Volume 4, No. 6, June 2006
Hot Topics
Obstetrics
Incontinence not correlated with vaginal delivery
Incontinence is a common problem for postmenopausal women, but that no difference in prevalence or severity could be demonstrated between parous and nulliparous sisters. Conversely, familial factors appear to be highly significant predictors of urinary incontinence. The authors suggest that the current focus on delivery in the etiology of incontinence is inappropriate and that research and preventive efforts be directed toward understanding familial factors.
CONCLUSION: Vaginal birth does not seem to be associated with urinary incontinence in postmenopausal women. Considering the high concordance in continence status between sister pairs, and considering that the majority of parous women are continent, an underlying familial predisposition toward the development of urinary incontinence may be present.
| Incontinence in nulliparous sister | None (%) | Parous sister present (%) | Total (%) | ||
| None | 47 (32.87) | 28 (19.58) | 75 (52.45) | ||
| Present | 25 (17.48) | 43 (30.07) | 68 (47.55) | ||
| Total | 72 (50.35) | 71 (49.65) | 143 (100.00) | ||
|
note: Seven sister pairs, in each of which one of the sisters had incontinence unrelated to stress or urge, were not included in this table. Adapted with permission from Buchsbaum GM, Duecy EE, Kerr LA, Huang LS, Guzick DS. Urinary incontinence in nulliparous women and their parous sisters. Obset Gynecol 2005;106:1256. |
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Buchsbaum GM, et al. Urinary incontinence in nulliparous women and their parous sisters. Obset Gynecol December 2005;106:1253-8.
OB/GYN CCC Editorial comment:
Do we inject a bias toward cesarean delivery based on future incontinence?
Hopefully this study will re-frame the discussion into the current situation in which cesarean delivery is being advocated (and demanded by some patients) to prevent urinary incontinence later in life. As Buchsbaum et al have raised serious questions about the argument that there is a direct correlation between vaginal delivery and future incontinence.
According to Wu et al, nearly two thirds of obstetricians support elective cesarean delivery for this reason. Combined with the current backlash against vaginal birth after cesarean delivery, the cesarean delivery rate seems set to spiral beyond the current 30 percent unless the debate can be refocused on scientific evidence of the net benefit for mothers.
Please see the series of articles on outcome based data from cesarean delivery in Perinatology Picks below.
Wu JM, Hundley AF, Visco AG. Elective primary cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists. Obstet Gynecol 2005;105:301-6.
Serious maternal morbidity increases with increasing number of cesarean deliveries
CONCLUSION: Because serious maternal morbidity increases progressively with increasing number of cesarean deliveries, the number of intended pregnancies should be considered during counseling regarding elective repeat cesarean operation versus a trial of labor and when debating the merits of elective primary cesarean delivery. LEVEL OF EVIDENCE: II-2
Silver, RM et al Maternal Morbidity Associated With Multiple Repeat Cesarean Deliveries
Obstetrics & Gynecology 2006;107:1226-1232
Characteristics of glyburide failures in GDM: EGA at diagnosis, parity, and fasting glucose
CONCLUSION: Glyburide was more likely to fail in women diagnosed earlier in pregnancy, of older age and multiparity, and with higher fasting glucoses, suggesting that earlier glucose intolerance and a reduced capacity to respond to an insulin secretagogue may distinguish this group. The time for glyburide as an alternative treatment has come; however, it should be prescribed after careful consideration of these patient characteristics to minimize the likelihood of failure. LEVEL OF EVIDENCE: II-2
Kahn BF et alPredictors of Glyburide Failure in the Treatment of Gestational Diabetes Obstetrics & Gynecology 2006;107:1303-1309
Improve the systems against maternal mortality from hemorrhage
CONCLUSION: Despite a significant increase in major obstetric hemorrhage cases, we found improved outcomes and fewer maternal deaths after implementing systemic approaches to improve patient safety. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage.
Skupski DW, et al Improving hospital systems for the care of women with major obstetric hemorrhage.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=16648399&dopt=Abstract
CCC Editorial comment
Please take this opportunity to double check if your ALSO status is current. If you haven’t taken the ALSO Course in the last 5 years, or feel you need a refresher, then please contact the ALSO office.
http://www.aafp.org/online/en/home/cme/aafpcourses/clinicalcourses/also.html
High-risk centers have higher rates of cesarean delivery for their low risk population
CONCLUSION: Maternity units that frequently manage high-risk pregnancies (levels 2b and 3) have higher rates of cesareans during labor for their population of nulliparas at low risk than do facilities that deal mainly with low-risk pregnancies. LEVEL OF EVIDENCE: II-2
Ray CL et alLevel of Perinatal Care of the Maternity Unit and Rate of Cesarean in Low-Risk Nulliparas. Obstetrics & Gynecology 2006;107:1269-1277
Influence of rest during pregnancy on birth weight in working women
CONCLUSION: The continuous increase in infants' birth weight among pregnant women in this study did not correlate with rest periods in the form of leave supported by social benefit programs. The effects of social benefit programs on pregnancy outcome may thus be overrated and merits further research.
Sydsjo A, et al Influence of rest during pregnancy on birth weight in working women. Obstet Gynecol. 2006 May;107(5):991-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=16648401&dopt=Abstract
Expand the use of oral analgesia in patients immediately after cesarean delivery
CONCLUSION: Oral analgesia with oxycodone-acetaminophen may offer superior pain control after cesarean delivery with fewer side-effects as compared with morphine patient-controlled analgesia. Consideration should be given to expanding the use of oral analgesia in patients immediately after cesarean delivery.
Davis KM, et al Oral analgesia compared with intravenous patient-controlled analgesia for pain after cesarean delivery: a randomized controlled trial. Am J Obstet Gynecol. 2006 Apr;194(4):967-71.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=16580284
Anal sphincter tears: Episiotomy, shoulder dystocia, forceps, and previous sphincter tear
CONCLUSION: The strongest clinical risk factors for anal sphincter tear in multiparous women are episiotomy, shoulder dystocia, previous sphincter tear, prolonged second stage of labor, and forceps delivery. LEVEL OF EVIDENCE: II-2
DiPiazza D et alRisk Factors for Anal Sphincter Tear in Multiparas Obstetrics & Gynecology 2006;107:1233-1237
Improvements in asthma management to prevent severe exacerbations may lead to a better outcome for both mother and baby
Women with asthma experience an increased rate of exacerbations during pregnancy and require substantial medical interventions. The rate of severe exacerbations is highest in mothers with the most severe prepregnancy asthma. Viral infections and nonadherence to medications appear to be common causes. The study was too small to establish significant relationships between exacerbations of asthma and poor pregnancy outcomes, but it showed significantly reduced birth weight in male infants. LEVEL OF EVIDENCE: II-2
Murphy VE, et al. Severe asthma exacerbations during pregnancy. Obstet Gynecol November 2005;106:1046-54.
