text:
Everyone experiences some unhappiness, often as a result of a change, either in the form of a setback or a loss, or simply, as Freud said, "everyday misery." The painful feelings that accompany these events are usually appropriate and temporary, and can even present an opportunity for personal growth and improvement. However, when sadness persists and impairs daily life, it may be an indication of a depressive disorder. Severity, duration, and the presence of other symptoms are the factors that distinguish normal sadness from clinical depression.
Clinical depression is classified as a mood disorder. The primary subtypes are major depression, dysthymia (longstanding but milder depression), and atypical depression. Other depressive disorders include premenstrual dysphoric disorder (PDD or PMDD) and seasonal affective disorder (SAD).
The other major mood disorder is bipolar disorder, formerly called manic-depressive illness, which is characterized by periods of depression alternating with episodes of excessive energy and activity. Bipolar disorder is not discussed in this report.
In major, or acute, depression, at least five of the symptoms listed below must occur for a period of at least 2 weeks, and they must represent a change from previous behavior or mood. Depressed mood or loss of interest must be present. Symptoms include:1. Depressed mood on most days for most of each day -- irritability may be prominent in children and adolescents2. Total or very noticeable loss of pleasure most of the time3. Significant increases or decreases in appetite, weight, or both4. Sleep disorders, either insomnia or excessive sleepiness, nearly every day5. Feelings of agitation or a sense of intense slowness6. Loss of energy and a daily sense of tiredness7. Sense of guilt or worthlessness nearly all the time8. Inability to concentrate occurring nearly every day9. Recurrent thoughts of death or suicide
In addition, other criteria must be met:
Episodes of major depression usually last about 20 weeks.
Depression in Children . Symptoms for major depression in children can differ from those in adults and may include:
Dysthymia, or chronic depression, afflicts 3 - 6% of the general population and is characterized by many of the same symptoms that occur in major depression. Symptoms of dysthymia are less intense and last much longer, at least 2 years. The symptoms of dysthymia have been described as a "veil of sadness" that covers most activities. Possibly because of the duration of the symptoms, patients who suffer from chronic minor depression do not exhibit marked changes in mood or in daily functioning, although they have low energy, a general negativity, and a sense of dissatisfaction and hopelessness.
About a third of patients with depression have atypical depression. Atypical depression refers to a subtype of depression characterized by mood reactivity, which is the ability to temporarily respond to positive experiences. It is accompanied by two or more associated symptoms such as sensitivity to rejection, hypersomnia (oversleeping), overeating (usually related to carbohydrate craving), and leaden paralysis (feelings of heaviness in the arms and legs).
Seasonal affective disorder (SAD) is characterized by annual episodes of depression during fall or winter that improve in the spring or summer. Other SAD symptoms include fatigue and a tendency to overeat (particularly carbohydrates) and oversleep in winter. A minority of individuals with SAD have symptoms of undereating and being sleepless. SAD tends to last about 5 months in those who live in the northern part of the U.S.
Seasonal changes affect many people's moods, regardless of gender and whether or not they have SAD. Simply being mildly depressed during the winter does not mean that one has SAD. Living in a northern country with long winter nights does not guarantee a higher risk for depression. Changes in light may not be the only contributor to SAD.
The causes of depression are not fully known. Most likely a combination of genetic, biologic, and environmental factors play a role.
Because depression often runs in families, it may have a genetic component. Data from family, twin, adoption, and genetic studies strongly indicate a genetic factor. Studies have found that close relatives of patients with depression are two to six times more likely to develop the problem than individuals without a family history.
Evidence supports the theory that depression has a biologic basis. The basic biologic causes of depression are strongly linked to abnormalities in the delivery of certain key neurotransmitters (chemical messengers in the brain). These neurotransmitters include:
The degree to which these chemical messengers are disturbed may be affected by other factors such as genetic susceptibility. For example, researchers have identified a defect in the gene known as SERT, which regulates serotonin and has been linked to depression.
Reproductive Hormones. In women, the female hormones estrogen and progesterone may play a role in depression.
Medications . Many prescription drugs can affect brain chemicals and trigger depression. These medications include certain types of drugs used for acne, high blood pressure, contraception, Parkinson's disease, inflammation, gastrointestinal relief, and other conditions.
According to major surveys, major depressive disorder affects nearly 15 million Americans (nearly 7% of the adult population) in a given year. While depression is an illness that can afflict anyone at any time in their life, the average age of onset is 32 (although adults age 49 - 54 years are the age group with the highest rates of depression.). Other major risk factors for depression include being female, being African-American, and living in poverty.
Women, regardless of nationality, race, ethnicity, or socioeconomic level, have twice the rate of depression than men. (Women with depression may also have accompanying eating disorders, such as anorexia nervosa and bulimia. ) While men are more likely than women to die by suicide, women are twice as likely to attempt suicide.
The causes of such higher rates of depression may be due in part to hormonal factors:
Depression is not rare in men. In fact, white men over age 85 have the highest rates of suicide of any group. Men may be more likely than women to mask their depression by using alcohol. Some research suggests that depression in men is associated with the following indicators:
Depression can occur in children of all ages, although adolescents have the highest risk. Risk factors for depression in young people include having parents with depression, particularly if it is the mother who is depressed. Early negative experiences and exposure to stress, neglect, or abuse also pose a risk for depression.
Adolescents who have depression are at significantly higher risk for substance abuse, recurring depression, and other emotional and mental health problems in adulthood.
Studies suggest that 3 - 5% of children and adolescents suffer from clinical depression, and 10 - 15% have some depressive symptoms.
About 1 - 5% of elderly people suffer from depression. The rate increases significantly for those who have other chronic health problems, especially medical conditions such as Alzheimer's, Parkinson's disease, heart disease, and cancer that interfere with functional abilities. Depression also occurs in some elderly people who require home healthcare or hospitalization. In addition, older people often have to contend with significant stressful life changes such as the loss of a spouse. Suicide in the elderly is the third-leading cause of death related to injury. Men account for the majority of these suicides, with divorced or widowed men at highest risk.
Severe or Chronic Medical Conditions. Any chronic or serious illness, such as diabetes, that is life-threatening or out of a person's control can lead to depression. Many medications taken for chronic medical problems can also cause depression.
Thyroid Disease. Hypothyroidism (a condition caused when the thyroid gland does not produce enough hormone) can cause depression. However, hypothyroidism may also be misdiagnosed as depression and go undetected.
Chronic Pain Conditions. Studies have reported a strong association between depression and headaches, including chronic tension-type and migraine. Fibromyalgia, arthritis, and other chronic pain syndromes are also associated with depression.
Stroke and Other Neurological Conditions. Having a stroke increases the risk of developing depression. Also, neurological conditions that impair movement or thinking are associated with depression.
Heart Failure . Patients with heart failure or patients who have suffered a heart attack may also be at increased risk for depression.
Insomnia and Sleep Disorders . Sleep abnormalities are a hallmark of depressive disorders, with many depressed patients experiencing insomnia. Likewise, insomnia or other changes in waking and sleeping patterns can have significant effects on a person's mood, and perhaps worsen or draw out an underlying depression.
Smoking. There is a significant association between cigarette smoking and a susceptibility to depression. People who are prone to depression face a 25% chance of becoming depressed when they quit smoking, and this increased risk persists for at least 6 months. What's more, depressed smokers find it difficult to stop smoking. Smokers with a history of depression are not encouraged to continue smoking, but rather to keep a close watch on recurrence of depressive symptoms if they do stop smoking.
Depression is often chronic, with episodes of recurrence and improvement. About a third of patients with a single episode of major depression will have another episode within 1 year after discontinuing treatment, and more than half will have a recurrence at some point in their lives. Depression is more likely to recur if the first episode was severe or prolonged, or if there have been prior recurrences. To date, even newer antidepressants have failed to achieve permanent remission in many patients with major depression, although the standard medications are very effective in treating and preventing acute episodes.
Many suicides are due to treatable disorders, most commonly depression or substance abuse. Depression is the cause of up to two-thirds of all suicides. Depressed men are more likely to commit suicide than depressed women. Suicidal preoccupation or threats of suicide should always be treated seriously. In addition, antidepressant medications may increase the risk for suicidal behavior in some children and adolescents.
Behavioral therapies, combined with antidepressants, may help prevent suicide. There has been a decline in adolescent suicides over the past decade, which some researchers attribute to the increased use of antidepressants in this population.
However, antidepressants can also raise the risk for suicidality (suicidal thoughts and behavior) in some young people, particularly those ages 18 - 24.
