Directly observed therapy for treatment completion of pulmonary tuberculosis: Consensus Statement of the Public Health Tuberculosis Guidelines Panel

OBJECTIVE: To evaluate evidence on the relative effectiveness of directly observed therapy in achieving treatment completion for pulmonary tuberculosis. PARTICIPANTS: A panel of 11 practitioners representing the public health, behavioral, and clinical management of tuberculosis was convened by the Council on Linkages Between Academia and Public Health Practice in 1995 to develop public health guidelines for tuberculosis treatment completion. EVIDENCE: English-language articles identified through MEDLINE (1966 to August 1, 1996) with original data on directly observed therapy, supervised therapy, compliance, treatment completion, case management, and treatment adherence for tuberculosis. CONSENSUS PROCESS: Each eligible article underwent structured review by at least 2 panel members for study design, sample size, evaluation methods, and treatment completion as the primary outcome. The full panel was convened twice, with intercurrent small group meetings, conference calls, and summary workshop to review findings. Recommendations made through this process were drafted by the panel chair and circulated twice for additional panel comments. CONCLUSIONS: Treatment completion rates for pulmonary tuberculosis are most likely to exceed 90%, as recommended by the Centers for Disease Control and Prevention, when treatment is based on a patient-centered approach using directly observed therapy with multiple enablers and enhancers. Other less intensive interventions, including nonsupervised strategies and modified approaches to directly observed therapy, are unlikely to achieve this recommended treatment completion goal. Directly observed therapy also appears to be cost-effective compared with self-administered therapy, although data on cost-effectiveness are limited.     

Report of the Canadian Hypertension Society Consensus Conference: 2. Nonpharmacologic management and prevention of hypertensive disorders in pregnancy

OBJECTIVE: To provide Canadian physicians with comprehensive, evidence-based guidelines for the nonpharmacologic management and prevention of gestational hypertension and pre-existing hypertension during pregnancy. OPTIONS: Lifestyle modifications, dietary or nutrient interventions, plasma volume expansion and use of prostaglandin precursors or inhibitors. OUTCOMES: In gestational hypertension, prevention of complications and death related to either its occurrence (primary or secondary prevention) or its severity (tertiary prevention). In pre-existing hypertension, prevention of superimposed gestational hypertension and intrauterine growth retardation. EVIDENCE: Articles retrieved from the pregnancy and childbirth module of the Cochrane Database of Systematic Reviews; pertinent articles published from 1966 to 1996, retrieved through a MEDLINE search; and review of original randomized trials from 1942 to 1996. If evidence was unavailable, consensus was reached by the members of the consensus panel set up by the Canadian Hypertension Society. VALUES: High priority was given to prevention of adverse maternal and neonatal outcomes in pregnancies with established hypertension and in those at high risk of gestational hypertension through the provision of effective nonpharmacologic management. BENEFITS, HARMS AND COSTS: Reduction in rate of long-term hospital admissions among women with gestational hypertension, with establishment of safe home-care blood pressure monitoring and appropriate rest. Targeting prophylactic interventions in selected high-risk groups may avoid ineffective use in the general population. Cost was not considered. RECOMMENDATION: Nonpharmacologic management should be considered for pregnant women with a systolic blood pressure of 140-150 mm Hg or a diastolic pressure of 90-99 mm Hg, or both, measured in a clinical setting. A short-term hospital stay may be required for diagnosis and for ruling out severe gestational hypertension (preeclampsia). In the latter case, the only effective treatment is delivery. Palliative management, dependent on blood pressure, gestational age and presence of associated maternal and fetal risk factors, includes close supervision, limitation of activities and some bed rest. A normal diet without salt restriction is advised. Promising preventive interventions that may reduce the incidence of gestational hypertension, especially with proteinuria, include calcium supplementation (2 g/d), fish oil supplementation and low-dose acetylsalicylic acid therapy, particularly in women at high risk for early-onset gestational hypertension. Pre-existing hypertension should be managed the same way as before pregnancy. However, additional concerns are the effects on fetal well-being and the worsening of hypertension during the second half of pregnancy. There is, as yet, no treatment that will prevent exacerbation of the condition. VALIDATION: The guidelines share the principles in consensus reports from the US and Australia on the nonpharmacologic management of hypertension in pregnancy.     

Consensus in work role requirements: The influence of discrete occupational context on role expectations.

