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PubMed1995

Efficacy of acute treatment for geriatric depression.

The antidepressant literature for depression in late life tends to be interpreted as saying that certain antidepressant medications--e.g, nortriptyline, doxepin, fluoxetine--have fewer and milder side effects than others, whereas overall efficacy is equivalent (Plotkin et al., 1987; Rush, 1993; Salzman et al., 1995; Schneider, 1994). Further examination of this literature, however, suggests that both efficacy and side effect rates for any particular medication vary among trials, and often depend on the medications being compared, the use of placebo, the dose, and the design of the trial. In this report we review selected clinical trials, and summarize and discuss a previously published meta-analysis. Treatment recommendations from the 1991 NIH Consensus Development Conference on the Diagnosis and Treatment of Depression in Late Life and from the Agency for Health Care Policy Research are discussed. Directions for future research are suggested. Both antidepressant medications and brief structured psychotherapies have efficacy in the acute treatment of elderly depressed outpatients with major unipolar, nondelusional depression. Effective treatment for depression involves consideration of the type and severity of illness, adequate prescribing, patient education, and regular patient monitoring for compliance, symptom change, side effects, and intercurrent medical disorders, which may complicate antidepressant therapy.

Aged↗
PubMed1997

Benefit of screening mammography in women aged 40-49: a new meta-analysis of randomized controlled trials.

Eight randomized controlled trials (RCTs) of screening mammography have been conducted involving women aged 40-49 at entry. Current data are now available from these trials at 10.5 to 18 years of follow-up (average follow-up time: 12.7 years). Meta-analysis has been performed using a Mantel-Haenszel estimator method to combine current follow-up data from the eight RCTs of mammography that included women aged 40-49 at entry, including new follow-up data presented at the NIH Consensus Development Conference held January 21-23, 1997. Combining the most recent follow-up data on women aged 40-49 at entry into all eight RCTs yields a statistically significant 18% mortality reduction among women invited to screening mammography (relative risk: 0.82; 95% confidence interval: 0.71-0.95). Combining all current follow-up data on women aged 40-49 at entry into the five Swedish RCTs yields a statistically significantly 29% mortality reduction among women invited to screening (relative risk: 0.71; 95% confidence interval: 0.57-0.89). Meta-analysis including the most recent follow-up data from all eight RCTs involving women aged 40-49 at entry demonstrates for the first time a statistically significant mortality reduction due to regular screening mammography in women of this age group.

Adult↗
PubMed1987

Dental hygienists' knowledge, opinions, and use of pit and fissure sealants: a comparison of two states.

This article reports results of a study of 563 practicing Minnesota and Wisconsin dental hygienists' knowledge, opinions, and use of pit and fissure sealants. The study was carried out six months prior to the 1983 NIH Consensus Development Conference on Dental Sealants in the Prevention of Tooth Decay. It therefore provides baseline information for two states prior to the initiation of widespread public information about the positive value of sealants that occurred as a result of that conference. Such baseline information is relevant for future studies of the diffusion of adoption of this caries-preventive technology by dental hygienists. Two independent samples were selected randomly from the populations of licensed dental hygienists residing in the two states. Data were collected using a 42-item mailed questionnaire, with an 84 percent response. Data were analyzed for both interstate and intrastate comparisons. Respondents were generally knowledgeable and had favorable opinions about sealants, although they had low levels of training in their use. Sealants were being used in 54 percent of the offices in which respondents practiced, with the dentist placing them most often. Among hygienists who applied sealants at all, more than two-thirds did so three or fewer times per week. Eighty-four percent indicated they would like to apply sealants more often. The most frequent reasons given for nonuse were lack of acceptance by the dentist-employer and nondelegation.

Adolescent↗
PubMed2001

Chronic depression in the elderly: approaches for prevention.