Risk for Suicide in Adolescents . Suicide is the third most common cause of death among adolescents, and is one of the most devastating events than can happen to a family. Suicide is most commonly associated with depression in young people but it is also linked with anxiety, psychosis, substance abuse, or impulsivity. More girls attempt suicide but more boys succeed, most often because they choose guns or violent methods while girls tend to overdose, which is more treatable. Nevertheless, attempts are major risk factors for a later suicide. Any expression of suicidal intent should be treated very seriously.
Children, adolescents, and young adults who are prescribed antidepressant medication should be carefully monitored by both their parents and doctor, especially during the first few months of treatment, for any worsening of depression symptoms or changes in behavior.
The following are danger signs in young people:
Risk factors for suicide include a history of neglect or abuse, history of deliberate self-harm, a family member who committed suicide, access to firearms, and living in communities where there have been recent outbreaks of suicide among young people. A romantic break-up is often the trigger for a suicidal attempt in teenagers. Feeling connected with parents and family can help protect young people with depression from suicide.
Parents should not hesitate to seek professional help for their children if they suspect they are thinking about killing themselves. This is a medical emergency and requires immediate treatment.
Major depression in the elderly or in people with serious illness may reduce survival rates, even independently of any accompanying illness. Decreased physical activity and social involvement certainly play a role in the association between depression and illness severity.
Heart Disease and Heart Attacks. Data suggest that depression itself may be a risk factor for heart disease as well as its increased severity. Patients with heart disease who are depressed tend to have more severe cardiac symptoms than those who are not depressed, and a poorer quality of life. Depression can worsen the prognosis of heart disease and increase the risk of death.
While the evidence is less conclusive, studies also indicate that depression in healthy people may increase the risk for developing heart disease. The more severe the depression, the greater the risk.
Obesity. People, especially adolescents, who are depressed have a high risk for obesity. Conversely, obese people are about 25% more likely than non-obese people to develop depression or other mood disorders. The conditions may have common risk factors such as low physical activity may also be a common factor.
Mental Decline . Depression in the elderly is associated with a decline in mental functioning, regardless of the presence of dementia.
Cancer. Depression does not increase the risk for cancer, but cancer can physically trigger depression by affecting chemicals in the brain. Sometimes depressive symptoms can manifest even before the cancer is diagnosed.
Effects of Parental Depression on Children. Depression in parents may increase the risk for childhood depression.
Effects on Marriage. . People who suffer from psychiatric disorders tend to have higher divorce rates than healthy people. Spouses of partners with depression are themselves at higher risk for depression.
Effect on Work. Depression can adversely affect a person's work life. It significantly increases the risk for unemployment and lower income.
Alcohol and Drug Abuse. Many people with major depression also have an alcohol use disorder or drug abuse problems. Studies on the connections between alcohol dependence and depression have still not resolved whether one causes the other or if they both share some common biologic factor.
Smoking. Depression is a well-known risk factor for smoking, and many people with major depression are nicotine dependent. Nicotine may stimulate receptors in the brain that improve mood in some people with depression.
A diagnosis of depression is based on symptoms meeting specific criteria. Many people who are depressed first seek help from their family doctors. Guidelines now recommend that family doctors screen for depression adults and adolescents (ages 12 - 18), as long as these doctors have appropriate systems in place to ensure accurate diagnosis, treatment, and follow-up of their patients.
To check if you have depression, a doctor may ask you questions such as:
Individuals who have certain factors might ask their doctor if they should be screened for depression. These include:
Mental health professionals may administer a screening test such as the Beck Depression Inventory or the Hamilton Rating Scale, both of which consist of about 20 questions that assess the individual for depression. However, most mental health professionals generally diagnose depression based on symptoms and other criteria.
Symptoms of depression can vary depending on a person's cultural and ethnic background, For example, people from non-Western countries are more apt to report physical symptoms (such as headache, constipation, weakness, or back pain) related to the depression, rather than mood-related symptoms.
Depression can sometimes be confused with other medical illnesses. Weight loss and fatigue, for example, accompany many conditions, some serious, but they can also occur with depression.
Depression is a treatable illness, with many therapeutic options available including psychotherapy, antidepressants, or both. In general, the treatment choice depends on the degree and type of depression and other accompanying conditions. It also may depend on age, pregnancy status, or other individual factors.
Unfortunately, many Americans with major depression receive either inadequate treatment or no treatment at all. Reasons may include treatment by providers who may not have sufficient information or training on dosages or specific drugs that would be best suited for individual cases, lack of recognition of depression symptoms by providers, poor access to health care services, lack of health insurance, and poor compliance with medications.
Patients with Major Depression. Numerous studies support a combination of cognitive behavioral therapy (CBT) plus antidepressants, typically a selective serotonin reuptake inhibitor (SSRI) or serotonin norepinephrine reuptake inhibitor (SNRI). Although some people may feel better after taking antidepressants for a few weeks, most people need to take medication for at least 4 - 9 months to ensure a full response and to prevent depression from recurring. Research indicates that patients respond better to medications when drug therapy is combined with CBT. Exercise may also help relieve depressive symptoms.
Patients with Treatment-Resistant Depression . For patients with severe depression who are not helped by SSRIs or SNRIs, other types of antidepressants are available. Sometimes an atypical antipsychotic drug may be given in combination with an antidepressant for patients with severe major depressive disorder.
Brain stimulation techniques, such as electroconvulsive therapy (ECT), are options for treatment-resistant depression. Experimental procedures, such as repetitive transcranial magnetic stimulation and implantable deep brain stimulation devices, are being studied and may be helpful. Researchers are also investigating new types of drugs (such as ketamine), which may provide rapid, if temporary, improvement. In general, the more treatment strategies that patients need, the less likely they are to recover completely from depression.
Patients with Minor Depression. Patients with minor depression (fewer than five symptoms that persist for fewer than 2 years) may respond well to watchful waiting to see if antidepressants are necessary. Counseling or cognitive behavioral therapy may be helpful, as is regular exercise.
Patients with Depression and Other Psychiatric Problems. Other psychiatric problems often coexist with depression. If patients also suffer from anxiety, treating the depression first often relieves both problems. More severe psychiatric problems, such as bipolar disorder or schizophrenia, require specialized treatments.
Patients with Depression and Medical Conditions. Depression can worsen many medical conditions and may even increase mortality rates from some disorders, such as heart attack and stroke. Depression, then, should be aggressively treated in anyone with a serious medical problem.
Patients with Depression and Substance Abuse Problems. Treating depression in patients who abuse alcohol or drugs is important and can sometimes help patients quit. However, absence from substance abuse is considered essential for adequate treatment of depression.
Most people with depression can be treated in an office setting by a psychiatrist, psychologist, or other therapist. Infrequently, the level of dysfunction may be serious enough to warrant hospitalization to provide protection from further deterioration or self-harm.
Health professionals who can prescribe antidepressants include:
Although other mental health professionals cannot prescribe drugs, most therapists have arrangements with a psychiatrist for providing medications to their patients. In general, mental health professionals are categorized by their training:
Tips for Selecting a Therapist:
Between 14 - 23% of women experience depressive symptoms during pregnancy, and some women develop full-blown postpartum depression following delivery. Although a mother's depression during and after pregnancy can have serious effects on her child, researchers are still trying to determine the best methods for preventing and treating pregnancy-related depression.
The American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women with depression receive care from a multidisciplinary team that includes the patient's obstetrician, primary care physician, and mental health clinician. Any woman who has suicidal or psychotic symptoms during depression should immediately seek treatment from a psychiatrist.
The use of antidepressants during pregnancy is controversial, especially for women with major depression who regularly take antidepressant medication. Most doctors advise women to avoid, if possible, any medications during pregnancy and nursing. But, women with depression who stop taking antidepressants during pregnancy may be likely to have a relapse of depression, which can have negative consequences for prenatal care and subsequent mother-child bonding. The risks for negative outcomes are highest when depression occurs during the late second or early third trimester. Depression during pregnancy may also increase the risk of developing postpartum depression.
ACOG and the American Psychiatric Association (APA) recommend that women who are pregnant or thinking about becoming pregnant should not stop taking antidepressants without first talking to their doctors. Women who have mild or no depressive symptoms for at least 6 months before becoming pregnant may be able to taper off or discontinue antidepressant medication, under supervision of their doctor. Stopping medication may be more difficult for women with a history of severe recurrent depression. Psychotherapy (preferably cognitive behavioral therapy or interpersonal therapy) may be helpful in addition to, or in replacement of, antidepressant medication. Electroconvulsive therapy (ECT) may be an option for pregnant women with severe depression.
