Larry Culpepper

Antimicrobials for acute otitis media? a review from the international primary care network

Increasing worldwide resistance of bacteria to antimicrobial drugs is causing a crisis, manifested by higher morbidity, mortality, and costs.1 In 1992 the Institute of Medicine in the United States warned of the growing threat posed by resistant bacteria,2 and in 1994 the Centers for Disease Control in Atlanta initiated a prevention strategy,3 linked to a global plan by the World Health Organisation.4 Proposed remedies include development of new antimicrobials, improved sanitation, and educating patients not to ask for antimicrobials when they are not useful and physicians to prescribe them conservatively.5 About 30% of British children under the age of 3 visit their general practitioner for acute otitis media each year6 and 97% receive antimicrobials.7 In America it is the most common reason for outpatient antimicrobial use. Because this use has uncertain benefits, it merits reconsideration. Increasing resistance to antimicrobial agents has been reported for the three most common bacterial causes of otitis media ( Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis ), but rates differ between countries.8 9 In England and Wales in 1990-5, resistance to penicillin by S pneumoniae increased from 1.5% to 3.9% and to erythromycin from 2.8% to 8.6%.10 Except in the Netherlands, antimicrobials are standard treatment for acute otitis media in most developed countries.7 11 Although type and duration vary between countries, generally ampicillin, amoxycillin, or co-amoxiclav (amoxycillin-clavulanate) are preferred, with co-trimoxazole a low cost alternative.7 In the Netherlands, treatment of symptoms without antimicrobials has been adopted as routine initial treatment for otitis media,12 and this policy is associated with decreased emergence of resistance among organisms commonly found in otitis media.13 14 This approach also is being adopted in Iceland.15 Seven randomised blinded studies have compared antimicrobials with placebo in patients with acute otitis …

Feasibility and Diagnostic Validity of the M-3 Checklist: A Brief, Self-Rated Screen for Depressive, Bipolar, Anxiety, and Post-Traumatic Stress Disorders in Primary Care

PURPOSE Mood and anxiety disorders are the most common psychiatric conditions seen in primary care, yet they remain underdetected and undertreated. Screening tools can improve detection, but available instruments are limited by the number of disorders assessed. We wanted to assess the feasibility and diagnostic validity of the My Mood Monitor (M-3) checklist, a new, 1-page, patient-rated, 27-item tool developed to screen for multiple psychiatric disorders in primary care. METHODS We enrolled a sample of 647 consecutive participants aged 18 years and older who were seeking primary care at an academic family medicine clinic between July 2007 and February 2008. We used a 2-step scoring procedure to make screening more efficient. The main outcomes measured were the sensitivity and specificity of the M-3 for major depression, bipolar disorder, any anxiety disorder, and post-traumatic stress disorder (PTSD), a specific type of anxiety disorder. Using a split sample technique, analysis proceeded from determination of optimal screening thresholds to assessment of the psychometric properties of the self-report instrument using the determined thresholds. We used the Mini International Neuropsychiatric Interview as the diagnostic standard. Feasibility was assessed with patient and physician exit questionnaires. RESULTS The depression module had a sensitivity of 0.84 and a specificity of 0.80. The bipolar module had a sensitivity of 0.88, and a specificity of 0.70. The anxiety module had a sensitivity of 0.82 and a specificity of 0.78, and the PTSD module had a sensitivity of 0.88 and a specificity of 0.76. As a screen for any psychiatric disorder, sensitivity was 0.83 and specificity was 0.76. Patients took less than 5 minutes to complete the M-3 in the waiting room, and less than 1% reported not having time to complete it. Eighty-three percent of clinicians reviewed the checklist in 30 or fewer seconds, and 80% thought it was helpful in reviewing patients’ emotional health. CONCLUSIONS The M-3 demonstrates utility as a valid, efficient, and feasible tool for screening multiple common psychiatric illnesses, including bipolar disorder and PTSD, in primary care. Its diagnostic accuracy equals that of currently used single-disorder screens and has the additional benefit of being combined into a 1-page tool. The M-3 potentially can reduce missed psychiatric diagnoses and facilitate proper treatment of identified cases.

