Nonpharmacologic and pharmacologic treatments of adult patients with major depressive disorder: a systematic review and network meta-analysis for a clinical guideline by the American College of Physicians

Primary care patients and clinicians may prefer alternative options to second-generation antidepressants for major depressive disorder (MDD). To compare the benefits and harms of nonpharmacologic treatments with second-generation antidepressants as first-step interventions for acute MDD, and to compare second-step treatment strategies for patients who did not achieve remission after an initial attempt with antidepressants.

Restricting evidence syntheses of interventions to English-language publications is a viable methodological shortcut for most medical topics: a systematic review.

OBJECTIVES: To assess the impact of restricting systematic reviews of conventional or alternative medical treatments or diagnostic tests to English-language publications. STUDY DESIGN AND SETTING: We systematically searched MEDLINE (Ovid), the Science Citation Index Expanded (Web of Science), and Current Contents Connect (Web of Science) up to April 24, 2020. Eligible methods studies assessed the impact of restricting systematic reviews to English-language publications on effect estimates and conclusions. Two reviewers independently screened the literature; one investigator performed the data extraction, a second investigator checked for completeness and accuracy. We synthesized the findings narratively. RESULTS: Eight methods studies (10 publications) met the inclusion criteria; none addressed language restrictions in diagnostic test accuracy reviews. The included studies analyzed nine to 147 meta-analyses and/or systematic reviews. The proportions of non-English-language publications ranged from 2% to 100%. Based on five methods studies, restricting literature searches or inclusion criteria to English-language publications led to a change in statistical significance in 23/259 meta-analyses (9%). Most commonly, the statistical significance was lost, but had no impact on the conclusions of systematic reviews. CONCLUSION: Restricting systematic reviews to English-language publications appears to have little impact on the effect estimates and conclusions of systematic reviews.

Excluding non-English publications from evidence-syntheses did not change conclusions: a meta-epidemiological study.

OBJECTIVES: We aimed to assess whether limiting the inclusion criteria solely to English-language publications affected the overall conclusions of evidence syntheses. STUDY DESIGN AND SETTING: Our analyses used a dataset of a previous methods study that included 59 randomly selected Cochrane intervention reviews with no language restrictions. First, we ascertained the publication language of all 2,026 included publications. Next, we excluded studies based on the following criteria: (1) publication solely in non-English language, or (2) main publication (in case of multiple publications of the same study) in non-English language. We then re-calculated meta-analyses for outcomes that were presented in the main summary of findings tables of the Cochrane reports. If the direction of the effect estimate or the statistical significance changed, authors of the respective Cochrane reviews were consulted to assess whether the new evidence base would have changed their conclusions. The primary outcome of our analyses examined the proportion of conclusions that would change with the exclusion of non-English publications. We set the threshold for the approach as noninferior if the upper limit of the 95% confidence interval of the proportion of changed conclusions did not cross a margin of 10%. RESULTS: Across all 59 Cochrane reviews, 29 (49%) included 80 non-English publications. For 16 (27%) of these Cochrane reviews, the exclusion of non-English publications resulted in the exclusion of at least one study. In the remaining 13 Cochrane reviews, the non-English publications were not the only or main publication of the study or they did not contribute to the main summary of the findings table, so their exclusion did not result in an exclusion of the study. Overall, the exclusion of non-English publications led to the exclusion of 31 studies contributing to 40 outcomes. For 38 of the 40 outcomes, the exclusion of non-English studies did not markedly alter the size or direction of effect estimates or statistical significance. In two outcomes, the statistical significance changed, but authors would have still drawn the same conclusion, albeit with less certainty. Thus, the proportion of changed conclusions in our sample was 0.0% (95% CI 0.0-0.6), which indicated the noninferiority of the approach. However, the majority of excluded studies were small. CONCLUSION: Exclusion of non-English publications from systematic reviews on clinical interventions had a minimal effect on overall conclusions and could be a viable methodological shortcut, especially for rapid reviews.

Unexpected phenotype in a patient with two chromosomal deletions involving 6pter and 22q11.

The 6p terminal deletions are rare and usually early diagnosed because of their association with eye and cranio-facial anomalies, particularly as part of Axenfeld-Rieger syndrome in relation with the haploinsufficiency of FOXC1 gene. Deletions in the 22q11 region are frequent, highly correlated with DiGeorge syndrome also named CATCH22, and may be associated with many clinical features of various severities. We report a 31-year-old man with an unbalanced 45,XY,der(6)t(6;22)(p25;q11.2),-22 karyotype leading to monosomies in both 6p25 and 22q11 regions, confirmed by FISH and array-CGH. The length of the deletions was respectively 770 Kb for 6pter and 2.9 Mb for 22q11. This karyotype was discovered at adult age following problems of fertility. The chromosomal formula was unexpected, regarding the patient's medical history and clinical features. This case makes a great example of the difficulties to correlate genotype and phenotype, and furthermore demonstrates the complexity of genetic counselling even in a case with two different chromosomal unbalances.

Correlation between Tgf-Β1 and Fsp-1 Expression in Chronic Viral Hepatitis - an Immunohistochemical Study.

