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Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes.

BACKGROUND: Depression is common in primary care but is suboptimally managed. Collaborative care, that is, structured care involving a greater role of nonmedical specialists to augment primary care, has emerged as a potentially effective candidate intervention to improve quality of primary care and patient outcomes. METHODS: To quantify the short-term and longer-term effectiveness of collaborative care compared with standard care and to understand mechanisms of action by exploring between-study heterogeneity, we conducted a systematic review of randomized controlled trials that compared collaborative care with usual primary care in patients with depression. We searched MEDLINE (from the beginning of 1966), EMBASE (from the beginning of 1980), CINAHL (from the beginning of 1980), PsycINFO (from the beginning of 1980), the Cochrane Library (from the beginning of 1966), and DARE (Database of Abstracts of Reviews of Effectiveness) (from the beginning of 1985) databases from study inception to February 6, 2006. RESULTS: We found 37 randomized studies including 12 355 patients with depression receiving primary care. Random effects meta-analysis showed that depression outcomes were improved at 6 months (standardized mean difference, 0.25; 95% confidence interval, 0.18-0.32), and evidence of longer-term benefit was found for up to 5 years (standardized mean difference, 0.15; 95% confidence interval, 0.001-0.31). When exploring determinants of effectiveness, effect size was directly related to medication compliance and to the professional background and method of supervision of case managers. The addition of brief psychotherapy did not substantially improve outcome, nor did increased numbers of sessions. Cumulative meta-analysis showed that sufficient evidence had emerged by 2000 to demonstrate the statistically significant benefit of collaborative care. CONCLUSIONS: Collaborative care is more effective than standard care in improving depression outcomes in the short and longer terms. Future research needs to address the implementation of collaborative care, particularly in settings other than the United States.

Confidence Intervals↗

Supportive care for patients with Guillain-Barré syndrome.

A multidisciplinary consensus group searched MEDLINE from 1966 to May 2003, extracted relevant references, and prepared recommendations on supportive care for Guillain-Barré syndrome. In the absence of randomized controlled trials, we agreed on recommendations by consensus based on observational studies and expert opinion. In the acute phase in bed-bound adult patients, the group recommended the use of heparin and graduated pressure stockings to prevent deep vein thrombosis, monitoring for blood pressure, pulse, autonomic disturbances, and respiratory failure, and the timely institution of artificial ventilation and tracheostomy. Pain management is difficult, but carbamazepine or gabapentin may help. The cautious use of narcotic analgesics may be needed. Disabled patients should be treated by a multidisciplinary rehabilitation team and should receive an assistive exercise program. Persistent fatigue following Guillain-Barré syndrome is common and may be helped by an exercise program. Because of a very small and possibly only theoretical increase in the risk of recurrence following immunization, the need for immunization should be reviewed on an individual basis. More research is needed to identify optimal methods for all aspects of supportive care.

Autonomic Nervous System Diseases↗

Laparoscopic cholecystectomy. A statewide experience. The Connecticut Laparoscopic Cholecystectomy Registry.

The explosion in laparoscopic cholecystectomy has posed many questions about its safety compared with the "gold standard" of open cholecystectomy. A statewide database was established in Connecticut to study these issues. Thirty-three (97%) of 34 hospitals in Connecticut participated in the study, which began at the inception of the laparoscopic procedure. Four thousand six hundred forty laparoscopic cholecystectomies were performed between May 1, 1990, and September 30, 1991. The overall conversion rate to open cholecystectomy was 6.9%. Conversions were more frequent with acute cholecystitis, in the elderly, and early in a surgeon's experience. The overall technical complication rate was 4.7%; common bile duct injuries occurred in 15 patients (0.3%). Complications decreased with increasing experience, to 0.98% after a surgeon's 75th procedure. Six patients (0.13%) died following laparoscopic cholecystectomy. The overall mortality rate associated with cholecystectomy fell during the study period. The frequency of cholecystectomy in Connecticut increased 29% with the advent of the laparoscopic procedure. The introduction of laparoscopic cholecystectomy has resulted in an increased frequency of surgery without an increase in surgical mortality. The incidence of common bile duct injuries was low. The decreasing incidence of technical complications demonstrates the learning curve for the procedure.

Adult↗

When authorship fails. A proposal to make contributors accountable.

