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Biomedical subjects

Larry Culpepper

Publications and source records attributed to Larry Culpepper.

At least 19 recordsLinked to original sources
PubMed2004

Clinical practice guideline: Otitis media with effusion.

The clinical practice guideline on otitis media with effusion (OME) provides evidence-based recommendations on diagnosing and managing OME in children. This is an update of the 1994 clinical practice guideline "Otitis Media With Effusion in Young Children," which was developed by the Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality). In contrast to the earlier guideline, which was limited to children aged 1 to 3 years with no craniofacial or neurologic abnormalities or sensory deficits, the updated guideline applies to children aged 2 months through 12 years with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The American Academy of Pediatrics, American Academy of Family Physicians, and American Academy of Otolaryngology-Head and Neck Surgery selected a subcommittee composed of experts in the fields of primary care, otolaryngology, infectious diseases, epidemiology, hearing, speech and language, and advanced practice nursing to revise the OME guideline. The subcommittee made a strong recommendation that clinicians use pneumatic otoscopy as the primary diagnostic method and distinguish OME from acute otitis media (AOM). The subcommittee made recommendations that clinicians should (1) document the laterality, duration of effusion, and presence and severity of associated symptoms at each assessment of the child with OME; (2) distinguish the child with OME who is at risk for speech, language, or learning problems from other children with OME and more promptly evaluate hearing, speech, language, and need for intervention in children at risk; and (3) manage the child with OME who is not at risk with watchful waiting for 3 months from the date of effusion onset (if known), or from the date of diagnosis (if onset is unknown). The subcommittee also made recommendations that (4) hearing testing be conducted when OME persists for 3 months or longer, or at any time that language delay, learning problems, or a significant hearing loss is suspected in a child with OME; (5) children with persistent OME who are not at risk should be reexamined at 3- to 6-month intervals until the effusion is no longer present, significant hearing loss is identified, or structural abnormalities of the eardrum or middle ear are suspected; and (6) when a child becomes a surgical candidate, tympanostomy tube insertion is the preferred initial procedure. Adenoidectomy should not be performed unless a distinct indication exists (nasal obstruction, chronic adenoiditis); repeat surgery consists of adenoidectomy plus myringotomy, with or without tube insertion. Tonsillectomy alone or myringotomy alone should not be used to treat OME. The subcommittee made negative recommendations that (1) population-based screening programs for OME not be performed in healthy, asymptomatic children and (2) antihistamines and decongestants are ineffective for OME and should not be used for treatment; antimicrobials and corticosteroids do not have long-term efficacy and should not be used for routine management. The subcommittee gave as options that (1) tympanometry can be used to confirm the diagnosis of OME and (2) when children with OME are referred by the primary clinician for evaluation by an otolaryngologist, audiologist, or speech-language pathologist, the referring clinician should document the effusion duration and specific reason for referral (evaluation, surgery), and provide additional relevant information such as history of AOM and developmental status of the child. The subcommittee made no recommendations for (1) complementary and alternative medicine as a treatment for OME based on a lack of scientific evidence documenting efficacy and (2) allergy management as a treatment for OME based on insufficient evidence of therapeutic efficacy or a causal relationship between allergy and OME. Last, the panel compiled a list of research needs based on limitations of the evidence reviewed. The purpose of this guideline is to inform clinicians of evidence-based methods to identify methods to identify, monitor, and manage OME in children aged 2 months through 12 years. The guideline may not apply to children older than 12 years because OME is uncommon and the natural history is likely to differ from younger children who experience rapid developmental change. The target population includes children with or without developmental disabilities or underlying conditions that predispose to OME and its sequelae. The guideline is intended for use by providers of health care to children, including primary care and specialist physicians, nurses and nurse practitioners, physician assistants, audiologists, speech-language pathologists, and child development specialists. The guideline is applicable to any setting in which children with OME would be identified, monitored, or managed. This guideline is not intended as a sole source of guidance in evaluating children with OME. Rather, it is designed to assist primary care and other clinicians by providing an evidence-based framework for decision-making strategies. It is not intended to replace clinical judgment or establish a protocol for all children with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Acoustic Impedance Tests↗
PubMed2004

The views of U.S. medical school deans toward academic primary care.