Prevention and Diagnosis of Fetal Alcohol Syndrome
Alcohol use among women of childbearing age is prevalent in the United States, with approximately 1 in 5 nonpregnant women reporting binge drinking (5 or more drinks on any one occasion) and 1 in 25 pregnant women reporting binge drinking. Alcohol use during pregnancy results in a spectrum of adverse outcomes known as fetal alcohol spectrum disorders. Fetal alcohol syndrome (FAS) is one of these disorders. Fetal alcohol syndrome is characterized by specific facial abnormalities and significant impairments in neurodevelopment and physical growth. Early identification of children with FAS has been shown to enhance their long-term outcomes. In an effort to improve clinical recognition of children with this condition, Centers for Disease Control and Prevention (CDC) was directed by Congress in 2002 to lead the development of uniform diagnostic criteria for FAS and other prenatal alcohol-related conditions. The purpose of this commentary is to provide clinicians a summary of the report released by CDC describing the current diagnostic criteria for FAS. In addition, advancements have been made in screening and brief interventions for alcohol use disorders in women who have the potential to make significant strides in the prevention of FAS spectrum disorders. Knowledge of the diagnostic criteria for FAS can lead to increased identification of the syndrome in infants and children and the provision of appropriate medical and support services. Screening for and intervening with women at risk for an alcohol-exposed pregnancy can prevent FAS and other fetal alcohol spectrum disorders.
Floyd RL, et al. Recognition and prevention of fetal alcohol syndrome. Obstet Gynecol November 2005;106:1059-64.
Calcium supplementation during pregnancy and lactation: Effects on mother and the fetus
Calcium consumption is essential for bone development and maintenance throughout life, yet more than one half of the female population in the United States does not consume the recommended amount of calcium. Calcium intake is especially crucial during pregnancy and lactation because of the potential adverse effect on maternal bone health if maternal calcium stores are depleted. There is often a transient lowered bone mineral density and increased rate of bone resorption, with the greatest consequence during the third trimester and throughout lactation. Studies indicate that calcium consumption should be encouraged, especially during pregnancy and lactation, to replace maternal skeletal calcium stores that are depleted during these periods. Because the fetus in utero and the neonate through breast-feeding are dependent on maternal sources for the total calcium load, adequate maternal calcium intake also can affect fetal bone health positively. Proper calcium consumption can be attained through the diet by the consumption of dairy products or leafy greens (such as kale), the consumption of fortified foods, or by supplementation with widely available calcium-containing supplement products. Because many women experience heartburn during pregnancy, calcium-based antacids are ideal for providing heartburn relief, and they offer a calcium supplement to ensure maternal and fetal bone health, without the danger of adverse effects on the neonate.
Thomas M, Weisman SM. Calcium supplementation during pregnancy and lactation: effects on the mother and the fetus. Am J Obstet Gynecol. 2006 Apr;194(4):937-45.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db
=pubmed&dopt=Abstract&list_uids=16580279
Gynecology
FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other Diseases in Females Caused by Human Papillomavirus
The Food and Drug Administration (FDA) announced the approval of Gardasil, the first vaccine developed to prevent cervical cancer, precancerous genital lesions and genital warts due to human papillomavirus (HPV) types 6, 11, 16 and 18. The vaccine is approved for use in females 9-26 years of age. Gardasil was evaluated and approved in six months under FDA's priority review process--a process for products with potential to provide significant health benefits.
"Today is an important day for public health and for women's health, and for our continued fight against serious life-threatening diseases like cervical cancer," said Alex Azar, Deputy Secretary, U.S. Department of Health and Human Services (HHS). "HHS is committed to advancing critical health measures such as the development of new and promising vaccines to protect and advance the health of all Americans."
HPV is the most common sexually-transmitted infection in the United States. The Centers for Disease Control and Prevention estimates that about 6.2 million Americans become infected with genital HPV each year and that over half of all sexually active men and women become infected at some time in their lives. On average, there are 9,710 new cases of cervical cancer and 3,700 deaths attributed to it in the United States each year. Worldwide, cervical cancer is the second most common cancer in women; and is estimated to cause over 470,000 new cases and 233,000 deaths each year.
For most women, the body's own defense system will clear the virus and infected women do not develop related health problems. However, some HPV types can cause abnormal cells on the lining of the cervix that years later can turn into cancer. Other HPV types can cause genital warts. The vaccine is effective against HPV types 16 and 18, which cause approximately 70 percent of cervical cancers and against HPV types 6 and 11, which cause approximately 90 percent of genital warts.
"This vaccine is a significant advance in the protection of women's health in that it strikes at the infections that are the root cause of many cervical cancers," said Andrew C. von Eschenbach, MD, Acting Commissioner of Food and Drugs. "The development of this vaccine is a product of extraordinary work by scientists as well as by FDA's review teams to help facilitate the development of very novel vaccines to address unmet medical needs. This work has resulted in the approval of a number of new products recently, including Gardasil, which address significant public health needs."
Gardasil is a recombinant vaccine (contains no live virus) that is given as three injections over a six-month period. Immunization with Gardasil is expected to prevent most cases of cervical cancer due to HPV types included in the vaccine. However, females are not protected if they have been infected with that HPV type(s) prior to vaccination, indicating the importance of immunization before potential exposure to the virus. Also, Gardasil does not protect against less common HPV types not included in the vaccine, thus routine and regular pap screening remain critically important to detect precancerous changes in the cervix to allow treatment before cervical cancer develops.
"This is the first vaccine licensed specifically to prevent cervical cancer. Its rapid approval underscores FDA's commitment to help make safe and effective vaccines available as quickly as possible. Not only have vaccines dramatically reduced the toll of diseases in infants and children, like polio and measles, but they are playing an increasing role protecting and improving the lives of adolescents and adults," said Jesse Goodman, MD, MPH, Director of FDA's Center for Biologics Evaluation and Research.
