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Obstetrics
Do Pregnant Women Require Rectal Swabs for GBS?
CONCLUSION: The group B streptococci detection rate from vaginal-perianal specimens is not significantly different from the detection rate from vaginal-rectal specimens. Therefore, pregnant women do not need to be subjected to the discomfort of collection of a rectal specimen. LEVEL OF EVIDENCE: II-2.
Jamie WE, et al. Vaginal-perianal compared with vaginal-rectal cultures for identification of group B streptococci. Obstet Gynecol November 2004;104:1058-61.
CONCLUSION: The group B streptococci detection rate from vaginal-perianal specimens is not significantly different from the detection rate from vaginal-rectal specimens. Therefore, pregnant women do not need to be subjected to the discomfort of collection of a rectal specimen. LEVEL OF EVIDENCE: II-2.
Jamie WE, et al. Vaginal-perianal compared with vaginal-rectal cultures for identification of group B streptococci. Obstet Gynecol November 2004;104:1058-61.
OB/GYN CCC Editorial comment:
While this article is of interest, it is Level II-2 evidence based on a small study of 200 patients in a prospective cohort. The current CDC Guidelines still recommend a combined vaginal rectal swab. http://www.ihs.gov/MedicalPrograms/MCH/M/DP44.asp#top
First Validated Model Predicts Risk of Failed Vaginal Birth After Cesarean
The factors that were predictive of emergency c-section were increasing maternal age, decreasing maternal height, male fetus, no previous vaginal birth, prostaglandin induction of labor, and birth at later than 40 weeks' gestation.
CONCLUSIONS: We present, to our knowledge, the first validated model for antepartum prediction of the risk of failed vaginal birth after prior cesarean section. Women at increased risk of emergency caesarean section are also at increased risk of uterine rupture, including catastrophic rupture leading to perinatal death
Smith
GC et al Predicting cesarean section and uterine rupture among women attempting
vaginal birth after prior cesarean section. PLoS Med. 2005 Sep;2(9):e252.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16146414&query_hl=28
http://www.greenjournal.org/cgi/content/abstract/106/4/700
MRSA Infection Emerging Problem in Pregnant Patients
Community-acquired MRSA in pregnancy is an emerging problem that most commonly presents as recurrent skin and soft tissue infections. Conclusion: Community-acquired MRSA is an emerging problem in our obstetric population. Most commonly, it presents as a skin or soft tissue infection that involves multiple sites. Recurrent skin abscesses during pregnancy should raise prompt investigation for MRSA. Level of Evidence: II-3.
Laibl VR et al. Clinical Presentation of Community-Acquired Methicillin-Resistant Staphylococcus aureus in Pregnancy. Obstet Gynecol. 2005 Sep;106(3):461-5.
Both obesity and excessive weight gain decrease the likelihood for VBAC
RESULTS: Obese patients were almost 50% less likely to have a successful VBAC when compared to underweight patients, odds ratio 0.53, 95% confidence interval 0.29–0.98, P = .043. Similarly, patients who gained more than 40 lb were almost 40% less likely to be successful at VBAC than those who gained less than that amount, odds ratio 0.63, 95% confidence interval 0.42–0.97, P = .034. They had a VBAC success rate of 66.8%, whereas patients who gained less than 40 lb were successful 79.1% of the time, P < .001.
CONCLUSION: Excessive weight gain during pregnancy and obesity both decrease VBAC success. Proper patient selection will help increase the likelihood of successful VBAC.
LEVEL OF EVIDENCE: II-2
Juhasz G et al Effect of Body Mass Index and Excessive Weight Gain on Success of Vaginal Birth After Cesarean Delivery Obstetrics & Gynecology 2005;106:741-746
Postnatal Depression - Clinical Evidence Concise
What are the effects of drug treatments?
likely to be beneficial
Antidepressants (Fluoxetine [Included on the Evidence of Its Effectiveness in the Treatment of Depression in General]). One small randomized controlled trial (RCT) showed limited evidence that fluoxetine plus one or six cognitive behavior therapy sessions may improve postnatal depression at four and 12 weeks compared with placebo plus one or six cognitive behavior therapy sessions. The RCT had methodologic weaknesses, a high withdrawal rate, and it excluded breastfeeding women. However, fluoxetine is known to be effective in managing depression in the general population and therefore is likely beneficial for the management of postnatal depression.
unknown effectiveness
Antidepressants Other Than Fluoxetine. We found no RCTs on the effects of other antidepressants in women with postnatal depression, and we found no RCTs that compared other antidepressants with psychological treatments.