Although role theory has long described how expectations shape role behavior, little empirical research has examined differences among work role requirements and how features of the discrete occupational context may influence the extent to which role expectations are shared among role holders. The authors examined consensus in work role requirements from a sample of over 20,000 incumbents across 98 occupations. They found that consensus systematically decreased as work role requirements ranged from molecular tasks to responsibilities to molar traits. In addition, they found that consensus in these work role requirements was significantly influenced by the amount of interdependence, autonomy, and routinization present in the surrounding task and social contexts. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

External genital warts: report of the American Medical Association Consensus Conference. AMA Expert Panel on External Genital Warts

A consensus process was undertaken to describe and evaluate current information and practice regarding the diagnosis, treatment, and evaluation of patients with external genital warts (EGWs) and their sex partners. This process developed a number of key statements that were based on strong evidence in the literature or reasonable suppositions and opinions of experts. Key statements included the following. In most cases, EGWs can be diagnosed clinically by visual inspection. No one treatment is ideal for all patients or all warts. Women with EGWs and female sex partners of men with EGWs are at increased risk for human papillomavirus-related cervical disease and, like all women, should be screened for cervical cancer. The diagnosis of EGWs in children requires a sexual abuse evaluation. Clinicians who treat EGWs have a responsibility to counsel patients and to provide information about the infectivity, diagnosis, treatment, and natural history of EGWs and general information about sexual health and other sexually transmitted diseases.     

Incorporating palliative care into primary care education. National Consensus Conference on Medical Education for Care Near the End of Life

The confluence of enhanced attention to primary care and palliative care education presents educators with an opportunity to improve both (as well as patient care) through integrated teaching. Improvements in palliative care education will have benefits for dying patients and their families, but will also extend to the care of many other primary care patients, including geriatric patients and those with chronic illnesses, who make up a large proportion of the adult primary care population. In addition, caring for the dying, and teaching others to carry out this task, can be an important vehicle for personal and professional growth and development for both students and their teachers.     

Nicotine–mecamylamine treatment for smoking cessation: The role of pre-cessation therapy.

The nicotinic antagonist mecamylamine was evaluated in a randomized smoking cessation trial. Four groups of participants (n?=?20 per group) received nicotine plus mecamylamine, nicotine alone, mecamylamine alone, or no drug for 4 weeks before cessation. After the quit-smoking date, all subjects received nicotine plus mecamylamine treatment for 6 weeks. Nicotine skin patches (21 mg/24 hr) and mecamylamine capsules (2.5–5.0 mg twice per day) were used. Precessation mecamylamine significantly prolonged the duration of continuous smoking abstinence; abstinence rates at the end of treatment were 47.5% with mecamylamine and 27.5% without mecamylamine. Nicotine + mecamylamine reduced ad lib smoking, smoking satisfaction, and craving more than either drug alone. Moreover, the orthostatic decrease in blood pressure caused by mecamylamine was offset by nicotine. Mecamylamine before smoking cessation may be an effective adjunct to nicotine patch therapy. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

New guidelines for the management of diabetes: a physician''s guide. Steering Committee for the Revision of the Clinical Practice Guidelines for the Management of Diabetes in Canada

We have recently described an optimised electrode for the detection of enzymatic and cellular superoxide (O2*-) production based on cytochrome c immobilized covalently at a surface-modified gold electrode and applied this system to the study of free radical production by activated human glioblastoma cells. In this paper we report the development of a mathematical model for the O2*- electrode responding to enzymically produced O2*- which should enable the determination of absolute concentrations of O2*- in biological systems when this electrode is employed for direct, real-time monitoring of free radical release and interactions.     

Results of heart valve replacement: especially on the selection criteria for valve prostheses and on a new anticoagulation regimen

Since March 1981 till the end of 1987, a total of 76 artificial heart valves were implanted in 72 patients. Heart valve prostheses were selected individually according to the patient's needs rather than assigning a single model to every patient. Postoperatively patients were placed on an anticoagulation therapy regimen consisting of reduced-dose warfarin (prothrombin time maintained at 30% of the control) and a small dose (81 mg/day) aspirin. During this period no bioprosthesis was implanted. For aortic valves, Starr-Edwards caged-ball valves were used in 53.1% and St. Jude Medical (SJM) valves in 37.5%. For mitral valves, SJM valves were used in 68%. No mechanical valve failure and no thrombosed valve was encountered. There was one patient-prosthesis missmatch. The incidence of thromboembolism for the entire series was 5/181.2 patient-years. There was 1-2/181.2 patient-years incidence of hemorrhagic complications. These figures were comparable to the ones with conventional warfarin therapy. No intracranial hemorrhage was encountered. Our selection criteria for artificial heart valves and our method of anticoagulation were discussed in detail. We conclude that at present there is no single prosthesis which satisfies all the varying needs of every patient, and the prosthesis which is best suited to that particular patient should be selected. We are generally happy with our current method of postoperative anticoagulation and will continue with this regimen.     

