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Purpose@#To evaluate and compare the clinical efficacy of matrix metalloproteinase-9 (MMP-9) immunoassay and tear osmolarity measurement in diagnosing dry eye severity. @*Methods@#Dry eye disease (DED) patients underwent diagnostic tests including MMP-9 assay, tear osmolarity measurement, fluorescein tear breakup time, ocular surface staining, anesthetized Schirmer test, Ocular Surface Disease Index questionnaire, and slit-lamp examination. The dry eye parameters were compared according to positive MMP-9 status and increased tear osmolarity. The correlation between dry eye profiles and MMP-9 positivity and high tear osmolarity was also analyzed. @*Results@#Those who tested positive in MMP-9 immunoassay had significantly higher corneal fluorescein staining score and worse DED severity than those who tested negative. The intensity of MMP-9 positivity showed positive correlation with the corneal staining score and DED severity. However, DED patients with high tear osmolarity above 308 mOsm/L did not show significantly different dry eye signs and symptoms compared to those with lower tear osmolarity values. Tear osmolarity was associated with ocular surface staining score in severe DED patients. @*Conclusions@#MMP-9 positivity was associated with ocular surface staining and worse dry eye severity. Therefore, it may be used as a useful indicator of disease severity in conjunction to other diagnostic tests.
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Purpose@#We analyzed the incidence and prevalence of neovascular age-related macular degeneration (AMD) and the treatment patterns of AMD in response to changes in health insurance policies in South Korea. @*Methods@#We retrospectively analyzed the incidence and prevalence of neovascular AMD in patients diagnosed between 2010 and 2019. Data were extracted from the Korean National Health Insurance System database. The incidence and prevalence per 10,000 person-years and corresponding 95% confidence intervals were calculated. Furthermore, we recorded the usage of ranibizumab and aflibercept among newly diagnosed patients with neovascular AMD between 2010 and 2014. @*Results@#In total, 90,012 patients were diagnosed with neovascular AMD between 2010 and 2019. The incidence of neovascular AMD increased with age, except for individuals aged ≥ 90 years. The prevalence of neovascular AMD increased significantly from 30.29 per 10,000 person-years in 2010 to 50.8 per 10,000 person-years in 2019. The rate of intravitreal ranibizumab injections decreased following the introduction of aflibercept in 2014. Patients who switched from ranibizumab to aflibercept exhibited a higher drug switch rate than those who switched from aflibercept to ranibizumab (28.83% vs. 8.40%). Among newly diagnosed patients, approximately 65% received treatment covered by the health insurance system. On average, six injections were administered per year between 2010 and 2019; the number of injections increased in accordance with the maximum limit supported by the government. @*Conclusions@#The incidence and prevalence of neovascular AMD demonstrated an increasing trend. The treatment patterns are influenced by changes in government funding support policies. These findings provide valuable information for planning neovascular AMD treatment.
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Objective@#Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one’s physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia. @*Methods@#Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology. @*Results@#Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended. @*Conclusion@#This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.
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Rifampin is a potent hepatic cytochrome enzyme inducer, promoting the metabolism of many drugs. Here, we describe a case wherein rifampin-induced drug interactions affected the clinical improvement of a patient on psychiatric drugs for bipolar disorder. He was administered divalproex, risperidone, quetiapine, and clonazepam, along with anti-tuberculosis drugs HERZ, containing 600 mg rifampin. Despite taking 900 mg/day divalproex, his serum valproate levels were below 2 μg/ml, and his manic symptom persisted. Therefore, the antipsychotic risperidone (5 mg) was replaced with olanzapine (20 mg). Following this, his manic symptoms improved rapidly. Rifampin is a potent CYP3A and CYP2D6 inducer and is known to significantly reduce serum risperidone levels. Thus, even a high dose of risperidone did not induce a significant clinical effect, which was observed immediately after replacing with olanzapine. Therefore, drug interactions may have had a significant effect on clinical outcomes. Clinicians should be cognizant of drug interactions when treating psychiatric patients on rifampin therapy. The case has been sufficiently revised to protect the patient’s personal information.
