The impact of burnout syndrome on practitioners working within rural healthcare systems

IntroductionBurnout syndrome (BOS) affects up to 50% of healthcare practitioners. Limited data exist on BOS in paramedics/firstresponders, or others whose practice involves trauma. We sought to assess the impact of BOS in practitioners of rural healthcare systems involved in the provision of trauma care within West Virginia.Methods: A 3-part survey was distributed at two regional trauma conferences in 2018. The survey consisted of 1) Demographic/occupational items, 2) The Mini Z Burnout Survey, and 3) elements measuring the impact, and supportive infrastructure to prevent and/or manage BOS.Results: Response rate was 74.7% (127/170 attendees). Respondents included emergency medical services (EMS) (44.9%), nurses (37.8%), and physicians (9.4%). Overall, 31% reported BOS - physicians (45.5%), EMS (35.1%), and nurses (25.0%). Most agreed that BOS impacts the health of medical professionals (99.2%) and presents a barrier to patient care (97.6%). Those with BOS reported higher stress (p < 0.001), chaos at work (p < 0.001), and excessive documentation time at home (p < 0.001). Fewer respondents with BOS reported job satisfaction (p < 0.001), control over workload (p = 0.001), sufficient time for documentation (p ≤0.001), value alignment with institutional leadership (p = 0.001), and team efficiency (p = 0.004). Unique factors for BOS in EMS included: lack of control over workload (p = 0.032), poor value alignment with employer (p = 0.002), lack of efficient teamwork (p = 0.006), and excessive time documenting at home (p = 0.003).ConclusionsBurnout syndrome impacts rural healthcare practitioners, regardless of discipline. These data highlight a need to address the entire team and implement occupation-specific approaches for prevention and treatment. Further prospective study of these findings is warranted.     

Effects of green coffee bean extract on C-reactive protein levels: A systematic review and meta-analysis of randomized controlled trials

Background & objective: The effects of green coffee bean extract (GCBE) supplementation on inflammatory biomarkers have been widely spread. The purpose of this article was to assess the impact of GCBE supplementation on C-reactive protein (CRP) levels.MethodsThe literature search was performed in four databases (Scopus, PubMed, the Cochrane Library, and Google Scholar) to identify studies that examined the influence of GCBE supplementation on CRP levels up to August 2019. Mean and standard deviation (SD) of the outcomes were used to estimate the weight mean difference (WMD) between intervention and control groups for the follow-up period.ResultsFive (5) studies, with 6 arms, reported CRP as an outcome. Statistically, the use of GCBE supplements resulted in a significant change in CRP levels (WMD: −0.017 mg/dL, 95 % CI: −0.032, −0.003, p = 0.018), whose overall findings were obtained from random-effects model. In addition, a significantly greater reduction in CRP was noted for studies with doses of GCBE supplements ≥ 1000 mg/d (WMD: −0.015 mg/dL, 95 % CI: −0.020, −0.010, p < 0.000), length of intervention < 4 weeks (WMD: -0.015 mg/dL, 95 % CI: −0.020, −0.010, p < 0.001), and for non-healthy subjects (WMD: −0.019 mg/dL, 95 % CI: −0.027, −0.011, p < 0.001). Dyslipidemia, hypertension and non-alcoholic fatty liver disease were the ailments of the studies that encompassed non-healthy patients.ConclusionsThis meta-analysis shows that the use of GCBE supplements resulted in a statistical decrease in CRP levels, mainly for non-healthy subjects. However, due to the limited number of studies, further randomized clinical trials are crucial in this regard.     

