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Am Fam Physician. 2021;104(6):566

What are indications for referral to audiology in patients with tinnitus?

According to guidelines from the American Academy of Otolaryngology-Head and Neck Surgery, patients should be referred for audiologic examination within four weeks if tinnitus is chronic (i.e., lasting six months or longer), bothersome, unilateral, or associated with hearing changes. Patients presenting with tinnitus associated with sudden sensorineural hearing loss should have urgent audiometry because this requires urgent treatment.

What is the appropriate initial management for patients with HIV infection?

Combination antiretroviral therapy should be initiated as soon as possible after HIV diagnosis. If the CD4 count is less than 200 cells per μL, initiate prophylaxis against Pneumocystis jiroveci. If the CD4 count is less than 100 cells per μL and Toxoplasma antibodies are positive, initiate prophylaxis against Toxoplasma gondii. Administer vaccines according to the standard adult vaccination schedule, avoiding live vaccines if the CD4 count is less than 200 cells per μL.

How should joint hypermobility disorders be diagnosed?

Suspect hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders in patients with joint hypermobility and associated symptoms such as joint pain or dislocations, typical skin findings, arthralgias, recurrent hernias, marfanoid habitus, or family history of Ehlers-Danlos syndrome. Assess joint hypermobility in patients suspected of having hypermobile Ehlers-Danlos syndrome/hypermobility spectrum disorders with a Beighton hypermobility score and a validated five-part questionnaire.

Are ketogenic diets effective at reducing seizure frequency in patients with drug-resistant epilepsy?

In children with drug-resistant epilepsy, a ketogenic diet decreases the risk of seizures by 50% after three to four months (number needed to treat [NNT] = 3; 95% CI, 1 to 5). Adverse effects such as gastrointestinal symptoms do not occur more often than in children who follow their usual diet. In adults, it is unclear whether ketogenic diets are beneficial, and adverse gastrointestinal effects are common.

Are nerve blocks effective in managing pancreatic cancer pain?

Celiac plexus blocks can be used for pain associated with pancreatic cancer. They slightly reduce pain while decreasing opioid consumption with fewer adverse effects compared with standard analgesic therapy. Celiac plexus neurolysis is not well studied but appears to provide temporary pain relief for many patients with end-stage pancreatic cancer.

Additional Online Only AFP Clinical Answers

How do Alcoholics Anonymous (AA) and similar 12-step facilitation programs compare to other established treatments for helping people with alcohol problems?

Manualized (standardized and replicable) AA and similar 12-step facilitation programs produce higher rates of continuous abstinence than other established treatments. Nonmanualized (nonstandardized) 12-step programs perform as well as other established treatments investigated across a variety of alcohol-related outcomes. Overall, 12-step programs may be superior to other treatments for increasing the percentage of days of abstinence and probably perform as well as other treatments at reducing drinking intensity.

What are best practices in initiating hormonal contraception?

Hormonal contraception can be started at any point during the menstrual cycle. Papanicolaou testing should not be required before prescribing hormonal contraception. A one-year supply of contraceptives should be dispensed or prescribed to reduce patient costs, improve adherence, and increase convenience.

Are epidural corticosteroid injections safe and effective for the treatment of lumbosacral radicular pain?

Epidural corticosteroid injections for the treatment of lumbosacral radicular pain may offer modest short-term (two weeks to three months) benefit compared with placebo injection for radicular leg pain and disability. After three months, there does not appear to be any added benefit with the use of a corticosteroid. Minor adverse effects from corticosteroid injection are no more common than with placebo injection.

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