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Objective@#The Functioning Assessment Short Test (FAST) is a relatively specific test for bipolar disorders designed to assess the main functioning problems experienced by patients. This brief instrument includes 24 items assessing impairment or disability in 6 domains of functioning: autonomy, occupational functioning, cognitive functioning, financial issues, interpersonal relationships, and leisure time. It has already been translated into standardized versions in several languages. The aim of this study is to measure the validity and reliability of the Korean version of FAST (K-FAST). @*Methods@#A total of 209 bipolar disorder patients were recruited from 14 centers in Korea. K-FAST, Young Mania Rating Scale (YMRS), Bipolar Depression Rating Scale (BDRS), Global Assessment of Functioning (GAF) and the World Health Organization Quality of Life Assessment Instrument Brief Form (WHOQOL-BREF) were administered, and psychometric analysis of the K-FAST was conducted. @*Results@#The internal consistency (Cronbach’s alpha) of the K-FAST was 0.95. Test-retest reliability analysis showed a strong correlation between the two measures assessed at a 1-week interval (ICC = 0.97; p ＜ 0.001). The K-FAST exhibited significant correlations with GAF (r = −0.771), WHOQOL-BREF (r = −0.326), YMRS (r = 0.509) and BDRS (r = 0.598). A strong negative correlation with GAF pointed to a reasonable degree of concurrent validity. Although the exploratory factor analysis showed four factors, the confirmatory factor analysis of questionnaires had a good fit for a six factors model (CFI = 0.925; TLI = 0.912; RMSEA = 0.078). @*Conclusion@#The K-FAST has good psychometric properties, good internal consistency, and can be applicable and acceptable to the Korean context.
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The aim of this study was to develop evidence-based recommendations for determining the surgical extent in patients with locally invasive differentiated thyroid cancer (DTC). Locally invasive DTC with gross extrathyroidal extension invading surrounding anatomical structures may lead to several functional deficits and poor oncological outcomes. At present, the optimal extent of surgery in locally invasive DTC remains a matter of debate, and there are no adequate guidelines. On October 8, 2021, four experts searched the PubMed, Embase, and Cochrane Library databases; the identified papers were reviewed by 39 experts in thyroid and head and neck surgery. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the quality of evidence, and to develop and report recommendations. The strength of a recommendation reflects the confidence of a guideline panel that the desirable effects of an intervention outweigh any undesirable effects, across all patients for whom the recommendation is applicable. After completing the draft guidelines, Delphi questionnaires were completed by members of the Korean Society of Head and Neck Surgery. Twenty-seven evidence-based recommendations were made for several factors, including the preoperative workup; surgical extent of thyroidectomy; surgery for cancer invading the strap muscles, recurrent laryngeal nerve, laryngeal framework, trachea, or esophagus; and surgery for patients with central and lateral cervical lymph node involvement. Evidence-based guidelines were devised to help clinicians make safer and more efficient clinical decisions for the optimal surgical treatment of patients with locally invasive DTC.
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Background@#Dermatofibromas (DF) are fibrohistiocytic tumors of unknown etiology, and multiple DF (MDF) are relatively rare. MDF have been reported in the setting of autoimmune diseases, human immunodeficiency virus infection, or comorbidities treated with immunosuppressive drugs. @*Objective@#The present study investigated whether underlying conditions with impaired immune function are associated with MDF. @*Methods@#A total of 338 patients with DF was enrolled. We divided patients into two groups as MDF and solitary DF (SDF) groups. We retrospectively reviewed patient medical records and classified all patients by underlying diseases. Statistical significance of SDF and MDF for each conditions was analyzed. @*Results@#The demographics and comorbidities were compared between MDF group (n=82) and SDF group (n=256). Among underlying conditions, systemic lupus erythematosus (SLE) (odds ratio, 10.397; 95% confidence interval, 2.743∼39.404; p＜0.001) was significantly associated with MDF over SDF. Vitiligo and post status of kidney transplant were related more highly to MDF (p=0.014; p=0.014, respectively) than to SDF. Presence of overall comorbidities, autoimmune diseases, and immunosuppressive drug use were associated with DF number (p＜0.001;p＜0.001; p＜0.001, respectively). @*Conclusion@#We propose an association between MDF and comorbidities, especially SLE and immunosuppressant use. MDF lesions seem to be impacted by compromised immune function. This is of significance since it is essential to search for associated conditions in patients presenting with MDF in dermatologic clinical settings.