Four studies, one in the United States and three multinational, were conducted in 21,000 women to show how well Gardasil worked in women between the ages of 16 and 26 by giving them either the vaccine or placebo. The results showed that in women who had not already been infected, Gardasil was nearly 100 percent effective in preventing precancerous cervical lesions, precancerous vaginal and vulvar lesions, and genital warts caused by infection with the HPV types against which the vaccine is directed. While the study period was not long enough for cervical cancer to develop, the prevention of these cervical precancerous lesions is believed highly likely to result in the prevention of those cancers.
The studies also evaluated whether the vaccine can protect women already infected with some HPV types included in the vaccine from developing diseases related to those viruses. The results show that the vaccine is only effective when given prior to infection.
Two studies were also performed to measure the immune response to the vaccine among younger females aged 9-15 years. Their immune response was as good as that found in 16-26 year olds, indicating that the vaccine should have similar effectiveness when used in the 9-15 year age group.
The safety of the vaccine was evaluated in approximately 11,000 individuals. Most adverse experiences in study participants who received Gardasil included mild or moderate local reactions, such as pain or tenderness at the site of injection.
The manufacturer has agreed to conduct several studies following licensure, including additional studies to further evaluate general safety and long-term effectiveness. The manufacturer will also monitor the pregnancy outcomes of women who receive Gardasil while unknowingly pregnant. Also, the manufacturer has an ongoing study to evaluate the safety and effectiveness of Gardasil in males.
http://www.fda.gov/cber/products/hpvmer060806.
htmhttp://www.fda.gov/womens/getthefacts/hpv.html
OB/GYN CCC Editorial comment:
Rapid Approval Marks Major Advancement in Public Health
This is the biggest news in Women’s Health since the advent of the pap smear. While FDA approval is very important, perhaps most important, programmatically, is when and how the Merck vaccine gets approved for roll out by the Advisory Committee on Immunization Practices (ACIP).
The ACIP meeting is due to occur in late June and it is really there that more of the salient details will arise”
Will it be indicated universally?
or just for high risk groups?
-If universally, then it will qualify for the Vaccines For Children (VFC) program approval and be essentially free to Natives through the State Immunization program
-If for high risk groups only, then it will be difficult to get broad acceptance, plus we would likely have to pay for it
As this would be the third new vaccine for adolescents in as many years (Read as: Expensive - approximately $120 each times 3 doses), the HPV vaccine will run into some stiff competition for limited State Immunization funding with acellular DPTa and Menactra (meningitis).
Typically ACIP rolls out new vaccines the first of the calendar year…hence January 2007 is the most likely roll out guess at this point
Each Indian Health site needs to be mindful that this vaccine is limited to only two of the major cancer causing subtypes, e. g., 16 and 18. In Alaska Natives our rates of 16 and 18 are somewhat similar to the national statistics, but we actually had a very high rate of multiple infections, e.g., subtypes not covered by either the Merck or GSK vaccines. It is for that reason one probably need to think along the lines of long term immunogenicity studies in your population to monitor its effect over time.
Similar studies and similar programmatic follow-up were very helpful during the Hep B vaccine national roll out. In addition, the Merck vaccine has not particularly well studied in minority patients to date.
This will be important because we need our patients with abnormal paps to become the local champions for this vaccine in their conversations with their adolescent daughters and sisters. Though we need to emphasize this is a ‘Cancer’ vaccine, there still will be some questions about the effect of a possible STI vaccine in a pre-pubescent girls. This is especially important to do asap because a possible ultimate rollout in 5- 6 months is really a short time line for something like this.
So……based on these and other issues, you may want to consider first maximizing patient education to facilitate the roll out (based on local focus group vetted materials), hopefully in the near term, e. g., the cancer preventing nature of this vaccine should be emphasized vs this is not primarily an STI preventing vaccine - with subsequent implications on sexual behavior in pre-teen girls. See Fact Sheet below
The FDA approved labeling for the new HPV vaccine.
http://www.fda.gov/cber/label/hpvmer060806LB.pdf
Human Papilloma Virus Vaccine Fact Sheet
This fact sheet on Human Papilloma Virus (HPV) vaccines provides questions and answers about HPV and HPV vaccines, which may be available soon. http://www.cdc.gov/std/hpv/STDFact-HPV-Vaccine.htm
Overlap repair of obstetric anal sphincter injury: Decrease in fecal incontinence
CONCLUSION: Primary overlap repair of the external anal sphincter is associated with a significantly lower incidence of fecal incontinence, urgency, and perineal pain. When symptoms do develop, they appear to remain unchanged or deteriorate in the end-to-end group but improve in the overlap group. LEVEL OF EVIDENCE: I
Fernando RJ et alRepair Techniques for Obstetric Anal Sphincter Injuries
A Randomized Controlled Trial. Obstetrics & Gynecology 2006;107:1261-1268
Criteria should be developed for the use of intraoperative cystoscopy to detect injuries
CONCLUSION: The reasons for higher injury detection rates when routine cystoscopy was performed are unclear. Further study is needed to identify the scenarios where routine cystoscopy is warranted after major gynecologic surgery.
Gilmour et alRates of Urinary Tract Injury From Gynecologic Surgery and the Role of Intraoperative Cystoscopy. Obstetrics & Gynecology 2006;107:1366-1372
Atypical glandular cell cytology confers a 38% risk of preinvasive disease or carcinoma
CONCLUSION: Atypical glandular cell cytology confers a risk (38%) of either preinvasive disease or carcinoma, with the risk of carcinoma increasing significantly for women aged older than 40. Adherence to recommended AGC management guidelines is crucial to identify underlying malignancies. LEVEL OF EVIDENCE: II-2
DeSimone CP et al Rate of Pathology From Atypical Glandular Cell Pap Tests Classified by the Bethesda 2001 Nomenclature. Obstetrics & Gynecology 2006;107:1285-1291
Cesarean scar ectopic pregnancies are becoming more frequent
CONCLUSION: Surgical treatment or combined systemic and intragestational methotrexate were both successful in the management of cesarean delivery scar pregnancy. Because subsequent pregnancies may be complicated by uterine rupture, the uterine scar should be evaluated before, as well as during, these pregnancies.