Herbal medications and other dietary supplements. A clinical review for physicians caring for older people

Evidence for the safety and effectiveness of dietary supplements is mixed. The extent to which older people use dietary supplements concomitantly with conventional medications is often under-appreciated by physicians. We conducted a literature review on clinical considerations associated with dietary supplement use, focusing on benefits and harms, motivations for use and contribution to polypharmacy among older people. Vitamin D?≥?800?IU has demonstrated benefits in fracture prevention. Vitamins A, E, and β-carotene have been associated with an increase in total mortality in several meta-analyses. A range of non-vitamin dietary supplements have been studied in randomized controlled trials but their efficacy remains largely unclear. Supplement use has been associated with a range of adverse events and drug interactions yet physicians rarely initiate discussions about their use with older patients. Older people may take dietary supplements to exercise control over their health. Given the contribution of supplements to polypharmacy, supplements may be targeted for “deprescribing” if the risk of harm is judged to outweigh benefits. This is best done as part of a comprehensive, patient-centered approach. A respectful and non-judgmental discussion may result in a shared decision to reduce polypharmacy through cessation of dietary supplements.

• KEY MESSAGES

• Herbal medications and other dietary supplements are highly prevalent among older people. Physicians are often unaware that their patients use herbal medications and other dietary supplements concomitantly with conventional medications.

• Herbal medications and other dietary supplements contribute to high rates of polypharmacy, particularly among older people with multimorbidity. Herbal medications and other dietary supplements can interact with conventional medications and be associated with a range of adverse events.

• Physicians need to be patient-centered and non-judgmental when initiating discussions about herbal medications and other dietary supplements. This is important to maintain and develop patient empowerment and self-management skills.

     

Knowledge,attitudes and barriers regarding vaccination against hepatitis A and B in patients with chronic hepatitis C virus infection: a survey of family medicine and internal medicine physicians in the United States

Background: Although vaccination against hepatitis A virus (HAV) and hepatitis B virus (HBV) is recommended for all patients with chronic hepatitis C virus (HCV) infection, physician vaccination practices are suboptimal. Since training for family medicine (FM) and internal medicine (IM) physicians differ, we hypothesised that there are differences in knowledge, attitudes and barriers regarding vaccination against HAV and HBV in patients with chronic HCV between these two groups. Methods: A two‐page questionnaire was mailed to 3000 primary care (FM and IM) physicians randomly selected from the AMA Physician Masterfile in 2005. The survey included questions about physician demographics, knowledge and attitudes regarding vaccination. Results: Among the 3000 physicians surveyed, 1209 (42.2%) returned completed surveys. There were no differences between respondents and non‐respondents with regard to age, gender, geographic location or specialty. More FM than IM physicians stated that HCV+ patients should not be vaccinated against HAV (23.7% vs. 11.8%, p < 0.001) or HBV (21.9% vs. 10.6%, p < 0.001). FM physicians were also less likely than IM physicians to usually/always test HCV+ patients for immunity against HAV (33.9% vs. 48.6%, p < 0.001) or against HBV (50.8% vs. 68.0%, p < 0.001). There were numerous barriers to HAV and HBV vaccination identified. The median number of barriers was 3 for FM physicians and 2 for IM physicians (p < 0.001). Conclusions: Despite recommendations to vaccinate against HAV and HBV in patients with chronic HCV infection, physicians often do not test or vaccinate susceptible individuals. Interventions are needed to overcome the barriers identified and improve vaccination rates.     

Knowledge and characteristics of herbal supplement usage among community pharmacy customers in a Malaysian population