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Background and Objectives@#The purpose of this study was to analyze the survival data of salivary gland cancer (SGCs) patients to construct machine learning and deep learning models that can predict survival and use them to stratify SGC patients according to risk estimate.Subjects and Method We retrospectively analyzed the clinicopathologic data from 460 patients with SGCs from 2006 to 2018. @*Results@#In Cox proportional hazard (CPH) model, pM, stage, lymphovascular invasion, lymph node ratio, and age exhibited significant correlation with patient’s survival. In the CPH model, the c-index value for the training set was 0.85, and that for the test set was 0.81. In the Random Survival Forest model, the c-index value for the training set was 0.86, and that for the test set was 0.82. Stage and age exhibited high importance in both the Random Survival Forest and CPH models. In the deep learning-based model, the c-index value was 0.72 for the training set and 0.72 for the test set. Among the three models mentioned above, the Random Survival Forest model exhibited the highest performance in predicting the survival of SGC patients. @*Conclusion@#A survival prediction model using machine learning techniques showed acceptable performance in predicting the survival of SGC patients. Although large-scale clinical and multicenter studies should be conducted to establish more powerful predictive model, we expect that individualized treatment can be realized according to risk stratification made by the machine learning model.
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Background/Objectives@#This study analyzed the prognostic significance of clinico-pathologic factors including comprehensive nodal factors in parotid gland cancers (PGCs) patients and constructed a survival prediction model for PGCs patients using machine learning techniques.Materials & Methods: A total of 131 PGCs patients were enrolled in the study. @*Results@#There were 19 cases (14.5%) of lymph nodes (LNs) at the lower neck level and 43 cases (32.8%) involved multiple level LNs metastases. There were 2 cases (1.5%) of metastases to the contralateral LNs. Intraparotid LNs metastasis was observed in 6 cases (4.6%) and extranodal extension (ENE) findings were observed in 35 cases (26.7%). Lymphovascular invasion (LVI) and perineural invasion findings were observed in 42 cases (32.1%) and 49 cases (37.4%), respectively. Machine learning prediction models were constructed using clinico-pathologic factors including comprehensive nodal factors and Decision Tree and Stacking model showed the highest accuracy at 74% and 70% for predicting patient’s survival. @*Conclusion@#Lower level LNs metastasis and LNR have important prognostic significance for predicting disease recurrence and survival in PGCs patients. These two factors were used as important features for constructing machine learning prediction model. Our machine learning model could predict PGCs patient’s survival with a considerable level of accuracy.
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Background and Objectives@#With the introduction of sialendoscopy, minimal invasive surgery has become possible for the removal of sialoliths, although sialendoscopic removal of parotid stones remains a surgical challenge. Sialendoscopic stone removal can be differently applied according to the location and size of stones. This study was conducted to evaluate the surgical outcomes of sialaendoscopic stone removal and to provide a strategy for choosing an adequate surgical approach according to the characteristics of parotid stones.Subjects and Method A retrospective study was conducted of 43 patients with parotid sialolithiasis who were treated by sialendoscopic stone removal between March 2017 and January 2021. Surgical techniques were classified into sialendoscopy alone (SA), sialendoscopy-assisted transoral approach (STO), and sialendoscopy-combined retroauricular approach (SRA). The parotid gland stones were categorized by size, location, and multiplicity. @*Results@#Of the 43 patients, 13 patients underwent SA, 10 received STO, and 20 were treated with different SRA approaches. The SRA approaches included three distal, seven proximal, and ten intraglandular stone removal cases. The success rate of stone removal was 92% (12 cases) by SA, 90% (9 cases) by STO, and 100% (20 cases) by SRA. In cases of SA and STO, all patients had distant stones except for one who had proximal stones. Postoperative complications including pain, swelling, wound dehiscence, sialocele, duct stricture, and facial palsy mainly occurred in cases treated with SRAs. @*Conclusion@#Appropriate use of various sialendoscopy-assisted approaches is mandatory to preserve the gland and minimize surgical complications in patients with different features of parotid gland stones.
