What is the best screening test for depression in chronic spinal pain patients?

Background contextHigh prevalence rates of depression have been found in patients with chronic spinal disorder (CSD). The biopsychosocial model has become widely adopted and, with it, the role of psychopathology in the development and/or exacerbation of CSD has become increasingly recognized. Standardized diagnostic criteria, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM), have been used to diagnose major depressive disorder (MDD). Many measures of MDD (and depressive symptom inventories) have been developed during the past 50 years, but their comparative utility in CSD populations is still unclear.PurposeTo systemically compare the performance of depression screening questionnaires in detecting MDD among a large sample of patients with CSD.Study design/settingProspective cohort study comparing the screening ability of four popular depression measures for diagnosing MDD against the “gold standard” Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), using a receiver operating characteristic (ROC) analysis in a CSD population.Patient sampleA consecutive cohort of 546 patients with CSD admitted to an interdisciplinary functional restoration program.Outcome measuresSensitivity, specificity, ROC curves, area under the curve (AUC), and optimal cutoff points that are most closely related to the prevalence rates of MDD, with balanced sensitivity and specificity analysis.MethodsUsing the SCID-I diagnosis as a “gold standard,” the ability of four screening measures in detecting MDD were compared. These included: the Beck Depression Inventory (BDI); Hamilton Rating Scale for Depression (HRSD); 9-Item Patient Health Questionnaire Depression Module (PHQ-9); and the Short Form-36 (SF-36).ResultsOf 542 CSD patients, 331 (61.1%) were diagnosed with MDD by the SCID-I. Results of the ROC analysis revealed that the BDI (AUC 0.768), HRSD (AUC 0.796), and PHQ-9 (AUC 0.768) have similar abilities to discriminate between depressed and nondepressed patients in this population. These depression measures outperformed the two mental health scales derived from the SF-36 (Mental Component Summary score/5-Item Mental Health Index; AUC 0.679–0.715). The optimal cut-off scores of 15 (for the BDI), 17 (for the HRSD), and 10 (for the PHQ-9) were also determined. Although the greatest overall accuracy (sensitivity of 81.3% and specificity of 65.4%) was obtained with the HRSD, it is the only clinician-administered instrument. Self-report measures of depression (the BDI and PHQ-9) showed comparable abilities to detect depression, only slightly less than the HRSD.ConclusionsCompared to the HRSD, both BDI and PHQ-9 are relatively short and easy to self-administer. The cut-off scores established in this study may be used to reliably determine whether a person should be evaluated more thoroughly for an MDD diagnosis. Using an acknowledged “gold standard,” the HRSD, BDI and PHQ-9 showed similar validity to recommend their use for future clinical and research purposes. The SF-36 is less appropriate for diagnosing MDD.     

What is the best method for treating osmidrosis?

Axillary osmidrosis is caused by excessive secretion of apocrine, which causes an acrid odor and extreme social embarrassment. Elimination of the apocrine glands by a radical surgical procedure is known as the best solution for axillary osmidrosis; however, it is often accompanied by marked complications. The purpose of this study was to seek a more effective surgical procedure by comparing the various preexisting subcutaneous apocrine gland elimination methods using four parameters: odor, scar, immobilization period, and other surgical complications such as hematoma, seroma, flap necrosis, and wound dehiscence. From March 1995 to March 2000, a total of 189 patients underwent surgery for axillary osmidrosis via manual subdermal shavings (N = 117), liposuction curettage (N = 32), CO2 laser vaporization (N = 18), and ultrasonic aspiration (N = 22). Of these procedures, manual shaving had the lowest recurrence rate for malodor. However, the disadvantages of this procedure included wide scar, a long immobilization period, and moderate cases of surgical complications. CO2 laser vaporization had results similar to manual shaving except for a clinically higher recurrence rate. Liposuction had advantages such as small invisible scars, a short-term immobilization period, and the least number of surgical complications, but it had a high rate of dissatisfaction in postoperative malodor (46.9%). Ultrasonic aspiration offered better results such as short surgical scar and relatively low recurrence rate, but it had some surgical complications (3 of 44 axillas). Therefore, removal of subcutaneous apocrine glands by manual subdermal shaving is the treatment of choice for axillary osmidrosis, with a low recurrence rate (7.7%). Other adjuvant procedures were effective in achieving short scars and low surgical complications, but there was dissatisfaction in the rate of recurrence.     