PURPOSE: To understand the views of U.S. medical school deans about their primary care faculties. METHOD: In 2000, the authors mailed a questionnaire containing 43 multipart items to deans of 130 U.S. allopathic medical schools. The questionnaire assessed the deans' attitudes about and evaluation of primary care at their school and their school's efforts to strengthen it. Deans were asked to compare family medicine, general internal medicine, and general pediatrics with nonprimary care clinical departments at their schools. RESULTS: Of the 83 (64%) deans who responded, 82% reported their school had departments or divisions of family medicine, general internal medicine, and general pediatrics. Deans rated general internal medicine and general pediatrics higher than nonprimary care faculty on clinical expertise and productivity (p < .001) and family medicine equivalent to nonprimary care faculty. Deans rated all three primary care faculties superior to nonprimary care faculty for teaching skills (p < .001) and programs (p < .05), but lower than nonprimary care disciplines for research productivity (p < .01) and revenues (p < .001). They rated family medicine and general pediatrics lower for research skills (p < .001), but 73% of deans stated research was equally important for primary care and nonprimary care departments. Deans considered overall financial resources to be equivalent for primary care and nonprimary care departments, but 77% of deans felt primary care departments or divisions needed financial support from the medical school to survive. Most deans attempted to strengthen primary care by changing the curriculum to promote primary care and by providing financial support. CONCLUSIONS: Deans ranked primary care faculty high on clinical and teaching measures. Although they considered research to be an important activity for primary care faculty, they evaluated it low relative to nonprimary care departments.

Administrative Personnel↗
PubMed2004

Chronicity in posttraumatic stress disorder and predictors of the course of posttraumatic stress disorder among primary care patients.

The present study examined the course of posttraumatic stress disorder (PTSD) in a sample of 84 primary care patients. More specifically, this study investigated the role of Axis I comorbidity, psychosocial impairment, and treatment participation in the maintenance of an episode of chronic PTSD and whether patients at follow-up met criteria for PTSD (full remission) or continued to exhibit residual PTSD symptoms and impairment (partial PTSD). Diagnostic structured interviews established all clinical diagnoses and information on the course of anxiety disorder symptoms, psychosocial functioning, and treatment status. Using a prospective, longitudinal design, this study found that during the first 2 years of follow-up, the probability of no longer meeting full DSM-IV criteria for PTSD was .69, and .18 for full remission from PTSD. The number of comorbid anxiety disorders and degree of psychosocial impairment at intake were significantly related to remission status (i.e., full and partial PTSD). This study suggests that, in a primary care setting, PTSD is a persistent illness, and that many subjects who have recovered from PTSD continue to suffer from subthreshold symptoms of PTSD.

Adult↗
PubMed2004

Suicidality as a Possible Side Effect of Antidepressant Treatment.

PHYSICIANS RESPOND TO THE FDA PUBLIC HEALTH ADVISORY ON WORSENING DEPRESSION AND SUICIDALITY IN PATIENTS BEING TREATED WITH ANTIDEPRESSANTS: On March 22, 2004, the U.S. Food and Drug Administration (FDA) issued a health advisory informing the public that manufacturers of several popular antidepressants have been asked to include a warning statement on product labeling. This warning statement recommends that antidepressant-treated patients-both children and adults-should be closely monitored for worsening of depression or emergence of suicidal behavior. The full text of the advisory, along with supporting information and presentations from the February 2004 meeting on which this advisory was based, can be found on the FDA's Web site at http://www.fda.gov/cder/drug/antidepressants/default.htm. Recently, the CME Institute, as a service to its members-you, the readers of this journal-and Larry Culpepper, M.D., Editor in Chief of the Primary Care Companion, assembled a group of psychiatrists and primary care physicians to discuss the FDA advisory and advise clinicians how it will affect their treatment of depressed patients. Their discussion and recommendations appear here. Faculty affiliations and disclosures appear at the end of this Commentary.

Journal Article↗
PubMed2004

Identifying and treating panic disorder in primary care.

