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QUESTIONS OF THE WEEK BETWEEN
October, 2006 and DECEMBER, 2006 |
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December 26, 2006
Q
What is the best way to get a teenager to quit smoking before he does further
damage to his health?
A "The
US Centers for Disease Control and Prevention (CDC) has reported in teens and
young adults more likely to use unassisted methods for smoking cessation
Young smokers aged 16 to 24 years are more likely to use unassisted cessation
methods rather than those recommended by the Public Health Service.
Recommended smoking cessation strategies for adults include talking with a
healthcare professional, use of nicotine-replacement products, bupropion
therapy, counseling, participating in a program or class, and calling a
telephone helpline.
Study results showed that whereas 6 of 11 unassisted methods were each used by
at least 36% of respondents, only 1 (talking with a nurse, physician, or
dentist) of 13 assisted methods was used by at least 20% of young adults in this
age group.
Most (88.3%) relied on decreasing the number of cigarettes they smoked, while
56% tried not buying cigarettes, 51.0% exercised more, 47.5% tried to quit with
a friend, 44.5% told others they no longer smoked, and 36.1% switched to light
cigarettes.
Women were more likely than men to seek help from health professionals (24.9% vs
15.6%), to quit with a friend (52.1% vs 43.2%), and to use self-help pamphlets
or videos (19.5% vs 12.5%). Men were more likely to try nicotine gum (20.3% vs
14.4%), use a strategy of increased exercise (55.7% vs 46.0%), and switch to
chewing tobacco, snuff, or other products (18.1% vs 1.6%).
The CDC notes that the high proportion of respondents who tried to quit smoking
by switching to light cigarettes (36.1% overall) or other tobacco products
(18.0% among men) is a concern due to the associated risk for undermining
cessation efforts.
Preliminary evidence suggests that clinical interventions that incorporate
cognitive-behavioral approaches are the most promising, particularly in smokers
younger than 18 years for whom pharmacotherapy (eg, nicotine-replacement
products or bupropion) is not approved by the US Food and Drug Administration."
December 18, 2006
Q
Did I not read that people who get depressed after a heart attack are making
sure that they have another?
A
"Patients with incident depression after a
myocardial infarction (MI) have an increased risk of another cardiovascular
event compared with post-MI patients who are not depressed.
About one half of post-MI depression episodes represent incident depression,
whereas the other half consist of ongoing or recurrent depression.
The researchers examined whether incident and non-incident depression after MI
result in different cardiovascular prognoses. They evaluated 468 patients for
depression during the year after the index MI. The International Classification
of Diseases-10 diagnostic criteria were used to define depression. The patients
were followed up for a mean of 2.5 years.
One hundred nineteen patients experienced depression in the year after their MI.
Fifty-three (44.5%) were incident depressions and 66 (55.4%) non-incident
depressions.
One hundred nine patients (23.3%) experienced a fatal (n = 10) or non-fatal (n =
99) cardiovascular event during follow-up. A cardiovascular event occurred in
21.5% of non-depressed controls, 33.3% with incident depression and 22.6% with
non-incident depression.
Patients with incident depression were 65% more likely than non-depressed
patients to have a cardiovascular event (p = 0.04). The risk among patients with
non-incident depression was increased by 12% compared with the non-depressed
controls, a nonsignificant difference. Controlling for confounders did not
significantly alter the data.
Findings stress the need for treatment strategies for post-MI depression, which
may be closer to cardiac rehabilitation and more focused on the consequences of
the MI than a purely depression-oriented approach.
The findings of this study may explain the relatively high effectiveness of
psychoeducational interventions, including stress management and relaxation, to
prevent cardiac events in coronary artery disease patients. The development of
new treatment strategies to treat post-MI depression may also prevent additional
cardiovascular events.
J Am Coll Cardiol 2006;48:2204-2208.
December 11, 2006
Q
Can't you take high blood pressure medication for PTSD?
A
The antihypertensive agent guanfacine, which lowers brain norepinephrine
activity, does not reduce the symptoms of posttraumatic stress disorder (PTSD).
There is evidence from a variety of studies that norepinephrine is
over-activated in PTSD. Because of this, experts in the field have recommended
guanfacine and clonidine (both alpha 2 adrenergic receptor agonists) as possibly
effective in PTSD. However, prior to our study, there were no data from
randomized controlled trials.