Studies have been inconsistent as to whether serotonin reuptake inhibitors (SSRIs) drugs increase the risk for birth defects. In general, the risks appear to be low, but doctors are still not sure. There is evidence that paroxetine (Paxil) may cause major birth defects -- including heart abnormalities -- if taken during the first trimester of pregnancy. ACOG recommends that doctors not prescribe paroxetine to women who are pregnant or planning on becoming pregnant. Some studies have indicated that sertraline (Zoloft) and citalopram (Celexa) may also increase the risk of heart defects. SSRIs, and most tricyclic antidepressants, are considered safe to use during breastfeeding but more research is needed to clarify the effects of SSRI on infant and child development.
In terms of non-drug treatment of postpartum depression, doctors recommend that women with signs of postpartum depression receive intensive and individualized psychotherapy within a month after giving birth.
Some doctors recommend only psychotherapy for elderly patients with mild depression. In many older patients, a regular exercise program may be sufficient to improve mood. The use of antidepressants in the elderly is problematic:
Studies suggest that when children or adolescents are treated for depression, a large majority recover. Still, up to a half of these young people have a recurrence of depression within 2 years of their first episode of depression.
It is important to recognize that childhood depression differs from adult depression and that children may respond differently than adults to antidepressant medication. These variances are due to childhood brain development processes as well as age-related differences in drug metabolism. Children may experience medication side effects not seen in adults, and some antidepressants that are effective for adults may not work for children.
Mild-to-Moderate Depression. The pediatrician may want to monitor a child with mild depression for 6 - 8 weeks before deciding whether to prescribe psychotherapy, antidepressant medication, or a referral to a mental health professional. Once medication has been started, the doctor will decide if the dosage needs to be increased after another 6 - 8 weeks. Medication may need to be continued for 1 year after the symptoms have resolved, and the doctor should continue to monitor the child on a monthly basis for 6 months after full remission of depression. For psychotherapy, cognitive therapy may be the best approach for children and adolescents with depression. Other types of psychotherapy, such as family therapy and supportive therapy, may also be effective.
Severe Depression. The American Academy of Child and Adolescent Psychiatry recommends an SSRI antidepressant for children and adolescents with very severe depression that does not respond to psychotherapy. Tricyclic antidepressants do not tend to help adolescents and children and these drugs have many side effects. MAOIs are also not commonly prescribed.
Many SSRIs appear to be safe and effective, but at this time fluoxetine (Prozac) and escitalopram (Lexapro) are the only ones approved for adolescents (ages 12 - 17), and fluoxetine is the only antidepressant approved for children age 8 and older. The FDA strongly advises against the use of some specific SSRIs, such as paroxetine (Paxil), due to concerns about an increased risk for suicidal behavior as well as the lack of any evidence supporting the drug's efficacy in pediatric patients. Some recent research indicates that the overall benefits of antidepressants for children and adolescents may outweigh the risks for suicidal behavior. For optimal results, SSRIs should be combined with either cognitive-behavioral or interpersonal psychotherapies.
Due to potential suicide risks, children and adolescents should be monitored regularly during the initial months of antidepressant treatment.
Major classes of antidepressants include:
All of these drugs appear to work equally well, although they may vary in terms of side effects. Your doctor will select an antidepressant based on side effects, cost, and your personal preference.
Approach and Duration of Initial Treatment. The guidelines for the duration of an initial antidepressant regimen are generally:
Treating Recurrence. Recurrence of depression is very common. About a third of patients will relapse after a first episode within a year of ending treatment, and more than half will experience a recurring bout of depression at some point during their lives. Among those at highest risk for early relapse and who may require ongoing antidepressants are:
There is no risk for addiction with current antidepressants, and many of the common antidepressants, including most standard SSRIs, have been proven safe when taken for a number of years.
Common Side Effects of Most Antidepressants. No matter how well a drug treats depression, the ability of patients to tolerate its side effects strongly influences their compliance with therapy. Lack of compliance is probably the major barrier to success. Side effects can be avoided or moderated if any regimen is started at low doses and built up over time. Although specific side effects are discussed under individual drugs, there are a few that are common to many of them:
In recent years, there has been concern that SSRI antidepressants can increase the risk for suicidal behavior. Of particular concern is a greater risk for suicide in young people taking these medications. While depression is itself the major risk factor for suicide, and antidepressant medication may revitalize suicidal attempts in patients who were too despondent before treatment to make the effort, evidence suggests that in some cases the medication itself can cause suicidal thoughts and behavior (suicidality). Paroxetine (Paxil) appears to have the strongest association with increased suicidal risk, particularly in younger adults.
In the U.S., all antidepressant medications now carry "black box" warnings on their prescribing label explaining the association between antidepressant use and increased risk for suicidality in children, adolescents, and young adults ages 18 - 24, especially during the first few months of treatment. The FDA's data do not show an increased risk for suicidality in adults older than age 24. Adults age 65 years and older taking antidepressants have a decreased risk for suicidality.
The FDA recommends that caregivers monitor children, adolescents, and young adults being treated with antidepressants for sudden behavioral changes, and immediately notify their doctor if such changes occur. These behavioral signs include:
The FDA's guidelines for medication usage also recommend that all patients see their doctors regularly after initiating drug treatment. The recommended schedule is:
Patients should immediately contact their doctor if depression symptoms worsen or if suicidal thoughts or behavior increase.
Selective serotonin-reuptake inhibitors (SSRIs) are now the first-line treatment for major depression. They work by increasing levels of serotonin in the brain. SSRIs include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro). There do not appear to be significant differences among SSRI brands in effectiveness for treating major depressive disorder, although individual drugs may have different side effects or benefits for specific patients.
At this time, fluoxetine and escitalopram are the only antidepressants approved for treatment of major depressive disorder in adolescents (ages 12 - 17). Fluoxetine is also approved for children age 8 and older. Because they act specifically on serotonin, SSRIs have fewer side effects than older antidepressants, which have more widespread effects in the body.
Candidates for SSRIs. SSRIs appear to best help people with the following conditions:
Duration of Effectiveness and Use. SSRIs take, on average, 2 - 4 weeks to be effective in most adults. They may take even longer, up to 12 weeks, in the elderly and in those with dysthymia. By 14 weeks, depression should be in remission in those who respond to the drugs. Unfortunately, recurrence is common once the drugs are stopped. Studies indicate that the standard SSRIs are generally safe to be taken long term, although it is still unclear which patients most benefit from on-going medication. Some doctors recommend withdrawing from medication after a year. If depression recurs, then the patient should go back on the antidepressant.
Side Effects of SSRIs. Side effects may include:
Drug Interactions. SSRIs can interact with other antidepressants such as tricyclics and, in particular, monoamine oxidase inhibitors (MAOIs). Due to a potentially fatal condition called serotonin syndrome, SSRIs should never be taken in combination with an MAOI or within 2 weeks after discontinuing MAOI treatment.(For more on serotonin syndrome, see MAOI section below.) Other serious interactions can occur with meperidine (Demerol) and illegal substances (such as LSD, cocaine, or ecstasy). SSRIs also interact with the antibiotic linezolid (Zyvox). People who take SSRIs may drink alcohol in moderation, although the combination may compound any drowsiness experienced with SSRIs, and some SSRIs increase the effects of alcohol.
Withdrawal Symptoms. Cognitive problems, sleep disturbances, increase in depressive symptoms, and electric shock-like symptoms have been known to occur with sudden discontinuation of SSRIs. The symptoms are more likely to occur with antidepressants with shorter half-lives as compared with fluoxetine, which has a long half-life. The dose of the antidepressant should be slowly reduced before stopping.
These antidepressants target other neurotransmitters, such as norepinephrine or dopamine, alone or in addition to serotonin. In general, the advantages of these antidepressants are:
These drugs do share some side effects with other antidepressants, including dizziness and dry mouth.
Dual Inhibitors. Dual inhibitors act directly on two neurotransmitters -- norepinephrine and serotonin. These drugs are also known as serotonin norepinephrine reuptake inhibitors (SNRIs). The following SNRIs are approved for treatment of major depression in adults:
Multiple Neurotransmitter Ihibitors (Bupropion). Bupropion (Wellbutrin, generic) affects the reuptake of serotonin, norepinephrine, and dopamine -- a third important neurotransmitter. In addition to depression, bupropion is also approved for treating seasonal affectiveness disorder (SAD) and, under the tradename Zyban, for smoking cessation. Bupropion causes less sexual dysfunction than SSRIs. About 25% of patients experience initial weight loss. Side effects include restlessness, agitation, sleeplessness, headache, and stomach problems. Bupropion has a risk for seizures, which increases with higher doses. High doses may also cause dangerous heart arrhythmias.
