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Am Fam Physician. 1999;59(3):700-704

APA Guideline on Panic Disorder

The American Psychiatric Association (APA) has issued a new treatment guideline for persons with panic disorder. According to the APA guideline, published in the May 1998 issue of the American Journal of Psychiatry, medication and cognitive behavioral therapy, a form of psychotherapy, are both effective treatments for persons with panic disorder. With proper treatment, 80 percent of patients with this disorder recover.

The guideline includes the following topics: a definition of panic disorder with a discussion of the natural history and epidemiology of panic disorder; treatment principles and alternatives; development of a treatment plan for the individual patient; and clinical features influencing treatment, such as psychiatric factors, concurrent general medical conditions and demographic variables.

Cognitive behavioral therapy is a symptom-oriented approach to the treatment of panic disorder. Some components contained in this approach include psychoeducation, continuous panic monitoring, breathing retraining, cognitive restructuring focused on correction of catastrophic misinterpretation of bodily sensations, and exposure to fear cues.

Effective medications include selective serotonin reuptake inhibitors, tricyclic antidepressants and monoamine oxidase inhibitors, and benzodiazepines. The goals, efficacy, side effects and implementation issues for each class of medications are discussed. The APA guideline strongly recommends that patients suspected of having panic disorder be thoroughly evaluated with special attention to the presence of other illnesses frequently associated with panic disorder, such as depression and substance use disorders.

Scientific Exhibit Deadline for AAFP Assembly

A call for scientific exhibits has been issued by the American Academy of Family Physicians (AAFP) for possible presentation at the 1999 Scientific Assembly to be held September 15–19 in Orlando. The scientific exhibits open on September 16th. Applications must be submitted by April 1, 1999. Membership in the AAFP is not a prerequisite for submission. Scientific exhibits provide a forum for the presentation of research that is of interest and educational value to family physicians. The exhibits include those presented by residents and medical students.

Travel grants of $1,000 may be awarded to a maximum of 15 resident/student scientific exhibitors whose applications are accepted for presentation at the assembly. In addition, cash awards for first, second, third and fourth places may be presented to resident/student exhibitors. Application forms may be obtained from Vicky Binder, Scientific Assembly Department, AAFP, 8880 Ward Pkwy., Kansas City, MO 64114; telephone: 800-274-2237, ext. 5264.

Alcohol and the Liver

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has published a research update on alcohol and liver disease (Alcohol Alert No. 42). The report, “Alcohol and the Liver: Research Update,” notes that alcohol-associated hepatitis develops in 10 to 35 percent of heavy drinkers and cirrhosis of the liver develops in 10 to 20 percent.

Alcohol consumption promotes inflammation, cell death and scarring in the liver. Susceptibility to alcohol-induced liver disease differs considerably among individuals, making it difficult to predict who will develop liver disease by how much they drink. According to the report, factors that increase the risk for advanced liver damage include genetic factors, dietary factors (dietary fat and carbohydrate levels influence the progression of liver disease), gender (women develop liver disease after consuming lower levels of alcohol over a shorter period of time, compared with men) and the presence of hepatitis C virus (having hepatitis C increases a person's susceptibility to liver disease).

Abstinence is the cornerstone of management for alcohol-induced liver disease. Fatty liver and alcoholic hepatitis are frequently reversible, and survival is improved among patients who abstain from alcohol, including those with cirrhosis. Liver transplantation is the only effective treatment for terminally ill patients.

The full report can be found on the NIAAA Web site at Copies may also be obtained from NIAAA Publications Distribution Center, attn: Alcohol Alert, P.O. Box 10686, Rockville, MD 20849–0686.

Treatment for Breakthrough Cancer Pain

A new product developed specifically for cancer patients with severe pain that breaks through their regular narcotic therapy has been approved by the U.S. Food and Drug Administration (FDA). It is indicated for patients who are already receiving and who can tolerate opioid therapy for their underlying persistent cancer pain. Pain relief can occur for up to several hours after taking the medication.

Oral transmucosal fentanyl citrate (Actiq) is the first product specifically designed and studied for breakthrough cancer pain. Fentanyl citrate is an opioid narcotic more potent than morphine, according to the FDA. Actiq is in the form of a flavored sugar lozenge that dissolves slowly in the mouth until the medication is consumed.

Actiq is contraindicated in the management of acute or postoperative pain and must not be used in patients who cannot tolerate opioids. Patients considered opioid-tolerant are those who are taking at least 60 mg of morphine per day, 50 μg of transdermal fentanyl per hour, or an equianalgesic dose of another opioid for one week or longer. The FDA approved Actiq under special regulations that restrict distribution as defined in a comprehensive risk-management plan.

Call for Papers of Family Practice Research Presentations

The American Academy of Family Physicians (AAFP) is inviting researchers to submit papers for possible presentation at the 1999 Scientific Assembly to be held September 15–19 in Orlando. Applications must be submitted by April 1, 1999. Membership in the AAFP is not a prerequisite for submission.