Many individuals who experience a panic attack at some point in their lives will meet criteria for panic disorder. However, although most primary care physicians recognize broad-spectrum mood and anxiety disorders, they may not make a specific diagnosis such as major depressive disorder or panic disorder. Comorbid panic disorder and other anxiety conditions are a well-established phenomenon in depressive disorders and can have a negative impact on treatment and worsen prognosis. This negative impact underscores the importance of specifically identifying these disorders and their comorbidities. Although an analysis of other potential causes of presenting symptoms is at times indicated, diagnosis should be made positively by identifying the symptoms diagnostic of the anxiety conditions rather than negatively by eliminating other conditions. Treatment of patients with panic disorder can improve quality of life and productivity as well as reduce health care costs. Pharmacotherapy, cognitive-behavioral therapy, and collaborative relationships with patients and psychiatrists can all aid primary care physicians in providing acute and long-term treatment for patients with panic as well as other mood and anxiety disorders.

Humans↗
PubMed2003

Mental health treatment received by primary care patients with posttraumatic stress disorder.

BACKGROUND: Posttraumatic stress disorder (PTSD) is receiving growing attention as a pervasive and impairing disorder but is still undertreated. Our purpose was to describe the characteristics of mental health treatment received by primary care patients diagnosed with PTSD. METHOD: 4383 patients from 15 primary care, family practice, or internal medicine clinics were screened for anxiety symptoms using a self-report questionnaire developed for the study. Those found positive for anxiety symptoms (N = 539) were interviewed with the Structured Clinical Interview for DSM-IV. Of these patients, 197 met diagnostic criteria for PTSD and were examined in the present study regarding the rates and types of mental health treatment they were currently receiving. Data were gathered from July 1997 to May 2001. RESULTS: Nearly half (48%) of the patients in general medical practice with PTSD were receiving no mental health treatment at the time of intake to the study. Of those receiving treatment, psychopharmacologic interventions were most common. Few patients were receiving empirically supported psychosocial interventions. Current comorbid major depressive disorder and current comorbid panic disorder with agoraphobia were significantly associated with receiving mental health treatment (major depressive disorder, p <.10; panic disorder with agoraphobia, p <.05). The most common reason patients gave for not receiving medication was the failure of physicians to recommend such treatment, which was also among the most common reasons for not receiving psychosocial treatment. CONCLUSIONS: Despite the morbidity, psychosocial impairment, and distress associated with PTSD, substantial proportions of primary care patients with the disorder are going untreated or are receiving inadequate treatment. Results suggest a need for better identification and treatment of PTSD in the primary care setting.

Adult↗
PubMed2003

Use of algorithms to treat anxiety in primary care.

The presentations of anxiety in primary care are more numerous and broader in spectrum than the presentations of depression, and the primary care physician is often faced with the challenge of teasing out a diagnosis from the full spectrum of anxiety disorders. A treatment algorithm that begins with recognition and diagnosis and carries the primary care physician and patient through long-term treatment and, finally, withdrawal of treatment can be a useful and appropriate tool. Use of an algorithm targeted specifically for primary care physicians treating patients with anxiety disorders would insure that patients in the primary care setting receive the best care during treatment of anxiety disorders, while primary care physicians become better able to serve a broader community.

Algorithms↗
PubMed2002

Nonpsychiatric illness among primary care patients with trauma histories and posttraumatic stress disorder.

OBJECTIVE: The authors examined the relationship between posttraumatic stress disorder (PTSD), trauma, and self-reported nonpsychiatric medical conditions in a sample of 502 primary care patients with one or more anxiety disorders. METHODS: Primary care patients with one or more DSM-IV anxiety disorders were assessed for comorbid psychiatric and substance use problems and for a history of trauma. These individuals also completed a self-report measure of current and lifetime medical conditions, lifetime tobacco use, and current regular exercise. RESULTS: Of 502 participants with at least one anxiety disorder, 84 (17 percent) reported no history of trauma, 233 (46 percent) had a history of trauma but no PTSD, and 185 (37 percent) met DSM-IV criteria for PTSD. Patients with PTSD reported a significantly greater number of current and lifetime medical conditions than did participants with other anxiety disorders but without PTSD. Primary care patients with PTSD were more likely to have had a number of specific medical problems, including anemia, arthritis, asthma, back pain, diabetes, eczema, kidney disease, lung disease, and ulcer. Possible explanations for the greater rates of medical conditions among participants with PTSD were examined as predictors in multiple regression. PTSD was found to be a stronger predictor of reported number of medical problems than trauma history, physical injury, lifestyle factors, or comorbid depression. CONCLUSIONS: These findings suggest that PTSD is associated with a higher rate of general medical complaints.

Adult↗