A published article is the primary means whereby new work is communicated, priority is established, and academic promotion is determined. Publication depends on trust and requires that authors be held to standards of honesty, completeness, and fairness in their reporting, and to accountability for their statements. The system of authorship, while appropriate for articles with only 1 author, has become inappropriate as the average number of authors of an article has increased; as the work of coauthors has become more specialized and relationships between them have become more complex; and as both credit and, even more, responsibility have become obscured and diluted. Credit and accountability cannot be assessed unless the contributions of those named as authors are disclosed to readers, so the system is flawed. We argue for a radical conceptual and systematic change, to reflect the realities of multiple authorship and to buttress accountability. We propose dropping the outmoded notion of author in favor of the more useful and realistic one of contributor. This requires disclosure to readers of the contributions made to the research and to the manuscript by the contributors, so that they can accept both credit and responsibility. In addition, certain named contributors take on the role of guarantor for the integrity of the entire work. The requirement that all participants be named as contributors will eliminate the artificial distinction between authors and acknowledgees and will enhance the integrity of publication.

Authorship↗

Sleepiness, driving, and motor vehicle crashes. Council on Scientific Affairs, American Medical Association.

OBJECTIVE: To assess the contribution of driver sleepiness to highway crashes and review recent recommendations to change federal hours-of-service regulations for commercial motor vehicle drivers. DATA SOURCES: Information was derived from a search of the MEDLINE, Transportation Research Information Service (TRIS), and Bibliographic Electronic Databases of Sleep (BEDS) databases from 1975 through 1997 and from manual review of the reference lists in relevant journal articles, government publications, conference proceedings, and textbooks. DATA SYNTHESIS: Driver sleepiness is a causative factor in 1% to 3% of all US motor vehicle crashes. Surveys of the prevalence of sleepy behavior in drivers suggest that sleepiness may be a more common cause of highway crashes than is reflected in these estimates. About 96% of sleep-related crashes involve passenger vehicle drivers and 3% involve drivers of large trucks. Risk factors include youth, shift work, alcohol and other drug use, over-the-counter and prescription medications, and sleep disorders. CONCLUSIONS: Increased awareness of the relationship between sleepiness and motor vehicle crashes will promote the health and safety of drivers and highway users. Physicians can contribute by encouraging good sleep habits, recognizing and treating sleep-related problems, and counseling patients about the risks of driving while sleepy. To protect public health and safety, the American Medical Association recommends continued research on devices and technologies to detect the signs of sleepiness and prevent the deterioration of driver alertness and performance. Educational programs about the risks of falling asleep while driving are needed for physicians, the public, and commercial truck drivers.

Accidents, Traffic↗

Mapping the evidence base of pathology.

Evidence-based medicine (EBM) is a paradigm that is beginning to exert an influence in related fields such as surgery, general practice, psychiatry, and now pathology. For example, a survey has shown that 70 per cent of therapeutic interventions in clinical haematology delivered in a district general hospital were based on research-derived evidence. A prerequisite to evidence-based pathology is availability of, and access to, the evidence base. As a discipline, pathology has certain characteristics that makes information retrieval more challenging. Nevertheless, a number of evidence-seeking techniques can be utilized to maximize the chances of success: focusing the question, use of an evidence-seeking protocol, and application of methodological filters. A number of key information sources are reviewed for their usefulness and a comparison is made with the yield from the World Wide Web. Conclusions are drawn from an example of the evidence-seeking process based on a clinical scenario involving immune thrombocytopenic purpura.

Databases, Bibliographic↗

The Medline/full-text research project.

This project was designed to test the relative efficacy of index terms and full-text for the retrieval of documents in those MEDLINE journals for which full-text searching was also available. The full-text files used were MEDIS from Mead Data Central and CCML from BRS Information Technologies. One hundred clinical medical topics were searched in these two files as well as the MEDLINE file to accumulate the necessary data. It was found that full-text identified significantly more relevant articles than did the indexed file, MEDLINE. The full-text searches, however, lacked the precision of searches done in the indexed file. Most relevant items missed in the full-text files, but identified in MEDLINE, were missed because the searcher failed to account for some aspect of natural language, used a logical or positional operator that was too restrictive, or included a concept which was implied, but not expressed in the natural language. Very few of the unique relevant full-text citations would have been retrieved by title or abstract alone. Finally, as of July, 1990 the more current issue of a journal was just as likely to appear in MEDLINE as in one of the full-text files.

Abstracting and Indexing↗

Relative size of the literatures for psychopathological disorders: number of articles pertaining to DSM-IV diagnostic categories.

