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					                                Original   Contributions                                                                Clinical Review


The Deliberate  Misdiagnosis of Major                                           333   Primary  Prevention of Coronary Heart                                     361
Depression in Primary Care                                                            Disease in Women: Should
Kathryn Rost, PhD; G. Richard Smith, MD;                                              Asymptomatic Women 50 Years of Age
Daryl    Matthews, MD, PhD;
            B.                                                                        Take Aspirin Regularly?
Ben Guise, MD                                                                         Scott E. Woods, MD

Physicians and Smoking Cessation:                                               341
A Survey of Office Procedures and                                                                                        Brief Reports
Practices in the Community
Intervention Trial                                                                    Accurate Dosing of Pediatrie                                              365
for Smoking Cessation                                                                 Medications
Elizabeth A. Lindsay, PhD;                                                            Ronald D. Reynolds, MD
Judith K. Ockene, PhD;
Norman Hymowitz, PhD; Carol Giffen, DVM;                                              The       Family Physician and Industrial                                 372
Larry Berger, MD; Paul Pomrehn, MD;                                                   Hygiene
for the Community Intervention Trial                                                  John R. Wheat, MD, MPH; Jerry                      T.   McKnight, MD;
                                                                                      William H. Weems, DrPH
for Smoking Cessation Research Group
Predicting Work Status for Patients in                                          349
                                                                                                                         Departments
an Occupational Medicine Setting Who
Report Back Pain                                                                      Family Album                                                              305
Marie A. Krousel-Wood, MD, MSPH;
Todd W. McCune, MD, MPH;                                                              Software Review                                                           311
Ahmed Abdoh, PhD; Richard N. Re, MD
                                                                                      Book Reviews                                                              312
Clinical Risk Factors for                                                       357
Methicillin-Resistant Staphylococcus                                                  Audiovisual Review                                                        314
aureus Bacteriuria in a Skilled-Care
                                                                                      Instructions for Authors                                                  377
Nursing Home
Patrick P. Coll, MB, BCh;                                                             Classified         Advertising                                            383
Benjamin F. Crahtree, PhD;
Patrick J. O'Connor, MD, MPH;                                                         Index       to   Advertisers                                           Cover 3
Scott Klenzak




                                                                         ARCHIVES
                                                                         FAMILY MEDICINE
Editor.                                          Charles E. Driscoll. MD              Barbara D. Reed, MD, MSPH                    Prevention and Health Promotion:
Marjorie    A.   Bowman, MD, MPA                 Iowa   City, Iowa                    Ann  Arbor, Mich                             Robert C. Rinaldi, PhD
Bowman Gray School of Medicine                   Steven C. Zweig, MD, MSPH            Milton H. Seifert, MD                        Chicago, 111
Medical Center Boulevard                         Columbia, Mo                         Excelsior, Minn
Winston-Salem, NC 27157-1084                                                          Thomas L. Speros, MD                         Science and Technology:
Phone: (910) 716-7318                            Editorial Board:                     Washington, NC                               Jerod M. Loeb, PhD
Fax: (910) 716-5850                                                                   David H. Thoin.    MD, MPH, PhD              Chicago, 111
                                                 W.   Eugene Broadhead, MD,   PhD     Palo Alto, Calif
                                                 Durham, NC                                                                        Statistical Consultant:
Deputy Editor:
                                                 Allen J. Dietrich, MD                Series Editors:
Joseph C. Konen, MD,     MSPH
                                                 Hanover, NH
                                                                                                                                   Mark A. Espeland, PhD
Winston-Salem, NC                                                                                                                  Winston-Salem, NC
                                                 John G. Halvorsen, MD, MS            Practice   Management:
Assistant to Editor:                             Minneapolis, Minn                    Christian N. Ramsey, Jr, MD                  Book and Software Review:
Tina M. Gibson
                                                 Myron S. Magen, DO                   Oklahoma City, Okla                          Michael L. Adler, MD
                                                 E. Lansing, Mich                                                                  Winston-Salem, NC
Associate Editors:                               Patrick J. O'Connor, MD, MPH         Ethics:
                                                 St Paul, Minn
Louise S.Acheson, MD, MS                                                              Katherine C. Krause, MD
Cleveland, Ohio                                                                       Hartford, Conn
DDAVFNasal Spray
(desmopressin acetate) 5mL                                                           L                                                                                  ARCHIVES
Dry Nights For Good Mornings                                                                                                                                            FAMILY MEDICINE
Brief Summary
CONTRAINDICATION: Known hypersensitivity to DDAVP Nasal Spray.
WARNINGS:
' For ¡ntranasal use
                     only.