In 2009, the FDA warned that bupropion products may cause symptoms such as changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide. Most of these symptoms were reported in patients who took bupropion to help stop smoking. However, the FDA also warns that patients who have major depressive disorder or other psychiatric illnesses (schizophrenia, bipolar disorder), may experience worsening of their symptoms while taking bupropion
Before the introduction of SSRIs, tricyclics were the standard treatment for depression.
Tricyclics are sometimes grouped into two categories:
Less commonly used tricyclics include doxepin (Sinequan), amoxapine (Asendin), maprotiline (Ludiomill), protriptyline (Vivactil), trimipramine (Surmontil), mianserin (Bolvidon), and dothiepin (Prothiaden).
Tricyclics are as effective for treating depression but they have many side effects. They may offer benefits for many people with dysthymia, who generally do not respond to SSRIs. They may also be prescribed in lower dosages to be taken at night to help with insomnia.
Side Effects of Tricyclics. Side effects are common with these medications. In an analysis of studies, more tricyclic users discontinued their drugs due to side effects than did SSRI or MAOI users. Side effects most often reported include:
Tricyclics can have serious, although rare, side effects:
Monoamine oxidase inhibitors (MAOIs) block monoamine oxidase, an enzyme which has negative effects on many of the neurotransmitters that are important for well-being. MAOIs include phenelzine (Nardil), isocarboxazid (Marplan), and tranylcypromine (Parnate).
Newer MAOIs, such as selegiline (Eldepryl, Movergan), target only one form of the MAOI enzyme. They may cause fewer side effects than older MAOIs. A skin patch form of selegiline (Emsam) is also available for treatment of major depressive disorder in adults.
Candidates for MAOIs. Because these drugs can have very severe side effects, they are usually prescribed only for severe depression or when other types of antidepressants do not help (treatment-resistant depression). MAOIs may also be effective for the following conditions:
Side Effects. MAOIs commonly cause the following side effects:
Serotonin Syndrome . Very dangerous side effects, such as serotonin syndrome, can occur from interactions with other antidepressants, including SSRIs. Serotonin syndrome is a potentially fatal condition that is caused by the interaction of serotonergic drugs. Symptoms include confusion, agitation, sweating and shivering, and muscle spasms. There should be at least a 2-week break between taking MAOIs and other antidepressants. MAOIs can have serious interactions with other drugs as well, including some common over-the-counter cough medications. In such cases, severe high blood pressure or dangerous reactions can occur. It is important that patients discuss with their doctors any other medications they are taking.
If patients fail to respond to antidepressants, doctors may try adding on a different type of drug. (This combination strategy is called "augmentation" or "adjunctive treatment".) Atypical antipsychotics are drugs that are usually prescribed for schizophrenia or bipolar disorder, but they can also play a role in the treatment of severe depression. Two atypical antipsychotics, aripiprazole (Abilify) and quetiapine (Seroquel), are currently approved in combination with antidepressant therapy for treatment of adults with major depressive disorder.
Ketamine . Ketamine, an anesthetic drug, may be helpful for patients with severe treatment-resistant depression. In a small preliminary study, a single intravenous dose of ketamine helped patients quickly recover from depression within 2 hours, and some patients sustained benefits for up to a week. (Standard antidepressant drugs usually take about 8 weeks to have an effect.) Ketamine blocks the NMDA brain protein receptor, which is involved in glutamate regulation. Glutamate is a brain chemical that is thought to be involved in depression.
Among the various psychotherapeutic "talk therapies," cognitive-behavioral therapy appears to be the most effective approach. If psychotherapy is used alone without medications, benefits should be evident within 8 weeks and symptoms should be fully resolved by 12 weeks. If these conditions are not met, then the patient should strongly consider antidepressant drugs.
In a major analysis, cognitive behavioral therapy (CBT) worked as well as antidepressants in treating severe depression for many patients. Like all psychotherapies, much of the success depends on the skill of the therapist. Many studies suggest that combining cognitive therapy with antidepressants offer the greatest benefits. Studies also indicate that the benefits of cognitive therapy persist after treatment has ended. Cognitive behavioral therapy has been shown to help prevent future suicide attempts in patients with a history of suicidal behavior.
Best Candidates . Although helpful for all patients with depression, CBT may be particularly helpful for the following patients:
Approach . CBT focuses on identification of distorted perceptions that patients may have of the world and themselves, on changing these perceptions, and on discovering new patterns of actions and behavior. These perceptions, known as schemas, are negative assumptions developed in childhood that can precipitate and prolong depression. CBT works on the principle that these schemas can be recognized and altered, thereby changing the response and eliminating the depression.
Over time, such exercises help build confidence and eventually alter behavior. Patients may take group or individual cognitive therapy. CBT is a time-limited treatment, typically lasting 12 - 14 weeks.
Based in part on psychodynamic theory, interpersonal therapy acknowledges the childhood roots of depression, but focuses on symptoms and current issues that may be causing problems. IPT is not as specific as cognitive or behavioral therapy, and all work is done during the sessions. The therapist seeks to redirect the patient's attention, which has been distorted by depression, toward the daily details of social and family interaction. The goals of this treatment method are improved communication skills and increased self-esteem within a short period (3 - 4 months of weekly appointments) of time. Among the forms of depression best served by IPT are those caused by distorted or delayed mourning, unexpressed conflicts with people in close relationships, major life changes, and isolation.
The intent of supportive psychotherapy or attention intervention is to provide the patient with a nonjudgmental environment by offering advice, attention, and sympathy. Supportive therapy appears to be particularly helpful for improving compliance with medications by giving reassurance, especially when setbacks and frustration occur.
Electroconvulsive therapy (ECT) is commonly called shock treatment. It has received bad press, in part for its potential memory-depleting effect. Since its introduction in the 1930s, ECT has been significantly refined, and is now considered an effective and safe treatment for severe depression in the appropriate situation. It is especially effective for patients with severe depression who experience delusions and hallucinations. Maintenance ECT may also help prevent relapse.
Candidates for ECT. ECT may be helpful for the following patients with severe depression:
The Procedure. In general, hospitalization is not necessary. ECT involves the following steps:
Side Effects. Side effects of ECT may include temporary confusion, memory lapses, headache, nausea, muscle soreness, and heart disturbances. Concerns about permanent memory loss appear to be unfounded.
The ECT procedure affects heart rate and blood pressure. Doctors should perform a medical evaluation of patients before they receive ECT. Patients, (especially those who are elderly), who have high blood pressure, atrial fibrillation, asthma, or other heart or lung problems may be at increased risk for heart-related side effects.
Repetitive transcranial magnetic stimulation (rTMS) uses high frequency magnetic pulses that target affected areas of the brain. It is generally regarded as a second line treatment after ECT. Researchers are continuing to refine rTMS techniques to attempt to improve treatment outcomes.
An implantable deep brain stimulation device (Reclaim), similar to a pacemaker and devices used for treating movement disorders like Parkinson's disease, has been approved for treatment of severe obsessive-compulsive disorder. It is currently in clinical trials for treatment-resistant depression. The device uses four electrodes that are surgically implanted into the brain and connected to a small generator that is implanted near the abdomen or collar bone. The generator delivers precisely controlled electrical pulses to target specific areas of the brain.
Vagus nerve stimulation (VNS) is a procedure that is effective for certain patients with epilepsy, and is now showing some success in patients with treatment-resistant depression
VNS involves implanting a battery-powered device under the skin in the upper left of the chest. The neurologist programs the device to deliver mild electrical stimulation to the vagus nerve. The two vagus nerves are the longest nerves in the body. They run along each side of the neck, then down the esophagus to the gastrointestinal tract. The vagus nerve travels to areas of the brain that control functions such as sleep and mood.
Studies report response rates of 35 - 46% in appropriate candidates with treatment-resistant depression. VNS is approved by the FDA for long-term treatment of chronic depression in adults who have not responded to typical treatments for their major depressive episode. Patients who use VNS may continue to show improvement in both their depression symptoms and quality of life.
Vagal stimulation can cause shortness of breath, hoarseness, sore throat, coughing, ear and throat pain, or nausea and vomiting. These side effects can be reduced or eliminated by reducing the intensity of stimulation. Long-term studies on patients with epilepsy have reported no serious adverse side effects, although the treatment may cause lung function deterioration in some people with existing lung disease.
Phototherapy is recommended as treatment for seasonal affective disorder (SAD), particularly for patients who do not wish to try antidepressants.