A computerized search of the 1991-1997 PsycLIT database was used to quantify the size of the literature for each of the DSM-IV mental disorders. The search included DSM-IV/IIIR diagnoses and alternative terms for the disorders to provide a complete assessment. Generally it was found that major disorders and those with neurophysiological components were investigated a great deal (there were over 10,000 articles for both major depression and schizophrenia) while there were few articles concerning rare or newly introduced disorders. Within diagnostic groups certain disorders received the preponderance of research attention. Factors related to the degree to which a mental disorder is investigated are discussed. These findings should stimulate consideration of whether clinical research is directing its efforts in a way that best promotes understanding of the nature and treatment of mental disorders.

Bibliometrics↗

Fast choice of separation conditions for analyses by capillary zone electrophoresis using an information system Xemic.

An information system Xemic applicable in analytical chemistry is described and its use in capillary electrophoresis for searching suitable separation conditions is demonstrated. This system is capable to provide suitable separation conditions even for analytes for which no electrophoretic experiments have been published so far. The system works with a database of components of anionic character the analyses of which have been performed, published in reviewed scientific journals, and included into a database created by an expert. Moreover, the system learned to search also in abstracts or complete scientific articles to find articles dealing with the determination of a substance in a given sample matrix. When no experiments have been published so far for a defined substance in a specific matrix, Xemic shows the separation conditions for determination of the substance regardless of the matrix. When no response can be found for the analyte of interest at all, the system Xemic works like an expert in the field and searches chemically similar substances and offers a series of substances the physicochemical properties of which are close to the followed analyte with respect to the behavior in the electric field, and shows working conditions for their analysis. Thus, the analyst puts only the order in the form of a given analyte in a given matrix and obtains a recommendation of a separation system that should enable to perform a successful separation. The system is not rigid and enables the operator to change the importance of individual attributes used in similarity search so as to obtain a broader or narrower group of similar components. With a certain probability the analyte of interest can be successfully analyzed under separation conditions that suited for the analysis of the most similar substances in the given matrix.

Computers↗

Do silicone breast implants cause rheumatologic disorders? A systematic review for a court-appointed national science panel.

OBJECTIVE: To assist in evaluating expert testimony and scientific evidence presented in law suits brought against silicone breast implant manufacturers, a US District Court Order established a National Science Panel to assess whether existing studies provide scientific evidence of an association between silicone breast implants and systemic classic/accepted connective disease, atypical connective disease, and certain signs and symptoms identified by plaintiffs in the law suits. Local disorders potentially associated with these implants were not addressed in this review. Therefore, we performed a systematic review of published studies on the association between silicone breast implants and systemic connective tissue disorders. METHODS: Data from relevant studies (human cohort, case-control, or cross-sectional studies with > or = 10 participants and appropriate controls) were identified through literature searches of Medline, Current Contents, HealthStar, Biological Abstracts, EMBase, Toxline, and Dissertation Abstracts. Two independent reviewers, using standard collection forms, extracted data from the included studies. Adjusted relative risks (RRs) in cohort studies and odds ratios (ORs) in case-control and cross-sectional studies were reported if provided; otherwise, unadjusted RRs and ORs were calculated. RESULTS: Twenty-four studies meeting inclusion criteria were identified. No association was evident between breast implants and any established or atypical connective tissue disorder. There was discordance among studies in reports of arthralgias, lymphadenopathy, myalgias, sicca symptoms, skin changes, and stiffness. CONCLUSION: The panel found no evidence to support expert testimony suggesting an association between silicone breast implants and connective diseases. Discordance for symptoms may reflect differences in symptoms included in various categories, the small number of cases, and the effect of having single subjects with > 1 symptom represented in analyses of each symptom reported. The process presented here is an early example of the use of independent scientific panels to help courts clarify scientific evidence in legal proceedings.

Breast Implants↗

Mass-to-surface area index in a large cohort.

Many biological and anthropological investigations have described the role between mass-to-surface area index (M/SA) and heat tolerance. No large M/SA database exists that can be used as a reference standard to interpret previous or future M/SA studies. This report presents the M/SA data of a large military cohort (1,170 males aged 17-54 years, 305 females aged 17-40 years). The effects of gender, ethnic group, and age on the distribution of M/SA, as well as the relationship between M/SA and other physical characteristics, were described. It was observed that the increases of M/SA with increasing age (over the 17-75 years category) were not significant. All descriptive characteristics (including M/SA) were different (P less than .001) between males and females. M/SA was not statistically different between ethnic groups among both males and females. These data may be utilized to compare the M/SA values of U.S. citizens to those of other ethnic groups and to identify those laborers or athletes who possess the greatest theoretical risk of heat intolerance.

Adolescent↗