Couple therapy as a treatment for depression: II. The effects of relationship quality and therapy on depressive relapse.

Investigated the effects of behavioral couple therapy, cognitive–behavioral therapy, and their combination on female depression 6 and 12 mo after therapy ended. It was predicted that couples receiving a behavioral couple treatment would be less likely to relapse than those receiving a cognitive–behavioral treatment for the depressed spouse alone. Relapse rates, however, did not discriminate between treatments at any follow-up point. Reductions in husband and wife dysphoria and increases in wife facilitative behavior during therapy predicted recovery. Moreover, high rates of husbands' facilitative behavior at posttest were associated with wife recovery and predicted low levels of depression at the 1-yr follow-up. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of Perceived Consensus on Stereotypes About Obese People: A New Approach for Reducing Bias.

In 3 experiments, the authors tested the effect of perceived social consensus on attitudes toward obese people. Participants completed self-report measures of attitudes toward obese people prior to and after manipulated consensus feedback depicting attitudes of others. In Study 1 (N=60), participants decreased negative and increased positive stereotypes after learning that others held more favorable attitudes toward obese people. In Study 2 (N=55), participants improved attitudes when they learned about favorable attitudes of obese people from an in-group versus an out-group source. In Study 3 (N=200), a consensus approach was compared with other stigma reduction methods. Social consensus feedback influenced participants' attitudes and beliefs about causes of obesity. Providing information about the uncontrollable causes of obesity and supposed scientific prevalence of traits also improved attitudes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A logistic regression model when some events precede treatment: the effect of thrombolytic therapy for acute myocardial infarction on the risk of cardiac arrest

When outcomes occur in clinical trials before treatment can be given, neither intent-to-treat nor according-to-protocol analyses give optimal estimates of the treatment effect. A better approach employs a time-dependent variable for treatment. Intent-to-treat analyses are conservative, biasing against treatment; according-to-protocol analyses bias in favor of treatment. We show how to measure the effect of a time-dependent variable in a logistic regression using person-time intervals as units of measurement and describe appropriate methods for reporting model performance. The method is applied to develop a model to predict the probability that a patient with a myocardial infarction will have a sudden cardiac arrest within 48 hours of presentation to emergency medical services both when treated with thrombolysis and when not treated. We use a time-dependent treatment variable because many patients went into cardiac arrest while awaiting treatment. This technique has been programmed into an electrocardiograph for real-time use in an emergency department.     

Hybrid pharmacologic and ablative therapy: a novel and effective approach for the management of atrial fibrillation

PURPOSE: This paper presents a critical review of the literature on neurosensory disturbances associated with implant surgery. MATERIALS AND METHODS: The reviewed literature includes mainly retrospective implant studies and patients' surveys, as well as a few prospective psychophysical studies on sensory disorders following maxillofacial surgeries. RESULTS: The available data suggest that injury to the peripheral branches of the trigeminal nerve and subsequent sensory disturbances are potential complications following implant surgery. Cross-sectional studies suggest that gross tactile sensation was regained in the vast majority of patients. However, data on the spatial and temporal patterns of recovery of this and other somatic sensation such as fine touch, nociception, and temperature sense after implant surgery is still lacking. The prevalence of sensory disturbances depends on several factors: the site of implant placement, the type of surgical procedures adopted, the design of the studies, the sensitivity of the testing methods, the choice of the outcome measures, and the terminology used to describe sensory disturbances. Extreme variation in the reported prevalence of neurosensory disturbances (0% to 100%) suggest that these problems have not been adequately evaluated. CONCLUSION: Although sensory disturbances are transient in the majority of implant patients, their profound impact on the quality of life of the subjects affected and the possibility that they may persist clearly indicate that they should be identified and evaluated through prospective studies, using validated testing protocols and outcome measures.     

A new frontier for clinical health psychologists: Our leadership role in the development and management of an inpatient weight management program.

The article provides an overview of the Tripler Army Medical Center Inpatient Obesity Program. Termed the LEAN Program (emphasizing healthy Lifestyles, Exercise, Emotions, Attitudes and Nutrition), it is the first inpatient hospital program completely developed, administratively owned, and directed by Department of Defense psychologists. The major components of the program are discussed, as is the conceptual framework that underlies the development. The LEAN Program model is offered as a guide for those who wish to develop other programs in inpatient health psychology. (PsycINFO Database Record (c) 2010 APA, all rights reserved)