Hormones. One small RCT that included women with severe postnatal depression showed that estrogen treatment improved postnatal depression at three and six months compared with placebo.
What are the effects of nondrug treatments?
likely to be beneficial
Nondirective Counseling. Limited evidence from two RCTs suggested that, in the short term (immediately after treatment), nondirective counseling improved postnatal depression compared with routine primary care. One RCT, with follow-up beyond 12 weeks, showed no clear long-term benefits (nine months to five years postpartum) from nondirective counseling compared with routine primary care, individual cognitive behavior therapy, or psychodynamic therapy.
Cognitive Behavior Therapy (Individual). One small RCT showed limited evidence that individual cognitive behavior therapy and ideal standard care improved depressive symptoms, but there was no significant difference between the two interventions. Limited evidence from one RCT suggested that individual cognitive behavior therapy may improve postnatal depression in the short term compared with routine primary care. The RCT found no clear long-term benefits from individual cognitive behavior therapy compared with routine primary care, nondirective counseling, or psychodynamic therapy.
Interpersonal Psychotherapy. One RCT showed that interpersonal psychotherapy improved postnatal depression compared with waiting list controls at 12 weeks.
Psychodynamic Therapy. One RCT provided limited evidence that psychodynamic therapy may improve postnatal depression in the short term compared with routine primary care. The RCT showed no clear long-term benefits from psychodynamic therapy compared with routine primary care, nondirective counseling, or cognitive behavior therapy.
unknown effectiveness
Light Therapy. We found no RCTs on the effects of light therapy.
Cognitive Behavior Therapy (Group). One small RCT that included women with a high level of depressive symptoms on screening showed that group cognitive behavior therapy improved symptoms at six months compared with routine primary care.
Psychoeducation with Partner. One small RCT showed that psychoeducation with partners reduced patients' depression scores and partners' psychiatric morbidity at 10 weeks compared with psychoeducation without partners.
Mother-Infant Interaction Coaching. One RCT showed that mother-infant interaction coaching had no significant effect on maternal depression scores compared with usual treatment, but it improved maternal responsiveness to the infant within 10 weeks of starting treatment.
Telephone-Based Peer Support (Mother-to-Mother). One small RCT showed that telephone-based peer support reduced depression scores compared with usual treatment at four months.
A Publication of BMJ Publishing Group http://www.aafp.org/afp/20051001/bmj.html
OB/GYN CCC Editorial comment:
Spotlight on Postpartum Depression - ACOG Co-Sponsors National Depression Screening
For the first time in its 15-year history, National Depression Screening Day (NDSD) is incorporating screening for postpartum depression in its Mental Health Screening Kits. In an effort to raise awareness about this often overlooked yet serious condition, the American College of Obstetricians and Gynecologists (ACOG) is among several health organizations co-sponsoring NDSD on October 6, 2005 http://www.acog.org/from_home/publications/press_releases/nr09-30-05-2.cfm
Obesity and Diabetes Independently Linked to Adverse Pregnancy Outcomes
CONCLUSIONS: In this large, population-based study, obesity and diabetes were independently associated with adverse pregnancy outcomes, highlighting the need for women to undergo lifestyle changes to help them control their weight during the childbearing years and beyond.
Rosenberg TJ, et al Maternal obesity and diabetes as risk factors for adverse pregnancy outcomes: differences among 4 racial/ethnic groups. Am J Public Health. 2005 Sep;95(9):1545-51 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16118366&query_hl=6
Fetal Pulse Oximetry Reduces Operative Deliveries
Fetal pulse oximetry does reduce the number of operative deliveries and the need for fetal scalp sampling in term pregnancies when there is a nonreassuring FHR pattern. They add that fetal pulse oximetry during active labor provides a more accurate assessment of fetal well-being and may reduce the need for interventions.
Kühnert M, Schmidt S. Intrapartum management of nonreassuring fetal heart rate patterns: a randomized controlled trial of fetal pulse oximetry. Am J Obstet Gynecol December 2004;191:1989-95.
