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January 29th, 2016

THE BLUES, REVISITED

THE STORY

The USPTF – the uber committee that specializes in mic dropping all over health policy issues – updated their screening guidelines for depression in adults.

THE CHANGES

The USPTF now recommends depression screening in all pregnant and postpartum patients. But they've also expanded their recs to include primary care depression screening for adults in the general population. When we last heard from the USPTF on depression in 2009, they recommended depression screening for primary care docs who had office resources in place to ensure effective treatment following diagnosis. This week they're back at us with a call for all primary docs to implement depression screening independent of office resources. The committee says they broadened their recs because mental health resources are more widely available than they were in 2009. For pregnant women, screen with the Edinburgh Postnatal Depression Screen. Use the 9-item Public Health Questionnaire (PHQ-9) for everyone else.
JAMA

THE EVIDENCE

For pregnancy, the committee cites a depression prevalence of roughly 10% in pregnant and postpartum patients. They pooled data from almost 12,000 patients in 6 trials and found a variable but significant decrease in the prevalence of depression following screening. For the general population, the committee focused on the efficacy of depression treatment rather than screening measures. They point to several studies that demonstrate high remission rates following treatment with drugs or psychotherapy. 

THE TAKEAWAY

Someone in the office – and if you're as junior as we are, that someone means you – is going to be passing out PHQ-9s about as often as med students print out research papers even they don't want to read. Hope your clinic has that ink toner that doesn't smudge.

SAY IT ON ROUNDS

WHEN YOU CRACK YOUR PHONE ON A 30 HOUR SHIFT

You cross your fingers for repair rather than replacement. It's not so simple with severe ischemic mitral regurgitation (MR). Investigators looked at whether mitral valve replacement was more effective than repair at 2 years. Much like the previously reported 1-year outcomes, there was no significant difference in mortality, but the repair group had more MR recurrence than the replacement group. They also had more heart failure complications and hospital admissions.
NEJM

WHEN YOU DREAM THAT YOU'RE A PRISONER OF THE HOSPITAL

Maybe it's time to stop the Chantix. The anti-smoking drug (varenicline) did not improve cessation rates vs. nicotine patches with and without lozanges in an 1,100 patient RCT. The researchers tested for carbon monoxide to confirm abstinence, and found that about one fifth of the participants in each group had stopped smoking at 26 weeks. The varenicline group suffered more side effects, including weird dreams.
JAMA

WHEN YOU WANT TO SOUND FANCY ON ONC ROUNDS

Mention venetoclax and acalabrutinib, two new drugs that show promising efficacy in patients with relapsed chronic lymphocytic leukemia. Both are second-generation agents that act more specifically than their predecessors on their respective targets, BCL2 and BTK. The recent pipeline of CLL therapies seems to have a much more promising future than Keystone.
NEJM

WHEN YOU WANT TO NEG YOUR PATIENTS

You know better. But if you want to give them negative reassurance against heart disease, know that a coronary artery calcium score of zero was found to most profoundly decrease estimated risk of cardiovascular disease among a panel of labs and imaging markers. Among clinical factors, a negative family history most reduced estimated CVD risk. 
Circulation

BRUSH UP

TO DIAGNOSE ACUTE RESPIRATORY DISTRESS SYNDROME

Check an ABG for hypoxemic respiratory failure. First exclude other reasons for patients to be hypoxemic, then look for bilateral infiltrates on lung imaging. Use the Berlin definition – how well the patient is oxygenating (PaO2) vs. how much oxygen you're supplying (FiO2) – to find the P/F ratio and categorize disease severity as mild, moderate, or severe. Then make sure you're in or on your way to an ICU.

WHAT'S THE EVIDENCE

For prone position in ARDS? 2013's ProSEVA trial found that for patients with a P/F ratio of less than 150 on more than 60% inspiratory oxygen and 5 mmHg of PEEP, intermittent time in prone position cut 28-day mortality in half. Previous studies had shown that proning could improve oxygenation, but ProSEVA was the first to show a mortality benefit.

WHAT YOU'RE PUBLIC HEALTH FRIENDS ARE TALKING ABOUT

By now you get it with the Zika virus. Mosquitos. South and Central America. Microencephalopathy in babies. Rapid spread. Yesterday we heard that the World Health Organization will convene an emergency meeting on the virus, and travel providers are issuing refunds to people who went wrong-place-wrong-time with their vacation plans. Want some more basics? Check out this fact sheet.

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