ObjectivesWe investigated the knowledge and characteristics of herbal supplement usage of the customers of community pharmacies in a Malaysian population.Design and settingSelf-administered questionnaires (in English, Malay, or Chinese) were provided to customers at three community pharmacies in Malaysia (Ipoh, Perak). Questionnaire validation and translation validation were performed. A pilot study was conducted before actual questionnaire distribution. Informed consent was obtained from all participants.ResultsTotal number of participants was 270 (99 males and 171 females) with majority from the 31–50 age group (41.5%). Among the participants, 45.6% were herbal users. The most commonly used herbal supplements were evening primrose oil (17.9%), ginkgo biloba (13.0%), and milk thistle (8.5%). The participants seemed to have sufficient knowledge regarding herbal supplements including safety, quality, and indication of use from medical literature. Participants obtained information about herbal supplements from pharmacists (26.9%), package inserts (25.2%), friends (20.5%), and the Internet (13.3%) more often than from their doctors (9.8%). Most herbal users did not inform their doctors about their usage of herbal supplements (68.3%) or the side effects (61.5%). Herbal supplement users also tended to be women, >50-year-old, and those with higher monthly household incomes.ConclusionsCommunity pharmacists have a vital role in educating their customers about the safe use of herbal supplements. The participants had sufficient knowledge about herbal supplement usage; therefore, customers of these community pharmacies may have benefitted from the advice of the pharmacists. Further studies could be carried out in future on the knowledge, skills and roles of community pharmacists in the safe use of herbal supplements.     

Deep Natural Language Processing Identifies Variation in Care Preference Documentation

ContextDocumentation of care preferences within 48 hours of admission to an intensive care unit (ICU) is a National Quality Forum-endorsed quality metric for older adults. Care preferences are poorly captured by administrative data.ObjectivesUsing deep natural language processing, our aim was to determine the rate of care preference documentation in free-text notes and to assess associated patient factors.MethodsRetrospective review of notes by clinicians using a deep natural language processing to identify care preference documentation, including goals-of-care and treatment limitations, within 48 hours of ICU admission within five ICUs (medical, cardiac, surgery, trauma surgery, and cardiac surgery) for adults 75 years and older. Covariates included demographics, ICU type, sequential organ failure assessment score, and need for mechanical ventilation.ResultsDeep natural language processing reviewed 11,575 clinician notes for 1350 ICU admissions. Median patient age was 84.0 years (interquartile range 78.0–88.4). Overall, 64.7% had documentation of care preferences. Patients with documentation were older (85 vs. 83 years; P < 0.001) and more often female (53.8% vs. 43.4%; P < 0.001). In adjusted analysis, rates of care preference documentation were higher for older patients, females, nonelective admissions, and admissions to the medical vs. the cardiac or surgical ICUs (all P ≤ 0.01).ConclusionCare preference documentation within 48 hours was absent in more than one-third of ICU admissions among patients aged 75 years and older and was more likely to occur in medical vs. cardiac or surgical ICUs.     

Boolean Search Experience and Abilities of Medical Students and Practicing Physicians

Background: Little is known about physician ability to utilize Boolean search skills to access information. Purpose: Determine the proficiency of medical students and practicing physicians to identify efficient Boolean phrases. Methods: Experiential survey and multiple-choice questions administered to 49 4th-year medical students and 42 practicing physicians. Subjects identified the best answer or correctly ranked 3 Boolean search phrase options. Results: Practicing physicians identified the single best query phrase significantly more often than did medical students (85.7% vs. 75.0%, p < 0.001), and both groups had significantly more difficulty correctly rank-ordering the queries (students, 75% vs. 54%, p < 0.001; practitioners, 85.7% vs. 57.1%, p <. 04). Only recent MEDLINE use was an independent predictor of accuracy in both groups. Conclusion: Students and physicians demonstrated deficiencies in identifying optimal Boolean phrases. Although formal instruction has not demonstrated clear improvement in skills, more creative teaching of Boolean search techniques should be undertaken and tested.     