Weigh gain correlated with complications in glucose tolerant pregnant women
CONCLUSIONS: Increasing weight gain in obese women is associated with increasing pregnancy complications. Our data suggest that minimal gestational weight gain might normalize birth weight. Prospective studies should be performed to clarify the safety of recommending limited gestational weight gain
Jensen
DM, et al Gestational weight gain and pregnancy outcomes in 481 obese glucose-tolerant
women. Diabetes Care. 2005 Sep;28(9):2118-22.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16123476&query_hl=1
Does Mifepristone Induce Labor in Term Pregnancies ?
Up to 600 mg of mifepristone does not induce labor in patients with unfavorable cervical status. They add that the failure of mifepristone in this study may be secondary to the conditions in which it was used. Other studies are needed to determine whether mifepristone effectively induces labor. Berkane N, et al. Use of mifepristone to ripen the cervix and induce labor in term pregnancies. Am J Obstet Gynecol January 2005;192:114-20.
Antibiotics for preterm rupture of the membranes: a systematic review
Number needed to treat to avoid neonatal complication: 7 to 17
The authors conclude that the use of antibiotics after PROM reduces maternal and neonatal morbidity. The data support the routine use of erythromycin or other penicillins to improve outcomes for mothers and infants. The authors also advise against the use of amoxicillin-clavulanate because of its increased risk of necrotizing enterocolitis. Further long-term follow-up will need to be completed to assess the health and development of the children involved in this trial.
Benefit was demonstrated in trials involving penicillins and erythromycin, but data were insufficient to compare different antibiotic regimens. Because erythromycin was used in larger trials, the evidence supporting its use was more robust. The incidence of necrotizing enterocolitis rose significantly when amoxicillin-clavulanate (Augmentin) was used.
Kenyon S, et al. Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol November 2004;104:1051-7
Progesterone Reduces Preterm Birth in High-Risk Mothers
CONCLUSION: The use of progestational agents and 17alpha-hydroxyprogesterone caproate reduced the incidence of preterm birth and low birth weight newborns.
Sanchez-Ramos L, et al. Progestational agents to prevent preterm birth: a meta-analysis of randomized controlled trials. Obstet Gynecol February 2005;105:273-9.
Attitudes About Elective Primary Cesarean Delivery
Approximately two thirds of participants would agree to primary elective Cesarean delivery, but a much lower percentage would choose this strategy for their own families-correlate with those of researchers in other countries. They draw attention to the differences between the responses from the urogynecology and maternal-fetal medicine subspecialists and speculate that this reflects the main concerns of the respective subspecialties. The authors also point out the possibility of selection bias because of the low response rate.
Wu JM, et al. Elective primary Cesarean delivery: attitudes of urogynecology and maternal-fetal medicine specialists. Obstet Gynecol February 2005;105:301-6.
Screening for Rh(D) Incompatibility: USPSTF Recommendation Statement
Summary of Recommendations
A recommendation The USPSTF strongly recommends Rh(D) blood typing and antibody testing for all pregnant women during their first visit for pregnancy-related care.
B recommendation The USPSTF found good evidence that Rh(D) blood typing, anti-Rh(D) antibody testing, and intervention with Rh(D) immunoglobulin, as appropriate, prevent maternal sensitization and improve outcomes for newborns. The benefits substantially outweigh any potential harms.
The USPSTF recommends repeated Rh(D) antibody testing for all unsensitized Rh(D)-negative women at 24 to 28 weeks' gestation, unless the biologic father is known to be Rh(D) negative.
The USPSTF found fair evidence that repeated antibody testing for unsensitized Rh(D)-negative women (unless the father also is known to be Rh[D] negative) and intervention with Rh(D) immunoglobulin, as appropriate, provide additional benefit over a single test at the first prenatal visit in preventing maternal sensitization and improving outcomes for newborns. The benefits of repeated testing substantially outweigh any potential harms.