Depression in old age frequently follows a chronic and/or relapsing course, related to medical comorbidity, cognitive impairment and depletion of psychosocial resources. As endorsed by the US National Institutes of Health (NIH) Consensus Development Conference on the Diagnosis and Treatment of Late Life Depression, a major goal of treatment is to prevent relapse, recurrence and chronicity. We believe that most, if not all, elderly patients with major depressive episodes are appropriate candidates for maintenance therapy, because of the vulnerability to relapse and recurrence and because of the favourable benefit to risk ratio of available treatments. Antidepressant pharmacotherapy is the mainstay of this therapeutic goal, but psychosocial approaches (especially interpersonal psychotherapy) have also been shown to contribute significantly to prevention of a chronic depressive illness and to prevention of the disability that attends depression. Studies published to date have established the long term or maintenance efficacy of the tricyclic antidepressant nortriptyline. Current, ongoing studies are addressing the maintenance efficacy of paroxetine and citalopram to prolong recovery in depression associated with old age. These studies are focusing particularly on patients aged 70 years and above, who are at high risk of recurrence, and on patients in primary care settings, where under-recognition and under-treatment of depression in the elderly have been costly from a public health perspective in terms of increased medical utilisation, burden to patients and families, and high rates of suicide. Depression in old age is a major contributor to the global burden of illness-related disability, but it is extremely treatable if appropriate pharmacotherapy is prescribed and accepted by patients and their caregivers.

Aged↗
PubMed2001

Present state and future prospects: a review of cooperative groups' adjuvant and neoadjuvant trials in breast cancer.

In patients with operable breast cancer, adjuvant hormonal therapy and adjuvant chemotherapy result in significant and long-term reductions in the rates of disease recurrence and death. These reductions are evident in both patients with node-negative as well as in those with node-positive disease. However, several issues in the adjuvant treatment of breast cancer still remain unresolved. These issues were recently considered at the 2000 National Institutes of Health (NIH) Consensus Development Conference, which reviewed the current state of knowledge on adjuvant therapy and outlined strategies for future research. In the area of adjuvant hormonal therapy, tamoxifen is still the gold standard, and present evidence supports the use of tamoxifen for patients with estrogen receptor (ER)-positive tumors irrespective of age, menopausal status, nodal status, or tumor size. Optimal duration of tamoxifen therapy is about 5 years. Future research directions include evaluating the benefit of extending tamoxifen beyond 5 years, the contribution of ovarian ablation, and the role of hormonal manipulations involving selective ER modulators and aromatase inhibitors instead of or in addition to tamoxifen. In the area of adjuvant chemotherapy, polychemotherapy regimens have been consistently found to be superior to single agents, and anthracycline-containing regimens produce a small but statistically significant improvement in survival when compared with regimens not containing an anthracycline. High-dose adjuvant chemotherapy with stem cell support has not been proven superior to standard regimens. Neoadjuvant therapy offers the possibility of testing in vivo the sensitivity of individual tumors to particular cytotoxic regimens and, hence, of improving ultimate disease control, as well as reducing the extent of local therapy. The contribution and optimal integration of taxanes in the adjuvant setting are yet to be established but are the subject of intense research effort. Similarly, novel targeted therapies such as trastuzumab and bisphosphonates are currently being evaluated in adjuvant studies

Antineoplastic Agents, Hormonal↗
PubMedDate not supplied

Acupuncture.

OBJECTIVE: The objective of this NIH Consensus Statement is to inform the biomedical research and clinical practice communities of the results of the NIH Consensus Development Conference on Acupuncture. The statement provides state-of-the-art information regarding the appropriate use of acupuncture, and presents the conclusions and recommendations of the consensus panel regarding these issues. In addition, the statement identifies those areas of study that deserve further investigation. Upon completion, the reader should possess a clear working clinical knowledge of the state-of-the-art regarding this topic. The target audience of physicians for this statement includes, but is not limited to, family practitioners, medical acupuncturists, psychiatrists, and specialists in pain medicine. PARTICIPANTS: A non-Federal, nonadvocate, 12-member panel representing the fields of acupuncture, pain, psychology, psychiatry, physical medicine and rehabilitation, drug abuse, family practice, internal medicine, health policy, epidemiology, statistics, physiology, biophysics, and the public. In addition, 25 experts from these same fields presented data to the panel and a conference audience of 1,200. EVIDENCE: The literature was searched through Medline, and an extensive bibliography of references was provided to the panel and the conference audience. Experts prepared abstracts with relevant citations from the literature. Scientific evidence was given precedence over clinical anecdotal experience. CONSENSUS PROCESS: The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented in open forum and the scientific literature. The panel composed a draft statement, which was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the World Wide Web immediately following its release at the conference and was updated with the panel's final revisions. CONCLUSIONS: Acupuncture as a therapeutic intervention is widely practiced in the United States. While there have been many studies of its potential usefulness, many of these studies provide equivocal results because of design, sample size, and other factors. The issue is further complicated by inherent difficulties in the use of appropriate controls, such as placebos and sham acupuncture groups. However, promising results have emerged, for example, showing efficacy of acupuncture in adult postoperative and chemotherapy nausea and vomiting and in postoperative dental pain. There are other situations such as addiction, stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome, and asthma, in which acupuncture may be useful as an adjunct treatment or an acceptable alternative or be included in a comprehensive management program. Further research is likely to uncover additional areas where acupuncture interventions will be useful.

