Simasek and Blandino review the literature on the treatment of the common cold in this issue of American Family Physician. (1) The authors conclude that the ability to make confident and specific treatment recommendations is limited because of flaws in the evidence.

The American College of Chest Physicians (ACCP) recently published evidence-based guidelines for diagnosing and treating acute cough (less than three weeks in duration), subacute cough (three to eight weeks in duration), and chronic cough (more than eight weeks in duration) in adults and chronic cough in children. (2) This editorial highlights key recommendations for treating adult patients with acute cough . Is an algorithm for the management of acute cough.

Because studies have inconsistently targeted the multiple cardinal symptoms of the common cold (e.g., rhinorrhea, nasal congestion, postnasal discharge, throat clearing, cough), the evidence on how to best treat any one symptom is not strong. Therefore, the Duke Center for Clinical health Policy Research (which conducted an evidence-based review of the literature for the ACCP guideline committee) limited its review to cough. (4) Clinically, there are several reasons why it makes sense to target cough caused by the common cold: the common cold, which is the most prevalent condition in humans, is accompanied by cough in up to 83 percent of persons (5); the common cold is the most prevalent cause of acute cough (6); and cough is the most common complaint seen by primary care physicians in the ambulatory setting in the united states, (7) probably because cough adversely affects health-related quality of life. (6)

Although acute cough from the common cold is usually transient and minor, it may be life threatening when caused by a more serious condition (e.g., congestive heart failure, pneumonia, pulmonary embolism). Therefore, the first step in managing an acute cough is to clinically determine whether it is caused by a potentially serious illness or one of a variety of non-life-threatening conditions (e.g., upper respiratory infection, bronchitis, mild asthma).

Because the common cold is the predominant cause of acute cough, it is useful to review the definition of the common cold and stress the importance of identifying acute nasal symptoms. The common cold is a minor, acute respiratory illness characterized by symptoms and signs usually related to the nasal passages with or without fever, lacrimation, throat irritation, hoarseness, and cough. Because the definitions of the common cold and acute bronchitis are similar, (8) an acute bronchitis diagnosis should not be made unless the common cold has been ruled out. (8) Other causes also should be ruled out before diagnosing acute bronchitis because it is often overdiagnosed, leading to more antibiotic prescriptions.

Acute bronchitis may imply a bacterial cause, making it more likely that antibiotics will be used. When acute bronchitis is diagnosed, antibiotics are prescribed in 65 to 80 percent of patients, (9) and extended-spectrum antibiotics are prescribed in more than 50 percent of older patients. (10) Moreover, many patients think that antibiotics are more important for recovery from acute bronchitis (44 percent of patients) than colds (11 percent of patients). (11) Asthma and acute exacerbation of chronic bronchitis related to smoking or other irritants also should be ruled out before making an acute bronchitis diagnosis because they commonly present as acute cough-phlegm syndromes (8); 30 to 65 percent of patients with these conditions have been misdiagnosed as having acute bronchitis. (12-14)

By using the most rigorous and current methods to develop its evidence-based clinical practice guideline for acute cough, the ACCP guideline committee made diagnostic and treatment recommendations based on two components: (1) the quality of the evidence, which was rated according to study design and strength of the modalities used; and (2) the net benefit of the recommendation based on the estimated benefit to the specific patient population (the net benefit represents an assessment of the balance between benefits and harms). (4) using this process, the committee’s recommendations are stronger than simasek and Blandino’s, (1) who based their recommendations on Cochrane reviews.

The committee strongly recommends that patients with acute cough from the common cold receive a first-generation antihistamine/decongestant or the nonsteroidal anti-inflammatory drug naproxen (Naprosyn, Aleve) unless there is a contraindication (e.g., glaucoma, benign prostatic hypertrophy, hypertension, renal failure, gastrointestinal bleeding, congestive heart failure). (15) They also strongly recommend that newer-generation, nonsedating antihistamines should not be used because they are ineffective. (15) The committee does not recommend over-the-counter combination cold medications, except for those that contain older antihistamine/decongestant ingredients, until they are proved effective in randomized controlled trials. (16) A meta-analysis has called into question whether the presumed increased sedation effect of first-generation antihistamines compared with newer nonsedating antihistamines is substantiated by objective data and if it is clinically relevant. (17)

Clinical approval Quiz questions are based on selected articles in this issue. Answers appear in this issue. American Family Physician has been approved by the American Academy of Family Physicians as having educational content acceptable for Prescribed credit. Term of covers issues published within one year from the beginning distribution date of January 2004. This issue has been reviewed and is acceptable for up to 3.5 Prescribed credits. Three quarters of one credit conforms to AAFP criteria for evidence-based CME content. When reporting CME credits, AAFP members should report total Prescribed credits earned for this activity. It is not necessary for members to label credits as evidence-based or Prescribed for CME reporting purposes.