The USPSTF found no new evidence addressing the role of screening, new screening tests, new treatment protocols, or potential harms associated with screening and treatment of Rh(D) incompatibility. However, there is preexisting good evidence for the efficacy and effectiveness of blood typing, anti-Rh(D) antibody screening, and postpartum Rh(D) immunoglobulin prophylaxis.
http://www.preventiveservices.ahrq.gov
Gynecology
Paroxetine Curbs Premenstrual Dysphoric Disorder
CONCLUSION: For the treatment of PMDD, luteal phase dosing with 12.5 mg and 25 mg of paroxetine CR is effective and generally well tolerated
Steiner
M, et al Luteal phase dosing with paroxetine controlled release (CR) in the
treatment of premenstrual dysphoric disorder. Am J Obstet Gynecol. 2005 Aug;193(2):352-60.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16098854&query_hl=8
Social and cultural barriers to Pap test screening: Fatalistic attitudes, lack of support
Fatalistic attitudes, lack of family support, and low levels of information about cervical cancer are associated significantly with lack of Pap screening in women with cervical cancer, as are the previously identified risk factors of recent immigration and low levels of education. The authors argue that attitudinal, financial, and cultural barriers must be overcome to improve cervical cancer screening in the United States, and that development of home testing may have only limited acceptability. The authors recommend mobilization of community resources to address attitudinal barriers to cervical cancer screening.
Behbakht K, et al. Social and cultural barriers to Papanicolaou test screening in an urban population. Obstet Gynecol December 2004;104:1355-61.
Tension-free vaginal tape procedure is effective over a period of 7 years
RESULTS: The follow-up time was a mean of 91 months (range 78-100 months). Both objective and subjective cure rates were 81.3% for the 80 women available for follow-up. Asymptomatic pelvic organ prolapse was found in 7.8%, de novo urge symptoms in 6.3%, and recurrent urinary tract infection in 7.5% of the women. No other long-term adverse effects of the procedure were detected. CONCLUSION: The tension-free vaginal tape procedure for treatment of female urinary stress incontinence is effective over a period of 7 years.
Nilsson CG, et al. Seven-year follow-up of the tension-free vaginal tape procedure for treatment of urinary incontinence. Obstet Gynecol December 2004;104:1259-62.
IDSA Guidelines for Diagnosis and Treatment of Asymptomatic Bacteriuria
The Infectious Diseases Society of America (IDSA) has released evidence-based recommendations for the diagnosis and treatment of asymptomatic bacteriuria in adults. The IDSA guidelines, are as follows:
• Diagnosis of asymptomatic bacteriuria should be based on the results of a urine culture collected in a way that prevents contamination. Diagnosis of bacteriuria in asymptomatic women is defined as two consecutive voided urine specimens in which the same strain of bacteria is isolated in quantitative counts of at least 10 5 cfu per mL. In men, diagnosis of bacteriuria is defined as one bacterial species isolated in a quantitative count of at least 10 5 cfu per mL in a clean-catch voided urine sample. In women and men, bacteriuria is diagnosed when, in a single catheterized urine sample, one bacterial species is isolated in a quantitative count of at least 10 2 cfu per mL.
• Antimicrobial treatment is not indicated when pyuria accompanies asymptomatic bacteriuria.
• Pregnant women should be screened for bacteriuria during early pregnancy and given antimicrobial therapy for three to seven days if the results are positive. Women with a positive screen should be monitored for recurrence of bacteriuria after treatment.
• Shortly before transurethral resectioning of the prostate, patients should be screened and treated for bacteriuria, but treatment should not be continued after the procedure unless a catheter remains in place.
• Screening and treatment are recommended before any urologic procedure in which mucosal bleeding is expected.
• Screening and treatment are not recommended for premenopausal women who are not pregnant, women with diabetes, older persons living in the community or institutions, patients with spinal cord injury, or catheterized patients while the catheter is in situ.
• Physicians should consider antimicrobial treatment of asymptomatic women with catheter-acquired bacteriuria if it persists for 48 hours after catheter removal.
• The IDSA does not recommend for or against screening or treatment of patients with renal or other solid-organ transplants.