Acupuncture Analgesia↗
PubMed2001

Radiographic diagnosis of dental caries.

The purpose of this report was to respond to aspects of the RTI/UNC systematic review relating to the radiographic diagnosis of dental caries. The systematic review was commissioned as part of the NIH Consensus Development Conference on Diagnosis and Management of Dental Caries Throughout Life. The systematic review evaluated the dental literature from 1966 to 1999. Well-defined search criteria along with clear inclusion and exclusion criteria were used to perform the review. Some of the inclusion and exclusion criteria used in the systematic review may have limited the evidence supporting the use of radiography, especially for the diagnosis of proximal surface caries. The RTI/UNC review only included studies in which sensitivity and specificity were reported or could be derived from the data presented. Studies that used the receiver operating characteristic as a measure of diagnostic accuracy were not included. Although the strength of evidence is considered poor, this does not mean that the use of radiographic methods is of no diagnostic value. It simply means that, using the criteria established by the systematic review, the evidence is inadequate to validate the method. Guidelines should be developed for assessing diagnostic methods that assist researchers in developing study designs that will hold up to critical review.

Bicuspid↗
PubMedDate not supplied

[A rare case of nerve-sheath sarcoma with rhabdomyoblastic differentiation (malignant triton tumor)].

Malignant peripheral nerve sheath tumors (MPNST) are spindle-cell sarcomas that appear in a setting of neurofibroma or schwannoma or are associated with peripheral nerves or demonstrate nerve sheath differentiation. Malignant triton tumor (MTT) is a subtype of MPNST that also contain tissue with skeletal muscle differentiation (embryonal, plemorphic and botryoid rhabdomyosarcoma). The estimated incidence of MPNSTs in patients with NF1 is 2-5% compared with 0.0001% in the general population and approximately 69% of the reported cases of MTT are associated with von Recklinghausen disease. In July 2002 a 37-year old man was readmitted to the Department of Oncologic Surgery of the S. Camillo-Forlanini Hospital in Rome for both a right-sided retroperitoneal paravertebral not palpable mass, incidentally detected at a follow-up MRI, and a left-sided popliteal mass, discovered at clinical evaluation. Seventeen months before, when the patient underwent surgery at the same Department for both a left-sided paravertebral inferior mediastinal neurofibroma and a right-sided axillary neurofibroma, diagnosis of von Recklinghausen disease (NF1) was made, according to the criteria established by the NIH Consensus Development. Conference on Neurofibromatosis of 1987. A xifopubic laparotomy was performed: the tumor appeared to be localized, well-capsulated and strictly associated to the lumbar and sacral nervous radicles (L4, L5, S1) without evidence of invasion. The tumor was completely resected with sparing of the psoas muscle and the lumbar plexus through a subperineural dissection technique. No intra-operative pathologic examination was performed. Postoperative pathologic findings showed evidence for a trition tumor. The popliteal mass was resected too and resulted to be a neurofibroma just like the tumors resected 17 months before when diagnosis of von Recklinghausen disease was made. The patient was disease free 6 months after initial surgery. Sarcoma arising in anatomic site other than extremity and superficial trunk are often more difficult to control because of anatomic constraints, delayed disease presentation, proximity to neurovascular and osseous structures and toxicity for normal adjacent tissues that limits the use of adequate radiation doses. Indeed, the anatomic site is an important prognostic factor in STS and the prognosis for retroperitoneal tumors is considerably worse than for extremity tumors. Reported local recurrence rates for retroperitoneal sarcomas range from 40% to 80% and, in marked contrast to extremity STS, most of patients can and do die from local recurrence in the absence of metastasis. In contrast to the benefit most patients with high grade soft tissue sarcomas of the extremities receive from adjuvant radiation and chemotherapy, these modalities have been of little value for retroperitoneal tumors. To overcome the problem of dose limitation, intraoperative electron beam radiotherapy (IORT) in combination with ERBT has been proposed. IORT plus ERBT was found to improve local control of disease in recent clinical trials. Current chemotherapy for retroperitoneal sarcomas is ineffective. Local adjuvant therapy such as intraperitoneal chemotherapy or experimental immunotherapy seems to be attractive in theory, but needs further investigations through prospective randomized multicentric trials. In conclusion, to date aggressive surgical management remains the most effective modality for selected primary and recurrent retroperitoneal soft tissue sarcomas including MPNSTs and the subtype MTT. Patients with incomplete resection and other risk factors such as younger age and high grade tumors may be suitable candidates for investigational adjuvant therapy.