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Premenstrual Syndrome (PMS) comprises a variety of symptoms that typically occur one or two weeks before menstruation and stop shortly thereafter (MedlinePlus Medical Encyclopedia, accessed 20/11/2006). The symptoms of PMS vary and range in severity, and commonly include headaches, abdominal cramps, bloating, backaches, breast tenderness, depression, food cravings, mood swings and irritability (Bendich, 2000). Up to 80% of women experience PMS at some point, while 20-50% of women experience symptoms severe enough to affect their lives significantly (Ward and Holimon, 1999).

The etiology of PMS is not well understood; however, it is thought that PMS symptoms are a result of fluctuating levels of hormones, such as estrogen, associated with the menstrual cycle (Lee and Kanis, 1994). More recently, Thys-Jacobs and Alvir (1995) observed mid-cycle fluctuations of calcium-regulating hormones and increases in parathyroid hormone (PTH) with transient, secondary hyperparathyroidism in women who suffered from PMS compared to controls. These data support the idea of a transient calcium deficiency in women suffering from PMS. Current treatments of PMS involve the use of drugs such as oral contraceptives, lifestyle therapies and calcium (Thys-Jacobs, 2000).

Thys-Jacobs et al. (1989) were the first to study calcium in the treatment of PMS using a double-blind, randomized, crossover trial wherein a significant decline in PMS symptoms was observed in women receiving 1,000 mg/day of calcium compared to the placebo group. Penland and Johnson (1999) later confirmed these findings, observing that a higher dose of calcium (1,336 mg/day) was more effective at reducing symptoms than a smaller dose (587 mg/day). To overcome the limitation of the small sample size in their previous trial, Thys-Jacobs et al. (1998) randomly assigned 231 women to 1,200 mg/day of calcium and 236 to a placebo for three menstrual cycles. Investigators found a 48% reduction in PMS symptoms in the calcium group compared to baseline scores, with only a 30% reduction in the placebo group. They also reported that symptom factors (negative affect, water retention, food cravings and pain) were significantly reduced. Additional evidence for calcium comes from a recent case/control study that found an inverse relationship between calcium intake and severity of PMS symptoms (Bertone et al., 2005).

Interestingly, significantly lower bone mineral density was observed in 26 PMS sufferers when compared to matched controls (Thysjacobs et al., 1995). Similarly, a retrospective case/control study (Lee and Kanis, 1994) found an association between postmenopausal osteoporosis and premenopausal PMS symptoms. Both studies suggested suboptimal calcium status in PMS sufferers and further supported the recommendation to increase daily calcium intake in these women. The similarity between the symptoms of hypocalcemia and PMS (i.e., anxiety, depression, muscle cramps) have also been noted, further implicating calcium in the pathophysiology of PMS (Thysjacobs, 2000).

Calcium carbonate supplements (which have a bioavailability comparable to calcium in milk) were used in the trials (Heaney, 1991). The recommended dose should depend on the woman’s current intake of calcium, so that it does not exceed the 2,500 mg/day upper limit (UL) (Food and Nutrition Board, 1997). Considering that women of menstruating age consume an average of 607-809 mg of calcium per day, supplementation with higher doses should be safe (Bendich, 2000). The supplement should be taken in divided doses throughout the day with meals for more efficient absorption (Heaney, 1991). The results of the treatment along with clients’ regular use of supplements should be carefully assessed through a PMS symptom diary (Freeman et al., 1996) after three months. This was the point at which investigators observed significant changes during the trials.

Calcium supplementation has several advantages compared to other treatments: calcium is inexpensive, generally safe if the UL is not exceeded, accessible to the general population, possesses fewer side effects than drug treatments and has the potential to prevent osteoporosis later in life by increasing bone mineral density (Heaney, 2006). Increasing calcium through food sources may have the same effects as calcium supplementation on PMS symptoms so long as daily intake is consistent. With the mounting support for supplemental calcium, dietary calcium as a treatment for PMS warrants future investigation. Further research should also be conducted to compare the effectiveness of calcium supplements with traditional drug treatments.

With the recent outbreaks of avian influenza A (H5N1), the risk for the next influenza pandemic has increased. For effective countermeasures against the next pandemic, investigation of past pandemics is necessary. We selected cases diagnosed as influenza from medical records and hospitalization registries of Japanese army hospitals during 1918-1920, the Spanish influenza era, and investigated clinical features and circumstances of outbreaks. Admission lists showed a sudden increase in the number of inpatients with influenza in November 1918 and showed the effect of the first wave of this pandemic in Tokyo. The death rate was high (6%-8%) even though patients were otherwise healthy male adults.

