Complex posttraumatic stress disorder: evidence from the primary care setting

The efficacies of somatostatin and octreotide have been widely studied in the control of bleeding from oesophageal varices. It has also been suggested that these drugs may be useful for the control of non-variceal upper gastrointestinal (UGI) bleeding, including that from peptic ulcers. In approximately 80% of patients presenting with non-variceal UGI bleeding, haemorrhage ceases spontaneously and does not recur. However, the remaining 20% of patients require active treatment. Results from recent studies have indicated that somatostatin is an effective treatment for the control of non-variceal UGI bleeding in high-risk patients, i.e. those in whom haemorrhage does not cease spontaneously or is likely to recur. In contrast there is no good evidence available at present to support a role for octreotide in this indication. The efficacy of somatostatin in controlling bleeding in patients with non-variceal UGI bleeding at high risk of mortality upon admission, or rebleeding following endoscopy, coupled with an excellent safety and tolerability profile, suggests that it may be a valuable therapeutic option in the management of non-variceal bleeding.     

Prostatitis: diagnosis and treatment in primary care

Prostatitis refers to the inflammation and/or infection of the prostate gland, which occurs in several forms or syndromes and presents with varied etiologies, clinical features, and sequelae. The four common forms of prostatitis are acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia. Differential diagnosis of prostatitis is based on history, physical exam findings, and, frequently, analysis of expressed prostatic secretions. Complaints may vary, but pain or discomfort in the rectal or perineal area is usually present. Clinicians in primary care settings should be knowledgeable about the types of prostatitis, etiology, and pathogenesis; the methods of diagnosis; and treatment/education issues.     

Diagnosis and treatment of leptospirosis in the primary care setting

Leptospirosis is an infectious illness that usually develops 1 to 2 weeks after indirect or direct exposure to the urine of infected animals. Infection occurs through open cuts, absorption through intact mucous membranes, and drinking contaminated water. The typical presentation is a flulike syndrome of sudden onset that tends to resolve within 2 weeks. A mild immunologic phase usually presents as an aseptic meningitis. A more severe immunologic phase (Well's syndrome) can result in jaundice, renal failure, adult respiratory distress syndrome, disseminated intravascular coagulation, and death. Laboratory tests take too long to replace clinical diagnosis, which is imperative so that antibiotic therapy can begin before the fourth day of illness. Although leptospirosis is more common in tropical climates, detection in the continental United States is increasing. Early, accurate detection and treatment in the primary care setting are vital for limiting life-threatening complications.     

Symptoms of post-traumatic stress disorder in abused women in a primary care setting

Abuse is a major source of trauma to women, and post-traumatic stress disorder (PTSD) results from exposure to extreme trauma. To describe the relationship between symptoms of PTSD and severity of abuse, an ethnically stratified cohort of 131 abused women in a primary care setting was interviewed. Symptoms of PTSD, both intrusion (i.e., trouble falling asleep, strong waves of feelings about the abuse) and avoidance (i.e., trying not to think or talk about the abuse, staying away from reminders of the abuse), were significantly (p < 0.01) correlated to severity of abuse, regardless of ethnicity. When asked about childhood physical or sexual abuse, women reporting physical abuse had significantly (p < 0.05) higher intrusion scores, whereas those reporting sexual abuse had significantly (p < 0.004) higher avoidance scores. Sixty-five percent of the women reported dreams, flashbacks, or terror attacks and had significantly (p < 0.001) higher mean results on both intrusion and avoidance. The need to offer abused women information about the connection between severity of abuse and symptoms of PTSD is discussed. We recommend that clinicians ask all abused women about dreams, flashbacks, or terror attacks to assess for further symptoms of PTSD.     

Primary hyperparathyroidism in the primary care setting

A series of 36 patients with surgically proved primary hyperparathyroidism is reported. From this group a clinical profile consisting of obesity, anxiety, and/or depression in a mildly hypertensive, middleaged female was derived. Women constituted 92 percent of the patients. The serum calcium was confirmed again as the single most valuable test in the evaluation of this disorder.     