2 In very young and elderly patients in particular, fluid intake should be adjusted m order to decrease the potential occurrence of water
intoxication and hyponatremia. Particular attention should be paid to the possibility of the rare occurrence of an extreme decrease in
plasma osmolality and resulting seizures                                                                                                       Publication Staff                     Electronic    Publishing Department
PRECAUTIONS:
Generai. DDAVP Nasal Spray at high dosage has infrequently produced a slight elevation of blood pressure, which disappeared with a             Offices: 515 N State St
reduction m dosage. The drug should be used with caution m patients with coronary artery insufficiency and/or hypertensive cardiovas¬
cular disease because of possible rise m blood pressure                                                                                        Chicago, IL 60610                     Director:   Mary   C. Steermann
DDAVP Nasal Spray should be used with caution m patients with conditions associated with fluid and electrolyte imbalance, such as cys¬                                               Assistant Director:
tic fibrosis, because these patients are prone to hyponatremia                                                                                                                                        Jave Matthews
Central Cranial Diabetes Insipidus: Since DDAVP Nasal Spray is used mtranasally, changes in the nasal mucosa such as scarring, edema,          Editorial Processing Department,
or other disease may cause erratic, unreliable absorption in which case DDAVP Nasal Spray should not be used For such situations,                                                    Manager, Color:
DDAVP injection should be considered.                                                                                                          Specialty Journals                      Tilomas J. Handrigan
Primary Nocturnal Enuresis: If changes in the nasal mucosa have occurred, unreliable absorption may result DDAVP Nasal Spray should
be discontinued until the nasal problems resolve                                                                                                                                     Graphics & Color Coordinator:
Information lor Patients- Patients should be informed that the bottle accurately delivers 50 doses of 10 meg each Any solution remaining       Director: Paula Glitman
after 50 doses should be discarded since the amount delivered thereafter may be substantially less than 10 meg of drug No attempt                                                      JoAnne Weiskopf
should be made to transfer remaining solution to another bottle Patients should be mslructed to read accompanying directions on use of         Manager: Barbara Clark                Electronic Coordinator:
the spray pump carefully before use.
Laboratory Jests: Laboratory tests for following the patient with central cranial diabetes insipidus or post-surgical or head trauma-related   Freelance Manager:                      Mar)' Ellen Johnston
polyuna and polydipsia include urine volume and osmolality In some cases plasma osmolality may be required For the healthy patient               Vickey Golden                       Graphic Designer:
with primary nocturnal enuresis, serum electrolytes should be checked at least once if therapy is continued beyond 7 days
Druqlnteractions Although the pressor activity of DDAVP Nasal Spray is very low compared to the antidiuretic activity, use of large doses      Assistant Freelance Coordinator:         Charl Richey-Davis
of DDAVP Nasal Spray with other pressor agents should only be done with careful patient monitoring.                                              Richard T. Porter
Carcinogenesis, Mutagenesis. Impairment ol Fertility: Teratology    studies in rats have shown no abnormalities No further information is                                            Electronic Production Associate:
available.                                                                                                                                     Senior Copy Editor/Alex Specialist:      Linda Knott
 Pregnancy-Category B: Reproduction studies performed in rats and rabbits with doses up to 125 times the human mtranasal dose (i.e.              Paul Frank                          Electronic Production Operators:
about 125 times the total adult human dose given systemically) have revealed no evidence of harm to the fetus due to desmopressin ace¬
tate There are several publications of management of diabetes insipidus m pregnant women with no harm to the fetus reported, however,          Senior Copy Editor:                     Gail Barrett
no controlled studies m
                          pregnant women have been earned out. Published reports stress that, as opposed to but the physician the
                                                                                                                             containing
natural hormones, DDAVP Nasal Spray [desmopressin acetate) in antidiuretic doses has no uterotonic action, preparations will have                Janice Snider                          Brenda Chandler-Haynes
to weigh possible therapeutic advantages against possible dangers in each individual case                                                                                              Leslie Koch
Nursing Mothers There have been no controlled studies m nursing mothers A single study in a post-partum woman demonstrated a                   Copy Editors:
marked change m plasma, but little if any change in assayable DDAVP Nasal Spray in breast milt following an mtranasal dose o' 10 meg             Diane L. Cannon                        Mary Ann Kuranda
Pediatrie Use Primary Nocturnal Enuresis. DDAVP Nasal Spray has been usedin childhood nocturnal enuresis Short-term [4-8 weeks]
DDAVP Nasal Spray administration has been shown to be safe and modestly effective in children aged 6 years or older with severe child¬           Gwen Chaffen                           Peter Watkins
hood nocturnal enuresis. Adequately controlled studies with DDAVP Nasal Spray in primary nocturnal enuresis have not been conducted
beyond 4-8 weeks. The dose should be individually adjusted to achieve the best results.                                                          Mary E.   Coerver                   Graphics Operators:
Central Cranial Diabetes Insipidus: DDAVP Nasal Spray has been used m children with diabetes insipidus. Use in infants and children will         Vonda L. Meltesen                     Carolyn Luton
require careful fluid intake restriction to prevent possible hyponatremia and water intoxication The dose must be individually adjusted to
the patient with attention in the very young to the danger of an extreme decrease in plasma osmolality with resulting convulsions. Dose        Manuscript Records Clerk:               Regina Vander Reyden
should start at 0.05 mL or less.                                                                                                                 Tonja Glover
Since the spray cannot deliver less than 01 mL (10 meg), smaller doses should be administered using the rhinal tube delivery system                                                  Manager, Proofreading:
Do noi use the nasal spray in pediatrie patients requiring less than 0.1 mL (10 meg) per dose.                                                                                          Teresa H. Omiotek
There are reports of an occasional change m response with time, usually greater trían 6 months. Some patients may show a decreased
                                                                                                                                                                                     Proofreaders:
responsiveness, others a shortened duration of effect There is no evidence this effect is due to the development of binding antibodies