March 1, 2005, Clinical Infectious Diseaseshttp://www.sochinf.cl/documentos/bacteriuria.pdf
Management of Spontaneous Abortion
Spontaneous abortion, which is the loss of a pregnancy without outside intervention before 20 weeks' gestation, affects up to 20 percent of recognized pregnancies. Spontaneous abortion can be subdivided into threatened abortion, inevitable abortion, incomplete abortion, missed abortion, septic abortion, complete abortion, and recurrent spontaneous abortion. Ultrasonography is helpful in the diagnosis of spontaneous abortion, but other testing may be needed if an ectopic pregnancy cannot be ruled out. Chromosomal abnormalities are causative in approximately 50 percent of spontaneous abortions; multiple other factors also may play a role. Traditional treatment consisting of surgical evacuation of the uterus remains the treatment of choice in unstable patients. Recent studies suggest that expectant or medical management is appropriate in selected patients. Patients with a completed spontaneous abortion rarely require medical or surgical intervention. For women with incomplete spontaneous abortion, expectant management for up to two weeks usually is successful, and medical therapy provides little additional benefit. When patients are allowed to choose between treatment options, a large percentage will choose expectant management. Expectant management of missed spontaneous abortion has variable success rates, but medical therapy with intravaginal misoprostol has an 80 percent success rate. Physicians should be aware of psychologic issues that patients and their partners face after completing a spontaneous abortion. Women are at increased risk for significant depression and anxiety for up to one year after spontaneous abortion. Counseling to address feelings of guilt, the grief process, and how to cope with friends and family should be provided.
Am Fam Physician 2005;72:1243-50.
http://www.aafp.org/afp/20051001/1243.html
Child Health
#1 cause of pediatric deaths!!!
The number one cause of death for children younger than 14 years is vehicular injury. Child safety seats and automobile safety belts protect children in a crash if they are used correctly, but if a child does not fit in the restraint correctly, it can lead to injury. A child safety seat should be used until the child correctly fits into an adult seat belt. It is important for physicians caring for children to know what child safety seats are available and which types of seats are safest. Three memory keys will help guide appropriate child safety seat choice:
(1) Backwards is Best;
(2) 20-40-80; and
(3) Boost Until Big Enough.
"Backwards is Best" cues the physician that infants are safest
in a head-on crash when they are facing backward. "20-40-80" reminds
the physician that children may need to transition to a different seat when they
reach 20, 40, or 80 lb. "Boost Until Big Enough" emphasizes that children
need to use booster seats until they are big enough to fit properly into an adult
safety belt. Biagioli
F. Child safety seat counseling: three keys to safety. Am Fam Physician.
2005 Aug 1;72(3):473-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16100862&query_hl=11
Broad portrait of what adolescents are doing and thinking
Freeze Frame: A Snapshot of America's Teens presents data on a wide variety of topics, from adolescents' sexual behavior to their religious beliefs. The chart book, produced by the National Campaign to Prevent Teen Pregnancy in conjunction with Child Trends, groups data into seven areas of influence -- health, family, peers and partners, school, community, media and consumer behavior, and religious and spiritual beliefs. The chart book is intended to help correct many common misconceptions about adolescents as well as to provide adults and those working directly with adolescents with a more textured understanding of adolescents. http://www.teenpregnancy.org/works/pdf/FreezeFrame.pdf
Concussion tool kit for coaches
The Heads Up: Concussion in High School Sports tool kits will be distributed by CDC to coaches, principals, and athletic directors at high schools throughout the United States. The tool kits can be ordered or downloaded free of charge at http://www.cdc.gov/ncipc/tbi/coaches_tool_kit.htm.
CDC Injury Center Media Relations, telephone 770-488-4902
AAP Report on Pregnancy in Adolescents
The American Academy of Pediatrics (AAP) published a clinical report on the state of adolescent pregnancy in the United States. "Adolescent Pregnancy: Current Trends and Issues"
Recently the percentage of adolescents who are sexually active has decreased; however, more than 45 percent of current high school-aged females and 48 percent of high school-aged males report having had sexual intercourse. The average age at first intercourse is 16 years for males and 17 years for females.
According to the report, use of contraception by adolescents is increasing, but 50 percent of all adolescent pregnancies occur within six months of first intercourse. In 2003, almost one half of sexually active adolescents reported not using a condom the last time they had intercourse. Many adolescents who reported using prescription contraceptives indicated a gap of at least one year between the time that they first had intercourse and the time that they visited a physician to seek a prescription contraceptive.
The United States has the highest adolescent birth rate among industrialized nations. Nearly 900,000 U.S. teenagers become pregnant each year, according to the report, and four in 10 women have been pregnant at least once before 20 years of age. Approximately 51 percent of adolescent pregnancies end in live birth, 35 percent in induced abortion, and 14 percent in miscarriage or stillbirth. Twenty-five percent of adolescent births are not first births, and the risk for pregnancy increases after an adolescent has had one infant.