Adult↗
PubMed2006

[Primary hyperparathyroidism].

Primary hyperparathyroidism is the most frequent cause of hypercalcemia in ambulatory patients. Elevated serum parathyroid hormone in the presence of persistent hypercalcemia is the diagnostic sine qua non for primary hyperthyroidism. Since examination of serum calcium became a routine diagnostic test, most patients with primary hyperparathyroidism are asymptomatic at the time of diagnosis. Primary hyperparathyroidism in most of patients is caused by parathyroid adenoma, and parathyroid hyperplasia and cancer are rare causes of the disorder. Parathyroidectomy is the primary treatment of choice for primary hyperparathyroidism by any cause. Parathyroidectomy should be performed in most of patients with primary hyperparathyroidism, but asymptomatic or only mildly hypercalcemic patients are treated according to the guidelines for surgical treatment established by the NIH Consensus Development Conference in 2002. For patients with osteoporosis who are not indicated for or decline surgical procedures can be treated with bisphosphonates.

Humans↗
PubMed1990

[Fats in the diet].

The importance of nutritional fats as a source of energy declined in the past in industrialized countries due to a decrease of physical activity. On the other hand the association between the intake of particular fats and the development of cardiovascular diseases is generally accepted. Thus, some scientific societies (American Heart Association, NIH Consensus Development Conference) recommend a maximal intake of 30% of total energy by fats. In regards to the quality of fats and their effect on blood levels of lipoproteins, it is accepted that large amounts of polyunsaturated fatty acids lower increased blood levels of low density lipoproteins; however, they lower in a small extent also the antiatherogenic high-density lipoprotein (HDL) particles. Monounsaturated fatty acids also tend to lower increased LDL, without any lowering effect on HDL, W-3-fatty acids (mainly from fish oil) lower increased triglyceride levels and therefore are used a therapeutic dietary regimen. However, their long-term effects are not quite well known.

Cardiovascular Diseases↗
PubMedDate not supplied

Building strong bones in childhood and adolescence: reducing the risk of fractures in later life.

The current focus on reducing the risk of osteoporosis and skeletal fractures in later life has placed an emphasis on the role of calcium in building strong bones during childhood and adolescence. Recent National Institutes of Health (NIH) Consensus Development Conference recommendations for optimal calcium intake encourage increased intake. Strategies to enhance optimal calcium intake in children and adolescents include dietary choices and the use of supplements.

Adolescent↗
PubMed1991

NIH conference. Gastrointestinal surgery for severe obesity. Consensus Development Conference Panel.

Surgeons, gastroenterologists, endocrinologists, psychiatrists, nutritionists, and other health care professionals, as well as members of the public convened to address nonsurgical treatments for severe obesity, surgical treatments for severe obesity, and criteria for selection, the efficacy, and risks of surgical treatments for severe obesity, and the need for future research on and epidemiologic evaluation of these therapies. The National Institutes of Health Consensus Development Panel recommended that patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program that integrates a dietary regimen, appropriate exercise, behavior modification, and psychological support; that gastric restrictive or bypass procedures could be considered for well-informed and motivated patients in whom the operative risks were acceptable; that patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise; that surgery be done by a surgeon who has substantial experience in the particular procedure and who works in a clinical setting with adequate support for all aspects of management and assessment; and that patients undergo lifelong medical surveillance after surgery.

