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Am Fam Physician. 2020;102(9):587

What is the evidence for augmentation therapy in patients with treatment-resistant depression?

There is weak research to guide treatment decisions for patients who have not responded to two adequate courses of antidepressant treatment. One randomized controlled trial of cognitive behavior therapy showed benefit over placebo. Aripiprazole (Abilify) had a small effect, but no other antipsychotic or lithium provided benefit over placebo.

Are hormonal contraceptives effective in decreasing heavy menstrual bleeding?

Combined oral contraceptives decrease the number of women reporting heavy menstrual bleeding over six months more than placebo, with a number needed to treat (NNT) of 2.7. The levonorgestrel-releasing intrauterine system (Mirena) is more effective, with an NNT of 3 to decrease heavy menstrual bleeding compared with combined oral contraceptives.

What testing should be used to diagnose venous thromboembolism (VTE)?

The American Society of Hematology recommends determining pretest probability using the Wells, Geneva, or Constans score to select testing to diagnose or rule out VTE. A d-dimer test alone can be used to rule out VTE for patients with a low or intermediate pretest probability of pulmonary embolism, low pretest probability of lower extremity deep venous thrombosis (DVT), or low pretest probability of upper extremity DVT. In patients with a low or intermediate pretest probability of pulmonary embolism but a positive d-dimer result, a ventilation-perfusion scan is recommended over computed tomography pulmonary angiography (CTPA), but CTPA is recommended for patients with a high pretest probability. Ultrasonography is recommended as the initial test for patients with a high pretest probability of lower extremity or upper extremity DVT with confirmatory testing if negative.

Which patients should be screened for pancreatic cancer?

The U.S. Preventive Services Task Force recommends against screening for pancreatic cancer in asymptomatic adults who are not at high risk of pancreatic cancer. Patients at high risk of pancreatic cancer include people with inherited genetic syndromes known to be associated with pancreatic cancer (e.g., Peutz-Jeghers syndrome, hereditary pancreatitis) or a family history with at least two affected first-degree relatives. Lesser risk factors such as smoking, diabetes mellitus, chronic pancreatitis, or obesity do not warrant screening.

Does immediate renal replacement therapy improve outcomes for acute kidney injury in patients with septic shock?

There is no difference in 90-day mortality between early initiation (less than 12 hours) and delayed initiation (after 48 hours).

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