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Am Fam Physician. 2021;104(4):354

What is an effective approach to treatment-resistant depression in adults?

Atypical antipsychotics can be an effective augmentation therapy for adults with treatment-resistant depression. According to a Cochrane review, adding quetiapine (Seroquel) to anti-depressant therapy reduces symptoms below the remission threshold (number needed to treat = 9), and the number of people who stop using the medicine increases only at the highest dosage. Augmentation with cariprazine (Vraylar) or ziprasidone (Geodon) improves the clinical response; however, the benefit is offset by increased treatment dropouts.

How should patients with degenerative cervical myelopathy be evaluated and treated?

Magnetic resonance imaging with and without contrast is the modality of choice for patients with suspected degenerative cervical myelopathy. Surgical management is indicated for patients with moderate to severe myelopathic signs and symptoms; however, even with surgery, many patients have residual deficits.

What are examples of clinical scenarios where diagnostic imaging is not indicated?

Do not perform imaging in patients with primary headache disorders without new or progressive features who have normal neurologic examination findings. Do not perform plain chest radiography for preoperative evaluations or baseline testing during hospitalizations for patients who are asymptomatic. Do not perform imaging in patients with acute (less than six weeks) low back pain and no red flag findings on history or physical examination.

What is the first-line treatment approach for patients with an eating disorder?

Family-based therapy should be a first-line approach for youths with anorexia nervosa and bulimia nervosa, and medications should not be used as monotherapy. If medications are used for adjunctive therapy, lisdexamfetamine (Vyvanse) can be effective in reducing binge-eating behaviors in persons with binge-eating disorder. [corrected]

Are vitamin K antagonists effective in preventing recurrence for patients with distal (below knee) DVT?

According to a Cochrane review, vitamin K antagonists reduce the recurrence of deep venous thrombosis (DVT) and venous thromboembolism (number needed to treat = 17), but not pulmonary embolism, compared with no anticoagulation or placebo. A treatment duration of three months or more reduces these recurrences, compared with six weeks of therapy. The risk of clinically relevant nonmajor bleeding (number needed to harm = 23), but not major bleeding, is increased with anticoagulation.

Additional Online Only AFP Clinical Answers

How does regular exercise impact the occurrence, severity, or duration of acute respiratory tract infections?

Regular exercise may reduce the overall severity of acute respiratory tract infections and the number of days with symptoms in adults, according to a Cochrane review. There is no evidence that exercise reduces the overall occurrence or duration of these infections.

How should hip pain in adults be evaluated?

Standing anteroposterior hip and pelvic radiographs are the first choice if performing imaging for a patient with undifferentiated chronic hip pain. If the patient’s history suggests a labral tear, stress fracture of the femoral neck, or early avascular necrosis, magnetic resonance imaging should be performed. Consider ultrasonography or magnetic resonance imaging to evaluate for gluteus medius tendon tears in patients with greater trochanteric pain syndrome not responding to conservative therapy.

How should dysphagia be managed?

Patients younger than 50 years who have esophageal dysphagia and no other worrisome symptoms should undergo a four-week trial of acid suppression therapy before endoscopy is performed. Patients with apparent oropharyngeal symptoms and a negative evaluation should be referred for esophagogastroduodenoscopy (EGD) to rule out esophageal pathology. EGD is recommended for the initial assessment of patients with esophageal dysphagia, and barium esophagography is recommended as an adjunct if EGD findings are negative.

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