Obsessive-compulsive disorder and separation anxiety

Little is known about the effects of intracavitary brachytherapy (ICB) performed in the presence of pyuria resulting from external beam pelvic irradiation for cervical cancer (CC). A retrospective study of one decade of ICB for CC showed that brachytherapy was performed in the presence of pyuria in 26 women. Twelve women without pyuria during ICB served as a control group. Antibiotic therapy was routinely administered during intracavitary application. The crude survival rate at 5 years was 39% in patients with pyuria and 42% in women without pyuria; the corresponding local recurrence rates were 23% and 17%; the serious complication rates were 12% and 0% respectively. Intracavitary brachytherapy in the presence of pyuria may have a limited adverse effect on the outcome of women with cancer of the cervix.     

Obsessive-compulsive disorder in children and adolescents

BACKGROUND: Obsessive-compulsive disorder (OCD) is a common psychiatric condition that usually emerges during childhood or adolescence. Over 80% of individuals with OCD have their onset before age 18 years. Epidemiologic studies suggest a prevalence of 1-2% for adolescents. METHOD: This article reviews current knowledge of paediatric OCD in the following areas: age of onset, nosology and classification, subtypes, prevalence, aetiology, pathophysiology, assessment, prognosis and treatment. RESULTS: Essential components of treatment include long-term commitment, care management and illness education. Specific components of treatment include cognitive-behavioural therapy, parent behaviour management training and medication. CONCLUSIONS: The most effective treatments are selective serotonin reuptake inhibitors (e.g. fluvoxamine, sertraline) and exposure/response prevention.     

Obsessive-compulsive disorder in elderly patients

Obsessive-compulsive disorder (OCD) is a common illness which starts in young adulthood and persists into late life. OCD is associated with dysregulation of the serotonin system and may also be related to the dysregulation of dopamine. When OCD starts in an elderly patient, either an organic or a neurological diagnosis should be considered. Clomipramine and serotonin reuptake inhibitors are the mainstay of treatment for OCD. Choice of a particular agent should be based on the patient's previous response and the adverse effect profile of the drug. Pharmacokinetics should also be a consideration due to age-related changes in hepatic and renal function leading to increased plasma concentrations as well as prolonged elimination half-lives of these agents. Behavioural therapy, in addition to pharmacological management, is essential to treat compulsions and to improve response.     

Obsessive-compulsive disorder in schizophrenia: epidemiologic and biologic overlap

AF64A (ethylcholine mustard aziridinium ion) was stereotaxically administered bilaterally (1 nmol/side) into rat lateral cerebral ventricles. Choline acetyltransferase (ChAT) activity and ChAT mRNA levels were measured at predetermined time points in the septo-hippocampal pathway and striatum, both well identified as rich in cholinergic neurons. AF64A caused a rapid but transient increase in ChAT mRNA (167%, P < 0.05) and ChAT activity (164%, P < 0.01) in the septum. By day 7 post treatment, there was a significant decrease in ChAT mRNA (42.5% of control, P < 0.05) in the septum although the ChAT activity still stayed high. This decreased ChAT mRNA level in the septum lasted for at least four weeks, and was paralleled by a long-lasting decrease in ChAT activity in the hippocampus. In the striatum, on the other hand, there were no observed changes in either ChAT activity or ChAT mRNA. These data suggest that the long term effect of AF64A on the septo-hippocampal cholinergic pathway may, at least in part, be due to an action of AF64A on gene expression in the cholinergic neuron. The difference in the response to AF64A between the septo-hippocampal and striatal cholinergic systems might be due to their difference in neuron types.     

Late-life suicide and depression in the primary care setting

Late-life depression and suicidal behavior in the primary care setting is a significant public health concern. The prevalence of depression in this population is substantial, yet rates of detection and treatment are far from adequate. Untreated depression has significant consequences with regard to morbidity and mortality. Although suicide is a relatively low-base-rate behavior, a substantial proportion of late-life suicides have contact with their primary care provider prior to their death; thus this offers an avenue for suicide prevention. There is a growing knowledge base concerning what constitutes barriers to the recognition and treatment of late-life depression as well as what constitutes useful screening tools and treatments for the depressed elderly. Important new findings with regard to the functional effects of subsyndromal depression, possible subtypes of late-life depression, the clinical utility of SSRIs and psychotherapeutic interventions, and innovative and collaborative models of care hold promise for advancing the science and practice of treating late-life depression.     