Digestive System Surgical Procedures↗
PubMed1999

Consensus conference. Rehabilitation of persons with traumatic brain injury. NIH Consensus Development Panel on Rehabilitation of Persons With Traumatic Brain Injury.

OBJECTIVE: To provide biomedical researchers and clinicians with information regarding and recommendations for effective rehabilitation measures for persons who have experienced a traumatic brain injury (TBI). PARTICIPANTS: A nonfederal, nonadvocate, 16-member panel representing the fields of neuropsychology, neurology, psychiatry, behavioral medicine, family medicine, pediatrics, physical medicine and rehabilitation, speech and hearing, occupational therapy, nursing, epidemiology, biostatistics, and the public. In addition, 31 experts from these same fields presented data to the panel and a conference audience of 883 members of the public. The conference consisted of (1) presentations by investigators working in areas relevant to the consensus questions during a 2-day public session; (2) questions and statements from conference attendees during open discussions that were part of the public session; and (3) closed deliberations by the panel during the remainder of the second day and part of the third. Primary sponsors of the conference were the National Institute of Child Health and Human Development and the National Institutes of Health Office of Medical Applications of Research. EVIDENCE: The literature was searched through MEDLINE for articles from January 1988 through August 1998 and an extensive bibliography of 2563 references was provided to the panel and the conference audience. Experts prepared abstracts for their conference presentations with relevant citations from the literature. The panel prepared a compendium of evidence, including a patient contribution and reports from federal agencies. Scientific evidence was given precedence over clinical anecdotal experience. CONSENSUS PROCESS: The panel, answering predefined questions, developed their conclusions based on the scientific evidence presented during the open forum (October 26-28, 1998) and in the scientific literature. The panel composed a draft statement that was read in its entirety and circulated to the experts and the audience for comment. Thereafter, the panel resolved conflicting recommendations and released a revised statement at the end of the conference. The panel finalized the revisions within a few weeks after the conference. The draft statement was made available on the Internet immediately following its release at the conference and was updated with the panel's final revisions. CONCLUSIONS: Traumatic brain injury results principally from vehicular incidents, falls, acts of violence, and sports injuries and is more than twice as likely to occur in men as in women. The estimated incidence rate is 100 per 100000 persons, with 52000 annual deaths. The highest incidence is among persons aged 15 to 24 years and 75 years or older, with a less striking peak in incidence in children aged 5 years or younger. Since TBI may result in lifelong impairment of physical, cognitive, and psychosocial functioning and prevalence is estimated at 2.5 million to 6.5 million individuals, TBI is a disorder of major public health significance. Mild TBI is significantly underdiagnosed and the likely societal burden is therefore even greater. Given the large toll of TBI and absence of a cure, prevention is of paramount importance. However, the focus of this conference was the evaluation of rehabilitative measures for the cognitive and behavioral consequences of TBI. Evidence supports the use of certain cognitive and behavioral rehabilitation strategies for individuals with TBI. This research needs to be replicated in larger, more definitive clinical trials and, thus, funding for research on TBI needs to be increased.

Adolescent↗
PubMed1991

NIH conference. Diagnosis and management of asymptomatic primary hyperparathyroidism: consensus development conference statement.

Endocrinologists, surgeons, radiologists, epidemiologists, and primary health care providers convened to address both indications for surgery in asymptomatic patients with hyperparathyroidism as well as how patients who do not have surgery should be monitored and managed to minimize the risk for complications. The National Institutes of Health Consensus Development Conference Panel concluded that a diagnosis of hyperparathyroidism is established by showing persistent hypercalcemia and an elevated serum parathyroid hormone concentration; that the current and acceptable treatment for hyperparathyroidism is surgery; that the diagnosis of hyperparathyroidism in an asymptomatic patient does not in all cases mandate referral for surgery; that conscientious surveillance may be justified in patients whose calcium levels are only mildly elevated and whose renal and bone status are close to normal; and that preoperative localization in patients without previous neck operation is rarely indicated and has not proved to be cost effective.

Clinical Laboratory Techniques↗