Characteristics of Frequent Users of Emergency Medical Services in Singapore

Objectives: This study aims to describe frequent users of Emergency Medical Services (EMS) conveyed to a Singapore tertiary hospital, focusing on a comparison between younger users (age <65) and older users in diagnoses and admission rates. Methods: All patients conveyed by EMS to a tertiary hospital 4 times or more over a 1-year period in 2015 had their EMS ambulance charts and Emergency Department (ED) electronic records retrospectively analyzed (n?=?243), with admission the primary outcome. Results: The 243 frequent users were analyzed with a combined total of 1,705 visits, out of a total of 10,183 patients with 12,839 visits conveyed by EMS to Singapore General Hospital (SGH) in 2015. Younger frequent users (<65 years age) were found to be predominantly male (79.6%, p?=?0.001) and were on average responsible for more visits than elderly frequent users (8.6 vs. 5.7, p?=?0.004). Medical co-morbidities were significantly more prevalent in older users. Younger frequent users were more likely to be smokers (60.2% vs. 22.3%), heavy drinkers (51.3% vs. 8.5%), substance abusers (12.4% vs. 0.8%), and bad debtors (49.6% vs. 20.0%, p?<?0.001). A larger proportion presented with altered mental states (11.7% vs. 5.4%, p?<?0.001) and alcohol related diagnoses (34.7% vs. 5.3%, p?<?0.001). Many were picked up from public areas (45.5% vs. 19.6%, p?<?0.001), and had lower acuity triage scores at both EMS (p?<?0.001) and ED (p?=?0.001). They had lower admission rates (40.5% vs. 78.7%, p?<?0.001) and shorter length of stay (4.3 vs. 5.9 days, p?<?0.001). Univariable and multivariable analysis showed alcohol related diagnoses, history of alcohol abuse and lower triage scores were less likely to require admissions. Conclusion: Frequent EMS users consume a disproportionate amount of healthcare resources. Two broad subgroups of patients were identified: younger patients with social issues and older patients with multiple medical conditions. EMS usage by older patients was significantly associated with higher rates of admission     

Prevalence of use and reported side effects of herbal medicine among adults in Saudi Arabia

ObjectiveDespite the availability of well characterized and scientifically proven medicines, many people prefer the use of the less known herbal therapies that have no-scientific or evidence-based values as their first line of treatment. While this represents a growing worldwide issue, it is commonly practiced in developing countries including Saudi Arabia. Hence, the aim of the present study is to assess the prevalence of herbal medicine use, the most reported side effects and influencing factors in Saudi Arabia.DesignA community based cross sectional survey study.SettingsParticipants were recruited by convenience sampling method from local malls and family recreation sites.Main outcome measuresPrevalence of herbal medicine use and the associated risks.ResultsOut of the 1300 surveyed individuals, 1226 respondents (94 %) used herbal medicines for therapeutic purposes with the majority of the respondents using them based on traditional beliefs 699 (57 %) or family recommendations 417 (34 %). Young respondents <35 year olds who live in urban cities, showed a significantly better knowledge about herbal medicines use and the associated risks than their counterparts (p < 0.001). Despite the high percentage of reported side effects (46 %), more than half of the respondents 702 (54 %) use herbal medicines as their first line of therapy. However, the most reported reasons for the use of herbal medicine are the belief that they are safer, more effective and cheaper to buy than the standard medicines.ConclusionThere is a high prevalence use of non-scientifically proven herbal medicine and a low level of knowledge about their risks amongst participants.     