Mental Health Conditions are Associated With Increased Health Care Utilization Among Urban Family Medicine Patients

Purpose: To assess the relationship between the presence of a mental health condition and health care utilization among family medicine patients. Methods: We used the Patient Health Questionnaire plus a posttraumatic stress disorder screen to measure 6 common mental health conditions. In a sample of 367 patients recruited from 3 urban family medicine practices affiliated with Boston University Medical Center, we measured self-reported health care utilization of primary care provider visits, emergency department visits, nonpsychiatric hospitalizations, and outpatient mental health visits. We determined the association between screening positive for the mental health conditions and health care utilization using both multivariable logistic regression and Poisson regression methods while controlling for sex, age, race, income, insurance status, marital status, educational level, and the presence of chronic medical conditions. Results: After controlling for potential confounders, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder were statistically significantly associated with more PCP visits, ED visits, and nonpsychiatric hospitalizations. Neither major nor minor depression were associated with more PCP visits, ED visits, or nonpsychiatric hospitalizations, except that minor depression was associated with 103% increase in PCP visits (P < .001). Alcohol use disorder was associated with 16% fewer PCP visits (P = .01) but 238% more nonpsychiatric hospitalizations (P < .001). Conclusions: After controlling for confounders we found that mental health conditions among a sample of family medicine patients were associated with increased use of ED services, nonpsychiatric hospitalizations, and, to a lesser extent, PCP visits.

Family physician self-efficacy with screening for inherited cancer risk.

BACKGROUND Recent evidence has shown low and inconsistent rates of family history screening among generalist physicians. Little has been done to investigate the physician factors likely to mediate this behavior. We investigated family physicians’ beliefs about screening their patients for inherited cancer risk, measuring their perceptions of self-efficacy and the importance of screening. METHODS We mailed a cross-sectional, 1-page questionnaire to all active members (691) of the Massachusetts Academy of Family Physicians, measuring their attitudes about predictive genetic cancer screening. RESULTS We received responses from 300 of the 691 members (43%). Although 87% believed screening to be important, less than two thirds believed they were effective in screening. CONCLUSIONS Many family physicians lack confidence in their ability to screen patients for a family history of cancer despite recognizing its importance to their practice.

Characteristics and predictors of full and partial recovery from generalized anxiety disorder in primary care patients.

The current study examined the naturalistic course of generalized anxiety disorder (GAD) in a sample of 113 primary care patients across a 2-year period. Initial diagnoses were established using structured clinical interviews according to DSM-IV diagnostic criteria. Results indicated that the majority of patients meeting DSM-IV diagnostic criteria for GAD were still symptomatic to some degree after 2 years of follow-up. Rates of full and partial recovery from GAD, however, were found to be higher than those reported for previous studies of GAD in psychiatric patients. Diagnostic comorbidity, severity of psychosocial impairment, and gender were found to be significantly associated with achieving full or partial recovery from GAD. Psychiatric treatment was not found to be associated with time to full or partial recovery from GAD symptoms, likely due to a treatment-biasing effect. These results underscore that GAD is a chronic and persistent illness in primary care patients.

Screening Tests for Adults with Intellectual Disabilities

Adults with intellectual disabilities need thoughtful, well-coordinated primary care from family physicians. However, evidence-based screening recommendations are lacking. We examined screening recommendations for common preventable conditions using the US Preventative Service Task Force guidelines. We also reviewed the literature about the prevalence of these conditions in adults with intellectual disabilities. Obesity, osteoporosis, and smoking are more prevalent in adults with intellectual disabilities, and enhanced screening for these conditions is recommended. Abnormal Papanicolaou smears and cervical cancer are less common in adults with intellectual disabilities and screening recommendations should be individualized. We also discussed strategies to make screening procedures less stressful for these patients.

Cardiovascular health and depression.