Rotas MA et alCesarean Scar Ectopic Pregnancies: Etiology, Diagnosis, and Management. Obstetrics & Gynecology 2006;107:1373-1381
Cervical cancer: An overview of the diagnosis, staging, and treatment
Worldwide, cervical cancer is the second most common malignancy in women and a major cause of morbidity and mortality. Until recently, the greatest strides in reducing cervical cancer mortality have occurred with the advent and implementation of screening programs. Many important advances have also taken place in the diagnosis and treatment of cervical cancer. This review article will highlight diagnostic and staging considerations with an emphasis on newer imaging modalities and how they might augment approved FIGO clinical staging. Management alternatives for patients with early-stage disease, locally advanced (stage IIB-IVA) disease, and metastatic cervical cancer will be discussed. Whenever possible, these discussions will unfold through an overview of pertinent clinical trials and current controversies.
Moore DH. Cervical cancer. Obstet Gynecol. 2006 May;107(5):1152-61.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16648423&dopt=Abstract
Assessment of Microscopic Hematuria in Adults (see Patient Education)
Microscopic hematuria, a common finding on routine urinalysis of adults, is clinically significant when three to five red blood cells per high-power field are visible. Etiologies of microscopic hematuria range from incidental causes to life-threatening urinary tract neoplasm. The lack of evidence-based imaging guidelines can complicate the family physician's decision about the best way to proceed. Patients with proteinuria, red cell casts, and elevated serum creatinine levels should be referred promptly to a nephrology subspecialist. Microscopic hematuria with signs of urinary tract infection should resolve with appropriate treatment of the underlying infection. Patients with asymptomatic microscopic hematuria or with hematuria persisting after treatment of urinary tract infection also need to be evaluated. Because upper and lower urinary tract pathologies often coexist, patients should be evaluated using cytology plus intravenous urography, computed tomography, or ultrasonography. When urine cytology results are abnormal, cystoscopy should be performed to complete the investigation. Am Fam Physician 2006;73:1748-54, 1759. http://www.aafp.org/afp/20060515/1748.html
Child Health
Maternal cholestasis is significantly associated with RDS in the newborn
RESULTS: The incidence of RDS in newborns from cholestatic pregnancies was twice that the reference population (28.6% vs 14%). The multivariate analysis showed that the risk of RDS in these newborns was approximately 2.5 times higher than in control infants. Within the ICP group, maternal and neonatal bile acid levels of infants affected by RDS were not significantly higher than those of healthy infants. The multivariate analysis showed that a low gestational age was the most important risk factor, but the probability of respiratory distress syndrome also increased by 2 per thousand for every additional micromole of the interaction term "neonatal by maternal bile acids level." CONCLUSIONS: Maternal ICP is significantly associated with the occurrence of RDS in the newborn. We hypothesize that bile acids can produce surfactant depletion in the alveoli reverting the reaction of phospholipase A2. This hypothesis could potentially be confirmed by bronchoalveolar lavage study.
Zecca E et al Intrahepatic cholestasis of pregnancy and neonatal respiratory distress syndrome. Pediatrics. 2006 May;117(5):1669-72.
OB/GYN CCC Editorial comment:
The incidence of intrahepatic cholestasis of pregnancy may also be elevated in certain AI/AN women.
Our preliminary survey shows a high prevalence (3.9 %) of IHCP in pregnant Alaska Native women.
Q. Is cholestasis in pregnancy significant in American Indians and Alaska Natives?
A. Yes, cholestasis can be associated with infant mortality and maternal discomfort. See link
http://www.ihs.gov/medicalprograms/mch/m/documents/cholestas4206.doc
Co-occurring maternal conditions and behavior problems in children
Our study suggests that, by 3 years of age, there is already evidence of the effect of adverse childhood experiences, occurring in this study in the form of parental mental health problems, substance use, and domestic violence.
The authors found that
- The risk of behavior problems in 3-year-olds increased with the number of categories -- mental health, substance use, and domestic violence -- in which the mother reported a condition in the year after delivery.
- The graded increase in risk was independent of sociodemographic and prenatal factors, as well as measures of paternal mental health and substance use in the year after delivery.
The authors conclude that "to play their most useful role, health care providers might wish to consider the health and well-being of the family, the social unit involved in the transfer of health between generations, rather than limiting their focus to the individual patient or to a particular developmental period."
Whitaker RC, Orzol SM, Kahn RS. 2006. Maternal mental health, substance use, and domestic violence in the year after delivery and subsequent behavior problems in children at age 3 years. Archives of General Psychiatry 63(5):551-560.
Treatment of Chlamydia trachomatis in Adolescents
CONCLUSIONS: Most teenagers received appropriate antibiotics, but fewer received other recommended care. The current study highlights important "missed-opportunity" clinical encounters for counseling to address high-risk behaviors, management of partners, detection of other sexually transmitted infections, and retesting for reinfections. Systems to address these gaps in care should be incorporated into the clinical management of adolescents infected with C. trachomatis. Hwang LY, et al. Examination of the treatment and follow-up care of adolescents who test positive for Chlamydia trachomatis infection. Arch Pediatr Adolesc Med December 2005;159:1162-6.
Extremely Low-Birth-Weight Infants Become Normal Adults
Clinical Question: Do extremely low-birth-weight infants achieve functional adulthood?
Bottom Line: Nearly all surviving extremely low-birth-weight children and adolescents overcome early cognitive and social difficulties and reach a functional level comparable with normal-birth-weight peers. (Level of Evidence: 1b)
Saigal S, et al. Transition of extremely low-birth-weight infants from adolescence to young adulthood: comparison with normal birth-weight controls. JAMA February 8, 2006;295:667-75.