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Warty dyskeratoma (WD) is an uncommon skin tumor that histologically presents as focal acantholysis and dyskeratosis and is a common finding among acantholytic diseases such as Darier’s disease. WD most commonly occurs on the head or neck of adults as an isolated papule or nodule. To our knowledge, only 6 cases of WD in the genital area have been previously reported in the literature, and no case have occurred on the scrotum to date.We report the first case of multiple WD that occurred on the scrotum successfully treated with 0.025% tretinoin cream. A 55-year-old male presented with asymptomatic, multiple, 0.1∼0.2-cm-sized, skin-colored papules on the scrotum for the previous 6 months. A skin punch biopsy and human papillomavirus (HPV) polymerase chain reaction test were performed for a clinical suspicion of genital warts or bowenoid papulosis. The histopathologic examination showed cup-shaped epidermal invaginations with central keratotic plug. Prominent villi, acantholytic clefting and corps ronds were also shown. The patient tested negative for HPV and was diagnosed with WD with typical pathologic findings. The patient was treated with 0.025% tretinoin cream for 2 weeks, and the lesions decreased in both size and number.
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Purpose@#To report the first case of a 53-year-old male patient diagnosed with central Horner syndrome, associated with vertebral artery dissection, which has never been reported in Korea to date.Case summary: A 53-year-old male patient presented with conjunctival hyperemia in the left eye for over 4 months, with a past history of acute subarachnoid hemorrhage and ruptured dissecting aneurysm in the left vertebral artery. On slit-lamp examination, mild ptosis of the upper eyelid and conjunctival hyperemia were noted in his left eye. The left pupil was smaller than the right without afferent pupillary defects in either eye. Anisocoria was greater in the dark, and dilation lag was noted in the left pupil. On systemic examination, he complained of numbness in the right upper and lower extremities and symptoms of leaning to the left when walking. After instillation of 0.5% apraclonidine, the anisocoria was reversed, and ptosis and conjunctival hyperemia disappeared. Magnetic resonance images revealed chronic infarction in the left lateral medulla, and he was diagnosed with central Horner syndrome associated with Wallenberg syndrome. @*Conclusions@#We present the first case in Korea of central Horner syndrome associated with lateral medullary infarction caused by vertebral artery dissection.
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The Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) first was published in 2002, and has been revised four times, in 2006, 2012, 2017, and 2021. In this review, we compared recommendations from the recently revised KMAP-DD 2021 to four global clinical practice guidelines (CPGs) for depression published after 2010. The recommendations from the KMAP-DD 2021 were similar to those from other CPGs, although there were some differences. The KMAP-DD 2021 reflected social culture and the healthcare system in Korea and recent evidence about pharmacotherapy for depression, as did other recently published evidence-based guidelines. Despite some intrinsic limitations as an expert consensus-based guideline, the KMAP-DD 2021 can be helpful for Korean psychiatrists making decisions in clinical settings by complementing previously published evidence-based guidelines, especially for some clinical situations lacking evidence from rigorously designed clinical trials.
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Background@#Cutaneous warts tend to recur despite of various treatment modalities. However, previous studies provided few data on their reinfection rate. @*Objective@#In this study, we investigated the reinfection rate along with the incidence and prevalence rates of cutaneous warts. @*Methods@#We conducted a nationwide, cross-sectional population-based study using the Korean National Health Insurance Service database from January 2006 through December 2016. Patients who visited outpatient clinics with an International Classification of Disease-10 code of viral warts (B07) were included. The reinfection rate was calculated as a percentage of patients with an initial visit in 2010 and subsequent visits for cutaneous warts with at least a six-month interval from last visit until 2016. @*Results@#From 2006 to 2016, the overall incidence and prevalence rates of cutaneous warts increased from 2.99 to 7.69 per 1,000 population and from 3.45 to 10.94 per 1,000 population, respectively. The overall reinfection rate of cutaneous warts was 30.9%. The reinfection rate of males and females was 31.6% and 30.0%, respectively. Children under ten years old had the highest reinfection rate (34.3%). @*Conclusion@#These results demonstrate that the reinfection rate of cutaneous warts is the highest in male children under ten years old. Therefore, these patients should be monitored closely after treatment.