Guanfacine relative to placebo did not result in greater improvement in PTSD
symptoms, depression, general psychological distress, sleep quality or quality
of life. The effect size of zero suggests no promise for demonstrating efficacy
even with larger samples. Moreover, guanfacine was associated with a number of
side effects, including somnolence, lightheadedness and dry mouth.
For chronic PTSD, the key message is to avoid guanfacine and be wary of using a
similar drug clonidine -- at least until there are results from randomized
controlled studies.
Another antihypertensive medication, prazosin, which has a different mechanism
of action than guanfacine and clonidine, has shown promise for the treatment of
chronic PTSD in randomized controlled trials.
The important distinction between guanfacine and prazosin is that the latter
drug does not lower brain norepinephrine release. Rather, it blocks the effect
of norepinephrine on one particular receptor (alpha 1) on the post-synaptic side
of the synapse, which may be implicated in anxious arousal." Am J Psychiatry
2006.
December 4, 2006
Q
Does my son have to be on Stattera for his ADHD. Are there any non-drug
approaches?
A
"Children with attention deficit/hyperactivity disorder (ADHD) can be trained
through biofeedback, based on electroencephalographic (EEG) parameters, to
regulate their brain waves. This learned control is associated with durable
improvements in behavior, attention and IQ scores.
Neurofeedback is used to modify activity of the brain, specifically of slow
cortical potentials for patients with ADHD. Slow cortical potentials are slow
event-related direct-current shifts of the EEG, originating from the upper
cortical layer. These shifts "occur as a consequence of external or internal
events."
Although previous studies have shown the improved self-regulatory capacities in
this patient population, no reports included EEG data during learning and
follow-up.
The training was introduced as a computer game. The subjects faced a computer
that provided visual feedback in the form of movement of a ball, in which the
position of the ball reflected amplitude of brain waves. Auditory feedback was
also given and the children received small gifts at the end of a session based
on the number of accurate responses.
While viewing a ball on the screen, they were told "to be attentive to the
feedback and to find the most successful mental strategy to move the ball into
the required goal."
The subjects completed 30 one-hour sessions divided into three phases. Each
phase lasted for 2 weeks and the training sessions were held 5 days per week.
After each phase was completed, the subjects took a 6 to 8-week break. During
the last phase, the children worked on their homework while they applied the
self-regulation strategy they had learned.
At the end of the training and at a 6-month follow-up, EEGs indicated that the
children had learned to regulate negative slow cortical potentials. Two of the
subjects at the end of training and three at follow-up no longer fulfilled the
diagnostic criteria for ADHD.
Performance IQ scores on Wechsler Intelligence Scale for Children, and measures
of attention improved significantly from screening to follow-up.
With voluntary regulation of slow control potentials, children may learn to
flexibly adjust their cholinergic-dopaminergic balance to task requirements.
They believe that the acquired skill becomes automatic over time."
Pediatrics 2006;118:e1530-e1540.
November 27, 2006
Q "My
son was born with low birthrate. I have read horror stories about the
future of such children. Can you point me a direction to start some research?"
A
Please take time to look up this article: "Very preterm or very low birth weight
children are more likely to have behavioral and emotional problems when they
start school. Children born very preterm (VP; less than 32 weeks' gestation) or
with very low birth weight (VLBW, less than 1500 g) are at risk for behavioral
and emotional problems during school age and adolescence. At school entrance
these problems may hamper academic functioning, but evidence on their occurrence
at this age in VP/VLBW children is lacking."
Researchers compared the prevalence of behavioral and emotional problems at age
5 years between VP/VLBW children and children of the same age in the general
population. In addition, they examined the association between these behavioral
and emotional problems and other developmental problems assessed by
pediatricians.
Overall, 13.2% of VP/VLBW children scored in the clinical range of CBCL total
problems, compared to 8.7% of children in the general population (odds ratio
1.60). The largest mean differences were observed for social and attention
problems. Children with pediatrician-diagnosed developmental problems at 5 years
had larger differences, as did children with severe perinatal problems."
Arch Dis Child Fetal Neonatal Ed 2006;91:F423-F428.
