Galactorrhea: Rapid Evidence Review.

Galactorrhea is the production of breast milk that is not the result of physiologic lactation. Milky nipple discharge within one year of pregnancy and the cessation of breastfeeding is usually physiologic. Galactorrhea is more often the result of hyperprolactinemia caused by medication use or pituitary microadenomas, and less often hypothyroidism, chronic renal failure, cirrhosis, pituitary macroadenomas, hypothalamic lesions, or unidentifiable causes. A pregnancy test should be obtained for premenopausal women who present with galactorrhea. In addition to prolactin and thyroid-stimulating hormone levels, renal function should also be assessed. Medications contributing to hyperprolactinemia should be discontinued if possible. Treatment of galactorrhea is not needed if prolactin and thyroid-stimulating hormone levels are normal and the discharge is not troublesome to the patient. Magnetic resonance imaging of the pituitary gland should be performed if the cause of hyperprolactinemia is unclear after a medication review and laboratory evaluation. Cabergoline is the preferred medication for treatment of hyperprolactinemia. Transsphenoidal surgery may be necessary if prolactin levels do not improve and symptoms persist despite high doses of cabergoline and in patients who cannot tolerate dopamine agonist therapy.

Hypothyroidism: Diagnosis and Treatment.

Clinical hypothyroidism affects one in 300 people in the United States, with a higher prevalence among female and older patients. Symptoms range from minimal to life-threatening (myxedema coma); more common symptoms include cold intolerance, fatigue, weight gain, dry skin, constipation, and voice changes. The signs and symptoms that suggest thyroid dysfunction are nonspecific and nondiagnostic, especially early in disease presentation; therefore, a diagnosis is based on blood levels of thyroid-stimulating hormone and free thyroxine. There is no evidence that population screening is beneficial. Symptom relief and normalized thyroid-stimulating hormone levels are achieved with levothyroxine replacement therapy, started at 1.5 to 1.8 mcg per kg per day. Adding triiodothyronine is not recommended, even in patients with persistent symptoms and normal levels of thyroid-stimulating hormone. Patients older than 60 years or with known or suspected ischemic heart disease should start at a lower dosage of levothyroxine (12.5 to 50 mcg per day). Women with hypothyroidism who become pregnant should increase their weekly dosage by 30% up to nine doses per week (i.e., take one extra dose twice per week), followed by monthly evaluation and management. Patients with persistent symptoms after adequate levothyroxine dosing should be reassessed for other causes or the need for referral. Early recognition of myxedema coma and appropriate treatment is essential. Most patients with subclinical hypothyroidism do not benefit from treatment unless the thyroid-stimulating hormone level is greater than 10 mIU per L or the thyroid peroxidase antibody is elevated.

Primary care patients' personal illness models for depression: relationship to coping behavior and functional disability.

OBJECTIVE: The applicability and clinical utility of Leventhal et al.'s model of illness cognition were evaluated in depressed primary care patients. The intercorrelations of illness beliefs and the mediational effects of coping behavior on these beliefs were also evaluated. Moderating effects of coping behaviors were explored. METHODS: Baseline evaluations of demographic information, depression diagnoses, depressive symptom severity, self-reported psychosocial and physical functioning, medical comorbidity, illness beliefs and depression coping strategies were obtained from 191 primary care patients receiving antidepressant medication for the treatment of depression. RESULTS: Patients' beliefs about depressive symptoms, causes, duration as well as controllability and the consequences of these symptoms are described. Leventhal et al.'s mediational model was partially supported for the outcome of psychosocial functioning. Coping behavior did not mediate the relationship between illness beliefs and physical functioning. The relationships between participants' beliefs about the cause, controllability and duration of depressive symptoms were mediated by the use of behavioral disengagement, venting or self-blame as a strategy to cope with depression. In addition, use of acceptance, religious coping or behavioral disengagement moderated the relationship between beliefs about the cause of depression (i.e., environment or chance or medical illness) and psychosocial functioning. CONCLUSIONS: Illness models for depression are important determinants of functioning in depressed primary care patients. These beliefs and coping behaviors are potentially modifiable and could be the target of interventions to decrease functional impairment in depressed patients.

Missed opportunities to vaccinate older adults in primary care.

OBJECTIVE: During the 2000 to 2001 influenza season, distribution of influenza vaccine was delayed, and national self-reported vaccination rates declined. The purposes of this study were to characterize missed opportunities for adult vaccinations and assess the impact of the vaccine delay on missed opportunities for influenza vaccination as recorded in medical records. METHODS: In a cross-sectional analysis, medical record data from 217 adult patients aged > or =65 years in primary care practices that received influenza vaccine supplies late in 2000 were used to assess rates and missed opportunities to vaccinate. Missed opportunities were defined as visits in which there was no record that vaccine had been given, discussed, or refused by the patient. RESULTS: During the mean study period of 37.1 +/- 5.7 months, patients averaged 12.1 +/- 5.9 visits to their primary care physician's office. Medical records indicated that 75% of patients had received pneumococcal polysaccharide vaccine (PPV) and 30% had received tetanus toxoid from 1991 to 2001; 81% had received at least one influenza vaccine in the previous 4 seasons. During the 2000 to 2001 influenza season, influenza vaccination rates declined significantly to 41% from 57% in 1999 to 2000. Overall missed opportunities to vaccinate during the study period averaged 3.4 +/- 3.0 for influenza vaccine, 10.7 +/- 7.3 for pneumococcal vaccine, and 10.8 +/- 5.9 for tetanus toxoid. During the delay season, the number of visits increased, but missed opportunities to vaccinate also increased significantly, even after vaccine supplies had been received. CONCLUSIONS: Missed opportunities to vaccinate occur frequently and vaccine shortages create additional challenges to adult vaccination. Missed opportunities may be minimized and maintenance of accurate adult immunization records may be achieved by assessing and recording vaccination status at each visit, regardless of vaccine availability. By so doing, providers can easily convey the message to their patients that immunizations are an important part of their care.

Effects of the year 2000 influenza vaccine delay on elderly patients' attitudes and behaviors.

BACKGROUND: A substantial delay in distribution of influenza vaccine occurred in the 2000-2001 influenza season. Our objective was to quantify the impact of this delay on immunization rates, location of receipt of immunization, and patient attitudes and beliefs about the influenza vaccine. METHODS: Inner-city and suburban medical practices that received influenza vaccine supply on-time or late in the season (late-receipt) were selected. A random sample of elderly patients from each practice completed telephone interviews. RESULTS: Of 775 eligible patients, we interviewed 72%. The odds of receiving influenza vaccine in late-receipt practices compared to on-time practices did not significantly differ in either the suburban stratum (adjusted OR = 0.9, 95% CI 0.5-1.6) or the inner-city stratum (adjusted OR = 1.5, 95% CI 0.8-2.8). Very few respondents (4%-11%) reported changes in their beliefs about the vaccine, its safety or efficacy, from previous years. More patients in late-receipt practices reported receiving influenza vaccine at locations other than their regular doctor's offices in the shortage year compared with the previous year. CONCLUSIONS: The 2000-2001 influenza vaccine delay changed vaccination location, but did not change influenza vaccination rates.