ACIP Updates Recommendations for Prevention of Hepatitis B Virus Transmission
The Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention has updated its strategy to eliminate hepatitis B virus (HBV) transmission in the United States. The report provides new recommendations to improve prevention of perinatal and early childhood HBV transmission, including implementation of universal infant vaccination beginning at birth, and to increase vaccine coverage among previously unvaccinated children and adolescents. December 23, 2005, Morbidity and Mortality Weekly Report http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm
Hypertension in Children and Adolescents
The development of a national database on normative blood pressure levels throughout childhood has contributed to the recognition of elevated blood pressure in children and adolescents. The epidemic of childhood obesity, the risk of developing left ventricular hypertrophy, and evidence of the early development of atherosclerosis in children would make the detection of and intervention in childhood hypertension important to reduce long-term health risks; however, supporting data are lacking. Secondary hypertension is more common in preadolescent children, with most cases caused by renal disease. Primary or essential hypertension is more common in adolescents and has multiple risk factors, including obesity and a family history of hypertension. Evaluation involves a thorough history and physical examination, laboratory tests, and specialized studies. Management is multifaceted. Nonpharmacologic treatments include weight reduction, exercise, and dietary modifications. Recommendations for pharmacologic treatment are based on symptomatic hypertension, evidence of end-organ damage, stage 2 hypertension, stage 1 hypertension unresponsive to lifestyle modifications, and hypertension with diabetes mellitus. Am Fam Physician 2006;73:1158-68.
http://www.aafp.org/afp/20060501/1558.html
Chronic Disease and Illness
Group visits: Promising approach to chronic care management for the motivated patient
RESULTS: Although the heterogeneity of the studies presented renders the assessment of this care model problematic, there is sufficient data to support the effectiveness of group visits in improving patient and physician satisfaction, quality of care, quality of life, and in decreasing emergency department and specialist visits.
CONCLUSION: Group visits are a promising approach to chronic care management for the motivated patient. Future research may benefit, however, from abandoning old nomenclatures and clearly defining the structure, processes of care, content of visits, and appropriate outcome measures.
Jaber R et al Group visits: a qualitative review of current research. J Am Board Fam Med. 2006 May-Jun;19(3):276-90.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=16672681&dopt=Abstract
Depression Relapse in Pregnancy High When Medication Stopped
Clinical Question: What is the risk of relapse of major depression in women who discontinue their antidepressant medication while pregnant?
Setting: Outpatient (specialty)
Bottom Line: Nearly 50 percent of women currently receiving antidepressant medication will experience a relapse of major depression during pregnancy. The risk is highest for those discontinuing their medication. It is likely that this study sample consists of patients with a higher severity of illness than those found in a routine community practice, so the findings may not generalize to other settings. (Level of Evidence: 1b)
Cohen LS, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA February 1, 2006;295:499-507.
Determining Eligibility for Gastric Bypass Surgery
Case Scenario: I have a 65-year-old patient with a body mass index (BMI) close to 50 kg per m2. Her weight dramatically affects her quality of life. She uses a wheelchair and has difficulty getting around. Her weight also has affected her health: she has congestive heart failure, sleep apnea, and pulmonary hypertension. A thallium stress test has shown that she has minimal coronary artery disease. The patient has been unable to lose weight with diet and exercise. I thought she was an acceptable candidate for gastric bypass surgery, and I referred her to a surgeon to discuss this option. But soon afterward, my patient returned to my office devastated. The surgeon had informed her that she was not a candidate for gastric bypass surgery because of her age.
Should this patient be allowed to have the surgery? Should I try to find another surgeon who is willing to perform the risky procedure? What are the ethical implications of allocating an expensive resource such as gastric bypass surgery?
See discussion http://www.aafp.org/afp/20060501/curbside.html
Metformin lowers cardiovascular risk factors in hyperinsulinemic women with PCOS
RESULTS: The hyperinsulinemic group had significantly lower high-density lipoprotein (HDL) (by 11%), higher total cholesterol to HDL ratio (by 23%), and greater triglycerides (by 57%) than the normoinsulinemic group. Six-month metformin therapy in hyperinsulinemic women was associated with a significant decrease of insulin level (by 35%), total cholesterol (by 11%), low-density lipoprotein (LDL) (by 12%), and triglycerides (by 33%). Levels of lipids in hyperinsulinemic women after metformin therapy were comparable to levels observed in normoinsulinemic subjects. CONCLUSION: The present study supports the notion that metformin may be considered as a prophylactic therapy lowering cardiovascular risk factors in hyperinsulinemic women with polycystic ovary syndrome.
Banaszewska B, et al Lipids in polycystic ovary syndrome: role of hyperinsulinemia and effects of metformin. Am J Obstet Gynecol. 2006 May;194(5):1266-72
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=16647909
Nonpharmacologic Strategies for Managing Hypertension (also see Patient Education)
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommends lifestyle modification for all patients with hypertension or prehypertension. Modifications include reducing dietary sodium to less than 2.4 g per day; increasing exercise to at least 30 minutes per day, four days per week; limiting alcohol consumption to two drinks or less per day for men and one drink or less per day for women; following the Dietary Approaches to Stop Hypertension eating plan (high in fruits, vegetables, potassium, calcium, and magnesium; low in fat and salt); and achieving a weight loss goal of 10 lb (4.5 kg) or more. Alternative treatments such as vitamin C, coenzyme Q10, magnesium, and omega-3 fatty acids have been suggested for managing hypertension, but evidence for their effectiveness is lacking. Am Fam Physician 2006;73:1953-6, 1957-8.
http://www.aafp.org/afp/20060601/1953.html
Screening for Depression - Cochrane for Clinicians
Clinical Question
Are screening tools for depression effective in primary care practice?
Evidence-Based Answer
Sensitive and specific screening tools and effective treatments are available for depression. However, screening for depression has not been shown to increase the number of patients who receive treatment or to improve patient outcomes. This may be because the positive predictive values of screening tests for depression are lower in primary care, or because physicians already are adept at identifying those patients most likely to benefit from treatment (i.e., those who have the most severe symptoms and the greatest functional limitations).
http://www.aafp.org/afp/20060501/cochrane.html
Carbamazepine for Acute and Chronic Pain - Cochrane for Clinicians
Clinical Scenario
A 52-year-old man with diabetic neuropathic pain has read on the Internet that some seizure medicines are helpful, and he asks for your recommendation.
Clinical Question
How effective is carbamazepine (Tegretol) in controlling pain?
