AFP Clinical Answers
Hemorrhoids, Tremor, C. difficile Infection, Migraine, Vitamin D Screening
Am Fam Physician. 2019 Mar 1;99(5):285.
What are some recommended therapies for managing hemorrhoids?
Increasing fiber intake is an effective first-line, nonsurgical treatment for hemorrhoids. Rubber band ligation is considered the preferred choice in the office-based treatment of grades I to III internal hemorrhoids because of effectiveness compared with other office-based procedures. Excisional (conventional) hemorrhoidectomy is effective for the treatment of grade III or IV, recurrent, or highly symptomatic hemorrhoids.
What are some diagnostic considerations when evaluating tremors?
Patients with new-onset tremor should have a comprehensive review of medications (prescribed and over-the-counter), with specific attention to medications started before the onset of tremor. A resting tremor is usually caused by parkinsonism. Tremor in children is potentially serious; patients should be promptly referred to a neurologist.
How effective are interventions to prevent and treat C. difficile infection?
Antibiotic stewardship and handwashing campaigns reduce Clostridium difficile infection without reported harms. Vancomycin has a higher initial cure rate than metronidazole, although the recurrence rate is equal between the two drugs. Fidaxomicin has a lower recurrence rate than vancomycin, although there is no difference in the initial cure rate. There is low strength, but consistent evidence that Lactobacillus, multiorganism probiotics, and fecal microbiota transplantation are effective in reducing C. difficile infection recurrence.
How should acute migraine be treated?
Nonsteroidal anti-inflammatory drugs are a first-line treatment for mild to moderate migraine. The choice of medication should be based on availability and adverse effect profile. Triptans are a first-line treatment for moderate to severe migraine. Dopamine antagonist antiemetics are second-line treatments for migraine. Parenteral dihydroergotamine (DHE 45), magnesium sulfate, valproate (Depacon), and opioids should be reserved for refractory migraine because of adverse effects, weaker evidence of effectiveness, and/or abuse potential.
Is vitamin D screening and supplementation recommended in asymptomatic adults?
There is insufficient evidence to recommend screening the general population for vitamin D deficiency. Routine vitamin D supplementation in community-dwelling adults is not recommended. Treating asymptomatic individuals with identified deficiency has not been shown to improve health. Potential harms of excessive vitamin D include nephrolithiasis, soft tissue calcification, and renal and cardiovascular damage.
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