Because of the emergence of avian influenza A (H5N1) virus in Southeast Asia, potential evolution of a novel type of influenza in the near future is of great concern (1,2). If an outbreak of a novel form of influenza occurs, a major worldwide pandemic is predicted because humans would not have immunity against this virus. To take effective countermeasures against new pandemics, investigation of past pandemics is essential.

Four pandemics occurred in the 20th century: Spanish flu in 1918, Asian flu in 1957, Hong Kong flu in 1968, and Russian flu in 1977 (3.4). Spanish influenza was the largest pandemic, and Japan was seriously affected. Despite abundant public records related to Spanish influenza, few primary documents, such as medical records, remain in Japan. Recently, medical records from the early 20th century were found in the depository of the International Medical Center of Japan (IMCJ) Hospital, Tokyo. We used these records to investigate the clinical characteristics of Spanish influenza. To help prepare countermeasures, we investigated the outbreak situation, clinical findings, and outcomes of Spanish influenza in the Japanese military during 1918-1920.

Patients and Methods

The documents were stored at the medical history depository of IMCJ Hospital, at the medical records and hospitalization registries of Tokyo First Army Hospital (a predecessor of IMCJ Hospital), and at the Fifth Japanese Army Garrison Hospital, Krasnoyarsk, Russia. Medical records in which influenza was diagnosed between January 1918 and December 1920 were selected. Because the influenza virus had not yet been discovered at that time, no serologic or virologic diagnostic methods for influenza infection were available, and no examinations such as chest radiographs were performed. Thus, the diagnosis flu (kanbo in Japanese) was defined as clinical influenza.

Three types of documents were investigated. The first type was the hospitalization registry of Tokyo First Army Hospital, in which records of 127 patients from January 1918 through November 1918 were included. Because these records were bound, it was assumed that no records were missing. The second type was the medical records of 132 patients at the Fifth Japanese Army Garrison Hospital in Russia from March 1919 through April 1920. These records were also bound, and it was again assumed that no records were missing. The third type was the medical records of419 patients at Tokyo First Army Hospital from January 1918 through May 1920. These records were not associated with time and were partially discontinuous, which indicated that some records (dates) were missing. Information on the hospitals (e.g., numbers of beds and physicians) was unclear. This research was reviewed and approved by the research review boards at IMCJ Hospital. Statistical significance of between-group differences was analyzed by using the Mann-Whitney U test. A p value <0.05 was considered statistically significant.

Results

We first investigated hospitalization registries of Tokyo First Army Hospital from January to November 1918. These registries had the names and diagnoses of patients admitted to the hospital on a monthly basis. Numbers of patients admitted for respiratory infectious disease during this period are shown in the Figure. Cases diagnosed as pneumonia, acute bronchitis, and influenza were classified as respiratory infectious diseases. Although records of patients with tuberculosis were found, we excluded them from this study. In the 10-month period from January to October, the mean ([+ or -] standard deviation) monthly numbers of patients with pneumonia, acute bronchitis, and influenza were 10.9 [+ or -] 6.5, 10.0 [+ or -] 3.6, and 1.8 [+ or -] 4.1, respectively (22.7 [+ or -] 9.6 for all 3 illnesses). Death rates from pneumonia, bronchitis, and influenza during this period were 3.4% (4/116), 0% (0/109), and 0% (0/18), respectively. The number of influenza patients suddenly increased to 109 in November, and 9 of them died (8%). Because our information about these 109 patients was found only in the hospitalization registries (the patients’ medical records were not found), we could not identify their clinical symptoms. However, it can be assumed that the hospital experienced the first wave of Spanish influenza in November 1918. Because no hospitalization registry before this period was found, comparison with outbreaks in average years was not possible.

QUESTION: During the last year a large number of patients with type II diabetes have been referred from primary care providers for evaluation and treatment of major depression. I know research findings are inconsistent concerning the co-occurrence of diabetes and depression, but what are the clinical implications for treating patients with diabetes and major depression?

