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Am Fam Physician. 2020;102(11):664

How should patients with cirrhosis be treated?

All patients with cirrhosis should be evaluated for hepatocellular carcinoma with ultrasonography every six months. Patients who have a Model for End-Stage Liver Disease score of 15 or more, or complications of cirrhosis that include ascites, hepatic encephalopathy, or variceal hemorrhage, should be referred to a transplant center. Patients with clinically apparent (i.e., moderate to severe) ascites should be managed with salt restriction and spironolactone with or without loop diuretics. Patients who have medium, large, or high-risk varices should be treated with nonselective beta blockers and/or endoscopic band ligation for primary prevention of variceal bleeds.

How effective are alpha blockers for increasing passage of ureteral stones?

The alpha blocker tamsulosin (Flomax) improves clearance of stones larger than 5 mm, shortens expulsion times, and reduces hospitalization. Alfuzosin (Uroxatral), doxazosin (Cardura), and silodosin (Rapaflo) are also effective but have significantly more adverse effects.

How should children and adolescents with depression be treated?

Adolescents should be screened annually for depression. For children and adolescents with mild depression, consider delaying pharmacotherapy and psychotherapy for six to eight weeks while providing supportive care and close monitoring, because patients may improve without further treatment. Children and adolescents with moderate or severe depression or persistent mild depression should be treated with fluoxetine (Prozac) or escitalopram (Lexapro) in conjunction with cognitive behavior therapy or other talk therapy. For patients who do not initiate combination therapy, monotherapy with an antidepressant or psychotherapy is recommended, although the likelihood of benefit is lower.

Is positional therapy effective for the treatment of obstructive sleep apnea?

Positional therapy for obstructive sleep apnea reduces scores on the apnea-hypopnea index and Epworth Sleepiness Scale compared with no treatment. Although continuous positive airway pressure improves apnea-hypopnea index scores more than positional therapy, patients seem to better tolerate positional therapy. Positional therapies likely have improved adherence over continuous positive airway pressure.

Should patients be screened for scoliosis?

The U.S. Preventive Services Task Force and the American Academy of Family Physicians concluded that evidence is insufficient to assess the balance of benefits and harms of screening for adolescent idiopathic scoliosis in patients 10 to 18 years of age.

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