What is the best treatment for malignant pleural effusions?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether chemical pleurodesis is superior to catheter drainage or pleuroperitoneal shunts (PPS) in the management of patients with pleural effusions. Overall 161 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that chemical pleurodesis is superior to chronic catheter drainage and PPS in terms survival length and mortality rates but in patients with trapped lung syndrome chronic intrapleural catheter placement is indicated. Six studies reported patient outcomes after treatment with chemical pleurodesis. They report high success rates (89.4%) and low mortality rates (2%) without any need to convert to open thoracotomy. Mean hospital stay of 2.33 days, complication rates of 16.5% and mean survival length of 23.8 ± 16.3 months were observed. Five studies managed malignant pleural effusions (MPEs) using chronic indwelling catheters. They reported mean survival length of 126 days. Symptomatic relief was achieved in 94.2% of patients. There was a significant reduction in the Medical Research Council dyspnoea score (3.0-1.9, P < 0.001) and despite complication rates of 22%, comparable mortality rates (7.5%) were observed. Even in patients with trapped lung syndrome, mean survival length was 125 days with symptomatic improvement being achieved in 90.9% of patients. Three studies treated MPEs using PPSs. Mean hospital stay was 6.2 days (range 2-26) with a mean survival length of 11 months. Pleurodesis success rates varied from 57.1% to 95% with a complication rate of 14.8%. PPSs were shown to produce lower success rates (57.1% vs. 92.3%), shorter survival lengths (4.3 ± 1.9 vs. 6.7 ± 2.1 months) and higher complication rates (14.3% vs. 2.8%) than talc pleurodesis. Overall, chemical pleurodesis is the optimal treatment option for MPE with use of chronic intrapleural catheters reserved in cases where talc pleurodesis is not possible.     

What is the best nutritional support for critically ill patients?

Optimum nutritional support in critical illness remains controversial. A recent review of nutritional interventions in the ICU concluded that few of them improved clinical outcomes. In our view, it is a serious shortcoming of these trials that they focused on calories, falling far short of current recommendations for protein provision. Well designed clinical trials that ensure sufficient protein provision are urgently needed if we are to improve the quality of nutritional support in the ICU.     

What is the best treatment of postpneumonectomy empyema?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether an open surgical approach is superior to minimally invasive surgery in patients with postpneumonectomy empyema (PPE). Overall 171 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that open surgical approaches are superior to minimally invasive surgery in terms of empyema recurrence rate, mortality and reintervention rate. Minimally invasive surgery includes chest tube drainage with or without chemical irrigation and video-assisted thoracoscopic surgery debridement. Whereas open surgery includes open debridement, open window thoracostomy (OWT) and thoracomyoplasty. To allow for an accurate comparison, success of an intervention was defined as prevention of empyema recurrence. Two studies reported surgical outcomes of patients treated with minimally invasive treatment options. They found high mortality rates (17.1%) and low success rates (31%) in patients treated by chest tube drainage with chemical irrigation. Five studies treated PPE using a combination of minimally invasive and open surgical approaches and reported a high reintervention rate of 3.5 (range 3-5) and an empyema recurrence rate of 13.3%. Higher success rates (6.7 vs. 95%), lower mortality rates (33 vs. 0%) and shorter hospital stay (47.5 vs. 17.6?days) were all noted with thoracomyoplasty compared to chest tube drainage therapy. Five studies managed PPE using OWT or thoracomyoplasty. The time between empyema diagnosis to resolution (3 vs. 38?months) was much shorter with immediate OWT than with delayed OWT therapy. The Clagett procedure resulted in a mean hospital stay of 12.9?days, an operative mortality rate of 7.1% and an overall success rate of 81%. Thoracomyoplasty led to a mean hospital stay of 34?days with a mortality rate of 6%. The shorter hospital stay, lower empyema recurrence rates and lower mortality rates may make open surgical approaches a more effective treatment option to minimally invasive options.     

