AFP

Question 1

Should primary care clinicians recommend low-dose aspirin for the primary prevention of cardiovascular disease in adults 60 years or older?

Answer 1

The U.S. Preventive Services Task Force (USPSTF) recommends against initiating low-dose aspirin (81 mg per day) for the primary prevention of cardiovascular disease in adults 60 years or older (D recommendation). The USPSTF recommends shared decision-making for the initiation of low-dose aspirin for the primary prevention of cardiovascular disease in adults 40 to 59 years of age with a 10% or greater risk of cardiovascular disease and without an increased risk of bleeding (C recommendation).

Question 2

Do nonsteroidal anti-inflammatory drugs prevent or delay fracture healing when used for pain management?

Answer 2

The use of nonsteroidal anti-inflammatory drugs for more than three days at higher doses during the postoperative or acute phase of fracture healing may lead to increased rates of nonunion, delayed union, and pseudarthrosis in adults, based on multiple systematic reviews of randomized controlled trials, cohort studies, and case-control trials.

Question 3

What is the preferred treatment for anxiety in children?

Answer 3

Cognitive behavior therapy and selective serotonin reuptake inhibitors are both effective therapies for anxiety in children. Combination treatment could be offered preferentially over cognitive behavior therapy or a selective serotonin reuptake inhibitor alone to patients six to 18 years of age diagnosed with social anxiety disorder, generalized anxiety disorder, separation anxiety disorder, specific phobia, or panic disorder.

Question 4

Does the use of procalcitonin and C-reactive protein levels to guide antibiotic use decrease antibiotic duration in hospitalized patients?

Answer 4

A meta-analysis showed a decreased duration of antibiotic use in hospitalized patients with sepsis or respiratory tract infections with the use of procalcitonin for guidance. Less research is available on the use of C-reactive protein for the same purpose.

Question 5

When should a cervical spine injury be suspected in an athlete?

Answer 5

Any athlete who is not moving, whether conscious, unconscious, or with decreased consciousness, should be assumed to have a cervical spine injury until proven otherwise. While maintaining cervical spine stabilization, the log roll or lift and slide maneuver can be used to transfer an injured athlete onto a spine board.

Question 6

What initial laboratory testing can be considered in patients presenting with lower-extremity edema?

Answer 6

Initial laboratory workup for patients with lower-extremity edema should include brain natriuretic peptide levels, thyroid-stimulating hormone, liver function tests, basic metabolic panel, and urine protein/creatinine ratio.

Question 7

What therapies are effective for monosymptomatic enuresis in children?

Answer 7

Enuresis alarm therapy is effective in the treatment of monosymptomatic enuresis in children, in which nighttime bedwetting is the only symptom. Desmopressin therapy is also effective but has a high relapse rate after discontinuation.

Question 8

What is the preferred treatment for group A beta-hemolytic streptococcal pharyngitis?

Answer 8

Amoxicillin or penicillin V should be used in patients with group A beta-hemolytic streptococcal pharyngitis to decrease the risk of acute rheumatic fever, symptom duration, and communicability.

Question 9

What treatments are recommended for primary open-angle glaucoma?

Answer 9

Reducing intraocular pressure is the only treatment proven to stop or slow the progression of vision loss in primary open-angle glaucoma. Topical medications are the most common treatment. Selective laser trabeculoplasty is another first-line treatment for primary open-angle glaucoma.

Question 10

What is the preferred treatment forHelicobacter pyloriinfection?

Answer 10

Bismuth quadruple therapy (proton pump inhibitor, bismuth, tetracycline, and metronidazole [Flagyl] or tinidazole)
or
concomitant therapy (proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole or tinidazole) is the recommended first-line treatment forH. pyloriinfection.
These regimens have similar eradication rates of up to 90%.

Question 11

What treatment is recommended for hyperarousal or nightmares in patients with posttraumatic stress disorder (PTSD)?

Answer 11

Consider using prazosin for nighttime trauma-related nightmares in patients with PTSD.

Question 12

What medical treatments are effective in decreasing pain from diabetic peripheral neuropathy?

Answer 12

In a randomized controlled trial, 130 adults with painful diabetic peripheral neuropathy had similar degrees of improvement with monotherapy using amitriptyline, duloxetine, and pregabalin. There was even greater improvement with subsequent combination therapy regardless of the initial choice of medication.

Question 13

What initial treatment for menstrual cycle irregularity is recommended for patients with polycystic ovary syndrome (PCOS) who do not want to become pregnant?

Answer 13

Hormonal contraception (e.g., oral contraceptives) should be used as the initial treatment for menstrual cycle irregularity, hirsutism, and acne in patients with PCOS who do not want to become pregnant.