Applications may be submitted in two different categories. Category I is for original research relevant to family practice; category II includes case studies and literature reviews. Each category has six author classifications: family physicians and fellows primarily in academic medicine, family physicians primarily in clinical practice, family practice residents, medical students, international attendees and others. The international attendee classification is open to anyone outside the United States who conducted clinical or educational research relevant to family medicine.

The best presentations in each category will receive cash awards of $1,000. Runners-up will receive $250. All awards are given at the discretion of the Subcommittee on Family Practice Research Presentations. Application forms may be obtained from Carrie Vickers, Scientific Assembly Department, AAFP, 8880 Ward Pkwy., Kansas City, MO 64114; telephone: 800-274-2237, ext. 5268.

HIV Testing for All Pregnant Women

All pregnant women should be tested for the human immunodeficiency virus (HIV) as part of routine prenatal care, according to a new report from an expert panel of the Institute of Medicine (IOM). The IOM panel believes this approach could help reduce the number of infants who acquire HIV infection from their mothers and improve the treatment of mothers who have HIV infection.

Current federal guidelines advise health care professionals to give extensive pretest counseling to all pregnant women, educating them about the risks of HIV infection and the benefits of being tested. Although counseling has increased the number of pregnant women who are tested, the IOM committee believes that the incidence of HIV transmission to newborns is still unacceptably high.

The report states that too many pregnant women do not receive testing and, therefore, HIV-infected women may miss the opportunity to receive zidovudine (Retrovir), which significantly reduces the incidence of HIV transmission to infants. While the IOM recommends that all women be told that HIV testing is part of routine prenatal care, the committee emphasizes that women still have the right to refuse the test. The report states that the cost of routine prenatal testing compares favorably with the costs of treating children who have HIV infection.

A copy of the report may be obtained for a fee from the National Academy Press, 2102 Constitution Ave., N.W., Washington, DC 20418; telephone: 202-334-3313 or 800-624-6242.

Guidelines for Anesthesia During Labor

New scientifically based guidelines on anesthesia care for women in labor have been released by the American Society of Anesthesiologists (ASA). “Practice Guidelines for Obstetrical Anesthesia” were developed by an expert panel of the ASA to reduce the incidence and severity of anesthesia-related complications during labor and delivery and to guide health care professionals in providing safe obstetric anesthesia care.

The guidelines include discussions on monitoring fetal heart rate, oral intake of fluids and solids by the mother during labor and on the various pain relievers available to women in labor.

The 27-page document includes the following recommendations:

  • All solid foods should be avoided during labor but, with physician approval, patients with uncomplicated labor can drink modest amounts of clear fluids (e.g., water, fruit juice without pulp, carbonated beverages, clear tea, black coffee).

  • The mother's request for pain relief during labor is sufficient justification for medical intervention, but a number of factors need to be considered in deciding which type of pain relief is best.

  • Providing mothers with an epidural block versus other pain-relief techniques should reflect patient needs and preferences, practitioner preferences or skills, and available resources.

The choices of pain relievers discussed in the guidelines include intravenous medications, local anesthesia, epidural blocks and spinal blocks.

The full text of the practice guidelines can be obtained from the ASA Web site at The ASA may also be contacted at 847-825-5586 (telephone) or 847-825-1692 (fax).

Tamoxifen for Prevention of Breast Cancer

The U.S. Food and Drug Administration (FDA) has approved tamoxifen (Nolvadex) for reducing the incidence of breast cancer in women at high risk for developing the disease. This new indication for tamoxifen resulted from a recent study of the drug, conducted by the National Cancer Institute (NCI), in more than 13,000 women who were at increased risk for breast cancer. The study showed that tamoxifen reduced the chance of getting breast cancer by 44 percent. The long-term effects of tamoxifen use are not known.

The FDA notes that caution must be used in prescribing the drug because of the potential for serious side effects, such as endometrial cancer, deep venous thrombosis and pulmonary embolism. The labeling specifies that in women age 50 years and older, the following risk factors result in an increased risk of breast cancer:

  • Family history of breast cancer (at least two direct-line relatives with breast cancer).

  • Personal health history (presence of atypical hyperplasia on breast biopsy).

  • First child born at age 30 years or older.

  • Onset of menses at age 11 years or younger.

The NCI and the manufacturer of tamoxifen are making the risk-assessment model used in the trial available on computer disk to health care professionals to aid in evaluating an individual woman's risk of developing breast cancer. To order the risk assessment model, call 800-4-CANCER or visit the Web site at

The FDA also approved tamoxifen for the reduction of contralateral breast cancer. Current data from clinical trials support the recommendation for five years of adjuvant tamoxifen therapy for patients with breast cancer.

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Copyright © 1999 by the American Academy of Family Physicians.

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