Significantly more adolescents who live in poverty become pregnant than do those from higher-income families. The total percentage of adolescents who live in low-income families is 38 percent; however, 83 percent of adolescents who give birth and 61 percent who have abortions are from low-income families. Similar to adolescent mothers, adolescent fathers are more likely than their peers to come from low-income families, have poor academic performance, drop out of school, and have decreased income potential.
The report indicates that in 2001, almost 79 percent of all adolescents who gave birth were unmarried, a statistic that has been rising since 1971. More than 90 percent of pregnant patients 15 to 19 years of age said their pregnancies were unplanned.
Pregnant patients younger than 17 years have a higher risk of medical complications than do older patients. Compared with adults, adolescents give birth to twice as many low birth weight infants, and the neonatal mortality rate is three times higher. Although still low, the maternal mortality rate is twice as high for adolescents. Adolescent pregnancy is associated with poor maternal weight gain, prematurity, pregnancy-induced hypertension, anemia, sexually transmitted diseases, substance abuse, and poor nutritional intake. Adolescent pregnancy also causes psychosocial problems such as interruption of school, persistent poverty, limited vocational opportunities, separation from the child's father, divorce, and repeat pregnancy. The children of adolescent mothers are at higher risk for developmental delays, academic difficulties, behavior disorders, substance abuse, early sexual activity, depression, and adolescent pregnancy.
The AAP reports that the most successful programs to prevent adolescent pregnancy include the promotion of abstinence along with information on and dissemination of contraception, sexuality education, school-completion programs, and job training. Parents, schools, religious institutions, physicians, social and government agencies, and adolescents themselves all should be a part of successful prevention programs. Research shows that discussion of contraception does not increase sexual activity, and programs that promote abstinence along with contraception do not decrease contraceptive use. http://www.pediatrics.org
Toxicity and Exposure Assessment for Children's Health (TEACH)
The ABCs of Raising Healthy Kids: Steps to Staying Safe and Healthy- CDC
http://www.cdc.gov/od/spotlight/nwhw/kids/abc.htm
How Parents can Encourage Girls to Play Sports
http://www.cdc.gov/tobacco/sport_initiatives/daugthertips.htm
7-Valent Pneumococcal Conjugate Vaccine Impact on Invasive Pneumococcal Disease
Direct and Indirect Effects of Routine Vaccination of Children with 7-Valent Pneumococcal Conjugate Vaccine on Incidence of Invasive Pneumococcal Disease --- United States, 1998—2003. September 16, 2005 / 54(36);893-897 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5436a1.htm
Chronic Disease and Illness
Native Americans with highest rates of major depressive disorder
Findings from the largest survey ever mounted on the co-occurrence of psychiatric disorders among U.S. adults afford a sharper picture than previously available of major depressive disorder* (MDD) in specific population subgroups and of MDD's relationship to alcohol use disorders (AUDs) and other mental health conditions. The new analysis of data From the 2001-2002 National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) shows for the first time that middle age and Native American race increase the likelihood of current or lifetime MDD, along With female gender, low income, and separation, divorce, or widowhood.
Asian, Hispanic, and black race-ethnicity reduce that risk.
Among race-ethnic groups, Native Americans showed the highest (19.17 percent) lifetime MDD prevalence, followed by whites (14.58 percent), Hispanics (9.64 percent), Blacks (8.93 percent), and Asian or Pacific Islanders (8.77 percent). Since information is scarce on diagnosed Mental disorders among Native Americans, this finding appears to warrant Increased attention to the mental health needs of that group, the authors maintain.
Major depression is a prevalent psychiatric disorder and a pressing Public health problem. That it so often accompanies alcohol dependence raises questions about when and how to treat each diagnosis. Today's results both inform clinical practice and Provide researchers with information to advance hypotheses about common biobehavioral factors that may underlie both conditions.
The NESARC results demonstrate a strong relationship of MDD to substance "dependence" and a weak relationship to substance "abuse", a finding that suggests focusing on dependence when studying the relationship of Depression to substance use disorders. This research direction is supported by earlier genetic studies that identified factors common to MDD and alcohol Dependence and at least one epidemiologic study that demonstrated excess MDD among long-abstinent former alcoholics.