DEBORAH ANTAI-OTONG RESPONDS: The precise relationship between diabetes and depression continues to be debated. However, most research implicates a positive correlation between depression and type II diabetes (Anderson, Freedland, Clouse, & Lustman, 2001; Nichols & Brown, 2003). Controversy about this relationship and necessity to screen patients presenting with diabetes exists as well (Brown, Sumit, Majumdar, & Johnson, 2006). Depression is widespread in patients with diabetes, but it often goes unrecognized and undertreated in primary care settings. Left untreated, depression can result in negative clinical outcomes, increased healthcare and economic burden, and a threat to overall health integrity and quality of life. Psychiatric nurses must be prepared to collaborate with primary care and other healthcare providers to screen patients with diabetes who are at risk for depression. Accurate diagnosis ensures the initiation of pharmacologic and nonpharmacologic treatments that reduce complications of both chronic diseases.

Incidence of Depression in Type II Diabetes

Major depression occurs in one in four patients with type I and type II diabetes mellitus (Andersen et al., 2001) and is associated with poor glycemic control, negative clinical outcomes, reduced quality of life and level of function, and diabetic-related mortality (Katon et al., 2004; Zhang et al., 2005). Several studies demonstrated that individuals with diabetes experienced up to threefold incidence of depression compared to those without diabetes (Anderson et al.; Hermanns, Kulzer, Krichbaum, Kubiak, & Haak, 2005; Nichols & Brown, 2003).

Major depression is frequently linked to diabetic-related complications, particularly micro- and macrovascular conditions (Wexler, 2006). For instance, depressed patients are twice as likely to develop diabetes compared to those who are not depressed (Knol, Twisk, Beekman, Snoek, & Pouwer, 2006). Moreover, depressed patients with diabetes are likely to experience an accelerated risk of coronary artery disease and significantly higher incidence of diabetes-related mortality (Brown, Majumdar, Newman, & Johnson, 2005; Egede, Nietert, & Zheng, 2005; Katon et al., 2005). Evaluation and treatment is a priority because of the relationship between depression and poor glycemic and metabolic management in patients with type II diabetes. The pathogenesis of this relationship is still poorly understood and necessitates further study. However, behavioral, physiologic, genetic, and environmental stressors may alter neuroendocrine and neurotransmitter functions.

It is imperative to recognize risk factors along with symptoms of co-occurring depression and their impact on chronic disease management because of negative prognostic implications associated with co-occurring diabetes and depression. Age, female gender, previous history of depression, complications from diabetes, such as peripheral neuropathic pain, impaired functional status and quality of life, and psychosocial stressors are risk factors (Hermanns et al., 2005; Legato et al., 2006). Steps to establish quality health care begin with collaboration with primary care providers, patients, and their families to develop and implement an individualized treatment plan.

Implications for Psychiatric Nursing Practice

Treating depression in the diabetic patient is similar to treating other co-occurring chronic diseases. It is imperative to evaluate the patient’s physical condition by asking questions about prescribed and over-the-counter medications and adherence to treatment adherence. Ordering blood chemistries, hemoglobin A^sub 1C^ (HgbA^sub 1C^), drug screens when appropriate, and lipid profile; measuring vital signs, height, and weight; and working with the primary care provider to evaluate metabolic/ glycemic control is advisable. It is equally important to rule out coexisting psychiatric (e.g., anxiety disorder, substance-related disorders) and medical conditions, including cardiovascular disease, hypertension high low-density lipoprotein cholesterol and triglycéride, and obesity. The decision to seek psychiatric evaluation and treatment can be unsettling to the patient who may deny the distress associated with diabetes and depression. Establishing collaborative relationships with the primary care provider helps ensure their support of mental health treatment. Open communication about the patient’s medical problems and history, including adherence to treatment, quality of support systems, cultural perceptions of diabetes and depression (e.g., gender, generational), and coping styles is helpful in co-collaborating.

Injection techniques are helpful for diagnosis and therapy in a wide variety of musculoskeletal conditions. Diagnostic indications include the aspiration of fluid for analysis and the assessment of pain relief and increased range of motion as a diagnostic tool. Therapeutic indications include the delivery of local anesthetics for pain relief and the delivery of corticosteroids for suppression of inflammation. Side effects are few, but may include tendon rupture, infection, steroid flare, hypopigmentation, and soft tissue atrophy. Injection technique requires knowledge of anatomy of the targeted area and a thorough understanding of the agents used. In this overview, the indications, contraindications, potential side effects, timing, proper technique, necessary materials, pharmaceuticals used and their actions, and post-procedure care of patients are presented. (Am Fam Physician 2002;66:283-8,290. Copyright[C] 2002 American Academy of Family Physicians.)

