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up to date and Emergency Medicine News are collaborating to present a selection of content synopses from UptoDate’s “What’s New in Emergency Medicine.” UpToDate is an evidence-based clinical support resource used worldwide by healthcare professionals to make point-of-care decisions. Visitwww.uptodate.comfor complete and current “What’s New” content or to become a subscriber for full content access. What’s New summaries are free for all healthcare professionals.

YEARS algorithm for the diagnosis of pulmonary embolism

Algorithms that incorporate pre-test probability (PTP) assessment using the Wells criteria with a fixed threshold for D-dimers (Lancet 2017 May 23; doi: 10.1016/S0140-6736[17]30885-1.)

Treatment of non-purulent cellulitis

Empirical antibiotic therapy for nonpurulent cellulitis (ie without purulent drainage or associated abscess) should be active against beta-hemolytic streptococci and methicillin-susceptible streptococci. Staphylococcus aureus (MSSA) but not necessarily methicillin resistant S. aureus (MRSA). This approach is supported by a randomized trial of nearly 500 patients with nonpurulent cellulitis, in which cephalexin plus placebo (active against beta-hemolytic streptococci and SASM) and cephalexin plus trimethoprim-sulfamethoxazole (TMP-SMX , which adds activity against MRSA) resulted in statistically similar clinical cure rates (69% vs. 76%). Although there was a trend towards higher cure rates with the addition of TMP-SMX, the results were likely skewed by a relatively large number of patients who did not complete the full treatment. (JAMA 2017;317[20]:2088.)

Glucocorticoids not needed for simple acute urticaria

Although patients with urticaria and symptoms involving other organ systems are treated with epinephrine given the likelihood of anaphylaxis, H1 antihistamines are the initial treatment for those with isolated urticaria. For these patients, the additional benefit of glucocorticoids is not well defined. In a randomized trial of 100 adults presenting to the emergency department with isolated urticaria (without angioedema, anaphylaxis, or fever) lasting less than 24 hours, patients received the H1 antihistamine levocetirizine plus either prednisone, or a placebo for four days. There was no significant difference in symptom resolution, and most patients were symptom-free within two days. This study supports our suggestion to reserve glucocorticoids for patients with new urticaria who have prominent angioedema or whose symptoms persist despite antihistamines. (Ann Emergency Med 2017 May 2. doi: 10.1016/j.annemergmed.2017.03.006.)

Medical use of prescription opioid drugs and misuse among adolescents

Surveys of high school students in the United States over 40 years show that prescription opioid use is strongly correlated with abuse in adolescents and that abuse generally follows patient medical use. Thus, healthcare providers should follow safe prescribing guidelines for prescription opioids, including the use of alternatives (eg, acetaminophen or ibuprofen) to control pain whenever possible. , using the lowest effective dose and minimum amount of prescription opioids when needed, and using prescription drug monitoring programs, where appropriate, to identify patients or caregivers at risk of abuse (i.e. misuse or divert) prescription opioid medications. (Ann Emergency Med 2016;68[5]:574.)

Secure storage of prescription opioids

Although safe storage of prescription opioid medications (eg, a locked cabinet) is recommended, this rarely occurs. In a nationally representative US survey of more than 1,000 adults who used prescription opioids in the past 12 months, only 9% said they stored their medications safely. (JAMA Medical Intern 2016;176[7]: 1027.) In a closer analysis of adults with children under 18 in the household, safe storage was reported in less than a third of households with young children and 12 percent of households with children over 6 years old. . (Pediatrics 2017;139[3]; doi:10.1542/peds.2016-2161.) These findings support the need for proactive counseling from healthcare providers, with an emphasis on safe storage of opioids and how it can limit the opioid abuse and overdoses, especially in households with children and adolescents. Further research should focus on the development and implementation of effective means of secure storage in households.

Persistence of childhood lead poisoning neurotoxicity into adulthood

Detectable blood lead (CSP) concentrations are associated with irreversible neurocognitive deficits in children and a lower CSP limit for this toxicity has not been established. Previous studies have shown that this effect persists into adolescence. In a longitudinal cohort study of over 1000 patients, lead exposure, based on blood lead levels obtained at age 11, was dose-dependently associated with lower intelligence quotient (IQ) and Lower socioeconomic status at age 38 after adjusting for IQ, Child IQ, and Child socioeconomic status. Thus, childhood lead exposure causes neurotoxicity that persists into adulthood. Primary prevention of lead exposure, including in pregnant women, can prevent these effects. (JAMA 2017;317[12]:1244.)

Immunoassay for acetaminophen-induced liver injury

Establishing the diagnosis of paracetamol (APAP) poisoning in patients who present more than 24 hours to several days after ingestion when a serum level of APAP may no longer be detectable may be difficult. However, a recent observational cohort study revealed excellent performance of a rapid immunoassay that measures serum APAP-protein adducts to identify patients with APAP-induced acute liver injury. In this study, a point-of-care immunoassay (AcetaSTAT) found 100% sensitivity and 100% negative predictive value against high-performance liquid chromatography results as the gold standard for identifying patients with such injury. If these results are validated in future clinical trials, this test may provide a quick way to distinguish APAP-induced ALI from other causes and quickly begin appropriate management. (Clin Gastroenterol Hepatol 2017;15[4]:555.)

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