November 20, 2006
Q "We
have been trying to get pregnant. No luck so far. This is very
depressing. Could depression make me infertile?."
A
"Middle-aged men with depression have reduced levels of bioavailable
testosterone as well as circulating total testosterone compared with their
counterparts without depression. There has been an interest for many years in
regards to the question of reproductive hormones in relationship to depression.
There is a logic to this in that the loss of libido is thought to be associated
with low testosterone, but there hasn't been much robust research done in the
area. Depressed subjects were untreated at the time of enrollment, but they
underwent a washout period in the event they had received an antidepressant drug
during the index period or for a previous episode of illness. Low testosterone
is associated with depression, even when you control for the effects of age. It
supports a trend that was generally uninformed by research, that there may be
some merit in adding a testosterone supplement in the treatment of depression,
particularly if men report low libido. The results show a link between decreased
hormonal levels and depression, but it is too premature to support hormonal
therapy in the way of a testosterone supplement for depressed men. This does not
mean patients should be on testosterone. The next step in research would look at
whether treating men with testosterone makes them less depressed. This study did
not address that. The finding of reduced bioavailable testosterone does not
establish if the decreased expression of testosterone caused depression or was a
consequence of the depression, noting depression can cause changes in how
hormones are processed in the body. The depression itself may be lowering the
bioavailable testosterone, rather than the other way around."
November 13, 2006
Q "Have
you heard anything about antidepressants being risky during pregnancy?."
A
“The use of selective serotonin reuptake inhibitors (SSRIs) early in pregnancy
seems to moderately raise the risk of congenital malformations in offspring.
It's unclear whether the effects were causal or due to factors related to the
underlying disease for which SSRIs were prescribed. However, the finding that
the association between SSRI use and risk of congenital malformations was
stronger during the second or third month of pregnancy is consistent with a
causal effect. There was no evidence that the association was specific to
particular malformations. Epidemiol 2006;17:701-70.”
November 6, 2006
Q "I
would think that being nervous would be hard on asthmatics."
A
"Depressive disorders and anxiety disorders are both
associated with worse asthma-related quality of life, but only depressive
disorders are associated with worse asthma control.
Having either a depressive (e.g., major depression) or anxiety (e.g., panic
disorder) disorder was associated with worse asthma-related quality of life, but
only depressive disorders were associated with worse asthma control levels.
These findings were observed independent of age, sex, and asthma severity, which
is significant because this means that the worse asthma control and quality of
life observed in patients with comorbid depressive and anxiety disorders were
not simply due to greater asthma severity in the psychiatric patients.
If depressed patients with asthma are at greater risk for worse asthma control
(independently of asthma severity), they could be targeted for more intensive
asthma care interventions as well as for psychotherapeutic or behavioral
interventions to improve their depressive status.
There are several symptoms of depressive disorders -- e.g., fatigue, lack of
energy, and decreased interest in daily activities that may include
self-management of chronic asthma -- that may make them less likely to adhere to
daily medication regimens ... which we know has a huge impact on control. As
such, detecting and treating comorbid psychiatric disorders may have
implications for both mental and physical (asthma) health."
Chest 2006;130:1039-1047.
October 30, 2006
Q "You
can get sick from anxiety, right?"
A
"Patients with physical maladies are at increased risk of having an anxiety
disorder as well. Furthermore, the severity of the physical illness and
resulting loss of function are exacerbated among patients with comorbid anxiety.
Analyses showed that the presence of an anxiety disorder -- panic disorder,
phobia, generalized anxiety disorder, agoraphobia, social phobia, or
obsessive-compulsive disorder -- was independently associated with diseases of
the respiratory and the gastrointestinal tracts, arthritis, allergies, thyroid
disease, migraine, and any past-month physical condition.
The onset of anxiety disorders was more likely to have preceded onset of
comorbid physical conditions, and that quality of life and physical functioning
were worse when comorbid anxiety disorders existed.
Anxiety disorders and physical illness can turn into a vicious circle. Painful
conditions like migraine and arthritis could increase a patient's anxiety about
the pain. Or panic attacks may be mistaken for asthma attacks.
Anxiety causes individuals to avoid situations that could precipitate symptoms,
leading them to restrict physical pursuits or avoid social activities. Obesity
or substance abuse may develop as a result, thereby raising the risk of other
painful conditions and physical diseases.
