Clinical Inquiries, 2004
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Item How useful is ultrasound to evaluate patients with postmenopausal bleeding?(Family Physicians Inquiries Network, 2004) Langlois, John P.; Nashelsky, JoanUsing a threshold of ≤5 mm, transvaginal ultrasound (TVUS) can be used to identify those patients with postmenopausal bleeding who are at low risk for endometrial cancer, polyps, or atypical hyperplasia at a sensitivity comparable with that of endometrial biopsy and dilatation and curettage (D&C) (strength of recommendation: B, based on systematic reviews of consistent exploratory cohort studies.)Item Should we screen women for hypothyroidism?(Family Physicians Inquiries Network, 2004) Olsen, Amy H.; Kelsberg, Gary; Coffey, John B.Testing for thyroid-stimulating hormone (TSH) finds more cases of unrecognized hypothyroidism than history and physical examination (strength of recommendation [SOR]: A, based on cohort studies). Women with an initial screening TSH >10 mU/L are more likely to develop complications of hypothyroidism and to benefit from treatment (SOR: A, based on prospective cohort studies). Treating women who have asymptomatic hypothyroidism and a screening TSH >10 mU/L prevents progression to symptomatic overt disease (SOR: A, based on prospective cohort studies) and reduces serum lipid levels (SOR: A, based on randomized controlled trials). Treating women who have subclinical hypothyroidism found by screening does not reduce symptoms (SOR: A, small randomized controlled trials), and its effect on cardiac disease remains controversial. Treatment may increase bone loss in premenopausal women (SOR: A, based on randomized controlled trials and controlled cross-sectional studies), and it may cause symptoms in certain individuals (SOR: C, based on observational studies).Item How should we treat chronic daily headache when conservative measures fail?(Family Physicians Inquiries Network, 2004) Junker, Jessie A.; Aitken, Paul V., Jr.; Flake, DonnaFor the purposes of this review, we considered conservative measures to include such therapies as nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and acetaminophen with codeine. Amitriptyline is the best-supported option for the treatment of chronic daily headaches for those patients who have not been treated by conservative measures (strength of recommendation [SOR]: A, based on a metaanalysis of randomized controlled trials [RCTs]). For patients who overuse symptomatic headache medications, medication withdrawal is effective (SOR: B, based on a systematic review of cohort and case-control studies). Additional therapies include other tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and prophylactic treatments for migraine (SOR: B).Item Do ACE inhibitors decrease mortality in patients with hypertension?(Family Physicians Inquiries Network, 2004) Neher, Jon O.When used to treat patients with hypertension, ACE inhibitors reduce cardiovascular and all-cause mortality as effectively as diuretics, beta blockers, and calcium channel blockers. [Strength of recommendation: A, based on meta-analyses of randomized controlled trials (RCTs) with patient-oriented outcomes]Item Which Patients with Atrial Fibrillation Do Not Need Anticoagulation Therapy with Warfarin?(Family Physicians Inquiries Network, 2004) Guthmann, Richard A.Anticoagulation therapy with warfarin is not indicated for use in patients with non- valvular atrial fibrillation who are at low risk for embolic cerebral vascular events. The classification of "low risk for embolic stroke" is defined as a 1 percent annual risk for stroke or lone atrial fibrillation (i.e., age younger than 65 years without history of hypertension, transient ischemic attack, stroke, coronary heart disease, recent congestive heart failure, or diabetes). Anticoagulation therapy with warfarin is beneficial in patients with atrial fibrillation who are at moderate or high risk for stroke. Patients with absolute contraindications to anticoagulation therapy (e.g., thrombocytopenia, recent trauma or surgery, hemorrhagic stroke, alcoholism) should not take warfarin. [Strength of recommendation: A, based on meta-analyses of large randomized controlled trials (RCTs).]