What is the best definition of contrast-induced nephropathy?

Radiological procedures require the intravascular administration of iodinated contrast media, which are becoming a great source of an iatrogenic disease known as contrast-induced nephropathy. The development of contrast-induced nephropathy is associated with prolonged hospitalization, the potential need for renal replacement therapy, and increased mortality. Despite numerous clinical and experimental studies, several important issues regarding contrast-induced nephropathy remain controversial. One of the controversial points is its very definition: a universally accepted definition of contrast-induced nephropathy does not exist. This can be a major problem. Differing definitions of contrast-induced nephropathy and the clinical importance of these definitions were discussed in this letter.     

What is the best reconstruction method after distal gastrectomy for gastric cancer?

Background

We performed this prospective randomized study to evaluate what is the best reconstruction method after distal gastrectomy for gastric cancer.

Methods

One hundred fifty-nine patients who underwent laparoscopy-assisted or open gastrectomy for gastric cancer were analyzed from March 2006 to August 2007. Billroth I (B-I) anastomosis, Billroth II (B-II) with Braun anastomosis, and Roux-en-Y (R-Y) anastomosis were applied randomly. Additionally, the patients were divided into two groups based on treatment type: laparoscopic and open operation. Endoscopy and hepatobiliary scans were performed to investigate gastric stasis and enterogastric reflux. The Gastrointestinal Quality of Life Index (GIQLI) was used to evaluate postoperative quality of life, and the hematologic test was used to assess nutritional aspect.

Results

Endoscopy revealed that reflux after the R-Y anastomosis procedure was significantly less frequent than after the other anastomosis types at 12?months. Comparison of the GIQLI and the nutritional parameters between the reconstruction types revealed that there were no differences, but a significantly higher GIQLI score was observed in the laparoscopic group immediately following the procedure (P?=?0.042).

Conclusions

R-Y anastomosis is superior to B-I and B-II with Braun anastomosis in terms of frequency of bile reflux, despite the fact that there is no difference in the postoperative quality-of-life index and nutritional status between reconstructive procedures. The laparoscopic approach is the better option than open surgery in terms of QOL in the immediate postoperative period.     

What is the best method for reporting tumor diameter in vestibular schwannoma?

OBJECTIVE: Various methods have been used to report the tumor diameter of vestibular schwannomas. To clarify the most appropriate method to represent the tumor volume, tumor diameters according to various measuring methods were statistically compared with the actual tumor volume. METHODS: Tumor volume was measured by three-dimensional constructive interference in steady state images in 52 unselected vestibular schwannomas. Pearson's correlation coefficient was obtained between the tumor volume and various tumor diameters, such as diameter parallel to the petrous edge (a); a pons-to-petrous diameter (b); ab, a maximum diameter of the portion in the cerebellopontine angle cistern (max CPA); a maximum diameter of the whole tumor (Max); and a diameter through an axis of the internal auditory canal (Axis). The tumors were divided into three groups on the basis of tumor volume, as follows: Group I (small, <0.5 cm(3)), Group II (medium, 0.5-2 cm(3)), and Group III (large, >2 cm(3)). RESULTS: Max and Axis correlated best with the tumor volume in Group I and correlated least with the tumor volume in Group II. Any of these measurements was acceptable in Group III tumors. The max CPA consistently revealed good correlation with the tumor volume in all three tumor groups. CONCLUSION: The max CPA measurement is the simplest and most appropriate way to represent the tumor volume in unselected tumors. Max or Axis is better only when small tumors (<0.5 cm(3) in volume) are being assessed-that is, those with a max CPA of less than 1 cm.