Self-Assessment Feedback Form Improves Quality of Out-of-Hospital CPR

Objective: Various continuous quality improvement (CQI) approaches have been used to improve quality of cardiopulmonary resuscitation (CPR) delivered at the scene of out-of-hospital cardiac arrest. We evaluated a post-event, self-assessment, CQI feedback form to determine its impact on delivery of CPR quality metrics. Methods: This before/after retrospective review evaluated data from a CQI program in a midsized urban emergency medical services (EMS) system using CPR quality metrics captured by Zoll Medical Inc. X-series defibrillator ECG files in adult patients (≥18 years old) with non-traumatic out-of-hospital cardiac arrest. Two 9-month periods, one before and one after implementation of the feedback form on December 31, 2013 were evaluated. Metrics included the mean and percentage of goal achievement for chest compression depth (goal: >5 centimeters [cm]; >90%/episode), rate (goal: 100–120 compressions/minute [min]), chest compression fraction (goal: ≥75%), and preshock pause (goal: <10?seconds [sec]). The feedback form was distributed to all EMS providers involved in the resuscitation within 72?hours for self-review. Results: A total of 439 encounters before and 621 encounters after were evaluated including basic life support (BLS) and advanced life support (ALS) providers. The Before Group consisted of 408 patients with an average age of 61?±?17 years, 61.8% male. The After Group consisted of 556 patients with an average age of 61?±?17 years, 58.3% male. Overall, combining BLS and ALS encounters, the mean CPR metric values before and after were: chest compression depth (5.0?cm vs. 5.5?cm; p?<?0.001), rate (109.6/min vs 114.8/min; p?<?0.001), fraction (79.2% vs. 86.4%; p?<?0.001), and preshock pause (18.8?sec vs. 11.8?sec; p?<?0.001), respectively. Overall, the percent goal achievement before and after were: chest compression depth (48.5% vs. 66.6%; p?<?0.001), rate (71.8% vs. 71.7%, p?=?0.78), fraction (68.1% vs. 91.0%; p?<?0.001), and preshock pause (24.1% vs. 59.5%; p?<?0.001), respectively. The BLS encounters and ALS encounters had similar statistically significant improvements seen in all metrics. Conclusion: This post-event, self-assessment CQI feedback form was associated with significant improvement in delivery of out-of-hospital CPR depth, fraction and preshock pause time.     

Comparison of the Quality of Patient Referrals From Physicians,Physician Assistants,and Nurse Practitioners

ObjectiveTo compare the quality of referrals of patients with complex medical problems from nurse practitioners (NPs), physician assistants (PAs), and physicians to general internists.Patients and MethodsWe conducted a retrospective comparison study involving regional referrals to an academic medical center from January 1, 2009, through December 31, 2010. All 160 patients referred by NPs and PAs combined and a random sample of 160 patients referred by physicians were studied. Five experienced physicians blinded to the source of referral used a 7-item instrument to assess the quality of referrals. Internal consistency, interrater reliability, and dimensionality of item scores were determined. Differences between item scores for patients referred by physicians and those for patients referred by NPs and PAs combined were analyzed by using multivariate ordinal logistical regression adjusted for patient age, sex, distance of the referral source from Mayo Clinic, and Charlson Index.ResultsFactor analysis revealed a 1-dimensional measure of the quality of patient referrals. Interrater reliability (intraclass correlation coefficient for individual items: range, 0.77-0.93; overall, 0.92) and internal consistency for items combined (Cronbach α=0.75) were excellent. Referrals from physicians were scored higher (percentage of agree/strongly agree responses) than were referrals from NPs and PAs for each of the following items: referral question clearly articulated (86.3% vs 76.0%; P=.0007), clinical information provided (72.6% vs 54.1%; P=.003), documented understanding of the patient's pathophysiology (51.0% vs 30.3%; P<.0001), appropriate evaluation performed locally (60.3% vs 39.0%; P<.0001), appropriate management performed locally (53.5% vs 24.1%; P<.0001), and confidence returning patient to referring health care professional (67.8% vs 41.4%; P<.0001). Referrals from physicians were also less likely to be evaluated as having been unnecessary (30.1% vs 56.2%; P<.0001).ConclusionThe quality of referrals to an academic medical center was higher for physicians than for NPs and PAs regarding the clarity of the referral question, understanding of pathophysiology, and adequate prereferral evaluation and documentation.     