Evidence-Based Answer
Two small trials have shown carbamazepine to be beneficial in the treatment of diabetic neuropathic pain. Carbamazepine shows similar clinical effect to gabapentin (Neurontin) and phenytoin (Dilantin), but there have been no head-to-head trials directly comparing these drugs. Carbamazepine is effective in the treatment of trigeminal neuralgia and may be effective for other types of neuropathic pain, but the data are limited. Carbamazepine is not beneficial for the treatment of acute pain.
http://www.aafp.org/afp/20060501/cochrane.html
Dietary Advice to Lower Cardiovascular Risk - Cochrane for Clinicians
Clinical Question
Does dietary advice to patients achieve sustained dietary change or improvements in cardiovascular risk profile?
Evidence-Based Answer
Dietary advice to lower fat and salt intake and increase intake of fruits, vegetables, and fiber produces modest improvements in cardiovascular risk factors. More intensive counseling yields greater effects. http://www.aafp.org/afp/20060501/cochrane.html
Thyroiditis
Thyroiditis is an inflammation of the thyroid gland that may be painful and tender when caused by infection, radiation, or trauma, or painless when caused by autoimmune conditions, medications, or an idiopathic fibrotic process. The most common forms are Hashimoto's disease, subacute granulomatous thyroiditis, postpartum thyroiditis, subacute lymphocytic thyroiditis, and drug-induced thyroiditis (caused by amiodarone, interferon-alfa, interleukin-2, or lithium). Patients may have euthyroidism, hyperthyroidism, or hypothyroidism, or may evolve from one condition to another over time. Diagnosis is by clinical context and findings, including the presence or absence of pain, tenderness, and autoantibodies. In addition, the degree of radioactive iodine uptake by the gland is reduced in most patients with viral, radiation-induced, traumatic, autoimmune, or drug-induced inflammation of the thyroid. Treatment primarily is directed at symptomatic relief of thyroid pain and tenderness, if present, and restoration of euthyroidism. Am Fam Physician 2006;73:1769-76 http://www.aafp.org/afp/20060515/1769.html
Managing Opioid Addiction with Buprenorphine (see Patient Education)
Legislation has enabled physicians to treat opioid-dependent patients with an office-based maintenance program using buprenorphine, a partial mu-opioid receptor agonist. Clinical studies indicate buprenorphine effectively manages opioid addiction. Buprenorphine is more effective than placebo for managing opioid addiction but may not be superior to methadone if high doses are needed. It is comparable to lower doses of methadone, however. Treatment phases include induction, stabilization, and maintenance. Buprenorphine therapy should be initiated at the onset of withdrawal symptoms and adjusted to address withdrawal symptoms and cravings. Advantages of buprenorphine include low abuse potential and high availability for office use. Disadvantages include high cost and possible lack of effectiveness in patients who require high methadone doses. Most family physicians are required to complete eight hours of training before they can prescribe buprenorphine for opioid addiction. Am Fam Physician 2006;73:1573-8, 1580.
http://www.aafp.org/afp/20060501/1573.html
Low-Carbohydrate Diets (also see Patient Education)
Americans spend $33 billion annually on weight loss products and services, and a large portion of this money is spent on low-carbohydrate diets. Because of their higher protein and fat content and lower fiber and carbohydrate content, concerns have been raised about the potential health consequences of low-carbohydrate diets. Published long-term data are lacking. Short-term studies comparing traditional low-fat diets with low-carbohydrate diets found lower triglyceride levels, higher high-density lipoprotein cholesterol levels, similar low-density lipoprotein cholesterol levels, and lower A1C levels in persons on low-carbohydrate diets. These diets induce greater weight loss at three and six months than traditional low-fat diets; however, by one year there is no significant difference in maintained weight loss. Weight loss is directly related to calorie content and the ability to maintain caloric restriction; the proportions of nutrients in the diet are irrelevant. Low-carbohydrate diets had lower dropout rates than low-fat diets in several studies, possibly because of the high protein content and low glycemic index, which can be appetite suppressing. Data indicate that low-carbohydrate diets are a safe, reasonable alternative to low-fat diets for weight loss. Additional studies are needed to investigate the long-term safety and effectiveness of these and other approaches to weight loss. Am Fam Physician 2006;73:1942-8, 1951.
http://www.aafp.org/afp/20060601/1942.html
Depressive Disorders
Clinical Evidence Concise A Publication of BMJ Publishing Group
What are the effects of treatments in mild to moderate or severe depression?
Beneficial
Prescription Antidepressant Drugs (Tricyclic Antidepressants [Including Low Doses], Selective Serotonin Reuptake Inhibitors [SSRIs], Monoamine Oxidase Inhibitors [MAOIs], Reboxetine, or Venlafaxine) Improved Symptoms Compared with Placebo in Mild to Moderate and Severe Depression). Systematic reviews and subsequent randomized controlled trials (RCTs) including persons 18 years or older in primary and secondary care showed that prescription antidepressant drugs were effective treatments for all grades of depressive disorders compared with placebo. However, the most robust available evidence on the effectiveness of antidepressant drug treatment is in the pharmacologic management of moderate and severe depression.
One systematic review and two subsequent RCTs including persons 55 years or older with all grades of depressive disorders showed that tricyclic antidepressants, SSRIs, or MAOIs reduced the proportion of persons who did not recover over 26 to 49 days compared with placebo. The reviews included little information on severe adverse effects of antidepressant drugs compared with placebo. There is evidence of publication bias in trials of SSRIs. Current evidence indicates no clear relationship between SSRIs and increased risk of suicide in adults, but SSRIs and tricyclic antidepressants may induce or worsen suicidal ideation and behavior during the early phases of treatment. This may be because of increased agitation and activation. SSRIs generally increase adverse events in children and adolescents compared with placebo, and regulatory authorities in several countries are reviewing the safety of these drugs.
Tricyclic Antidepressants vs. Other Prescription Antidepressant Drugs. Three systematic reviews showed no significant difference in outcomes with different kinds of antidepressant drugs. One systematic review and one subsequent RCT showed no significant difference between tricyclic antidepressants and venlafaxine in the proportion of persons who responded over one to 12 months. Another systematic review suggested that tricyclic antidepressants were more effective than MAOIs in persons with severe depressive disorders, but that it may be less effective in atypical depressive disorders with biologic features (e.g., increased sleep and appetite). A third systematic review showed that tricyclic antidepressants were associated with higher rates of adverse effects than SSRIs, but the difference was small. One systematic review and two case-control studies showed no significant difference in risk of suicide between SSRIs and tricyclic antidepressants.