The treatment of depression in older adults in the primary care setting: An evidence-based review.

The objective of this study was to conduct an evidence-based review of treatments for depression in older adults in the primary care setting. A literature search was conducted using PsycINFO and Medline to identify relevant, English language studies published from January 1994 to April 2004 with samples aged 55 and older. Studies were required to be randomized controlled trials that compared psychosocial interventions conducted within the primary care setting with "usual care" conditions. Eight studies with older adult samples met inclusion criteria and were included in the review. Two treatment models were evident: Geriatric Evaluation Management (GEM) clinics and an approach labeled integrated health care models. Support was found for each model, with improvement in depressive symptoms and better outcomes than usual care; however, findings varied by depression severity, and interventions were difficult to compare. Further efforts to improve research and clinical care of depression in the primary care setting for older adults are needed. The authors recommend the use of interdisciplinary teams and more implementation of psychosocial treatments shown to be effective for older adults. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abnormal liver function tests in the primary care setting

Results of laboratory tests ordered during a primary care encounter may reveal findings of abnormal liver function tests, including elevated liver enzymes, hyperbilirubinemia, hypoalbuminemia or abnormal coagulation tests. The object of this study was to describe the spectrum of these liver function test (LFT) abnormalities in primary care. Results of all laboratory tests ordered during 10 months in an urban primary care clinic were retrospectively reviewed and the medical charts of patients with abnormal LFTs were studied. In 217/1088 (20%) of the tests at least 1 LFT abnormality was found in 156 patients. New diagnoses were made in 104 patients. The main diagnostic groups were: non-alcoholic fatty liver changes, Gilbert's disease, acute infectious hepatitis, alcoholic liver disease and cirrhosis and hepatotoxic drug injury. In 60 patients the physician classified the abnormality as negligible and not associated with significant disease. However, an abnormal test that had been ordered for evaluation of a specific complaint, was indeed likely to represent significant disease (X2 = 29.5, p < 0.001). We conclude that finding abnormalities in liver function tests is common in the primary care clinic but does not often indicate significant liver disease.     

Working effectively with interpreters in the primary care setting

Because of immigration to the United States, the number of persons who speak languages other than English has grown over the past several decades. In addition, many groups whose primary language is not English are exhibiting rapid population growth rates. As a result, health care providers may find they require an interpreter to communicate with patients. Guidelines are presented to facilitate the effective choice and utilization of interpreters in primary care. Suggestions are also presented to help interpreters work effectively in the health care setting.     

Viral hepatitis: primary care diagnosis and management

Many patients in primary care settings have hepatitis. This article discusses signs and symptoms of acute hepatitis and outlines differential diagnoses. The characteristics and methods of transmission of individual hepatotropic viruses, including hepatitis A, B, C, D, E, and G/GB-C are reviewed. Serologic diagnosis of the causative agent is explained. Patient care includes sign and symptom management, medication administration, prevention of transmission to friends and family members, follow-up serologic testing, and evaluation for chronic infection. Preventive measures include vaccination and the use of immune globulin agents for hepatitis A and B. Health care providers should be aware of recent developments in the treatment of chronic infection with hepatitis B and C.     

