Fatigue is commonly reported in the primary care setting; however, its cause is often unclear. This article presents 3 cases involving patients with chronic fatigue syndrome who responded poorly to treatment. After clinical evaluation, all patients were found to meet criteria for attention-deficit/hyperactivity disorder (ADHD) and underwent a standard regimen of a psychostimulant medication. After treatment with psychostimulants, the 3 patients reported improved symptoms of fatigue and pain, and cognitive and core ADHD symptoms. These cases suggest that ADHD and chronic fatigue syndrome (and possibly fibromyalgia) share a common underlying mechanism. This article presents a model suggesting that over time, ADHD (predominantly inattentive type) develops into a syndrome of chronic fatigue and pain. These cases indicate that fatigue may be an important presenting symptom of adult ADHD. These cases also suggest the need for additional research to determine the prevalence of ADHD in patients who present with fatigue, and, in those meeting criteria for ADHD, the responsiveness of fatigue to psychostimulant treatment.

To investigate the potential bidirectional relationships between severity of inattention and depression across early childhood.Children (N = 216) from the New York, NY, metropolitan area were recruited when they were aged 3 to 4 years (T1) and studied again at age 6 (T2) and 7 (T3) years. Child inattention symptoms were measured using the Kiddie-Schedule for Affective Disorders and Schizophrenia for School-Aged Children-Present and Lifetime, along with both parent and teacher reports on the Behavior Assessment System for Children, Second Edition (BASC-2). Severity of child depression was assessed at each time point using parent and teacher reports on the BASC-2. After examining correlations between child inattention and depression, structural equation modeling was used to investigate whether child inattention was longitudinally related to child depression, and whether child depression symptoms were associated with later child inattention.Severity of child inattention at T1 and T2 was longitudinally associated with increased severity of child depression at T2 and T3, respectively. Early child depression was not longitudinally associated with later child inattention.Child inattention is a risk factor for increased levels of child depression. Pediatricians and clinicians who assess children's inattention symptoms also need to investigate symptoms of depression. This study makes a case for treating children's inattention symptoms at preschool and early childhood, before emotional problems become more severe.

The purpose of this study was to describe practice patterns of US psychiatrists with regard to the diagnosis and management of depression in adults with bipolar I disorder and to identify relevant gaps in clinical knowledge and competence.Two focus groups were conducted using nominal group technique via a web interface and teleconference to elicit barriers that psychiatrists face in managing depression in patients with bipolar I disorder. These results framed a case-based survey that was administered to 200 US-based psychiatrists to explore and quantitatively assess their knowledge and practice patterns with respect to the diagnosis and management of depression in patients with bipolar I disorder. We completed all statistical analyses with PASW Statistics 18 and used descriptive statistics to summarize survey responses.To identify previously undiagnosed mania, 67% of clinician respondents said that they asked depressed patients if they had previously experienced all Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision mania-defining symptoms. To treat a patient with symptoms of depression and no other risk factors for bipolar I disorder, 85% of the respondents said that they would use an antidepressant; 55% of respondents were not concerned that their choice of treatment would lead to a manic episode; 5% thought that there was no greater risk of treatment-emergent mood disorder when treating depression in patients with bipolar I disorder compared with major depressive disorder. If the patient had depression and risk factors for bipolar I disorder, 54% of the respondents said that they would still prescribe an antidepressant as monotherapy.The clinician responses were not adherent to evidence-based practice based on clinical trial results or current guideline recommendations. There is an unmet need for education to enable psychiatrists to differentiate between unipolar and bipolar depression, to identify the risk of treatment-emergent mood disorders with the use of antidepressants, and to effectively manage patients at risk for bipolar I disorder.

Patients with diabetes are routinely asked to fast for laboratory tests. If not properly prepared, they may be at risk for hypoglycemia, which may result in traffic accidents while driving en route to and from laboratory facilities. We undertook this study to evaluate the magnitude of this overlooked problem, and to evaluate the effectiveness of a prevention program implemented in our clinic.A retrospective study consisting of chart reviews and telephone interviews of consecutive hypoglycemic events (blood glucose level < 70 mg/dL). The study cohorts, A and B, were extracted from our central laboratory database. Cohort A (from January 2008-September 2009) consisted of patients prior to--and cohort B (from October 2009-June 2011) subsequent to--the implementation of a prevention program involving blood glucose monitoring and adjustment of antidiabetic medications. Duration of each cohort was 21 months. For the purpose of this article, we use the acronym FEEHD (fasting-evoked en-route hypoglycemia in diabetes) to describe this overlooked form of hypoglycemia.Of a total of 1801 blood glucose test results retrieved, cohort A included a total of 55 hypoglycemic events in 51 patients (4 patients with 2 events each). Cohort B included a total of 23 hypoglycemic events in 22 patients (with 1 patient sustaining 2 events) out of a total of 2561 blood glucose test results retrieved. In cohort A, of 35 patients on antidiabetic medications who recalled fasting or probably fasting, there were 39 hypoglycemic events (2.2% frequency), compared with 18 events (0.7% frequency) in 17 patients in cohort B. This indicates a 68% risk reduction. The frequency of critical hypoglycemia (< 50 mg/dL) was more significantly reduced, from 11 events (0.6%) to 2 events (0.07%), indicating a risk reduction of 88%.This study showed a 68% risk reduction of FEEHD with implementation of the prevention program, and an 88% reduction of severe FEEHD (blood glucose level < 50 mg/dL). Reporting on the first prevention program of its kind, this is the first study to evaluate an overlooked safety problem in diabetes management. Clinicians should consider if fasting laboratory tests are in fact necessary, and when ordered, clinicians should properly instruct their patients on adequate blood glucose monitoring and adjustment of antidiabetic medications. We present the guidelines that proved effective in our program to help patients with diabetes and their clinicians avert this potentially harmful complication.