Coexisting substance dependence disorder and MDD predict poor outcome among clinic patients. A decade ago, many treatment leaders discouraged Treating MDD in patients with substance dependence on the grounds that arresting substance dependence was the more immediate need and that its resolution well might also resolve MDD. Results from foregoing epidemiologic surveys and several clinical trials over time altered that picture, so that treating both disorders simultaneously is today common practice.
Grant BR et al Epidemiology of Major Depressive Disorder 2005 Archives of General Psychiatry October 3 National Institute on Alcohol Abuse and Alcoholism (NIAAA) Laboratory of Epidemiology and Biometry, NIH http://niaaa.census.gov/www.jamamedia.org
"Menopausal Arthritis" May Develop in Women Receiving Aromatase inhibitors
Estrogen deprivation may be associated with increased arthralgias in women secondary to greater sensitivity to nociceptive stimuli, which is mediated by NO and prostaglandin E 2; production of enkephalin in the spinal cord; and opioid effects on the CNS.
The arthralgias of estrogen deprivation are typically characterized by joint pains in the hands, knees, hips, lower back, and shoulders, and by early morning stiffness.
Felson
DT, Cummings
SR. Aromatase inhibitors and the syndrome of arthralgias with estrogen deprivation.
Arthritis Rheum. 2005 Sep;52(9):2594-2598.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16142740&query_hl=5
Metformin for Overweight and Obese Adults: Not proven outside of DM or PCOS yet
CONCLUSION Insufficient evidence exists for the use of metformin as treatment of overweight or obese adults who do not have diabetes mellitus or polycystic ovary syndrome. Further studies are needed to answer this clinical question.
Levri KM et al Metformin as Treatment for Overweight and Obese Adults: A Systematic Review Annals of Family Medicine 3:457-461 (2005) http://www.annfammed.org/cgi/content/full/3/5/457
Systematic review: TCAs and SSRIs effective, low-dose TCAs also effective - primary care
CONCLUSION This systematic review is the first comparing antidepressants with placebo for treatment of depression in primary care. Both TCAs and SSRIs are effective. This review is also the first to show that low-dose TCAs are effective in primary care. Prescribing antidepressants in primary care is a more effective clinical activity than prescribing placebo
Bruce Arroll, et al Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared With Placebo for Treatment of Depression in Primary Care: A Meta-Analysis Annals of Family Medicine 3:449-456 (2005)http://www.annfammed.org/cgi/content/full/3/5/449
Blood pressure reading is one of the most inaccurately performed measurements
Updated Hypertension Guidelines - Diagnosis and treatment of hypertension depend on accurate measurement of auscultatory blood pressure. The lowering of target blood pressure for patients with diabetes or renal disease has made detection of small differences more important. However, blood pressure reading is one of the most inaccurately performed measurements in clinical medicine.
"True" blood pressure is defined as the average level over a prolonged duration. Thus, in-clinic blood pressure measurement, which generally makes no allowance for beat-to-beat variability, can be a poor estimation and may fail to catch high blood pressure that occurs only outside the clinic setting. In addition, faulty methods and the "white coat effect" (an increase in blood pressure when a physician is present) may lead to misdiagnosis of hypertension in normotensive patients. To increase accuracy of clinic readings, and in recognition of major changes over the past 10 years (including the prohibition of mercury in many countries), the American Heart Association (AHA) has published a new set of recommendations for the measurement of blood pressure.
Pickering
TG et al Recommendations for blood pressure measurement in humans and experimental
animals: Part 1: blood pressure measurement in humans: a statement for professionals
from the Subcommittee of Professional and Public Education of the American Heart
Association Council on High Blood Pressure Research.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15611362&dopt=Abstract
Exercise Training Beneficial for Older Women with CAD
CONCLUSIONS: Older women with CAD should perform aerobic and strength training to attain optimal improvements in overall physical fitness and quality of life
Hung C, et al. Exercise training improves overall physical fitness and quality of life in older women with coronary artery disease. Chest October 2004;126:1026-31.
Should all patients with fever, rash, and pharyngitis be tested for acute HIV infection?