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Background@#Ultrasonography is an effective noninvasive imaging modality for the diagnosis of subcutaneous masses. To date, few studies have reported skin ultrasonography using deep convolutional neural networks (DCNNs).We investigated the accuracy of DCNNs for the diagnosis of epidermal cysts, lipomas, and other subcutaneous masses. @*Objective@#The purpose of this study was to evaluate whether DCNNs could diagnose subcutaneous masses with ultrasonographic images at level of competence comparable to dermatologists. @*Methods@#We created a dataset of 1,361 skin ultrasonography images obtained from 202 patients diagnosed with epidermal cysts, lipomas, and other subcutaneous masses, to train the DCNNs using ResNet18. Performance was compared with another set of 93 ultrasonographic images (24 epidermal cysts, 25 lipomas, and 44 other subcutaneous masses) from open-access articles. @*Results@#The DCNNs yielded 87.10% classification accuracy and 86.10% F1-scores. The area under the curve, sensitivity, and specificity were 0.92 (95% confidence interval [CI] 0.86∼0.98), 75.00%, and 98.55% for epidermal cysts; 0.93 (95% CI 0.88∼0.98), 80.00%, and 94.12% for lipomas; and 0.97 (95% CI 0.93∼1.00), 97.73%, and 85.71% for other subcutaneous masses, respectively. Analysis using gradient-weighted class activation mapping revealed that the DCNNs could detect specific ultrasonographic findings of epidermal cysts and lipomas. @*Conclusion@#We propose that DCNNs combined with ultrasonography may aid in the diagnosis of subcutaneous masses in outpatient settings.
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Objectives@#. In subset of patients, acinic cell carcinoma (AcCC) exhibits aggressive features such as recurrence, distant metastasis, and mortality. This study aimed to investigate clinicopathologic factors influencing patients’ prognosis and to identify adverse features predictive of an unfavorable prognosis. @*Methods@#. Between January 2000 and December 2016, 59 patients with AcCC were enrolled in this study. @*Results@#. The patients’ 5-year overall survival rate was 93.3%, and their 5-year recurrence-free survival rate was 80.5%. During the study period, recurrence occurred in 10 patients. The mean time to recurrence after surgery was 26 months (range, 5–60 months). During the study period, three patients died from the disease. Univariate analysis showed that sex, surgical extent, extranodal extension, T classification, and TNM stage were significantly associated with disease recurrence. Multivariate analysis showed that, among the clinicopathologic factors included in the analysis, only TNM stage displayed a statistically significant correlation with disease recurrence. @*Conclusion@#. Surgical treatment alone yielded good results for AcCC, and additional treatment did not affect the recurrence-free survival rate or the overall survival rate, even when the resection margin was less than 1 mm. Other pathologic factors did not show prognostic significance for disease recurrence or death.
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This paper analyzed previous research data to identify the most important issues to be considered during treatment of parotid gland cancer (PGC) and reviewed recent advancements in techniques in parotid surgery. For successful treatment of PGC, a preoperative surgical plan should be designed with consideration of the histologic characteristics and anatomical complexity of the tumor, and the functional and anatomical integrity of the facial nerve should be carefully inspected during surgery and damage to the nerve minimized. The need for adjuvant radiotherapy should be determined based on intraoperative findings and pathologic findings of the specimen after surgery. To optimize treatment outcomes for PGC, the extent of surgery and adjuvant radiotherapy should be decided according to histologic characteristics and risk stratification.