Research has shown that depression increases the likelihood that otherwise healthy people will develop ischemic heart disease (IHD) and worsens the prognosis of patients who already have IHD. Moreover, concerns about safety (e.g., cardiac side effects, drug-drug interactions) have caused physicians to be hesitant about using antidepressant agents in patients with IHD. This article is based on a recent roundtable of experts who met to discuss risk, diagnosis, and treatment options for depression in patients with IHD. This article reviews clinical and epidemiological studies that have described a link between depression and the subsequent development of IHD and have examined the role of depression as a predictor of cardiac events in patients with existing IHD. The article addresses the issue of whether depression can be safely and efficaciously treated both in patients with stable IHD and in those with acute coronary syndromes. The authors discuss safety issues related to the potential for interactions between antidepressants and cardiovascular medications, the use of nonpharmacologic treatment options such as psychosocial interventions, and the effect of antidepressant therapy on quality of life in patients with IHD. The article concludes with practical clinical guidance concerning the management of depression in patients who have recently experienced myocardial infarction.

Predictive genetics in primary care: expectations for the motivational impact of genetic testing affects the importance family physicians place on screening for familial cancer risk.

Purpose: To investigate whether the importance family physicians place on familial cancer-risk screening is influenced by expectations for the motivational impact of a high-risk genetic test result.Methods: Mailed survey of the Massachusetts Academy of Family Physicians.Results: Respondents expected patients would increase pursuit of screening for cancer (99.6%) and other diseases (89.9%), quit smoking (93.6%), and improve diet/exercise (92.5%). The degree of motivational effect was significantly related to the importance they place on screening.Conclusions: Family physicians believe that a high-risk cancer genetic-test result would motivate their patients to pursue risk-reduction behavior, and this belief is related to the importance they place on screening their patients for an inherited risk of cancer.

Post-discharge hospital utilization among adult medical inpatients with depressive symptoms†

BACKGROUND Little evidence exists to determine whether depression predicts hospital utilization following discharge among adult inpatients on a general medical service. OBJECTIVE We aimed to determine whether a positive depression screen during hospitalization is significantly associated with an increased rate of returning for hospital services. DESIGN A secondary analysis was performed using data from 738 English-speaking, hospitalized adults from the Project RED randomized controlled trial (clinicaltrials.gov Identifier: NCT00252057) conducted at an urban academic safety-net hospital. MEASUREMENTS We used the nine-item Patient Health Questionnaire (PHQ-9) depression screening tool to identify patients with depressive symptoms. The primary endpoint was hospital utilization, defined as the number of emergency department (ED) visits plus readmissions within 30 days of discharge. Poisson regression was used to control for confounding variables. RESULTS Of the 738 subjects included in the analysis, 238 (32%) screened positive for depressive symptoms. The unadjusted hospital utilization within 30 days of discharge was 56 utilizations per 100 depressed patients compared with 30 utilizations per 100 non-depressed patients, incident rate ratio (IRR) (confidence interval [CI]), 1.90 (1.51-2.40). After controlling for potential confounders, a higher rate of post-discharge hospital utilization was observed in patients with depressive symptoms compared to patients without depressive symptoms (IRR [CI], 1.73 [1.27-2.36]). CONCLUSIONS A positive screen for depressive symptoms during an inpatient hospital stay is associated with an increased rate of readmission within 30 days of discharge in an urban, academic, safety-net hospital population.

Is anyone really M.A.D.? : The occurrence and course of mixed anxiety-depressive disorder in a sample of primary care patients

We examined the occurrence and 1-year course of mixed anxiety-depressive disorder (MAD) in a sample of primary care patients. Participants are part of the Primary Care Anxiety Project, a naturalistic, longitudinal study of anxiety disorders in primary care. Participants completed a questionnaire screening for anxiety symptoms. Those screening positive were invited for an interview to diagnose MAD and DSM-IV Axis I disorders. Participants were then interviewed at 6 and 12 months postintake. Of 1634 participants completing an intake interview, four participants (0.2%) met complete DSM-IV MAD criteria. The adjusted probability of remitting from MAD in 1 year was 80%. Although this was not a prevalence study, results indicate a very low occurrence of MAD across 15 primary care settings. Further, they indicate that this diagnosis may not be stable across time and raise doubts about its utility.