Injection of joints, bursae, tendon sheaths, and soft tissues of the human body is a useful diagnostic and therapeutic skill for family physicians. With training, physicians can incorporate joint and soft tissue injection into daily practice, yielding many benefits. For example, a lidocaine (Xylocaine) injection into the subacromial space can help in the diagnosis of shoulder impingement syndromes, and the injection of corticosteroids into the subacromial space can be a useful therapeutic technique for subacromial impingement syndromes and rotator cuff tendinopathies. Evidence-based reviews of joint and soft tissue injection procedures have found few studies that support or refute the efficacy of common joint interventions in medical practice.(1-3) However, substantial practice-based experience supports the effectiveness of joint and soft tissue injection for many common problems.

These injections are most useful in instances of joint or tissue injury and inflammation. History of pain, local and referred, will provide important clues to the underlying pathology. Physical examination is extremely helpful in ascertaining the diagnosis. Knowledge of the anatomy of the area to be injected is essential. Intratendinous injection should be avoided because of the likelihood of weakening the tendon. Corticosteroid injections also should be avoided in cases of Achilles or patella tendinopathies.

Therapeutic responses to corticosteroid injections are variable.(4) The patient’s response to previous injection is important in deciding whether and when to proceed with reinjection. Most patients, if they are going to respond, will respond after the first injection. If the patient has achieved significant benefit after the first injection, an argument can be made to give a second injection if symptoms recur. However, patients who have gained no symptom relief or functional improvement after two injections should probably not have any additional injections, because a subsequent positive outcome is low.

If therapeutic effect is achieved, a maximum of four injections per year is recommended. There is some concern that corticosteroid preparations, with repeated use, may accelerate normal, aging-related articular cartilage atrophy or may weaken tendons or ligaments. When symptoms are resistant, or when there is a history of trauma, a radiograph or other imaging study should be performed to help assist in the diagnosis.

Indications

The indications for joint or soft tissue aspiration and injection fall into two categories: diagnostic and therapeutic. A common diagnostic indication for placing a needle in a joint is the aspiration of synovial fluid for evaluation. Synovial fluid evaluation can differentiate among various joint disease etiologies including infection, inflammation, and trauma. A second diagnostic indication involves the injection of a local anesthetic to confirm the presumptive diagnosis through symptom relief of the affected body part.

Therapeutic indications for joint or soft tissue aspiration and injection include decreased mobility and pain, and the injection of medication as a therapeutic adjunct to other forms of treatment.(5) Caution must be exercised when removing fluid for pain relief because of the possibility of introducing infection and precipitating further or new bleeding into the joint. Also, early reaccumulation of fluid can occur in many cases.

Therapeutic injection with corticosteroids should always be viewed as adjuvant therapy.(6) The improper or indiscriminate use of corticosteroids is likely to have a bad outcome. These injections should never be undertaken without diagnostic definition and a specific treatment plan in place. Physicians should resist external pressure for a quick return of athletes to playing sports by the use of joint or soft tissue injections. Table 1 lists soft tissue and joint condition indications for diagnostic and therapeutic injections.

Rationale: Recent U.S. data suggest an increased risk of work-related asthma among health care workers, yet only a few specific determinants have been elucidated.

Objectives: To evaluate associations of asthma prevalence with occupational exposures in a cross-sectional survey of health care professionals.

Methods: A detailed questionnaire was mailed to a random sample (n = 5,600) of all Texas physicians, nurses, respiratory therapists, and occupational therapists with active licenses in 2003. Information on asthma symptoms and nonoccupational asthma risk factors obtained from the questionnaire was linked to occupational exposures derived through an industry-specific job-exposure matrix.

Measurements: There were two a priori defined outcomes: (1) physician-diagnosed asthma with onset after entry into health care (”reported asthma”) and (2) “bronchial hyperresponsiveness-related symptoms,” defined through an 8-item symptom-based predictor.

Main Results: Overall response rate was 66%. The final study population consisted of 862 physicians, 941 nurses, 968 occupational therapists, and 879 respiratory therapists (n = 3,650). Reported asthma was associated with medical instrument cleaning (odds ratio [OR], 2.22; 95% confidence interval [CI], 1.34-3.67), general cleaning (OR, 2.02; 95% CI, 1.20-3.40), use of powdered latex gloves between 1992 and 2000 (OR, 2.17; 95% CI, 1.27-3.73), and administration of aerosolized medications (OR, 1.72; 95% CI, 1.05-2.83). The risk associated with latex glove use was not apparent after 2000. Bronchial hyperresponsiveness-related symptoms were associated with general cleaning (OR, 1.63; 95% CI, 1.21-2.19), aerosolized medication administration (OR, 1.40; 95% CI, 1.06-1.84), use of adhesives on patients (OR, 1.65; 95% CI, 1.22-2.24), and exposure to a chemical spill (OR, 2.02; 95% CI, 1.28-3.21).