The Procedure. The procedure is noninvasive and simple. It is best performed immediately after waking in the morning. The patient sits a few feet away from a box-like device that emits very bright fluorescent light (10,000 lux) for about 30 minutes every day.
Some people report mood improvement as early as 2 days after treatment. In others, depression may not lift for 3 - 4 weeks. If no improvement is experienced after that, depressive symptoms will be unlikely to respond to phototherapy. Phototherapy may work best when combined with cognitive behavioral therapy.
Side Effects. Side effects include headache, eye strain, and irritability, although these symptoms tend to disappear within a week. Patients taking light-sensitive drugs (such as those used for psoriasis), certain antibiotics, or antipsychotic drugs should not use light therapy. Patients should be examined by an ophthalmologist before undergoing this treatment.
A surgical technique called cingulotomy interrupts the cingulate gyrus, a bundle of nerve fibers in the front of the brain, by applying heat or cold. A variation of this procedure using MRI scans to guide the surgeon has been shown to produce long-term improvement in patients with severe intractable depression. The procedure is generally safe with few serious complications. It does not affect intellect or memory.
Generally, manufacturers of herbal remedies and dietary supplements do not need FDA approval to sell their products. Just like a drug, herbs and supplements can affect the body's chemistry, and therefore have the potential to produce side effects that may be harmful. There have been a number of reported cases of serious and even lethal side effects from herbal products. Always check with your doctor before using any herbal remedies or dietary supplements.
St. John's wort . St. John's wort ( Hypericum perforatum ) is probably the most studied herbal remedy. Although its efficacy has not been clearly shown, it may help some patients with mild-to-moderate depression. It does not appear to help patients with moderate or severe depression.
The following guidelines are recommended:
Side effects are uncommon but may include nausea, dry mouth, allergic reactions, and fatigue. This herb may increase sensitivity to light (photosensitivity). Some people have reported temporary nerve damage after sun exposure, specifically pain and tingling on sun-exposed areas.
L-Tryptophan. Some people report relief from depression by eating foods or diet supplements that boost levels of tryptophan, an amino acid involved in the production of serotonin. (Simply eating a high amount of carbohydrates, however, is not a solution for depression.)
Impurities found in diet supplements containing L-tryptophan itself have caused cases of eosinophilia-myalgia syndrome, a condition that elevates certain white blood cells and can be fatal. Supplements containing L-tryptophan are currently banned in the U.S. by the FDA.
Fish Oil. Some studies have suggested that an imbalance in the ratio of specific fatty acids (omega-6 to omega-3) may increase the risk for depression. Both are polyunsaturated fats, but omega-6 fatty acids are mostly found in corn, safflower, soybean, and sunflower oil whereas omega-3 fatty acids are found in fish oil, canola oil, soybeans, flaxseed, and certain nuts and seeds.
The bottom line may be to increase intake of omega-3 rich foods, such as fish, nuts, and canola oil, and reduce consumption of foods containing omega-6 fatty acids, such as corn and sunflower oils. Such a dietary approach is healthy in any case. Researchers are studying whether eating fish or taking fish oil supplements can reduce depression. Small preliminary studies suggest that these dietary approaches may be helpful for some patients. Recent research has also indicated that the Mediterranean Diet, which is high in omega-3 rich foods as well as vegetables and fruit and low in saturated fats from meat, may help reduce the risk of developing depression. Scientists are also investigating which type of fish oil compound -- eicosapentaenoic acid (EPA) or docosahexaenoic acid (DHA) -- provides the greatest benefit.
Vitamins. Certain B vitamins have been associated with some protection against depression.
Studies report major benefits from exercise for people with depression.
Aerobics. Either brief periods of intense training or prolonged aerobic workouts can raise chemicals in the brain, such as endorphins, adrenaline, serotonin, and dopamine that produce the so-called runner's high.
Yoga. Yoga practice, which involves rhythmic stretching movements and breathing, may help improve and stabilize mood. Meditation may also be helpful.
Some small studies have suggested that acupuncture may help in relieving depression. Larger studies are required to confirm its benefits.
A strong network of social support is important for both prevention and recovery from depression. Support from family and friends must, however, be healthy and positive.
ACOG Committee on Practice Bulletins--Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists number 92. Use of psychiatric medications during pregnancy and lactation. Obstet Gynecol . 2008 Apr;111(4):1001-20.
Adams SM, Miller KE, Zylstra RG. Pharmacologic management of adult depression. Am Fam Physician . 2008 Mar 15;77(6):785-92.
Alwan S, Reefhuis J, Rasmussen SA, Olney RS, Friedman JM; National Birth Defects Prevention Study. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med . 2007 Jun 28;356(26):2684-92.
Belmaker RH, Agam G. Major depressive disorder. N Engl J Med. 2008 Jan 3;358(1):55-68.
Bridge JA, Iyengar S, Salary CB, et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA . 2007 Apr 18;297(15):1683-96.
Cassano P, Fava M. Mood disorders: major depressive disorder and dysthymic disorder. In: Stern TA, Rosenbaum JF, Fava M, Biederman J, Rauch SL, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry . 1st ed. Philadelphia, Pa: Mosby Elsevier; 2008:chap 29.
Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management. Pediatrics . 2007 Nov;120(5):e1313-26.
Cipriani A, Furukawa TA, Salanti G, Geddes JR, Higgins JP, Churchill R, et al. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet. 2009 Feb 28;373(9665):746-58.
Fortinguerra F, Clavenna A, Bonati M. Psychotropic drug use during breastfeeding: a review of the evidence. Pediatrics . 2009 Oct;124(4):e547-56. Epub 2009 Sep 7.
Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA . 2010 Jan 6;303(1):47-53.
Gartlehner G, Gaynes BN, Hansen RA, Thieda P, DeVeaugh-Geiss A, Krebs EE, et al. Comparative benefits and harms of second-generation antidepressants: background paper for the American College of Physicians. Ann Intern Med . 2008 Nov 18;149(10):734-50.
Janicak PG, O'Reardon JP, Sampson SM, Husain MM, Lisanby SH, Rado JT, et al. Transcranial magnetic stimulation in the treatment of major depressive disorder: a comprehensive summary of safety experience from acute exposure, extended exposure, and during reintroduction treatment. J Clin Psychiatry . 2008 Feb;69(2):222-32.
Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry . 2006 Dec;63(12):1337-44.
Kennedy SH, Milev R, Giacobbe P, Ramasubbu R, Lam RW, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. IV. Neurostimulation therapies. J Affect Disord . 2009 Oct;117 Suppl 1:S44-53. Epub 2009 Aug 5.
Lin PY, Su KP. A meta-analytic review of double-blind, placebo-controlled trials of antidepressant efficacy of omega-3 fatty acids. J Clin Psychiatry . 2007 Jul;68(7):1056-61.
Little A. Treatment-resistant depression. Am Fam Physician . 2009 Jul 15;80(2):167-72.
March JS, Vitiello B. Clinical messages from the Treatment for Adolescents With Depression Study (TADS). Am J Psychiatry . 2009 Oct;166(10):1118-23. Epub 2009 Sep 1.
Nelson JC, Papakostas GI. Atypical antipsychotic augmentation in major depressive disorder: a meta-analysis of placebo-controlled randomized trials. Am J Psychiatry . 2009 Sep;166(9):980-91. Epub 2009 Aug 17.
O'Connor EA, Whitlock EP, Beil TL, Gaynes BN. Screening for depression in adult patients in primary care settings: a systematic evidence review. Ann Intern Med . 2009 Dec 1;151(11):793-803.
Pearlstein T, Howard M, Salisbury A, Zlotnick C. Postpartum depression. Am J Obstet Gynecol . 2009 Apr;200(4):357-64.
Qaseem A, Snow V, Denberg TD, Forciea MA, Owens DK; Clinical Efficacy Assessment Subcommittee of American College of Physicians. Using second-generation antidepressants to treat depressive disorders: a clinical practice guideline from the American College of Physicians. Ann Intern Med . 2008 Nov 18;149(10):725-33.
Rapaport MH. Dietary restrictions and drug interactions with monoamine oxidase inhibitors: the state of the art. J Clin Psychiatry . 2007;68 Suppl 8:42-6.
Sánchez-Villegas A, Delgado-Rodríguez M, Alonso A, Schlatter J, Lahortiga F, Majem LS, et al. Association of the Mediterranean dietary pattern with the incidence of depression: the Seguimiento Universidad de Navarra/University of Navarra follow-up (SUN) cohort. Arch Gen Psychiatry . 2009 Oct;66(10):1090-8.
Stone M, Laughren T, Jones ML, Levenson M, Holland PC, Hughes A, et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ . 2009 Aug 11;339:b2880. doi: 10.1136/bmj.b2880.
