Important Clinical Updates

Updates will be listed on this page.

Important Updates:

Update as of March 2015:

Update to Head Injury chapter Volume 6 Edition 8:

Important Study:

Thomas DG et al. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial.

PEDIATRICS. Volume 135, number 2, February 2015.

These investigators sought to investigate the effectiveness of recommending 5 days of strict rest compared with the usual care of 24 to 48 hours of rest on outcomes after discharge from the ED with acute concussion in a population of patients aged 11-22.

Neurocognitive and balance assessments were performed at 3 and 10 days. From the abstract: There was no clinically significant difference in neurocognitive or balance outcomes. However, the intervention group reported more daily postconcussive symptoms (total symptom score over 10 days, 187.9 vs 131.9, P,.03) and slower symptom resolution.

This supports the recommendations to gradually return to activities based on tolerance with appropriate medical supervision. However, “cocoon”-like therapies may not be beneficial.

Link to the article:

Link to editorial in Pediatrics

Update as of July 2014:

Update to Cellulitis chapter Volume 4 of Edition 8:

Link is here:

The Infectious Diseases Society of America has published an updated Practice Guidelines for the Management of Skin and Soft Tissue Infections. This document updates the previous version, published in 2005 (referenced in the original chapter). It builds off of the 2011 MRSA guidelines (which I also reference in the original chapter) in that the first branch-point in management of SSTI is the classification of it as a non-purulent or a purulent infection based on clinical evaluation. The most important contribution of this lengthy document, in the author’s opinion, is Figure 1. This simple algorithm illustrates the above-mentioned classification scheme and further sub-divides purulent and non-purulent SSTIs into Mild, Moderate, or Severe infections. Mild infections are typical presentations in a patient without the systemic inflammatory response syndrome (SIRS). Moderate infections are typical presentations with SIRS. Severe infections are those in patients are immunocompromised or have failed oral antibiotics and, if purulent, incision and drainage (I&D), and present with SIRS. Importantly, for mild purulent infections, only I&D is necessary. 

Update as of January 2014:

Update to Hypertension Volume 4 of Edition 8 Chapter 1

After the completion of our Chapter on Hypertension by Stephen Huot, the panel members appointed to the Joint National Committee released updated Hypertension Guidelines were published in JAMA on December 18, 2013 (JNC8). Major changes to note: The new goal for blood pressure control for persons 60 years of age and older who do not have diabetes or chronic kidney disease is under 150/90. For persons 18-59 who have no comorbidities or any adults with diabetes or chronic kidney disease, the goal blood pressure goal is under 140/90. First line agents should now include one of the following choices: thiazides, calcium channel blockers, ACE inhibitors or ARBs. Patients of African-American descent should be initiated on thiazides or calcium channel blockers instead of ACE inhibitors. All patients with chronic kidney disease, regardless of ethnic or racial background, should be started on ACE inhibitors or ARBs. Paul A. James, et al 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8) JAMA. Published online December 18, 2013. Three editorials accompanied this article as well. doi:10.1001/jama.2013.284427. Several excellent summaries are also available. Allan S. Brett, MD JNC 8 Has Finally Arrived. NEJM Journal Watch. December 24, 2013 reviewing James PA et al. JAMA . Weber MA et al. J Clin Hypertens (Greenwich) 2013 Dec 17. Krumholz, Harlan M. 3 Things to Know About the New Blood Pressure Guidelines. New York Times. December 18, 2013.