Conclusions: The contribution of occupational exposures to asthma in health care professionals is not trivial, meriting both implementation of appropriate controls and further study.

Keywords: work-related asthma; health care workers

It is well established that certain occupational groups are at increased risk of developing asthma, including Western red cedar workers (1), isocyanate chemical workers (2), construction workers (3), and farmers (4). However, whereas the risk magnitude and etiologic agents are well characterized for many of these occupations, this has been less well studied in the case of health care workers (HCWs), where data largely derive from case series but relatively few population-based studies or surveillance systems.

In the 1990s, attention began focusing on respiratory hazards among HCWs, partly because of increasing concern over occupational latex allergy after passage of the 1992 Occupational Safety and Health Administration (OSHA) bloodborne pathogens standard, which resulted in a significant increase in the use of latex-containing personal protective equipment, such as powdered latex gloves. However, potential asthmagens in health care settings go beyond latex, and may include disinfectants and sterilants (e.g., glutaraldehyde, formaldehyde), pharmaceuticals (e.g., psyllium, antibiotics), sensitizing metals (e.g., in dental alloys), methacrylates, irritant aerosolized medications (e.g., pentamidine and ribavirin), and cleaning products (5, 6).

Previous studies from various countries have reported cases of work-related asthma among specific groups of HCWs, including physicians (7), respiratory therapists (8), workers in endoscopy units and radiology departments (9), nurses (10), and general HCWs (5). Confirmation and estimation of risk, however, in population-based studies has been more problematic. In a cross-sectional analysis of the European Community Respiratory Health Study (ECRHS), significant excesses of risk among HCWs were not consistently observed (4). In the United States, using data from the National Health and Nutrition Examination Survey III, conducted between 1988 and 1994, the odds for either work-related asthma or wheezing in health-related occupations were not significantly increased (11). Data from the 2001 National Health Interview Survey did find significantly increased odds for physician-diagnosed asthma in the U.S. health care industry, but this excess was limited to white females (12). More recently, surveillance data from four U.S. states found that work-related asthma among HCWs represented 16% of total reported cases, exceeding their representation in the workforce (8%) (6). Interestingly, the U.S. National Institute for Occupational Safety and Health (NIOSH) reported that 5 of the top 11 industries and 9 of the 22 leading occupations associated with significantly increased asthma mortality were related to health care services (13).

Thus, results are inconsistent, and few studies have been conducted in HCW populations allowing a more detailed characterization of potential associations between asthma and various workplace exposures. Studies that address these remaining issues are particularly important considering that HCWs comprise approximately 8% of the U.S. workforce, and constitute one of the fastest growing sectors of the workforce (14). Using representative samples of selected HCW groups in Texas, the purpose of this study was to evaluate associations of asthma prevalence with occupational exposures in health care professionals, and to estimate their magnitude.

Hysterectomy is a common surgical procedure that provides definitive treatment for menorrhagia. However, many women prefer to continue medical therapy for several years because hysterectomy is irreversible and associated with surgical risks. No randomized controlled trials have compared medical and surgical treatment of menorrhagia in women who did not have a strong preference or medical indications for either strategy. Learman and colleagues compared the outcome of these two treatment strategies in 63 premenopausal women referred to four teaching hospitals in the United States because of symptomatic menorrhagia.

Study participants were 30 to 50 years of age and reported abnormal menstrual flow lasting more than seven days each month or sufficient flow to cause anemia for at least two months. Women who were older than 45 years were tested for menopause by measuring follicle-stimulating hormone level and also were tested for endometrial hyperplasia or carcinoma before being enrolled in the study. Exclusion criteria included coagulopathies, other causes of anemia, endocrine conditions, pelvic pathology, desire for pregnancy, and recent use of oral contraceptives or long-acting hormonal therapies.

A total of 413 women initially began the trial and were given cyclic medroxyprogesterone acetate for 10 to 14 days per month. Patients who were dissatisfied with this regimen were invited to participate in the comparison trial of hysterectomy and extended medical therapy. Patients assigned to medical therapy received a combined oral contraceptive plus a prostaglandin inhibitor, but variations in the actual regimen were permitted. Patients were followed every three months for two years to assess health status, beliefs and attitudes, gynecologic and urinary symptoms, and other relevant symptoms, such as back pain and sexual function.

On entry to the study, both groups reported multiple pelvic symptoms and low satisfaction with their current health status and symptom management. The median duration of abnormal bleeding symptoms was three to four years. Initially, 29 of the 32 women assigned to medical treatment received hormonal therapy, but only 17 of these women also received a prostaglandin inhibitor. Within two years, 17 of these women had undergone a hysterectomy.