Question 14

Does treatment with customized or prefabricated foot orthoses improve pain, function, or quality-of-life scores in children with flat feet (pes planus)?

Answer 14

Customized or prefabricated foot orthoses do not result in significant improvements in pain, function, or parent and child quality-of-life scores. Further targeted studies are needed to identify the clinical utility of foot orthoses in children with flat feet that are associated with underlying conditions.

Question 15

What strategies help reduce the risk of recurrence of depressive symptoms when discontinuing antidepressants?

Answer 15

Cognitive behavior therapy should be used to help prevent relapse and recurrence of depressive symptoms when discontinuing antidepressants.

Question 16

When should systemic antibiotics be considered for treatment of acute otitis externa?

Answer 16

Systemic antibiotics should be used only if the infection has spread beyond the ear canal or in patients at high risk of worsening infection, such as those who are immunocompromised or have uncontrolled diabetes mellitus.

Question 17

What medications may be helpful in the treatment of fibromyalgia pain?

Answer 17

Amitriptyline, cyclobenzaprine, duloxetine (Cymbalta), milnacipran (Savella), and pregabalin (Lyrica) are effective for pain in fibromyalgia.

Question 18

Is pharmacogenomic-guided antidepressant treatment beneficial in the management of major depressive disorder in adults?

Answer 18

Based on a randomized controlled trial of 1,944 patients, pharmacogenomic testing for drug-gene interactions in adults with major depressive disorder resulted in reduced prescribing of medications with potential drug-gene interactions. However, there was no significant difference in symptom remission rates between the gene-tested group and the usual care group at six months.

Question 19

Which oral potassium binders can be considered for initial treatment of hyperkalemia?

Answer 19

Patiromer (Veltassa) or sodium zirconium cyclosilicate (Lokelma) is preferred to sodium polystyrene sulfonate in patients with chronic hyperkalemia due to higher efficacy and lower risk of serious adverse effects.

Question 20

How long should a patient with osteoporosis take bisphosphonates?

Answer 20

A drug holiday should be considered in patients who have received oral bisphosphonate therapy for five years or intravenous bisphosphonate therapy for three years.

Question 21

Are topical corticosteroids safe during pregnancy?

Answer 21

Low- to midpotency topical corticosteroids are not associated with adverse pregnancy outcomes.

Question 22

What initial steps can be considered for management of trigger point pain?

Answer 22

Massage and physical therapy should be considered as less invasive first-line treatments for trigger point pain. The routine use of trigger point injections is not supported by clinical trials.

Question 23

When should patients with hip fractures undergo surgical repair?

Answer 23

Operative management of a hip fracture should occur within 24 to 48 hours of injury unless a delay is needed to stabilize comorbidities. Early operative management improves pain control, decreases length of hospitalization, and reduces complications.

Question 24

When can patients with infectious mononucleosis return to sports?

Answer 24

Individuals with infectious mononucleosis should not participate in athletic activity for three weeks following symptom onset to decrease the risk of splenic rupture, beginning with light, noncontact exercise. Athletes should return only when they feel clinically well and are afebrile. Shared decision-making should be used to determine the timing of return to sports. There is no strong evidence to support the use of ultrasonography in expediting the patient’s return to sports.

Question 25

What is the preferred oral contraceptive during breastfeeding?

Answer 25

Progestin-only contraceptives are preferred to combination oral contraceptives during breastfeeding.
The estrogen in oral contraceptives does not affect the composition of breast milk or infant growth and development but may decrease milk production.
Combination oral contraceptives should be avoided for at least three weeks postpartum because of the increased thrombotic risk.

Question 26

What is the preferred treatment for hyperprolactinemia due to a prolactinoma?

Answer 26

Dopamine agonists are first-line therapy for hyperprolactinemia. Cabergoline is preferred because it has been shown to more effectively lower prolactin levels and decrease tumor size. Dopamine agonist therapy should be continued for at least two years, after which tapered discontinuation may be attempted if prolactin levels have normalized and tumor size is significantly reduced.

Question 27

When should tonsillectomy be considered for those with recurrent tonsillitis?

Answer 27

Watchful waiting is typically preferred over tonsillectomy for recurrent tonsillitis if there have been less than seven episodes in the past year, less than five episodes per year in the past two years, or less than three episodes per year in the past three years.

Question 28

Does early treatment of screen-detected anal high-grade squamous intraepithelial lesions in patients with HIV reduce risk of progression to invasive anal cancer?

