Clinical Inquiries, 2008
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Item Which patients undergoing noncardiac surgery benefit from perioperative beta-blockers?(Family Physicians Inquiries Network, 2008) Haynes, Jamie; Kelsberg, Gary; Jamieson, BarbaraPatients with moderate to high cardiac risk (a Revised Cardiac Risk Index [RCRI] score of 2 or higher [Table]) have a reduced risk of in-hospital death following perioperative beta-blocker therapy (strength of recommendation [SOR]: B, based on a large retrospective cohort study). There is, however, no proven benefit to perioperative beta-blocker therapy without prior cardiac risk stratification (SOR: A, based on systematic reviews).Item Which lab tests are best when you suspect hypothyroidism?(Family Physicians Inquiries Network, 2008) Miller, Glenn D.; Rogers, Jared C.; DeGroote, Sandra L.Thyroid-stimulating hormone (TSH) level is the preferred test for initial evaluation of suspected primary hypothyroidism (strength of recommendation [SOR]: C, expert opinion). If TSH is abnormal, a free thyroxine (T4) level will further narrow the diagnosis. Obtain a triiodothyronine (T3) level if TSH is undetectable and free T4 is normal. When assessing the adequacy of replacement therapy in primary hypothyroidism, the TSH is the most important parameter to monitor (SOR: C, expert opinion). Because TSH levels can't be used to monitor central hypothyroidism, use free T4 and T3 concentrations (SOR: C, case series).Item Which clinical features and lab findings increase the likelihood of temporal arteritis?(Family Physicians Inquiries Network, 2008) Nusser, John A.; Howard, EllenJaw claudication, diplopia, or a temporal artery abnormality on physical exam increase the likelihood of temporal arteritis. A finding of thrombocytosis in a patient with suspected temporal arteritis moderately increases the likelihood of this diagnosis (strength of recommendation: B, based on systematic reviews of retrospective cohort studies). Patients with temporal arteritis frequently complain of headaches, and often have mildly abnormal erythrocyte sedimentation rates (ESR), but neither of these findings helps in the diagnosis.Item Which drugs are safest for moderate to severe depression in adolescents?(Family Physicians Inquiries Network, 2008) Guirguis-Blake, Janelle; Wright, Andrew; Rich, JoanneSelective serotonin-reuptake inhibitors (SSRIs) appear to be the safest, given current data. Major safety concerns--prompting a US Food and Drug administration (FDA) black box label warning--have been raised about increased risk of suicidality (ideation, behavior, and attempts) among adolescents receiving antidepressant therapy. Information about the safety of tricyclic antidepressants in young people is limited because adverse effects have not been systematically reported in trials (SOR: A, meta-analysis).Item Which drugs are most effective for moderate to severe depression in adolescents?(Family Physicians Inquiries Network, 2008) Guirguis-Blake, Janelle; Wright, Andrew; Rich, JoanneFluoxetine is the only selective serotonin-reuptake inhibitor (SSRI) approved by the US Food and Drug Administration (FDA) to treat depression in children 8 years of age and older; it also has the most favorable benefit-to-risk profile compared with placebo in trials lasting up to 12 weeks (strength of recommendation [SOR]: A, meta-analysis). Fluoxetine combined with cognitive behavioral therapy (CBT) is superior to fluoxetine alone, CBT alone, or placebo (SOR: B, single well-done randomized controlled trial [RCT]). Further research is needed to address the long-term efficacy of fluoxetine treatment.