 21-hour three-bag intravenous (IV) protocol and a simplified 20-hour two-bag IV protocol. A meta-analysis with more than 7600 patients found that a two-bag protocol, as compared with the three-bag protocol, was associated with fewer nonallergic anaphylactic reactions and other adverse events (3 versus 11 percent) without an increased risk of hepatoxicity [29]. Given these findings, we suggest use of the two-bag protocol instead of other protocols. For a patient with an acute acetaminophen ingestion, regardless of which protocol is chosen, it should deliver at least 300 mg/kg acetylcysteine orally or IV during the first 20 to 24 hours of treatment. The acetylcysteine IV solution product label has been updated to include the two-bag protocol. (See "Acetaminophen (paracetamol) poisoning: Management in adults and children", section on 'Simplified 20-hour (two-bag) intravenous protocol'.)
Ibogaine toxicity reported to United Kingdom poison centers (March 2025)
Ibogaine is a psychoactive alkaloid extracted from the root of Tabernanthe iboga, a perennial shrub found in Africa. Although not approved by the FDA and illegal in many countries, it is used to mitigate opioid withdrawal symptoms and has been previously reported to prolong the QT interval and cause ventricular dysrhythmias. In a case series of seven patients from United Kingdom poison centers, three patients developed either cardiac arrest or torsade de pointes while the others had intoxication, somnolence, bradycardia, or vomiting [30]. Ibogaine toxicity should be considered in a patient with an opioid use disorder who presents with a ventricular dysrhythmia or cardiac arrest. (See "Intoxication from LSD and other common hallucinogens", section on 'Ibogaine'.)
Sibutramine and sildenafil found in weight loss supplements in France (March 2025)
Weight loss supplements are commonly used worldwide and may contain active ingredients that can cause adverse effects. In 2023, 29 people from France reported using weight loss supplements that were analyzed and found to contain sibutramine and sildenafil [31]. Sibutramine is no longer available by prescription because it increases the risk of stroke and myocardial infarction. Many of the patients in this study reported anorexia, tachycardia, chest pain, increased blood pressure, headaches, and insomnia. These findings support our recommendation to counsel patients not to use weight loss dietary supplements since none are proven safe or effective, and they often contain potentially harmful adulterants. (See "High-risk dietary supplements: Patient evaluation and counseling", section on 'Weight loss supplements'.)
Adult cannabis poisoning in states with medical and recreational cannabis laws (March 2025)
States with medical and recreational cannabis laws have seen an increase in pediatric cannabis poisoning, but the impact of these laws on poisoning in adults is less clear. A study of an employer-sponsored United States health insurance claims database (over 110 million enrollees) from 2011 to 2021 found that adult patients in states with medical and recreational cannabis laws were associated with an increase of 89 and 32 percent, respectively, in cannabis poisoning diagnoses compared with states without these laws [32]. These results suggest that cannabis legalization is also associated with an increase in adults poisoning, although likely to a lesser extent than pediatric poisoning. (See "Cannabis (marijuana): Acute intoxication", section on 'Epidemiology'.)
Endoscopic removal of retained packets in asymptomatic body packers (March 2025)
In asymptomatic body packers, whole bowel irrigation (WBI) is the first-line treatment as it is safe and hastens packet removal; endoscopic packet removal is controversial because packet perforation can release dangerous amounts of drug. However, a study with 82 patients who underwent endoscopic removal of retained cocaine packets (all covered with a wax coating) found no evidence of packet rupture [33]. Sophisticated modern packaging techniques (ie, outside wax coating) and improved endoscopic techniques (ie, basketing instead of snaring) likely mitigate the risk of packet perforation. Given these findings, we suggest endoscopic removal in asymptomatic patients who have a few retained packets following WBI or when WBI is otherwise contraindicated. (See "Internal concealment of drugs of abuse (body packing)", section on 'Role of endoscopic removal of packets'.)
TRAUMA
Timing of primary repair of open-globe injury (May 2025)
Definitive management of an open-globe injury is primary closure by an ophthalmologist, but practice variation exists regarding the timing of surgery. Infection (ie, endophthalmitis) is associated with poor visual outcomes. A meta-analysis that included over 6400 eyes found that primary repair within 24 hours after injury, compared with beyond 24 hours, was associated with a lower rate of endophthalmitis (11 versus 28 percent) [34]. These findings support our advice that closure within 24 hours of injury is ideal. (See "Open globe injuries: Emergency evaluation and initial management", section on 'Definitive management'.)
Fractures and child abuse in young children (March 2025)
The American Academy of Pediatrics has published a clinical report that provides guidance for the evaluation of fractures in young children [35]. This report reaffirms the importance of a careful history and physical examination with special attention to the reported mechanism of injury, the developmental capability of the child, associated injuries on examination, and the specific type of fracture. A skeletal survey (table 1), under the guidance of a pediatric radiologist or a multidisciplinary child abuse team led by a child abuse specialist, is indicated for children <24 months old who have a fracture that is concerning for abuse (table 2). (See "Orthopedic aspects of child abuse", section on 'Overview' and "Physical child abuse: Recognition", section on 'Fractures'.)
Risk of delayed bleeding in older adults following head trauma (January 2025)
Older adults, particularly those taking anticoagulant medication, are at high risk for intracranial hemorrhage (ICH) following blunt head trauma. However, the risk of delayed ICH is less well studied. In a prospective observational study of 3425 older adult patients with acute head injury (median age 82, 33 percent of whom were prescribed anticoagulants), acute ICH was identified in 6.7 percent of patients but only 0.4 percent had delayed ICH [36]. The rates of delayed bleeding were similar for patients prescribed anticoagulants versus those who were not. All delayed bleeding occurred between several hours and five days following injury. These findings are consistent with prior studies and support the safety of discharge in older adults with isolated closed head injury who have a normal initial neurologic examination, no bleeding on CT scan (if obtained), and remain stable with no change in neurologic status after 12 hours of observation. (See "Geriatric trauma: Initial evaluation and management", section on 'Risk of bleeding'.)
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