Of the 31 women assigned to hysterectomy, 28 had the surgery. Most of these women (86 percent) required a one- to two-day hospitalization. Two patients had perioperative complications and three required readmission because of late complications. After six months, women in the hysterectomy group reported significantly greater improvements in pelvic pain, breast pain, urinary urgency, and sensation of incomplete bladder emptying than women receiving medical treatment. They also reported nonstatistically significant improvements in pelvic or bladder pressure and lower back pain compared with women treated medically.

By two years, the most significant differences recorded between the groups were hot flushes and incomplete bladder emptying. Women who remained on medical treatment showed significant improvements from baseline in pelvic pain, pelvic or bladder pressure, and stress incontinence symptoms. Women who crossed over to hysterectomy reported significant improvements in bleeding; pelvic, back, or breast pain; and urinary frequency and urgency. Conversely, women who crossed over from medicine to hysterectomy had more days lost from usual activities and more days in bed than women who remained on medical therapy.

The authors conclude that hysterectomy may be the better treatment option for women who seek relief of symptoms such as bleeding, pelvic pain, breast pain, lower back pain, and bladder symptoms. Conversely, medical therapy can provide substantial improvements in symptoms with fewer overall days of restricted activities in the short term for women who do not want to have a hysterectomy.

ANNE D. WALLING, M.D.

Learman LA, et al. Hysterectomy versus expanded medical treatment for abnormal uterine bleeding: clinical outcomes in the medicine or surgery trial. Obstet Gynecol May 2004;103:824-33.

EDITOR’S NOTE: Deciding on the optimal treatment strategy for an individual woman with menorrhagia can be challenging for several reasons. Although the medical literature is difficult to assess objectively, about one third of patients are reported to have strong personal preferences for a specific therapy. The options are much wider than suggested in this article. A review (1) in the BMJ Best Treatments series (http://www.besttreatments.org) concluded that nonsteroidal anti-inflammatory drugs (NSAIDs), tranexamic acid, hysterectomy (after failure of medical therapy), and endometrial thinning before hysteroscopic surgery are “treatments that work,” and that endometrial destruction (after failure of medical therapy) is a “treatment likely to work.”

“Treatments that need further study” include ethamsylate, oral contraceptives, intrauterine progesterones, gonadotropin-releasing hormone (GnRH), and myomectomy. One of the more interesting facts found in this review is that women adequately treated with NSAIDs reported a 25 to 50 per-cent reduction in bleeding, but in the above study, only a small proportion of the women assigned to treatments including NSAIDs actually took them. Although hysterectomy is the definitive therapy for menorrhagia (and the leading indication for the more than 600,000 hysterectomies performed in the United States per year), studies that followed patients for more than two years after hysterectomy or endometrial ablation found no significant difference between the groups in satisfaction at longer follow-up. Women treated by endometrial ablation were calculated to have a mean reduction in operating time of 23 minutes and returned to work 4.5 weeks sooner than women undergoing hysterectomy.–A.D.W.

Several abbreviated checklists perform well in distinguishing children with attention deficit/ hyperactivity disorder (ADHD) from those without ADHD under ideal conditions and in research settings. While many guidelines and experts recommend using these checklists as an efficient method to collect data from multiple sources (strength of recommendation: B, based on extrapolation from cohort studies to define test characteristics and consensus opinion), experts point out the subjective nature of responses on behavior rating scales, and the limitations in using checklists as the sole source of information.

The Swanson, Nolan, and Pelham (SNAP) checklist from the Diagnostic and Statistical Manual of Mental Disorders, revised 3rd edition (DSM-III-R) has been shown to have a sensitivity and specificity in excess of 94% to distinguish hyperactive, inattentive, and impulsive children with ADHD from those without ADHD. This was based on criteria in the DSM-III-R. The DSM-IV SNAP checklist (available at www.adhd.net/snap-iv-form.pdf; scoring at www.adhd.net/snap-iv-instructions.pdf), based on the newer diagnostic criteria, has not been adequately evaluated. The ADHD Rating Scale-IV (in DuPaul et al, AD/-/D Rating Scale IV–Checklists, Norms, and Clinical Interpretations, available from Guilford Press) and the ADD-H Comprehensive Teacher/Parent Rating Scale (ACTeRS; available from MetriTech, Inc at www.metritech.com) are useful for their brevity, but they do not perform as well in differentiating children with ADHD from those without ADHD.

