Table of Contents

The authors randomly assigned 41 primary care physicians from 5 clinics to receive depression decision support or usual care. Depression decision support was provided by a team that included a psychiatrist and a nurse care manager and involved an initial telephone contact, patient education, monthly record review, and a progress report sent to primary care physicians every 3 months. Depression severity improved equally in both groups over 12 months, despite evidence that intervention clinicians delivered more depression-related services.

The authors reviewed malpractice claims alleging injury from a missed or delayed diagnosis. In 181 cases in which there was a high likelihood that error led to the missed diagnosis, the authors analyzed where the diagnostic process broke down and why. The most common missed diagnosis was cancer, and the most common breakdowns were failure to order appropriate tests and inadequate follow-up of test results. A median of 3 process breakdowns occurred per error, and 2 or more clinicians were involved in 43% of cases.

In this double-blind trial, 29 adults with a history of high-altitude pulmonary edema (HAPE) were randomly assigned to receive prophylactic tadalafil, dexamethasone, or placebo during a 24-hour ascent and 2-day stay at 4559 m. Compared with placebo recipients, adults taking dexamethasone less often experienced acute mountain sickness and those taking dexamethasone or tadalafil less often had HAPE.

This survey of practices of 122 professional sports teams in North America found that team physicians always perform history taking and physical examinations, usually perform electrocardiography (92%) and lipid panels (89%), and infrequently perform exercise testing (17%) and echocardiography (13%). League recommendations about the content of the history and physical examinations varied among sports leagues.

The authors studied 4 intermediate outcome measures (anemia, serum albumin level, functioning vascular access, and dialysis adequacy) in a 5% random sample of all U.S. patients receiving long-term hemodialysis. Annual mortality rates in patients who met 0, 1, 2, 3, or 4 quality measures were 29%, 25%, 21%, 14%, and 7%, respectively.

The articles in this Update in Geriatrics came from a review of approximately 30 peer-reviewed journals during 2005. The selected articles are important clinical research studies that pertain to elderly patients in the primary care setting, with a concentration on improving functionality. Topics covered are cognitive and physical function, stroke, age and frailty, and quality of care.

Recent national recommendations have proposed that physicians should titrate lipid therapy to achieve low-density lipoprotein (LDL) cholesterol levels less than 1.81 mmol/L (<70 mg/dL) for patients at very high cardiovascular risk and less than 2.59 mmol/L (<100 mg/dL) for patients at high cardiovascular risk. To examine the clinical evidence for these recommendations, the authors sought to review all controlled trials, cohort studies, and case–control studies that examined the independent relationship between LDL cholesterol and major cardiovascular outcomes in patients with LDL cholesterol levels less than 3.36 mmol/L (<130 mg/dL).

Patients who experience electrical shock, including being struck by lightning, sustain a wide spectrum of injuries with unique pathophysiologic characteristics that require special management. The authors review the physics and mechanisms of tissue damage, typically encountered injuries, and the prognosis of patients with electrical injuries.

Primary care clinicians know depression well, yet diagnostic and treatment failures are common. In answer to the pressing need to do better, the elegant study by Dobscha and colleagues in this issue adds critical information to the existing body of work on improving depression outcomes in primary care, showing that in depression care, there's no free lunch.

The study by Gandhi and colleagues in this issue uses settled malpractice claims to help us better understand the nature of diagnostic errors in the ambulatory setting. Their findings—that such errors are common (59% of all outpatient claims) and are due to an array of both individual and system factors—are sobering, since they do not offer a single target and the promise of a magic bullet. Nevertheless, the study helps point the way to changes in training, practice, and systems that might prevent many of these errors.

In this issue, Maggiorini and colleagues explore several aspects of the pathogenesis of high-altitude pulmonary edema. Their study yields important practical answers and serendipitously generates new intriguing questions about basic lung pathophysiology and pharmacology.