Arch Intern Med 2006;166:2109-2116.
October 23, 2006
Q "Aside
from damage to your body and making you steal from the family, are there other
things that cocaine does to a person?."
A
In a recent presentation, it was reported that "A number of studies show that
cocaine use negatively affects neuronal functioning of the brain, primarily in
the prefrontal cortex but also in a number of other areas in the brain.
The result is a reduced ability to weigh benefits versus drawbacks, and to
control behavior.
During fMRI, subjects were asked to identify various amounts of money and rank
them in order of value, or "reward."
More than half of the addicts could not differentiate between values. FMRI
showed a "disconnect," or a "conflict pattern in response to monetary rewards.
There was a decreased response overall...in the prefrontal cortex.
The prefrontal cortex is the region in which impulse control occurs. An
inability to distinguish between different values of money "means that this
reward system can not be used to change behavior" in cocaine addiction.
Although there is some improvement in function (in the prefrontal cortex) once
the drug is removed, it never completely returns to normal."
October 16, 2006
Q "Do
many people commit suicide when diagnosed with breast cancer?."
A
Importantly, a significant number of people who survive breast cancer later
commit suicide. "Breast cancer survivors are 37% more likely to commit suicide
than other women, and the elevated risk persists for at least 25 years after
diagnosis. Previous studies have looked at suicide risk in breast cancer
survivors, but most have not examined the long-term risk.
In an analysis of data for 723,810 breast cancer survivors who were diagnosed
between 1953 and 2001. During follow-up through 2002, 836 subjects committed
suicide. The standardized mortality ratio was 1.35 for the breast cancer
survivors compared with the general population. The excess absolute risk was 4.1
per 100,000 person-years.
After 25 or more years, breast cancer survivors still had a 35% increased risk
of suicide. Black cancer survivors were most likely to commit suicide, with a
2.88-fold elevated risk. The risk of suicide rose as cancer stage increased.
At 30 years after breast cancer diagnosis, the cumulative probability of suicide
was 0.20%.
Although the cumulative probability of suicide is small, our results suggest
that long-term follow-up programs for breast cancer survivors should include
resources devoted to psychosocial concerns."
J Natl Cancer Inst 2006;98:1416-1419.
October 9, 2006
Q "Our
dad had a stroke and is very slow to mobilize. The doctors say that he should be
recovering faster. Any thoughts?."
A
Yes, consider the possibility that he is depressed: "Despite a high rate of
depression, which can have a significant impact on stroke survivors' mortality,
the majority of clinically depressed stroke patients do not receive
antidepressant medication. Researchers found that at 5 years after stroke,
almost 20% of survivors suffered from depression, yet only 22% were treated for
the condition. Stroke patients suffering from depression have been found to have
reduced quality of life and a higher rate of death, so it is important to
identify and treat depression after stroke. The low treatment levels found may
indicate that physicians are unwilling to prescribe treatments that have not
been demonstrated to be an effective and safe treatment for depression among
stroke patients. Another factor may be that depression among stroke patients is
not being diagnosed. Interestingly, a high proportion of patients (72%) taking
an antidepressant were not depressed. This could indicate efficacy of
antidepressant therapy or may be because the medications were prescribed for an
indication other than depression, such as pain." Stroke. 2006.
October 2, 2006
Q "Our
family doctor told us that our son's social pressures do not influence his
asthmatic attacks ."
A Perhaps
you misunderstood what he said, but "Young people with asthma who also have an
anxiety or depressive disorder have a significantly increased asthma symptom
burden. After controlling for variables including asthma severity, adolescents
with anxiety or depressive disorders had significantly more days of asthma
symptoms over the previous 2 weeks than those with no anxiety or depressive
disorders.
A significant association was observed between the overall number of reported
asthma symptoms and the number of anxiety and depressive symptoms reported by
the subjects (p < 0.001).
A diagnosis of an anxiety or depressive disorder was "strongly associated" with
both asthma-specific symptoms and nonspecific somatic symptoms."
Pediatrics 2006;118:1042-1051.
Past
Questions of the Week are available through the
educational resources
of the website. If you would like to submit your own question for consideration
as a public Question of the Week, please contact the practice.
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