* EVIDENCE SUMMARY

A variety of brief ADHD-specific rating scales are used for both parent and teacher assessment of child behavior. Rating scales are generally evaluated to establish mean scores for affected and unaffected children. Many scales publish such normative data in commercially available manuals. Some scales have been evaluated by 1 or more independent studies to compare children with and without ADHD. Rating scales have not been evaluated as a sole tool for the diagnosis of ADHD.

The test characteristics of a particular scale depend on the cut points for a positive or negative test. The usefulness of psychological tests in discriminating normal from abnormal behavior is often reported as “effect size.” The effect size is the difference in mean scores between 2 populations divided by an estimate of the individual standard deviation. (1) An effect size of 4.0 means that abnormal subjects and normal controls are separated 4 standard deviations and thus almost completely separated. An effect size of 1.0 shows significant overlap between the 2 populations. An effect size of 4.0 is roughly equivalent to a sensitivity and specificity of 97%. An effect size of 1.0 is roughly equal to a sensitivity and specificity of 71%.

Table 1 outlines the characteristics and effect size of several available brief ADHD-specific checklists. (2-4,6,11-13) Typically, the gold standard was a clinical diagnostic interview, usually conducted by a clinical psychologist, as well as supporting data from schools and parents.

* RECOMMENDATIONS FROM OTHERS

The American Academy of Pediatrics states that the use of ADHD-specific checklists is a clinical option when evaluating children for ADHD. They caution that the ADHD scales may function less well in clinicians’ offices than suggested by reported effect size and, in addition, rating scales are subject to bias and may convey a false sense of validity. They also state that it is not known if these scales provide additional information beyond a careful clinical assessment. (7)

The Institute for Clinical Systems Improvement recommends use of at least 1 ADHD-specific rating scale to be administered to parents and teachers. This information should be used as part of the overall historical database for the child and should not be used as the sole criteria for diagnosis of ADHD. (8)

Many sources agree that ADHD-specific rating scales allow a rapid and consistent collection of information from multiple sources. However, the information they provide is necessary, but not sufficient, to make a definitive diagnosis of ADHD. In addition to assisting in diagnosis, checklists can be helpful in monitoring treatment changes once a diagnosis has been established.

TABLE
Descriptive characteristics of abbreviated symptom
checklists for ADHD

Scale                      Minutes        # Items         Age

ACTeRS                      5-10            25           5-12
Parent Version

ACTeRS                      5-10            24           5-12
Teacher Version

DSM-IV SNAP                 5-10            40           6-12

DSM-III-R                   5-10            38           6-12
SNAP

ADHD                          5             18           5-18
Rating Scale-IV

Conners Rating              5-10            27           3-17
Scale, Revised
(1997, Short
Version) (11,12,13)

Effect size

Scale                   Hyperactivity   Inattention   Impulsivity

ACTeRS                       1.5            2.0           NA
Parent Version

ACTeRS                       NA             NA            NA
Teacher Version

DSM-IV SNAP                  NA             NA            NA

DSM-III-R                  3.1-5.1        3.5-4.2       4.0-5.5
SNAP

ADHD                         1.1            1.2           1.1
Rating Scale-IV

Conners Rating               NA             NA            NA
Scale, Revised
(1997, Short
Version) (11,12,13)

Numbers reported in ranges indicate multiple studies.

ACTeRS, ADD-H Comprehensive Teacher Rating Scales; DSM, Diagnostic and
Statistical Manual of Mental Disorders; SNAP Swanson, Nolan, and
Pelham: ADHD, attention deficit/hyperactivity disorder; NA, not
available.

Any factor that inhibits the ability of an individual with asthma to recognize their symptoms appropriately may contribute to treatment delay, “near miss” events, and death during acute severe asthma. The purpose of this study was to investigate the effects of two common features of acute severe asthma-hypoxia and hypercapnia-on respiratory sensation. Sixteen individuals with stable asthma were exposed to three gas conditions (34 minutes each): isocapnic hypoxia (arterial blood O2 saturation of approximately 80%), hypercapnia (increase in end-tidal CO2 of approximately 5-10 Torr), or isocapnic normoxia on 3 separate days. The perceived magnitude of externally applied resistive loads, measured during each gas condition, was reduced throughout hypoxia compared with normoxia, and there was a trend for a progressive decline during hypercapnia. Within the 15-minutes postgas inhalation period, methacholine-induced symptoms of difficult breathing, chest tightness, and breathlessness, measured using modified Borg scales, were 25-30% lower after hypoxia compared with normoxia but were not reduced after hypercapnia. We conclude that 30 minutes of sustained hypoxia and possibly hypercapnia impair sensations of respiratory load and that the effects of hypoxia persist for at least 10 minutes after returning to normoxia.