Myelofibrosis (MF), polycythemia vera (PV), and essential thrombocythemia (ET) are referred to as the classic Philadelphia chromosome (BCR-ABL1)-negative myeloproliferative neoplasms. Although each has distinct pathologic features, all 3 display alterations in Janus kinase (JAK) signal transduction activator of transcription signaling. Myelofibrosis is the most serious of the 3, associated with shortened survival (median survival, 5-7 years); bone marrow failure with anemia; progressive splenomegaly; and chronic, burdensome symptoms, including fatigue, night sweats, itching, abdominal discomfort, loss of appetite/early satiety, unintentional weight loss, and bone, chest, and abdominal pain. Treatments for MF have been mainly palliative, with the exception of allogeneic stem cell transplantation, which, although potentially curative, is feasible only in a small subpopulation of patients. In November 2011, ruxolitinib, an inhibitor of JAK1 and JAK2, was approved by the US Food and Drug Administration for the treatment of intermediate- or high-risk MF, including primary MF, post-PV MF, and post-ET MF. In clinical trials, ruxolitinib was shown to reduce spleen volume and improve MF-related symptoms and quality-of-life measures. Evidence also suggests that ruxolitinib therapy has a survival advantage over placebo and best available therapy. Thrombocytopenia and anemia were the most common adverse events with treatment. Ongoing trials are assessing the efficacy and safety of ruxolitinib therapy in patients with PV and ET.

Extended-release (ER) opioid analgesics are associated with prolonged analgesia and greater stability in pain relief compared with immediate-release formulations. Due to the pharmacokinetic (PK) characteristics of ER opioids and additional clinical advantages, the use of ER opioids for patients with moderate-to-severe chronic noncancer pain has increased. Primary care physicians are the major prescribers of opioids and require an in-depth understanding of the risks and benefits of opioid treatment in pain management. With appropriate knowledge of PK profiles and clinical outcomes of commonly prescribed ER opioids, primary care physicians can safely and effectively manage this patient population. In addition, the development of ER opioids with abuse-deterrent features marks an important milestone in potentially reducing abuse and may be factored into the clinical decision-making process. This article provides a comprehensive review of the PK and clinical effects of ER opioids and discusses novel ER opioid formulations that may limit abuse potential.

Hyperuricemia can accelerate renal decline associated with aging. Chronic kidney disease is frequently seen in patients with hyperuricemia and gout.Assess the impact of urate-lowering therapy on renal function in subjects with gout who were treated with febuxostat for ≤ 48 months.Subjects from 2 phase 3 clinical studies were enrolled in the phase 3, long-term, open-label Febuxostat/Allopurinol Comparative Extension Long-Term (EXCEL) study. In the EXCEL study, 1086 subjects initially were treated with febuxostat 80 or 120 mg daily, or allopurinol 300 mg daily. The subjects were permitted to switch between doses of febuxostat and/or allopurinol during the first 6 months of treatment to achieve and maintain a serum uric acid (SUA) level ≥ 3 to < 6 mg/dL. For the analysis presented in this article, data from 551 subjects who received only febuxostat throughout the duration of both the phase 3 and EXCEL studies (≤ 48 months) were used to determine the impact of SUA reduction on estimated glomerular filtration rates (eGFRs).At baseline of the 2 original phase 3 studies, subjects' mean SUA level was 9.8 mg/dL. Greater sustained decreases in subjects' SUA levels were associated with less renal function decline (P < 0.001) by statistical modeling. The study data predicted that for every 1 mg/dL of chronic reduction of SUA level in subjects with gout, there would be a preservation of 1.15 mL/min of eGFR.Sustained urate-lowering therapy with febuxostat appears to impede renal decline in patients with gout. The results discussed in this article support similar observations previously reported in 116 hyperuricemic subjects with gout who received febuxostat for ≤ 5 years.

Osteoarthritis (OA) of the knee is a chronic and progressive disease that is the product of failure of the joint to repair cartilage breakdown and wear. This article reviews the physiologic properties and pathological changes in the synovial fluid that occur in patients with OA. Exogenous hyaluronic acid (HA) has analgesic, chondroprotective, and disease-modifying effects. Viscosupplements of HA are useful in the treatment of OA in conjunction with other methods of conservative treatment. Viscosupplementation may be better tolerated than oral medication, which can have significant side effects and drug interactions. Unlike other OA treatments, viscosupplements do not carry precautions for comorbidities, such as diabetes or cardiovascular disease. A number of HA viscosupplements are available for intra-articular injection in the treatment of knee OA. These supplements vary in molecular weight, dosage per injection, residence time in the joint, and number of injections required for treatment.