Infection with hepatitis C virus (HCV) is the most important stimulus for chronic hepatitis and subsequent progression to cirrhosis and hepatocellular carcinoma. Fibrosis that follows inflammation represents the main complication. One of the mechanisms that could be associated with development of liver fibrosis is epithelial-mesenchymal transition (EMT). Transforming Growth Factor ß1 (TGF-ß1) is an important mediator of fibrosis and also able to trigger phenotypic changes in EMT. Fibroblast-specific protein 1 (FSP-1), a marker of fibroblasts in organs undergoing tissue remodeling, is used to identify cells that derive from EMT. In this study, we assessed the expression of TGF-ß1 and FSP-1 in liver biopsies obtained from HCV-infected patients using immunohistochemistry and correlated them in order to evaluate the relation between fibrosis and EMT in liver disease progression. Staining of liver sections revealed increased amount of type III collagen and clusters of inflammatory cells invading portal spaces. The number of TGF-ß1-positive cells was directly proportional to the incidence of liver injury. In cases of mild fibrosis, FSP-1 positive cells were observed in cells lining sinusoids. As fibrosis progressed, increased number of FSP-1 positive fibroblasts, isolated cholangiocytes and hepatocytes was observed. Even EMT via the activation of TGF-ß signaling pathway is recognized as a pathogenic mechanism of HCV-induced liver disease, FSP-1 alone couldn't be used as a valuable marker for cells that undergo EMT.

Nodular thyroid cancer. Diagnostic value of real time elastography.

BACKGROUND: The most important aspect in the diagnostic approach of thyroid nodule is identifying the malignancy Elastography is a newly technique that measures the elasticity of tissue, after applying a external force, standardized control. US elastography is currently used in differentiation of malignant from benign lesions. PATIENTS: This prospective study included 69 patients, mean age 50.08 +/- 12.43 years, 67 females and 2 men, with thyroid nodules on conventional US, with a volume higher than 0.20 ml. All patients underwent surgery after complete evaluation. Extemporaneous and postsurgical histopathological exam was performed in all cases. Tissue stiffness was scored from one (greatest elasticity) to 5 (no strain), according to the UENO scale. RESULTS: In the 69 cases we diagnosed 107 nodules, which we analyzed. 27 nodules had score 1 on US elastography and 37 nodules had score 2. All nodules were benign on histopathological exam. Score 3 was found in 33 cases, 32 benign and one papillary carcinoma. Score 4 as found in 10 cases, all carcinomas. ES score of 4 is highly predictive for malignancy (sensitivity of 90.9%, specificity of 98.96%, positive predictive value of 100%, negative predictive value if 98.60%). The diagnostic quality of elastography was independent of the nodule volume. CONCLUSION: US elastography has a good potential in diagnosing thyroid malignancy, independent of nodule volume, allowing the study of small nodules, less than 0.5 ml.

[Antifungals, their potentials, limits and outlook]. / Antifungicele, posibilitati, limite si perspective.

A review of the history of antifungal therapy shows that after a long period of empiricism the therapeutic arsenal available for the nowadays practitioner has suffered a spectacular change. Indicated in the topical and systemic treatment of mycoses, their practical use requires experience and responsibility. The impartial analysis of their antifungal benefits refers to such targets as: ergosterol, protein syntheses and mitoses from fungal cells.

Viral hepatitis in Bucharest.

A seroprevalence survey of viral hepatitis was conducted in Bucharest, Romania, between April and July 1990 on a systematic sample of 1355 persons drawn from the general population and groups at higher risk of infection. Sera were tested for hepatitis A, B, and C (HAV, HBV and HCV, resp.) markers using an enzyme-linked immunosorbent assay (ELISA) method. The prevalences of HAV and HBV markers were high in all groups. A total of 47% of the adults from the general population and 39.8% of the children aged 0-16 years had at least one HBV marker. Of the pregnant women 7.8% were positive for hepatitis B surface antigen. Among infants (0-3 years of age) living in orphanages, the prevalence of at least one HBV marker was 54.6%. The findings also confirmed that HCV was circulating in Romania. The results are consistent with national surveillance data and confirm that viral hepatitis is a major public health problem in Romania. Preventive measures will have to include HBV immunization of infants, with an appropriately targeted immunization strategy being determined through further epidemiological studies.

