Clinical Briefs

Am Fam Physician. 2002 May 15;65(10):2164-2169.

HTAC Report on Seasonal Affective Disorder

The Health Technology and Advisory Committee (HTAC) has published a report on light therapy for seasonal affective disorder (SAD). HTAC was established in 1992 by the Minnesota state legislature. It is an independent, nonpartisan advisory body that evaluates new and emerging health care technologies based on existing scientific research and technology assessments.

According to HTAC, SAD most often involves the onset of depression in the late fall or early winter with remission in the spring or summer. Light therapy is the recommended first-line treatment for SAD. Light boxes are most often used for light therapy, but dawn light simulation and light visors are also available.

Based on its research, HTAC has come to the following conclusions:

  • Light therapy is an investigational treatment. Light boxes have not yet received marketing approval by the U.S. Food and Drug Administration (FDA). However, the Agency for Health Care Policy and Research (now called the Agency for Health-care Research and Quality [AHRQ]) published guidelines in 1993 that gave light therapy a qualified recommendation under specific conditions.

  • Both the FDA and the AHRQ state that light therapy should be administered to properly diagnosed patients (who have no psychotic disorder and who are not suicidal) under the guidance of an experienced and trained health care professional.

  • Studies available to date support reasonable beneficial effect of light therapy as a treatment of SAD in patients in whom light deprivation is thought to be the cause of illness.

This report and others by HTAC may be obtained free of charge by calling 651-282-6374 or by e-mail (htac@health.state.mn.us). All reports are also available online at www.health.state.mn.us/htac/index.htm.

Prevention of PKU-Associated Mental Retardation

According to a small interview study conducted by the Centers for Disease Control and Prevention, when pregnant women who have phenylketonuria (PKU) fail to follow the special diet prescribed by their physicians, they put their infants at risk for the development of mental retardation. Two thirds of the study participants were not properly managing their diets at the time of conception.

While newborn screening has been successful in the prevention of mental retardation associated with PKU, preventing maternal PKU-associated mental retardation has proved more difficult. Physicians recommend a lifelong special diet for persons with PKU, but the diet is often discontinued during adolescence. When women with PKU become pregnant and do not follow their special diets, their infants are likely to be affected by mental retardation and other birth defects. Such defects are not caused by PKU in the infant, but by the mother's condition, and most can be prevented in newborns if the mothers maintain PKU-specific diets before and during pregnancy.

According to the director of the National Center on Birth Defects and Developmental Disabilities, several barriers may complicate an affected woman's ability to follow the lifelong diet, including cost, adverse tastes, and poor adherence to medical recommendations. To prevent maternal PKU-associated mental retardation, these barriers must be addressed.

These study results appear in the February 15, 2002, issue of Morbidity and Mortality Weekly Report.

CDC Analysis of Sudden or Unexpected Cardiac Death

According to an analysis of state data by the Centers for Disease Control and Prevention (CDC), despite advances in the prevention and treatment of heart attacks, more than 63 percent of the 728,743 deaths from heart disease in 1999 were unexpected or sudden. About 47 percent of these deaths occurred outside of the hospital and 16.5 percent occurred in the emergency department, or the patients were pronounced dead on arrival at the hospital. The analysis appears in the February 15, 2002, issue of Morbidity and Mortality Weekly Report.

The CDC found that women (51.9 percent) were more likely than men (41.7 percent) to die before reaching the hospital. The U.S. states with the highest rates of sudden cardiac death (SCD) were Wisconsin (72.9 percent of deaths from heart disease), Idaho (72.2 percent), Utah (72.1 percent), Colorado (71.3 percent), and Oregon (71.0 percent). States with the lowest rates of SCD were Hawaii (57.2 percent), Arkansas (57.5 percent), New Jersey (57.6 percent), Kentucky (58.4 percent), and Oklahoma (58.5 percent). However, these percentages were still close to 60 percent.

CDC researchers speculate that the mortality rates are so high because of the unexpected nature of SCD and the failure to recognize early warning symptoms of heart disease. Because of this, the CDC and its partners are working closely with states to educate health care professionals and the public about the common and uncommon signs of heart attack. Uncommon signs include cold sweat, nausea, and lightheadedness, while more common signs are chest discomfort or pain; discomfort or pain in one or both arms, or in the back, neck, jaw, or stomach; and shortness of breath.

Preventing Unintentional Injuries and Deaths in Schools

According to the Centers for Disease Control and Prevention (CDC), about two thirds of all deaths among children and adolescents five to 19 years of age are the result of injury-related causes such as motor-vehicle crashes, other unintentional injuries, homicide, and suicide. To address this important issue, the CDC has created school health guidelines to prevent unintentional injuries and violence among young persons. The guidelines appear in the December 7, 2001, issue of the Recommendations and Reports series of Morbidity and Mortality Weekly Report.

The CDC recommendations are based on an in-depth review of research, theory, and current practice in unintentional injury, violence, and suicide prevention; health education; and public health. Because not every recommendation is appropriate or feasible for every school to implement, schools should determine which recommendations merit the highest priority based on the needs of the school and the available resources.

To prevent unintentional injury, violence, and suicide, the CDC makes the following recommendations for health care in schools:

  • Establish a social environment that promotes safety and prevents unintentional injuries, violence, and suicide.

  • Provide a physical environment, inside and outside school buildings, that promotes safety and prevents unintentional injuries and violence.