PURPOSE Recognizing primary human immunodeficiency virus (HIV) infection is important for public health. The prevalence in outpatient settings is largely unknown but would be useful in developing testing guidelines. The objective of this study is to estimate the national prevalence of primary HIV infection in symptomatic ambulatory patients regardless of risk factors. RESULTS Patients complaining of fever and other visit reasons consistent with primary HIV infection had a disease prevalence of 0.66% (0.57%–1.02%), those with rash had a prevalence of 0.50% (0.31%–0.82%), and those with pharyngitis had a prevalence of 0.16% (0.11%–0.22%). Patients with other symptoms represented numbers of visits insufficient for reliable estimates of their prevalence. CONCLUSIONS These estimates of the prevalence of primary HIV infection in ambulatory patients with fever, rash, and pharyngitis can aid with development of clinical testing guidelines and clinical decisions around testing for acute HIV infection.
Coco A. Prevalence of Primary HIV Infection in Symptomatic Ambulatory Patients Annals of Family Medicine 3:400-404 (2005) http://www.annfammed.org/cgi/content/full/3/5/400
New Guidelines for Diagnosis and Management of Metabolic Syndrome
The AHA and NHLBI writing group found the NCEP-ATP III criteria to be robust and clinically useful, and they recommended maintaining them with minor modifications
Grundy SM, et al Diagnosis and Management of the Metabolic Syndrome. An American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation. 2005 Sep 12 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16157765&query_hl=7
Diverticular Disease: Diagnosis and Treatment
Diverticular disease refers to symptomatic and asymptomatic disease with an underlying pathology of colonic diverticula. Predisposing factors for the formation of diverticula include a low-fiber diet and physical inactivity. Approximately 85 percent of patients with diverticula are believed to remain asymptomatic. Symptomatic disease without inflammation is a diagnosis of exclusion requiring colonoscopy because imaging studies cannot discern the significance of diverticula. Fiber supplementation may prevent progression to symptomatic disease or improve symptoms in patients without inflammation. Computed tomography is recommended for diagnosis when inflammation is present. Antibiotic therapy aimed at anaerobes and gram-negative rods is first-line treatment for diverticulitis. Whether treatment is administered on an inpatient or outpatient basis is determined by the clinical status of the patient and his or her ability to tolerate oral intake. Surgical consultation is indicated for disease that does not respond to medical management or for repeated attacks that may be less likely to respond to medical therapy and have a higher mortality rate. Prompt surgical consultation also should be obtained when there is evidence of abscess formation, fistula formation, obstruction, or free perforation. Am Fam Physician 2005;72:1229-34, 1241-2. http://www.aafp.org/afp/20051001/1229.html (also see Patient Education, below)
Herpes Zoster and Postherpetic Neuralgia: Prevention and Management
The recognizable appearance and the dermatomal distribution of herpes zoster lesions usually enable a clinical diagnosis to be made easily. Herpes zoster and postherpetic neuralgia occur mainly in older patients. The role of the varicella vaccine in preventing herpes zoster is uncertain, but is being studied. There is evidence to support using antiviral therapy and possibly low-dose tricyclic antidepressants to prevent postherpetic neuralgia. There is good evidence that treating herpes zoster with antiviral medication is beneficial, particularly in patients older than 50 years with severe outbreaks. The use of steroids has an unfavorable risk-benefit ratio. In patients who develop postherpetic neuralgia, there is good evidence to support treatment with gabapentin and tricyclic antidepressants. More evidence for treatment with capsaicin cream, lidocaine patch, and opioids is needed. Intrathecal methylprednisolone is an option for patients with persistent pain. Am Fam Physician 2005;72:1075-80, 1082. http://www.aafp.org/afp/20050915/1075.html
Respecting End-of-Life Treatment Preferences
Most patients eventually must face the process of planning for their future medical care. However, few Americans have a living will or a durable power of attorney for health care. Although advance directives provide a legal basis for physicians to carry out treatment using a health care proxy or a living will, they also should reflect the patient's values and preferences. Family physicians are in a position to integrate medical knowledge, individual values, and cultural influences into end-of-life care. Family physicians can best respect the autonomy of patients by allowing the patient and family to prospectively identify relevant health care preferences, by sustaining an ongoing discussion about end-of-life preferences, and by abiding by the decisions their patients have made. Am Fam Physician 2005;72:1263-8,1270 http://www.aafp.org/afp/20051001/1263.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.