PIP: Viral hepatitis is a major public health problem in all parts of the world. Infections with hepatitis B are of particular concern since such infection in some individuals can lead to chronic liver disease, cirrhosis of the liver, and hepatocellular carcinoma. Comparative studies of the morbidity rates of hepatitis B and hepatitis A virus infections in various European countries indicate that these diseases are highly endemic in Romania. A 300 case per 100,000 population incidence was reported in 1989 national surveillance data for all types of viral hepatitis. A seroprevalence survey of viral hepatitis was conducted in Bucharest, Romania, during April-July 1990 on 1355 people from both the general population and groups at higher risk of infection. The low-risk sample was comprised of 201 individuals aged 0-16 years who had been admitted to the hospital for the first time in their life and who had a noninfectious diagnosis; 200 healthy adults who were attending premarital or recruitment medical examinations; and 204 pregnant women attending antenatal clinics. 214 children younger than three years old selected at random from the five orphanages in Bucharest and 336 medical personnel working at any of four health facilities in the city comprised the high-risk sample. ELISA was used to identify markers of hepatitis A, B, and C in sera. The prevalences of hepatitis A and B markers were high in all low-risk groups, with a past history of acute hepatitis reported by 10.5% of healthy adults. The prevalence of anti-hepatitis A markers increased with age. Almost two-thirds of the subjects younger than 20 years old had been infected with hepatitis A, 50.7% of the 77 children under 5 years old were positive for at least one hepatitis B virus marker, and 34.8% of individuals aged 5-19 years demonstrated seropositivity for hepatitis B virus. 47% of adults from the general population had at least one marker for hepatitis B, 7.8% of pregnant women were seropositive for hepatitis B surface antigen, and 54.6% of the infants aged 0-3 years living in orphanages had at least one marker for hepatitis B. Hepatitis C is circulating in the country. These results are consistent with national surveillance data and confirm that viral hepatitis is a major public health problem in Romania. Prevention measures must include hepatitis B immunization of infants, with an appropriately targeted immunization strategy determined through further epidemiological studies.

[An analysis of the medical contraindications for poliomyelitis vaccination in a district of the city of Bucharest]. / Analiza contraindicatiei medicale la vaccinarea antipoliomielitica într-un sector din municipiul Bucuresti.

The authors report on the results of the analysis of frequency, motives and possible consequences associated to the medical contraindication of inoculations with TPDV (thermal polio-destroyed virus) during the antipoliomyelitis vaccination in the spring of 1989 in District 3 of Bucharest. The failure share in the first antipoliomylitis vaccination was of 2.2% in the 2,500 children selected: 46 (83.6%) were CIM in one of the inoculations and 9 (16.4%) in both inoculations with TPDV of the vaccination. Infectious acute affections were the most numerous motives (89.1-57.1%) of the medical contraindications of inoculation with TPDV; in 59.6-31.2% of these causes the hospitalization of the cases was necessary. The false contraindications were at the basis of 10.9-42.9% of the medical decisions that contraindicated inoculation with TPDV. Of the children with contraindications at inoculation with TPDV, 41.8% met the risk criteria after the first stage and 12.7% after the second stage of the vaccination.

[Further comment on the importance of microscopy in clinical microbiology. The argument for the diagnosis of the skin manifestations of histoplasmosis and coccidioidomycosis]. / Inca o data despre importanta microscopiei în microbiologia clinica. Argumentum dupa diagnosticarea unor manifestari cutanate ale histoplasmozei si coccidioidomicozei.

This paper presents two interesting cases: a patient with cutaneous coccidioidomycosis, the first case in Romania, and a female patient with latent histoplasmosis with cutaneous manifestations, periodically reactivated during her pregnancies. The etiological diagnosis problems of these affections in relation with the degrees of competence of the clinical laboratories is discussed. The role of direct microscopic examination in the early and more rapid diagnosis of deep mycoses is underlined.

[An estimate of the index of collective measles immunity among the pupils in 8-year elementary education in 1988-1989 in sector III of the city of Bucharest]. / Estimarea indicelui de imunitate colectiva antirujeoloasa la elevii din învatamîntul elementar de 8 ani din anul 1988-1989 din sectorul III al municipiului Bucuresti.

The authors have verified morbidity antecedents in the medical files of 18.5% of the cohort of 47,354 students registered in classes I-VIII in the year 1988-1989 in the III-rd Sector of Bucharest. On the basis of simple hypotheses concerning the post-infectious anti-rubeola immunity, and the post-vaccinal immunity respectively an index was estimated of the anti-rubeola collective immunity of 89.1% a value associated to the risk of transmission of the rubeola infection in this cohort. These observations have permitted the authors to suggest anti-rubeola vaccination of students without documented evidence of anti-rubeola immunity on the one hand, immediately in all the classes (I--VIII) of the present scholar year, and, on the other hand, to vaccinate all the students in the first class, yearly, as an additional measure in the present control anti-epidemic strategy of rubeola.

[The etiopathogenesis of psoriasis]. / Beitrag zur Atiopathogenese der Psoriasis.

In the onset, persistence or aggravation of psoriasis numerous factors are involved. This paper is the result of the investigations carried out on 446 cases of psoriasis admitted to the Dermatological Clinic of Iasi and 1455 cases admitted to the Dermatological Clinic of Algeria.

[A plan for poliomyelitis vaccination]. / Unele consideratii privind schema de vaccinare antipoliomielitica.

A study of the vaccinal antecedents on a representative group of children between 12 and 45 months in the district 3 of Bucharest showed that there exists a certain and direct correlation between the number of simultaneous DTP/VPOT administrations programmed in the immunization scheme and the vaccinal coverage with I DTP revaccination at the minimum age recommended. Administration of VPOT at the ages of 3, 5 and 11 months, simultaneously with the corresponding doses of DTP is the most efficient immunization scheme with these vaccines, in order to proceed to steady rate of antipoliomyelitis vaccination.