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Background@#As the use of laser therapy for skin lesions has increased significantly, laser treatment is performed in many cases without an accurate diagnosis. @*Objective@#This study aimed to analyze cases in which skin lesions recurred or remained after laser treatment by investigating the clinicopathological diagnosis. @*Methods@#We retrospectively analyzed the patients who visited the Seoul Saint Mary’s hospital from January 2011 to December 2020, the clinical records of 518 cases of patient who had a history of laser treatment and underwent histopathological examination. @*Results@#The number and proportion of patients who visited the hospital showed a steadily increasing trend for 10 years. In 187 patients, the time between laser treatment and hospital visits was ＞1 year. The most common site of lesions was the face (66.2%), especially the cheek (29.3%) and nose (12.2%). Final diagnosis of the lesion yielded 59 cases (11.4%) of premalignant diseases and 55 cases (10.6%) of malignant tumors, and the rate increased with increasing age. The most common malignant tumor was basal cell carcinoma (69.1%), followed by squamous cell carcinoma (14.5%) and malignant melanoma (12.7%). @*Conclusion@#In this study, we found that laser treatment for premalignant and malignant tumors is not rare. This study emphasizes that indiscriminate laser treatment should be avoided, and an accurate diagnosis and proper medical treatment by an experienced dermatologist are needed.
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Objectives@#：In this study, socio-demographic, drinking and emotional characteristics, and their correlations were compared among patients with alcohol use disorder (AUD) according to the presence or absence of any type of criminal record. @*Methods@#：Among patients admitted to the hospital with AUD, 27 with and 31 without criminal records were included. Socio-demographic data and drinking characteristics such as first drinking age, average daily alcohol consumption were collected. In addition, the severity of alcohol problems, the degree of change readiness for drinking alcohol, depressive symptoms, anxiety symptoms, and impulsivity were evaluated using scales and statistically analyzed. Pearson’s correlation test was applied to reveal the differences in correlation of the characteristics according to the presence or absence of criminal records. @*Results@#：The first drinking age was significantly earlier in the AUD group with criminal records. Interestingly, the degree of change readiness regarding alcohol problem as shown in SOCRATES-K was significantly higher in the AUD group with criminal records. Anxiety symptoms were statistically significantly higher in the AUD group with criminal records. In AUD with criminal records, first drinking age negatively correlated with the degree of change readiness. In AUD without criminal records, first drinking age correlated negatively with the severity of alcohol problem, and the degree of change readiness, and the degree of change readiness negatively with age, and the degree of change readiness positively with the severity of alcohol problem. In Both groups, anxiety symptoms positively correlated with depressive symptoms. @*Conclusions@#：This study showed that AUD patients with criminal record had a faster first drinking age and the higher degree of change readiness regarding alcohol problem. Significantly higher symptoms of anxiety were also presented in AUD patients with criminal record than AUD patients who have no criminal records. Some differences were identified in correlations among characteristics between the two groups.
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Objectives@#An expert consensus guideline for the treatment of depressive disorder, the Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD), was first established in 2002 and updated in 2017. To provide an up-to-date treatment guideline, KMAP-DD 2021 was recently completed. This study was undertaken to provide a guideline for the treatment of depressive disorder in a selected population that included females and elderly. @*Methods@#The survey conducted consisted of 7 questionnaires for each population, females and elderly, with depressive disorder. A total of 65 of 97 experienced psychiatrists answered the survey. @*Results@#For the treatment of premenstrual dysphoric disorder, the selective serotonin reuptake inhibitors, venlafaxine, and desvenlafaxine were recommended as first-line therapies. For major depressive disorder (MDD) during pregnancy, antidepressant (AD) monotherapy was recommended as a first-line therapy for mild to moderate and severe depression, and combined electroconvulsive therapy and AD with atypical antipsychotics (AAP) were recommended as a first-line therapy for severe depression with psychotic features. AD plus AAP was generally recommended for post-partum depression. In elderly with depression, AD monotherapy was recommended as the treatment of choice for mild to moderate episodes, and AD monotherapy and AD plus AAP were recommended as a first-line therapy for severe depression without psychotic features. Lastly, AD plus AAP was chosen as the treatment of choice for psychotic depression. @*Conclusion@#Present study provides an updated algorithm for the treatment of females and elderly with depressive disorders. This algorithm provides a practical aid to clinicians for the treatment of females and elderly with MDD.