Answer 28

In a large randomized controlled trial, immediate treatment of screen-detected anal high-grade squamous intraepithelial lesions reduced the likelihood of progression to invasive anal cancer compared with active surveillance (number needed to treat = 111 over 26 months). The study was not powered to detect a reduction in mortality.

Question 29

What is the preferred initial treatment for postinflammatory hyperpigmentation?

Answer 29

First-line topical therapies for postinflammatory hyperpigmentation include hydroquinone 4% and triple combination therapy with fluocinolone 0.01%/hydroquinone 4%/tretinoin 0.05% (Tri-Luma). This triple combination therapy is more effective but more costly than hydroquinone alone.

Question 30

Is pharmacotherapy effective for reducing symptoms of posttraumatic stress disorder in adults?

Answer 30

Selective serotonin reuptake inhibitors improve symptoms of posttraumatic stress disorder and are considered first-line pharmacologic agents, based on consistent, good-quality, patient-oriented evidence. Mirtazapine and amitriptyline also improve posttraumatic stress disorder symptoms, based on inconsistent or limited-quality, patient-oriented evidence.

Question 31

What vaccination is recommended to prevent pneumococcal infection in people 65 years and older?

Answer 31

Adults 65 years and older who have not previously received a pneumococcal conjugate vaccine (PCV) should receive one dose of PCV15 (Vaxneuvance) or PCV20 (Prevnar 20). If PCV15 is administered, it should be followed by a dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23) after one year; however, the interval can be shortened to eight weeks for people with immunocompromising conditions, cerebral spinal fluid leak, or cochlear implant. If PCV20 is used for the first pneumococcal immunization, a subsequent dose of PPSV23 is not indicated.

Question 32

What treatment in addition to glucocorticoids may be considered in patients with polymyalgia rheumatica?

Answer 32

Early addition of methotrexate to glucocorticoid therapy should be considered in patients with polymyalgia rheumatica who are at high risk of relapse (e.g., those with high baseline erythrocyte sedimentation rate), glucocorticoid-related adverse effects, or comorbidities that are likely to be exacerbated by glucocorticoids (e.g., diabetes mellitus, osteoporosis).

Question 33

What additional imaging should be performed in patients with newly diagnosed giant cell arteritis?

Answer 33

In patients with newly diagnosed giant cell arteritis, noninvasive vascular imaging (i.e., magnetic resonance imaging or computed tomography angiography) of the neck, chest, abdomen, and pelvis should be performed to evaluate for large vessel involvement. Patients who have hypertension when giant cell arteritis is diagnosed are at higher risk of thoracic or aortic aneurysm and should be evaluated for large vessel involvement with angiography or ultrasonography.

Question 34

Does early aerobic exercise following concussion improve or impair recovery in adolescent patients?

Answer 34

Early aerobic exercise for symptoms of concussion more than 72 hours after injury may decrease symptom severity and frequency and time to recovery from the day of injury.

Question 35

What is the preferred treatment for malaria?

Answer 35

The World Health Organization recommends treating uncomplicated cases of malaria with artemisinin combination therapy regardless of the geographic region of infection. Artemether/lumefantrine (Coartem) can be used in all trimesters, whereas most artemisinin combination therapies are not recommended in the first trimester. Artemisinin combintation therapies are well tolerated and highly effective against allPlasmodiumspecies.

Question 36

What validated nutrition questionnaire can help obtain a nutrition history and identify patients who would benefit from a referral or a brief intervention?

Answer 36

The Rapid Eating Assessment for Participants–Shortened Version, v.2 can be used to assess nutrient intake in ambulatory patients with omnivorous, vegetarian, and vegan diet patterns.

Question 37

What interventions are recommended to assist in smoking cessation?

Answer 37

All nonpregnant adults who smoke cigarettes should be offered pharmacotherapy and behavior interventions to help with cessation attempts. Behavior interventions combined with pharmacotherapy improve smoking cessation rates.

Question 38

What is the preferred pharmacologic treatment for chronic constipation in adults?

Answer 38

First-line pharmacologic treatment options for normal transit and slow transit constipation include bulk laxatives and osmotic laxatives. Polyethylene glycol (Miralax) is the preferred osmotic laxative over lactulose for the treatment of constipation because it is more effective and has fewer adverse effects.

Question 39

What initial treatment should be considered for patients with endometriosis symptoms?

Answer 39

The first-line treatment for symptoms of endometriosis is combined hormonal contraceptives. Patients presenting with clinical symptoms of endometriosis can start empiric treatment and then plan for diagnostic laparoscopy if symptoms do not improve or if medication is not tolerated.

Question 40

When should patients be offered a spiritual assessment?