Obsessive-compulsive disorder in pregnancy, the puerperium, and the premenstruum

BACKGROUND: Recent reports suggest that pregnancy and the puerperium may precipitate or exacerbate obsessive-compulsive disorder (OCD). The influence of this illness on other reproductive events, such as the premenstruum, is unknown. We examined retrospectively the relationships of pregnancy, the puerperium, and premenstruum to the course of OCD in 57 women. METHOD: Women outpatients with OCD meeting DSM-III-R criteria completed a standardized telephone interview administered by a psychiatric resident. They were asked retrospectively about the clinical course of their illness premenstrually and during and after pregnancy. RESULTS: Of 72 women eligible for the study, 79% (N = 57) completed the interview. Premenstrual worsening of OCD was described by 24 (42%) of the 57 women, and 12 (21%) described premenstrual dysphoria. Of the 57 women, 38 (67%) had been pregnant at least once; 31 (54%) had delivered at least one child. Pregnancy was associated with the onset of OCD in only 5 (13%) of the 38 women. Of the 29 women with preexisting OCD who became pregnant, 20 (69%) described no change in symptoms during pregnancy, 5 (17%) described worsening, and 4 (14%) described improvement. Postpartum exacerbation of OCD symptoms was reported by 7 (29%) of the 24 women with preexisting OCD who completed full-term pregnancies. Nine (37%) of the 24 women with both preexisting OCD and completed pregnancies also reported postpartum depression. CONCLUSION: The premenstrual and postpartum exacerbation of OCD symptoms in some women suggests that the course of this disorder may, in some cases, be influenced by changes in gonadal hormones. Our finding that women with OCD may be at increased risk for postpartum depression underscores the importance of careful postpartum evaluation of women with OCD to prevent maternal and infant morbidity.     

Prevention services in primary care: taking time, setting priorities

Standard family history and family study methods were used with 650 first- and 1174 second-degree biological relatives of 133 adolescents who were studied initially 6 to 8 years ago. They included 69 prepubertal children considered at risk for suicidal behavior and 64 prepubertal children selected from the community. This study aimed to identify relationships between family psychopathology and adolescents' lifetime history of suicidal states. Family discord, suicide attempts of mother, and substance abuse of mothers and fathers were significantly more prevalent among adolescents with lifetime history of a suicide attempt. Mothers' and fathers' substance abuse was associated with adolescents' lifetime history of suicidal ideation. Results highlight importance of evaluating and treating family psychopathology to reduce risk for youth suicidal states.     

Using DSM-IV primary care version: a guide to psychiatric diagnosis in primary care

The prevalence of patients with psychiatric disorders in primary care settings indicates that family physicians have a need for a diagnostic manual suited to the realities of their practice. This article reviews the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., primary care version (DSM-IV-PC) and highlights the ways it accommodates the clinical needs of family physicians. DSM-IV-PC emphasizes the use of nine diagnostic algorithms for the most prevalent psychiatric disorders in primary care. The authors review the conceptual similarities between DSM-IV and DSM-IV-PC and the diagnostic features that are unique to DSM-IV-PC, and offer an illustrative case that incorporates a DSM-IV-PC approach to diagnosis. The authors also outline clinical and technical issues that remain unresolved in DSM-IV-PC.     

Obsessive-compulsive disorder in the community: an epidemiologic survey with clinical reappraisal

OBJECTIVE: To examine the prevalence of obsessive-compulsive symptoms and DSM-IV obsessive-compulsive disorder (OCD), the authors conducted a telephone survey of 2,261 adults in four regions of Canada. METHOD: Trained lay interviewers administered a modified version of the OCD section of the Comprehensive International Diagnostic Interview. A subsample of respondents with probable cases and probable subclinical cases of OCD was then blindly reinterviewed by research personnel experienced in the assessment of OCD, using the Structured Clinical Interview for DSM-IV and the Yale-Brown Obsessive Compulsive Scale, to confirm the diagnosis and gauge the severity of OCD. RESULTS: The weighted 1-month prevalence of OCD in the entire sample according to the lay interviews was 3.1%. Upon clinical reappraisal, the 1-month prevalence estimate of OCD dropped to 0.6%; an additional 0.6% had subclinical OCD. The mean Yale-Brown Obsessive Compulsive Scale score of the individuals with OCD was 19.0 (SD = 4.6, median = 21); for those with subclinical OCD, the mean score was 15.4 (SD = 2.4, median = 14). Common reasons for overdiagnosis of OCD by the lay interviewers were inappropriate labeling of worries or concerns as obsessions and overestimating the degree of interference or distress attributable to obsessive-compulsive symptoms. CONCLUSIONS: OCD, while hardly a rare condition, may be somewhat less prevalent than had been believed on the basis of previous surveys. Additional studies are needed to substantiate these findings and to delineate precisely the extent of disability and reduced quality of life attributable to OCD (and OCD variants) in the community.