Tess AV, Smetana GW. Medical evaluation of patients undergoing electroconvulsive therapy. N Engl J Med. 2009 Apr 2;360(14):1437-44.
US Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: US Preventive Services Task Force Recommendation Statement. Pediatrics . 2009 Apr;123(4):1223-8.
U.S. Preventive Services Task Force. Screening for depression in adults: U.S. preventive services task force recommendation statement. Ann Intern Med . 2009 Dec 1;151(11):784-92.
Williams SB, O'Connor EA, Eder M, Whitlock EP. Screening for child and adolescent depression in primary care settings: a systematic evidence review for the US Preventive Services Task Force. Pediatrics. 2009 Apr;123(4):e716-35.
Yonkers KA, Wisner KL, Stewart DE, Oberlander TF, Dell DL, Stotland N, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol . 2009 Sep;114(3):703-13.
Zuckerbrot RA, Cheung AH, Jensen PS, Stein RE, Laraque D; GLAD-PC Steering Group. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics . 2007 Nov;120(5):e1299-312.


text:
Joel Quenneville deflected all of the credit Friday after learning that he was a finalist for the NHL's coach of the year award.
The three finalists for the prize, which is named the Jack Adams Award, were Quenneville, Bruce Boudreau of the Anaheim Ducks and Paul MacLean of the Ottawa Senators. The winner will be announced during the Stanley Cup Final series.
Quenneville said he was grateful for the recognition but he was not the main reason for the team's success.
"The players deserve the credit," Quenneville said.
OK, maybe, but Quenneville has done his part, as well. He led the Hawks to the best record during the regular season, including a 24-game point streak to start the year.
Quenneville said it was clear from the start of the season that his players were ready to make another run at a Stanley Cup title. He coached the Hawks to a championship during the 2009-10 season but did not win the Jack Adams Award that season.
"You've got to commend them from the start of the season, the way they prepared themselves," Quenneville said. "The consistency. The way they competed. The predictability in their game.
"It was fun to be a part of it. You look back on certain seasons. The fun factor this year working with this group is over-the-top. It was a special regular season."
Only one coach in Hawks history has won the Jack Adams Award. Orval Tessier was named as the league's best coach during the 1982-83 season.
Meanwhile, the playoffs continue with Game 2 of the Western Conference semifinals set for Saturday. The Hawks lead the series, 1-0, against the Detroit Red Wings.
-Tom Musick

subset: commoncrawl


text:
Monday, October 27, 2014
Avoid premature performance standards
This tweet inspired this post:
"@ACSmaggus: This history of peri-operative beta-blockade is a good case for allowing evidence to mature before changing practice http://t.co/jPZwrJG5JG"
Learning from mistakes in clinical practice guidelines: the case of perioperative beta-blockade
Unfortunately, I do not have access to the entire article, but this quote stands out.
On one level, what may be most remarkable about the rise and fall of preoperative beta-blocker guidelines is how unremarkable it seems. Preoperative beta-blockade is only one of several recent examples in which expert endorsements of promising therapies changed markedly when new evidence highlighted potential harms that had been overlooked by these endorsements.
Most experienced physicians learn not to believe the first reports of anything. When new pharmaceuticals arrive, we delay rapid acceptance. Too often the initial reports are over enthusiastic.
This phenomenon also occurs with research. My first NEJM article was a refutation of a clinical prediction rule. Inability to predict relapse in acute asthma.
My good friend Sandy Schwartz taught us this with a brilliant abstract presentation at the Society for Medical Decision Making in 1981. He had developed a decision rule, but after the abstract was accepted for presentation, he found that retesting the rule with fresh data yielded a failed rule.
Science is a process. Scientists do studies, report them, then other scientists check the results. Especially when the results do not make sense, we need further studies.
Declaring a new performance standard prematurely can have (drum roll please) UNINTENDED CONSEQUENCES. We talk often about ill-advised performance measures. This article should influence guideline writers and performance measurement developers. We must continue to question research findings and argue against premature adoption of practice standards. The emperor is not always clothed.
db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.
Labels: db's Medical Rants, evidence-based medicine, guest post, guidelines, performance measures, Robert M. Centor
0 Comments:
Subscribe to Post Comments [Atom]
This is a printer-friendly version of this page
Contact ACP Internist
Send comments to ACP Internist staff at email@example.com.
Previous Posts
- What I learned from Ebola
- The 'nocebo effect,' statins, and Dr. Ben Goldacre...
- Ebola: The questions keep coming
- Which medical specialty should medical students ch...
- Medicare follies, or, the Annual Wellness Visit
- Clinical practice guidelines, autism, and ordering...
- We physicians need a Ganesh attitude
- Donning and doffing
- How can we make hand-offs a good thing?
- The very real-world limits of patient satisfaction...
Blog log
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs,
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
PLoS Blog
The Public Library of Science's open access materials include a blog.
White Coat
One of the most popular anonymous blogs written by an emergency room physician.


text:
The Holiness of God: 2000 Portland Conference
Conference Messages by R.C. Sproul
When Scripture calls God "holy," it is speaking of everything that sets Him apart from us, including His acts of justice and mercy. How can we comprehend the holiness of God? What happens to us when we do? What about … Learn MoreDownload Audio $8.00 $6.40 Add to Cart
The Holiness of God: 2009 National Conference
Conference Messages by Various Authors
The holiness of God has been obscured, and, consequently, the church's doctrine and ethics have been tarnished. Entertainment has replaced worship in many places, the Gospel is misunderstood and neglected, and the church assimilates itself to the culture instead of … Learn MoreDVD $75.00 $67.50 Add to Cart
Also available in three other formats
The Holiness of God: Extended Version
Teaching Series by R.C. Sproul
In the year King Uzziah died, the prophet Isaiah saw a vision of the Holy One of Israel that made him understand the horror of sin and gave him a passion to proclaim the hope of restoration to all who … Learn MoreCD $38.00 $34.20 Add to Cart
Also available in one other format
The King Without a Shadow
Book by R.C. Sproul
In The King Without a Shadow, Dr. R.C. Sproul tells of a king who hears of another King — one so great He casts no shadow. The first king embarks on a search for the Great King, a search that … Learn MoreHardcover $18.00 $14.40 Add to Cart
Also available in two other formats
The Pursuit of Holiness
Book by Jerry Bridges
What does holiness look like? For starters, it doesn't look anything like perfection. And it doesn't necessarily look like victory. Mostly, it consists of effort, prayer, grace, and obedience. "Scripture speaks of both a holiness we have in Christ before … Learn MorePaperback $13.00 $10.40 Add to Cart
Also available in one other format
‹ Previous 1 2 Next ›


text:
Lesson module sends all time 100 % results to the gradebook. Attached is a screen with a lesson result 67% thats shown in gradebook as 10 point (100 %.).
MDL-16355 and MDL-12883 discuss parts of this problems. MDL-16355 didn't solve it.
See also: http://moodle.org/mod/forum/discuss.php?d=98346
Gliffy Diagrams
Issue Links
- All
- Comments
- Work Log
- History
- Activity
- Links Hierarchy
This is a major bug and should really be fixed ASAP.
See http://moodle.org/mod/forum/discuss.php?d=98346
Thanks in advance,
This IS a problem. How ever many points you get on a lesson, that same number becomes your percentage score! 5 out of 5 points becomes a score of 5%. Thanks for your attention to this.
Any progress on this? This bug has completed disabled our ability to use Lesson as a graded item unless we complete rework the gradebook into weighted categories and completely redoing the gradebook for all our classes with graded lessons in the middle of the semester is really not an option. We have 1.9.2+ PLEASE HELP ASAP. This combined with other gradebook challenges is really decreasing the moodle enthusiasm to a level I have never seen. I fear serous mutiny. This lesson problem is the last straw for many but if it can be fixed quickly their might be hope. Appreciate whatever anyone could do. I would help if I had the skills.
Hi All:
I've encountered a bug in the lesson module that may be related to this issue in at least two builds of 1.9.4+. I'm currently running 1.9.4+ (Build: 20090218).
Environment: php 5.2.8, V1.9.4+ (Build: 20090218), MySQL 5.0.67-community, Apache 2.2.11 (Unix), Perl 5.8.8, Operating system Linux Kernel 2.6.28
Any time a question includes a short answer, the question attempt is recorded. However, the response is not recorded as correct even if it was correct. This causes the student score to be incorrect. The lesson pages process correctly. The correct feed back is displayed. Everything appears to work perfectly, except that he total score for the lesson is not incremented properly.