Two RCTs, primarily including persons with severe depression, showed no significant difference in symptoms between desipramine or imipramine and reboxetine at four weeks, but results were sensitive to outcome scales used. One systematic review showed no significant difference between milnacipran and imipramine in persons with major depressive disorder, although it showed that imipramine had an overall higher incidence of adverse events. One systematic review showed no significant difference between low-dose and standard-dose tricyclic antidepressants in the proportion of responders at six to eight weeks. One systematic review showed that combined antidepressants (primarily tricyclic antidepressants) with benzodiazepines increased response rates within one week compared with antidepressants alone, although this difference was not significant at six weeks.
SSRIs and Related Drugs vs. Other Prescription Antidepressant Drugs. Three systematic reviews showed no significant difference in outcomes with different kinds of antidepressant drugs, although one systematic review showed that SSRIs were less effective than venlafaxine in increasing the proportion of persons who responded. RCTs including persons with major depression showed similar response rates for fluoxetine and reboxetine at six weeks, but they showed that reboxetine may be slightly more effective in improving social functioning. One RCT showed that mirtazapine was significantly more effective than sertraline during the first two weeks of treatment, although this benefit did not last longer than two weeks. Another RCT showed no significant difference between paroxetine and mirtazapine after 24 weeks.
One systematic review showed that SSRIs were associated with fewer adverse effects than tricyclic antidepressants, but the difference was small. Two systematic reviews, one retrospective cohort study, and two case-control studies showed contradictory evidence about the risk of suicide in adults treated with SSRIs. One of the systematic reviews and the case-control studies reported no significant difference in risk of suicide between SSRIs and tricyclic antidepressants. One RCT and observational data suggested that abrupt withdrawal of SSRIs was associated with adverse symptoms (e.g., dizziness, rhinitis) and that these symptoms were more likely to occur with drugs with a short half-life (e.g., paroxetine). There is evidence of publication bias in trials of SSRIs.
Current evidence indicates no clear relationship between SSRIs and increased suicide in adults; however, SSRIs and tricyclic antidepressants may induce or worsen suicidal ideation and behavior during the early phases of treatment. This may be because of increased agitation and activation. SSRIs generally increase adverse events in children and adolescents compared with placebo, and regulatory authorities in several countries are reviewing the safety of these drugs.
MAOIs vs. Other Prescription Antidepressant Drugs. Three systematic reviews showed no significant difference in outcomes with different kinds of antidepressant drugs. One systematic review showed that MAOIs were less effective than tricyclic antidepressants in persons with severe depressive disorders. However, the review showed that MAOIs may be more effective for atypical depressive disorders with biologic features (e.g., increased sleep and appetite).
Venlafaxine vs. Other Prescription Antidepressant Drugs. One systematic review and one RCT showed no significant difference between venlafaxine and tricyclic antidepressants in the proportion of persons who responded to treatment over one to 12 months. The review showed that venlafaxine increased the proportion of persons who responded compared with SSRIs, although one subsequent RCT showed no significant difference between extended-release venlafaxine and escitalopram. One RCT showed no significant difference between venlafaxine and mirtazapine in the proportion of persons who responded, but both treatments improved baseline depressive symptoms.
Electroconvulsive Therapy (in Severe Depression). One systematic review including persons, mostly inpatients, with moderate to severe depressive disorder showed that electroconvulsive therapy improved symptoms over one to six weeks compared with simulated electroconvulsive therapy or antidepressant drugs. The review showed that bilateral electroconvulsive therapy improved symptoms compared with unilateral therapy and that high-dose electroconvulsive therapy was more effective than low-dose therapy. The degree of reported short-term cognitive impairment seemed to be inversely related to treatment effectiveness.
Another systematic review provided insufficient evidence to assess electroconvulsive therapy in older adults. Electroconvulsive therapy is a short-term treatment and may be inappropriate for some patients; therefore, the consensus is that the therapy normally should be reserved for persons who cannot tolerate or have not responded to antidepressants. Electroconvulsive therapy may be useful when a rapid response is required.
Cognitive Therapy (in Mild to Moderate Depression). One systematic review including younger and older adults showed that cognitive therapy improved symptoms compared with no treatment. Three systematic reviews including younger and older adults with mild to moderate depression showed that psychological therapies (mainly interpersonal psychotherapy and cognitive therapy) increased the proportion of persons whose depression was in remission over 10 to 34 weeks compared with control (i.e., usual care, usual care plus a placebo pill, or supportive therapy). These reviews did not report results for cognitive therapy alone compared with control.
One systematic review showed no significant difference between cognitive therapy and interpersonal therapy, although it showed that cognitive therapy was more successful than combined interpersonal therapy, brief psychodynamic therapy, or supportive therapy. One systematic review showed no significant difference between short-term psychodynamic psychotherapy and cognitive therapy in remission rates or improvement of depressive symptoms. One systematic review of poor-quality RCTs including persons 55 years or older with mild to moderate depression showed no significant difference in symptom improvement between psychological treatments (e.g., cognitive therapy, cognitive behavior therapy) and no treatment.
Interpersonal Psychotherapy (in Mild to Moderate Depression). Two systematic reviews including adults with mild to moderate depression showed that psychological therapies increased the proportion of persons whose depression was in remission over 10 to 34 weeks compared with control. These reviews did not report results for interpersonal therapy alone compared with control. One RCT identified by a third review showed that interpersonal therapy increased response rates compared with usual care, although the review showed no difference between cognitive therapy and interpersonal therapy. One RCT showed that group interpersonal psychotherapy improved depressive symptoms in adults in Uganda compared with no treatment. One systematic review including older adults showed no significant difference among interpersonal therapy, psychodynamic psychotherapy, and no treatment.
Likely to be beneficial
Reboxetine vs. Other Antidepressant Drugs (in Mild to Moderate or Severe Depression). Two RCTs that primarily included persons with severe depression showed no significant difference in symptoms at four weeks among reboxetine, desipramine, and imipramine, but results were sensitive to the outcome scales used. RCTs including persons with major depression showed similar response rates at six weeks between reboxetine and fluoxetine, although reboxetine may have slightly improved social functioning.