Answer 40

Consider offering a spiritual assessment to patients at hospitalization, if a significant clinical decline occurs in the hospital setting, when addressing end-of-life care, or when providing psychosocial services for the treatment of substance use disorders in the hospital setting.

Question 41

Does medical cannabis help chronic pain?

Answer 41

Noninhaled medical cannabis or cannabinoids slightly improve pain levels (number needed to treat = 10; 95% CI, 7 to 20) to decrease average pain by 1 cm more on a 10-cm visual analog scale compared with placebo for people living with chronic cancer or noncancer pain. These medications slightly improve sleep quality and physical functioning compared with placebo.

Question 42

What are the most effective forms of emergency contraception?

Answer 42

The copper IUD (Paragard) is the most effective form of emergency contraception, with the levonorgestrel-releasing intrauterine system, 52 mg, (Mirena, Liletta) found to be similarly effective, followed by oral ulipristal (Ella); oral levonorgestrel, 1.5 mg (Plan B One-Step); and the Yuzpe method.

Question 43

What treatment is recommended for immune thrombocytopenia (ITP)?

Answer 43

Initial treatment for ITP is corticosteroid therapy or intravenous immune globulin (human) infusion. Recurrent or unresponsive cases are treated with thrombopoietin receptor agonists or immunomodulators (e.g., rituximab). ITP is the most common cause of isolated thrombocytopenia. There is no specific laboratory test for ITP, so it is often a diagnosis of exclusion. Primary ITP is distinguished from secondary ITP by the absence of chronic medical conditions or acute infections.

Question 44

Are over-the-counter formulas that contain antihistamines, analgesics, or decongestants effective in treating symptoms of the common cold?

Answer 44

Antihistamine/analgesic/decongestant combinations have some general benefits in adults and older children. However, these benefits must be weighed against the risk of adverse effects. There is no evidence of effectiveness in young children.

Question 45

What adjunctive therapies are helpful for the management of schizophrenia in addition to antipsychotic medication?

Answer 45

Adjunctive treatments with psychosocial therapies such as cognitive behavior therapy for psychosis, psychoeducation, supported employment services, assertive community care, and family interventions should be offered.

Question 46

What lifestyle recommendations should be provided to patients to prevent diverticulitis and recurrent diverticulitis?

Answer 46

Consumption of popcorn, nuts, or seeds is not a risk factor for developing diverticulitis. A high-fiber diet is associated with a lower incidence of diverticular disease, but evidence about whether it prevents the recurrence of diverticulitis is lacking. Tobacco cessation, reduced meat intake, physical activity, and weight loss are recommended interventions to decrease the risk of recurrence.

Question 47

Do all patients with diverticulitis require treatment with antibiotics?

Answer 47

No. Select patients with uncomplicated diverticulitis can be treated without antibiotics. A meta-analysis of nine randomized controlled trials with 2,505 patients showed that those treated without antibiotics had shorter hospital stays than those treated with antibiotics, and there was no difference in complication or readmission rates.

Question 48

Who should be screened for abdominal aortic aneurysm (AAA)?

Answer 48

The U.S. Preventive Services Task Force (USPSTF) recommends one-time screening for AAA with ultrasonography in men 65 to 75 years of age who have ever smoked and selective screening with ultrasonography in men 65 to 75 years of age with risk factors for AAA who have never smoked, rather than routinely screening all men in this group. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for AAA in women 65 to 75 years of age who have ever smoked or have a family history of AAA.

Question 49

Are intravenous steroids more effective than oral steroids in treating acute relapses of multiple sclerosis?

Answer 49

There is no difference in effectiveness between oral and intravenous steroids in treating acute relapses of multiple sclerosis. A higher dosage of steroids, such as 1,000 mg per day of methylprednisolone for three days, is recommended.

Question 50

Is intravenous iron infusion superior to oral iron for avoiding blood transfusion in adults with iron deficiency anemia?

Answer 50

Intravenous iron administration does not reduce the need for blood transfusion compared with oral iron supplementation, based on multiple meta-analyses of randomized controlled trials.

Question 51

What clinical signs and scoring system can help identify testicular torsion?

Answer 51

The Testicular Workup for Ischemia and Suspected Torsion scoring system should be used if testicular torsion is suspected. Clinical parameters include testicular swelling (2 points), hard testicle (2 points), absent cremasteric reflex (1 point), nausea or vomiting (1 point), and high-riding testicle (1 point). If the score is 5 or greater, the risk of torsion is highly likely.

Question 52

Are epidural steroid injections effective for low back pain?

Answer 52

Treatment with epidural steroid injections in the lower spine is not effective for reducing pain and disability. The injections may be more effective than placebo at short-term follow-up, but the effects are not clinically meaningful.