Between my hosting company and myself, we have done some fairly extensive trouble shooting, and it looks like it is a bug.
This is really becoming a problem on our site!
@ Carl Keller
More specifically this is what I have observed with latest 1.9.4 version.
if lesson parameter custom scoring is set to YES, then all question types will record the correct scores
if lesson parameter custom scoring is set to NO, then all question types will record the correct scores EXCEPT short answer!
There are obviously serious bugs in the scoring system in the Lesson module. Mark, please can you fix those ASAP?
Looks like the problem is that the lesson module stores percentages in its grade table and then was sending the percentage to the gradebook instead of the raw grade.
I'm attaching a patch that should now send the correct grade to the gradebook and also fix current grades via a lesson upgrade (so, need to visit Site Administration > Notifications). If anyone would like to test the patch, that would be fantastic! Just remember to use it on a copy of your database and that the patch is not finalized yet.
I'd like someone from core to review the patch before it goes in as I'm not the most familiar with gradebook nor am I certain if the version bump was done correctly (I think it's OK, but don't want to mess up upgrades to 2.0).
Also, in the patch, the same snippet of code is executed in upgrade.php for different versions (once for the gradebook update and now for this fix). I'm wondering if I should try to prevent that from happening twice or not (that being calling lesson_update_grades() twice in one upgrade).
Petr, from what I understand, you are familiar with the gradebook upgrade, etc. Could you take a look at the patch when you get a chance?
I applied your most recent patch (lesson_grade2.patch) to my current moodle 1.9.4 local installation.
1- it works OK as far as grades are concerned
2- but it throws an error when I delete selected attempts:
Notice: Trying to get property of non-object in C:\Program Files\xampp\htdocs\moodle19dev\moodle\mod\lesson\lib.php on line 433
Fatal error: Cannot use object of type object as array in C:\Program Files\xampp\htdocs\moodle19dev\moodle\mod\lesson\lib.php on line 433
Good catch. It appears that $grades can be several different values and types. Looking into a solution now.
Attaching a new patch (lesson_grade3.patch). Looks like grade_update() eventually converts $grades to an array of arrays. The lesson code now does this as it calculates the raw grade.
so am I correct in assuming the grade2 patch is for v1.9.2+ That is the version we are having issues with. If so will have remote learner install and I can go in and see if that worked. thanks for your efforts. This has been a nightmare for instructors with lots of graded lessons.
lesson_grade3,patch is the current one, not lesson_grade2.patch. The patch is against 1.9.4+ (Build: 20090224), which is the llatest in MOODLE_19_STABLE. The patch has not been finalized yet, Petr was planning on testing it today.
So is a patch going to be created for version Moodle 1.9.2+ (Build: 20080813)
I am the original person who posted this on moodle.org and Joseph so kindly posted this in tracker.
We can not upgrade to 1.9.4+ because we have activity locking installed and it is not stable for v1.9.4+
looking at the code, I think the grade altering should would look much better in lesson_get_user_grades() , right?
I hope you backported all the security patches somehow, if not you are in big trouble
"looking at the code, I think the grade altering should would look much better in lesson_get_user_grades() , right? "
That would assume that the only grades that are passed to lesson_grade_item_update() are from lesson_get_user_grades(). Doesn't seem like a safe assumption, but maybe it is? I'm not sure what else might call lesson_grade_item_update().
Full text search is your best friend if you need to know how and where are xxx_grade_item_update() used
Hi All:
Will someone please point me toward a resource explaining how to install this patch on a shared server? Our online courses are really in a bind over this because they rely heavily on lessons for grading. Also please see
Committed to 1.9 branch and merge to trunk. Had to modify the upgrade code to match the new API in Moodle 2.0.
so will this fix version 1.9.2+ we are dying! help! remote-learner is trying hard to assist. We can not upgrade to 1.9.4. Thanks for your help!
Not entirely sure what's in the 1.9.2+ code. If you cannot upgrade, then your best bet would probably be to try to apply lesson_grade3.patch (attached to this ticket). Please test on a copy of your code and database. If that doesn't work, then you'll need a programmer to look at your specific code and derive a solution for it.
Actually, I take some of that back. You may upgrade your lesson module past incremental upgrades that might be introduced between your version and the current 1.9 version. So, you'll have to have a programmer to look at your code and see what can be done.
When I upgrade HEAD I get:
Warning: Missing argument 1 for lesson_update_grades(), called in /home/tim/Workspace/moodle_head/mod/lesson/db/upgrade.php on line 52 and defined in /home/tim/Workspace/moodle_head/mod/lesson/lib.php on line 383
is unnecessary (and evil) in HEAD. We have stopped outputting successful SQL there, so actually, the $DB->set_debug(false); is irrelevant, and that $DB->set_debug(true); screws things up.
Ah, I think the call should be to lesson_upGRADE_grades, but I am guessing. I'll checking the changes, since they make the error messgage go away, but I will leave this bug reopened because:
- Someone who understands should review the chagnes.
- The change may need backporting to 1.9 branch, and I have not done that.
Tim, your right, the function that needs to be call in HEAD is lesson_upgrade_grades() - it's a new function in trunk which does what lesson_update_grades() did when no parameters are passed. Removing the debug lines is fine, I didn't know about that change.
Nothing should be backported as I believe these are all HEAD specific issues.
Let me know if your committing your code or if I should make the changes and commit.
Never mind, just noticed that you committed already. Looks good to me.
Hi Guys!
I have upgraded to the latest version, and I my lessons still won't increment properly when short answers are used! Any ideas? This is quite an issue for us.
Hello Everybody
I use Moodle 1.9.4+. I patched all three of files using patch 'lesson_grade3.patch', but lesson grades in gradebook are still displayed always as 100%.
The patch has been applied to the code already and is in the weekly download (http://download.moodle.org/). Did you visit the admin notifications area to run database updates? And did you try attempting a lesson to see if you get 100% in the gradebook while not getting a perfect score?
Thanks for Your response.
When i attempt a lesson after applying patch, and my score is not 100%, the grade shown in gradebook is displayed propertly. But attempts made before patching are still displayed always as 100%. Entering in admin notification does not applying database updates.
Finally I changed whole /mod/lesson/ folder to this taken from latest weekly download, but admin notification still do not apply database updates, and previous lesson attempts are shown as 100% in gradebook. I changed grade of this attempts manually, because there was very few of them.
Regards, ?ukasz
Hi Petr:
As far as I am concerned, the lesson part of the issue was fixed when I installed the updated download that Mark Nielsen mentioned in his comment on 24/Mar/09 01:39 AM.
resolving as fixed, please file a new issue if needed, thanks everybody
I created a lesson with a maximum grade of 5. Completed the lesson as a student and my grade appears to be being correctly represented on the grader report. I was also able to delete attempts at the lesson without an error. Closing.


text:
Continue reading »
Atlassian Hack House is Back!
As part of our unique on-boarding program, we're sending our new Sydney-based graduate hires to an upscale apartment in the city's hip Surry Hills neighborhood. Similar to last year, the grads will spend a week receiving training and mentorship from our top engineers, begin working on some of our products and build products to be sold in the Atlassian Marketplace. The grads will also be tasked with completing their first ShipIt Day, our renowned quarterly innovation event, and presenting their


text:
By PATSY STODDARDEditor
The Southeastern Utah Energy Producers held their annual banquet on Oct. 2 at the Carbon County events center. SEUEPA's president Rick Olsen welcomed everyone to the banquet. He is proud of SEUEPA's growth and the organization has strength in numbers.
Deb Dull from Rocky Mountain Power introduced Dr. Laura Nelson from Ecoshale, a company involved with the development of oil shale. Nelson said energy is a critical and vital part of the lives we lead. Most people don't think much about what is behind the production of energy. They just switch on their lights and take energy production for granted.
Ecoshale is operating in the Uintah Basin and can deliver the resource in a short amount of time. Why do we have to develop oil shale, Nelson asked. It can be a viable part of our energy future. The United States imports 58 percent of its energy needs. "Energy costs affect everyone. We need to work to offset our imports and give households greater support. Imports are expected to climb to 70 percent in the next few years," said Nelson.
Nelson doesn't view dependency on oil and energy as a bad thing. It has enabled our country to develop a good quality of life for its citizens. But with that dependency comes a responsibility to develop new energy sources. A lot of our petroleum is coming from the tar sands in Canada.
A percentage comes from Saudi Arabia and 20 percent comes from Africa. These sources from unstable parts of the world are cause for concern. Nelson said the last tests of reserves in the Middle East were in 1982. "We are counting on those reserves to be there, but we really don't know. What can we do to off set our needs. We can look at efficiency. We are not super efficient, only 58 percent. Other countries are increasing their energy demands rapidly," said Nelson.