  • Implement health and safety education curricula and instruction that help students develop the knowledge, attitudes, behavioral skills, and confidence needed to adopt and maintain safe lifestyles and to advocate for health and safety.

  • Provide safe physical education and extracurricular physical activity programs.

  • Provide health, counseling, psychologic, and social services to meet the physical, mental, emotional, and social health needs of students.

  • Establish mechanisms for short-and long-term responses to crises, disasters, and injuries that affect the school community.

  • Integrate school, family, and community efforts to prevent unintentional injuries, violence, and suicide.

  • For all school personnel, provide regular staff development opportunities that impart knowledge, skills, and confidence to effectively promote safety and prevent unintentional injury, violence, and suicide, and support students in their efforts to do the same.

Guidelines for Treatment of Chronic and Acute Heel Pain

The American College of Foot and Ankle Surgeons (ACFAS) has released new clinical guidelines to assist physicians in the diagnosis and treatment of chronic and acute heel pain. The guidelines were developed after extensive evaluation of current treatment methods and success rates, and a thorough review of the medical literature.

The ACFAS guidelines are intended to help physicians differentiate types of heel pain that can be treated conservatively from those that require more specialized care. The five basic types of heel pain are as follows:

  • Mechanical. This is one of the most frequent conditions seen by foot and ankle subspecialists. An estimated 15 percent of all adult foot complaints involve mechanical heel pain caused by plantar fasciitis.

  • Mechanical Posterior. This is the second most common type of mechanically induced heel pain, caused by inflammation of the Achilles tendon and bursitis.

  • Neurologic. Neurologic heel pain can be caused by irritation of one or more of the nerves in the region.

  • Arthritic. Arthritis can present as heel pain. Patients with arthritic heel pain usually have other joint problems as well.

  • Traumatic Heel Pain. This type of pain is usually caused by fractures in the hindfoot area.

According to the ACFAS guidelines, plantar fasciitis should first be treated conservatively following physical examination and radiography. Initial treatment may involve anti-inflammatory drugs, padding and strapping of the foot, and corticosteroid injections. Patients should also be advised to stretch their calf muscles regularly, avoid wearing flat shoes and walking barefoot, use over-the-counter arch supports and heel cushions, and limit the frequency of extended physical activities.

Copies of the guidelines are available from the ACFAS by calling 847-292-2237.

ACIP Prioritization for Use of Varicella Vaccine

In February 2002, the Advisory Committee on Immunization Practices (ACIP) voted to recommend prioritizing the use of limited supplies of varicella vaccine because of a shortage in the United States.

While the shortage persists, the ACIP recommends that all vaccine providers in the United States should delay vaccination of children 12 to 18 months of age until the 18-month or two-year office visit. For children whose dose of varicella vaccine is delayed, vaccine providers should implement a call-back system when vaccine becomes available.

According to the ACIP, the duration of the shortage is uncertain, but will likely last until late spring or early summer of 2002.

APS Guideline on the Treatment of Arthritis Pain

The American Pain Society (APS) recently released a clinical guideline on the treatment of acute and chronic pain associated with arthritis. This multidisciplinary, evidence-based guideline was developed by a panel of experts in arthritis pain management and is intended for use by physicians and other health care professionals who treat adults and children who have arthritis.

The major recommendations of the APS include the following:

  • All arthritis treatment should begin with a comprehensive assessment of pain and function.

  • For persons with mild to moderate arthritis pain, use of acetaminophen is preferred because of its mild side effects, over-the-counter availability, and low cost.

  • For persons with moderate to severe pain from osteoarthritis and rheumatoid arthritis, COX-2 non-steroidal anti-inflammatory drugs (NSAIDs) are the best choice for their pain-relieving potency and lower incidence of gastrointestinal (GI) side effects. Use of nonselective NSAIDs should be considered only if the patient does not respond to acetaminophen and COX-2 drugs, and is not at risk for NSAID-induced GI side effects. Because of the high cost of COX-2 agents, some patients may benefit from nonspecific NSAID therapy combined with a medication to moderate GI distress.

  • Opioid medications such as oxycodone and morphine are recommended for the treatment of severe arthritis pain when COX-2 drugs and nonspecific NSAIDs fail to provide adequate relief.

  • In the absence of medical contraindications, most patients with arthritis should be referred for surgical treatment when drug therapy is ineffective and function is severely impaired to prevent minimal physical activity. Surgery should be recommended before the onset of severe deformity and advanced muscular deterioration.

The APS panel also makes the following recommendations for patients with juvenile chronic arthritis (JCA):

  • Pain assessment should be ongoing in children with JCA.

  • Use of analgesia should be the same for children and adults with arthritis pain.

  • Patient and family education should be emphasized to increase self-care skills.

  • Cognitive-behavioral therapy should be used to help reduce pain and psychologic disability and to enhance pain-coping skills.

  • Physicians should take appropriate measures to minimize pain and anxiety associated with diagnostic and therapeutic procedures for JCA.

  • Whenever sedation is required for any procedure, use of guidelines developed by the American Academy of Pediatrics is recommended.

For a copy of the guideline, write to the APS, 4700 W. Lake Ave., Glenview, IL 60025-1485, or visit the APS Web site at www.ampainsoc.org.


Copyright © 2002 by the American Academy of Family Physicians.
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