but maybe due to a local mactivation of the peptide                                                                                                                                     Kathleen Czernik
ADVERSE REACTIONS: Infrequently, high dosages have produced transient headache and nausea Nasal congestion, rhinitis and
flushing have also been reported occasionally along with mild abdominal cramps. These symptoms disappearedwrih reduction in dos¬                                                        Brenda J. Gregoline
age Nose-bleed, sore throat, cough and upper respiratory infections have also been reported.                                                                                           Daniel James
The following table lists the percent of patients having adverse experiences without regard to relationship to study drug from the pooled
pivotal study data for nocturnal enuresis.                                                            DDAVP                      DDAVP         Production & Distribution             Production Assistant: Janey Stennis
                                                                       PLACE 30                      20 meg                      40 meg
                                                                         (N=69)                      (N:60)                      (N-61I        Department
ADVERSE REACTION                                                            %                                                       %
BODY AS A WHOLE                                                                                                                                Director: Carl Braun
     Abdominal Pain                                                         0                           2                           2                                                Circulation     Department
     Asthenia
      Chills
                                                                            0                           0                           2          Manager: Carole Piszker
                                                                            0                           0                           2
       Headache                                                             0                           2                           5          Production Associates:                Director:   Beverly Martin
      Throat Pain                                                           2                           0                           0            .Debbie Pogorzelski
NERVOUS SYSTEM                                                                                                                                                                       Reprints:    Rita Houston
       Depression                                                           2                           0                           0            Christine M. Wagenknechl
      Dizziness                                                             0                           0                           3            E. Ruth White
RESPIRATORY SYSTEM
       Epistaxis                                                            2                           3                           0          Senior Production Assistant:
                                                                                                                                                                                     Specialty Journal     Division Office
       Nostril Pam                                                          0                           2                           0
                                                                                                                                    0            Kira Culver
       Respiratory Infection
       Rhinitis
                                                                            2
                                                                            2
                                                                                                        0
                                                                                                        8                            3                                               Administrative Assistant:
CARDIOVASCULAR SYSTEM                                                                                                                          Production Assistant:                   Maria Hall
      Vasodilation                                                          2                           0                           0           Jo Anne Turner
DIGESTIVE SYSTEM
      Gastrointestinal Disorder                 0 2 0                                                                                          Manager, Distribution:                Licensing & Indexing Department
      Nausea                                  .002                                                                                               Paul Gasiecki
SKIN & APPENDAGES
      Leg Rash                                                              2                           0                           0                                                Director: Norman Frankel
      Rash                                                                  2                           0                           0
SPECIAL SENSES                                                                                                                                 Publishing Operations     Division    Staff:
       Conjunctivitis                                                       0                        2                         0               Office
       Edema Eyes                                                          0                         2                         0                                                        George Kruto
       Lachrymation Disorder                                               0                         0                         2                                                        Mary Kay Tinerella
OVERDOSAGE: See adverse reactions above In case of overdosage. the dose should be reduced, frequency of administration                         Manager. Budgets & Costs:
decreased, or the drug withdrawn according to the seventy of the condition There is no known specific antidote for DDAVP Nasal Spray             Bonnie Van eleven                   Permissions: I aslo   Hunyady
An oral LD50 has not been established An intravenous dose of 2 mg/kg in mice demonstrated no effect.
HOW SUPPLIED: A 5-mL bottle with spray pump delivering 50 doses of 10 meg (NDC 0075-2450-02] Also available as 2 5 mL per vial,                Manager, Advertising   Production:
packaged with two rhinal tube applicators per carton (NDCÌJ075-2450-01). Keep refrigerated at 2°-8°C (36°-46eF}. When traveling,                 Vanessa Hayden
product will maintain stability for up to 3 weeks when stored at room temperature, 22"C (72°F)
CAUTION: Federal (U S.A.) law prohibits dispensing without prescription.                                                                       Staff Assistant: Diane Darnell
Please see full prescribing information m product circular
                                                                                                                                               Office Manager: Karen Branham
                                                                                                                                               Production Assistant:
                                                                                                                                                  Valeric Balkcom
References:
1. Alad j em M, Wohl R. Boichis II, et al: Desmopressin in nocturnal ennresis. Arch Dis Child 1982:57:137-140.
2. Bloom DA: '¡'he American experience with desmopressin. Clin Pedidtr l^Only. special edition};28-M.




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