Nelson said the country needs to look at unconventional energy sources. They have to be part of our future. Oil production in Mexico is declining. Nelson said renewables are only part of the answer, they are a small source. Renewables can't meet the demand for the future. "Emerging countries seek a greater quality of life. We want to provide the same opportunities we have had to future generations. Unconventional energy is part of that future. We need it all, wind, solar, coal, biofuels, oil shale," said Nelson.
Ecoshale holds leases on state and school trustlands, but no federal leases. Federal leases will be needed in the future to pursue oil shale more seriously. It's estimated in Utah, Colorado and Wyoming there are 800 billion barrels of oil shale.
The technology to develop this oil shale is already in place. Nelson outlined the steps involved: Step 1: We carefully set aside overburden to preserve topsoil biodiversity. This allows us to rapidly reclaim the site within a few weeks, as well as support new grasses and brush for wildlife, within months.
Step 2: We build an environmental protection layer within an impoundment. Such clay impoundments are used to protect the environment in the mining industry and provide long-term protection of ground water and aquifers.
Step 3: We fill the impoundment with freshly mined ore from shale. The shale contains rich hydrogen content. The ore will be sized, sorted and roasted in the impoundment to extract a premium, bottomless fuel source.
Step 4: We place pipes that are designed to biodegrade harmlessly within the impoundment. Without using any water, we transfer dry, low emission heat from clean burning natural gas burners into the pipes. When finished, we remove the heat by circulating air through the pipes into the adjacent prepared impoundment. No rock is burned at any time. Instead, by burning clean natural gas, we avoid nearly two-thirds of typical retort emissions.
Step 5: Once we've completed heating the shale and producing 34 API gravity kerogen oil, we upgrade the kerogen to remove all nitrogen and sulfur. Upgraded kerogen oil is the feedstock for premium low sulfur diesel fuel--approved and highly sought-after by environmentally conscious energy consuming states such as California. ULSD is a premium fuel because it far outpaces the mileage efficiency of fuels such as ethanol, and can help Low Emission Diesel vehicles compete toe-to-toe with hybrids. In some cases, Low Emission Diesel vehicles ("green" diesel) achieve better mileage than hybrids.
Step 6. Our process mining is rapidly reclaimed. Instead of years to reclaim, we return native soils within weeks. New grasses and brush begin to appear within months.
Nelson said they are starting small with a five acre site which can produce 5,000 barrels a day. They have people ready to buy their product once it is produced.
"Yes it can be done and yes it can be done economically," said Nelson. Ecoshale will use the best practices and technology available. They plan to be part of the communities where they work and will support and interact with the communities. Royalties from the product will go into the school trustlands funds and if federal leases are developed royalties will be generated that will be returned to the state of Utah. Nelson said oil shale has a 90 percent recovery rate.


text:
My Registrations
My Certificate |
My Transcript |
My Profile |
Activity Registration
The Fundamentals of Diabetes Management
Wednesday, May 08, 2013
Scripps Whittier Diabetes Institute
2nd Floor Classroom
10140 Campus Point Drive, Suite 200
San Diego, CA 92121
Sign In
To sign in, please follow the steps below:
1. Enter your Email Address:
2. Please select one of the following:
I already have a password, and my password is:
Forgot Password?
I am a new user (You'll create a password later)
Sign In
The email you use will be your log in username. If the email address is used in more than one profile, neither attendee will be able to access their profile, transcripts, register, or receive their CME Certificate after a course. If you are an assistant registering a physician for a conference be sure to use the physicians email address when logging in. If you need a receipt sent to an alternate email address please call our office.


text:
Connacht fly-half Dan Parks will make his Heineken Cup debut for the Irish province in Saturday's clash with Zebre in Parma.
Connacht fly-half Dan Parks makes his Heineken Cup debut for the Irish province in Saturday's clash with Italian outfit Zebre at Stadio XXV Aprile.
This is only Connacht's second season in Europe's premier cup competition following fifteen years in the Amlin Challenge Cup.
Parks is fourteenth on the all-time scoring list in Europe, with 355 points after previously representing Cardiff Blues and Glasgow Warriors in the competition.
Eric Elwood's troops will be full of confidence of claiming a win after their 30-17 triumph over Zebre in Parma in their PRO12 clash earlier this season.
Meanwhile, Zebre's former Waratahs utility-back Daniel Halangahu will also make his Heineken Cup debut at full-back.
Rugby Union betting odds
The teams:
Zebre: 15 Daniel Halangahu, 14 Giovanbattista Venditti, 13 Matteo Pratichetti, 12 Gonzalo Garcia, 11 Sinoti Sinoti, 10 Luciano Orquera, 9 Tito Tebaldi,8 Dries van Schalkwyk, 7 Mauro Bergamasco, 6 Nicola Belardo, 5 Josh Sole, 4 Quintin Geldenhuys, 3 Luca Redolfini, 2 Davide Giazzon, 1 Salvatore Perugini.
Replacements: 16 Carlo Festuccia, 17 Matias Aguero, 18 Carlo Fazzari, 19 Mike Van Vuuren, 20 Filippo Ferrarini, 21 Luca Martinelli, 22 Ruggero Trevisan, 23 Leonardo Sarto.
Connacht: 15 Robbie Henshaw, 14 Tiernan O'Halloran, 13 Eoin Griffin, 12 Dave McSharry, 11 Fetu'u Vainikolo, 10 Dan Parks, 9 Kieran Marmion, 8 George Naoupu, 7 Willie Faloon, 6 John Muldoon, 5 Mike McCarthy, 4 Michael Swift, 3 Nathan White, 2 Ethienne Reynecke, 1 Dennis Buckley.
Replacements: 16 Adrian Flavin, 17 Rodney Ah You, 18 Ronan Loughney, 19 Dave Gannon, 20 Johnny O'Connor, 21 Dave Moore, 22 Miah Nikora, 23 Mata Fifita.
Date: Saturday, October 13
Kick-off: 14:35 local (13:35 BST)
Venue: Stadio XXV Aprile
Referee: Leighton Hodges (Wales)
Assistant referees: Wayne Davies (Wales), Greg Morgan (Wales)
Television match official: Nigel Whitehouse (Wales)
Timekeeper: Giorgio Maggi (Italy)
Assessor: Michel Lamoulie (France)
Citing commissioner: Wade Dooley (England)


text:
Shibui Knits Silk Cloud Yarn is a similar yarn: mohair, hand wash, 25 gram. You may also like Berroco Briza Yarn, which is another similar yarn: mohair, hand wash, and worsted (19-20 sts/4 in).
What about yarn that have the same look and feel? Find more yarn with a soft halo, hairy and airy texture.
You may enjoy taking a look at the , and Rowan Kidsilk Haze Lacy Box Top kits all using Rowan Kidsilk Haze Yarn.
Hopefully our suggested project ideas for Rowan Kidsilk Haze Yarn can help you come up with your next exciting new project idea!


text: You are browsing in Zazzle's S6 Samsung cases department, where you'll find a range of S6 Samsung case designs ready to be personalized or purchased as is. Designed, engineered and built to protect your Samsung in style, Zazzle's custom Samsung cases are printable in full colour, and you can add photos or text for free. To enjoy a vast array of more related products, go to the main s6 page.


text:
Metal Shower Basket Large
$52 Regular
$20 Member
Crafted of chrome-plated brass, our classic wire baskets offer strong, rust-resistant shower storage. The sleek wires allow moisture to drip away, and raised sides keep bottles and soap bars steady and in easy reach.
Show Details +
- 5¾"W x 6¾"D x 2½"H
Shown in polished chrome.
Metal Shower Basket Large - 5¾"W x 6¾"D x 2½"H
$52 Regular
$20 Member


text:
Santoni Leather Slingback Sandal
Sorry, this item is sold out!
Looks like you've got more shoe shopping to do - have fun!
Looks like you've got more shoe shopping to do - have fun!
Item # 262598
Santoni is the perfect blend of high quality craftsmanship and innovation. You can expect nothing less than luxurious perfection when you slip into this leather platform sandal.
- Leather upper
- Slingback strap with an adjustable buckle
- Almond toe
- Fully lined in leather
- ¾" platform, 4" heel
- Leather sole
- Made in Italy
- View more Women's Santoni Shoes
- Online Exclusive!
Tell us what you think!
Everyone has an opinion. Here's your chance to share yours! Be the first to write a review of this product and help your fellow shoppers pick the best of the best.