St. John's Wort (More Effective Than Placebo, as Effective as Other Antidepressants in Mild to Moderate Depression). One systematic review showed that St. John's wort (Hypericum perforatum) improved depressive symptoms over four to 12 weeks compared with placebo. The review showed no significant difference between St. John's wort and tricyclic antidepressants or SSRIs. The results of the RCTs should be interpreted cautiously, because many patients did not use standardized preparations of St. John's wort and dosages of antidepressants varied. Questions have been raised regarding the methodologic quality of available studies, which have examined heterogenous patient populations and have used standardized symptom rating instruments inconsistently. St. John's wort likely interacts with many more drugs than previously reported.
Nondirective Counseling (in Mild to Moderate Depression). One systematic review including persons 18 years or older with recent-onset psychological problems, including depression, showed that brief, nondirective counseling in the primary care setting reduced short-term (less than six months) symptom scores in persons with mild to moderate depression compared with usual care. However, the review showed no significant difference in long-term (more than six months) scores. One RCT showed that eight counseling sessions significantly improved anxiety and depression symptoms compared with no treatment.
Combining Prescription Antidepressant Drugs and Psychological Treatments (in Mild to Moderate and Severe Depression). Two systematic reviews showed that a combination of pharmacotherapy and psychotherapy improved depressive symptoms compared with either treatment alone. One subsequent poor-quality RCT showed no significant difference in response rate between a combination of interpersonal therapy and sertraline and either therapy alone. A subsequent RCT showed no significant difference between short-term psychodynamic psychotherapy plus antidepressants and antidepressants alone, although subgroup analysis showed that combination therapy was more effective in persons with depression and a personality disorder.
Unknown effectiveness
Problem-Solving Therapy (in Mild to Moderate Depression). One systematic review including younger and older adults presenting to primary care physicians with mild to moderate depression showed that psychological therapies (including problem-solving therapy) improved outcomes compared with usual care. The review did not report results of problem-solving therapy alone in persons with moderate depression. It showed no significant difference between problem-solving therapy and usual care in symptoms at six to 11 weeks in persons with mild depression or dysthymia. One large subsequent RCT showed that problem-solving therapy increased the proportion of persons who were not depressed at six months compared with usual care. However, it showed no significant difference at one year. A smaller RCT showed no significant difference between problem-solving therapy and usual care in symptoms at eight or 26 weeks in persons, most of whom were depressed, presenting to primary care physicians with emotional disorders. RCTs showed insufficient evidence to assess the relative effectiveness of drug and nondrug treatments of severe depression.
Befriending (in Mild to Moderate Depression). One small RCT provided insufficient evidence to assess befriending in persons with mild to moderate depression.
Exercise (in Mild to Moderate Depression). One systematic review including adults showed limited evidence from poor-quality RCTs that exercise may improve symptoms compared with no treatment, and that it may be as effective as cognitive therapy. One poor-quality RCT including older adults identified by the review showed limited evidence that exercise may be as effective as antidepressant drugs in improving symptoms and may reduce relapse over 10 months.
Lithium Augmentation. RCTs provided insufficient evidence to assess augmentation of prescription antidepressants with lithium in younger and older adults with treatment-resistant depression.
Pindolol Augmentation. RCTs provided insufficient evidence to assess augmentation of prescription antidepressants with pindolol in younger and older adults with treatment-resistant depression.
Which interventions reduce relapse rates?
Beneficial
Continuing Prescription Antidepressant Drugs (Reduced Risk of Relapse After Recovery in Persons with Mild to Moderate Depression). One systematic review showed that continuing prescription antidepressant drug treatment after recovery reduced the proportion of persons who experienced a relapse over one to three years compared with placebo. The effect of continuing antidepressant therapy was independent of the underlying risk of relapse, the duration of treatment before randomization, or the duration of previous antidepressant treatment.
Five subsequent RCTs also showed that continuing antidepressant treatment reduced absolute risk of recurrence by up to one half compared with treatment discontinuation. Two RCTs including persons 60 years or older showed that continued treatment after recovery with dosulepin (dothiepin) or citalopram reduced the risk of relapse over one to two years compared with placebo, but it may increase the risk of ischemic heart disease. One RCT showed no benefit from continuing treatment with sertraline for another two years compared with placebo.
Unknown effectiveness
Cognitive Therapy (Weak Evidence That May Reduce Relapse Over One to Two Years After Stopping Treatment in Persons with Mild to Moderate Depression Compared with Antidepressant Drugs). One systematic review, including younger and older adults with mild to moderate depression, that combined relapse rates across RCTs showed limited evidence that cognitive therapy reduced the risk of relapse over one to two years after stopping treatment compared with antidepressant drugs. Four subsequent RCTs showed limited evidence that cognitive therapy reduced relapse rates up to one year after remission. We found no systematic review or RCT that specifically included older adults.
Relapse Prevention Program (Improved Symptoms Over One Year After Recovery in Persons with Mild to Moderate Depression but No Significant Difference in Relapse Rates). One RCT identified by a systematic review showed that a relapse prevention program improved depressive symptoms over one year compared with usual care in persons who had recovered after eight weeks of antidepressant treatment. However, there were no significant differences in relapse rates.
What are the effects of interventions to improve delivery of treatments?
Likely to be beneficial
Care Pathways (in Mild to Moderate Depression). Two systematic reviews and eight subsequent RCTs showed that care pathways improved the effectiveness of treatment for depression (i.e., antidepressant drugs or cognitive behavior therapy) compared with usual care in persons older than 18 years with mild to moderate depression. These pathways included collaboration between primary care physicians and psychiatrists, intensive patient education, case management, and telephone support. The RCTs also showed that clinical practice guidelines and educational strategies without other organizational processes did not improve detection or outcome of depression compared with usual care. It was not possible to determine from the results which components of care pathways were most effective.
One RCT including older persons with depression showed that initial care by a community mental health team did not improve depressive symptoms compared with usual care from a primary physician. Another RCT showed that management of depression in older persons by a community nurse improved symptoms and increased recovery after three months compared with usual primary care. One RCT including persons older than 60 years with major depression, dysthymic depression, or both who were treated in a variety of primary care clinics showed that collaborative care was more effective than usual care in reducing depressive symptoms. One RCT showed that treatment recommendations had no significant effect on depressive symptoms in older persons compared with usual primary care. However, diagnosis of depression and antidepressant prescribing were more prevalent in the intervention group.
http://www.aafp.org/afp/20060601/bmj.html
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