A survey of primary care physicians' perceptions of their patients' use of complementary medicine

PURPOSE: To study the perceptions and attitudes of primary care physicians concerning their patients' use of complementary medicine. METHODS: A questionnaire was distributed to all 165 primary care physicians attending a routine continuing-medicine education program. Items included physicians' estimated rates of patient utilization of complementary medicine or herbal remedies and of patient reportage of such use; physicians' knowledge about side effects and interactions of herbal remedies; and frequency with which physicians questioned their patients on the use of complementary medicine and herbal remedies. RESULTS: The compliance rate was 90.0% (n=150). Sixty-eight percent of physicians estimated that up to 15% of their patients use complementary medicine; 58% always or often asked their patients about it; 50% estimated that 10% of patients report use of complementary medicine, and 60% estimated the same rate for herbal remedies; 51% believed that herbal remedies have no or only mild side effects; more than 70% claimed that they had little or no knowledge about what herbal remedies are; 24% never referred patients for complementary medicine, and 69% did so occasionally. Twenty-five percent had some training in complementary medicine, and 31% practiced some kind of complementary medicine. Most of the physicians believed that people turn to alternative methods when they are dissatisfied with conventional medicine. CONCLUSIONS: Physicians underestimate the rate of complementary medicine use by patients, suggesting that many patients do not report such use to their physician. Since alternative treatments are potentially harmful and may interact with conventional medications, physicians should be encouraged to communicate with patients about complementary medicine in general and herbal remedies in particular, and they should regularly include questions about their use when taking histories. They should also inform themselves about risks of alternative treatments particularly with herbal remedies, and have access to appropriate information systems.     

Association Between Do Not Resuscitate/Do Not Intubate Orders and Emergency Medicine Residents’ Decision Making

BackgroundResearch has shown that do not resuscitate (DNR) and do not intubate (DNI) orders may be construed by physicians to be more restrictive than intended by patients. Previous studies of physicians found that DNR/DNI orders are associated with being less willing to provide invasive care.ObjectivesThe purpose of this study was to assess the influence of code status on emergency residents’ decision-making regarding offering invasive procedures for those patients with DNR/DNI compared with their full code counterparts.MethodsWe conducted a nationwide survey of emergency medicine residents using an instrument of 4 clinical vignettes involving patients with serious illnesses. Two versions of the survey, survey A and survey B, alternated the DNR/DNI and full code status for the vignettes. Residency leaders were contacted in August 2018 to distribute the survey to their residents.ResultsThree hundred and three residents responded from across the country. The code status was strongly associated with decisions to intubate or perform CPR and influenced the willingness to offer other invasive procedures. DNR/DNI status was associated with less frequent willingness to place central venous catheters (88.2% for DNR/DNI vs. 97.2% for full code, p < 0.001), admit patients to the intensive care unit (89.9% vs. 99.0%, p < 0.001), offer dialysis (79.3% vs. 98.0%, p < 0.001), and surgical consultation (78.7% vs. 94.2%, p < 0.001).ConclusionsIn a nationwide survey, emergency medicine residents were less willing to provide invasive procedures for patients with DNR/DNI status, including the placement of central venous catheters, admission to the intensive care unit, and consultation for dialysis and surgery.     

Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System

Objective. Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop andimplement medical direction andquality assurance programs. We report subsequent changes to system performance over time. Methods. Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, andskills maintenance andeducation programs were implemented. Credentialing, physician chart auditing, clinical remediation, andonline medical command/hospital notification systems were introduced. Results. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- andpost-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20–0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9–9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004–1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices andsecuring devices (0.7% compliance to 98%, OR 714 [95% CI 64–29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09–1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35–1,604], p < 0.001). Conclusions. We suggest that implementation of a physician medical direction is associated with improved clinical indicators andoverall quality of care at an established EMS system     

Evaluation of the effect of carrot seed (Daucus Carota) in women of fertile age with hypoactive sexual desire disorder: A randomized double-blind clinical trial

BackgroundHypoactive Sexual Desire Disorder (HSDD) is a common sexual problem of women which has negative impacts on their health and quality of life. Given the side effects of pharmacologic interventions, it would be beneficial to patients trying to find new options based on herbal medicine.ObjectivesTo evaluate efficacy of carrot seed on sexual dysfunction of women with HSDD compared with placebo.MethodsIn this randomized double-blind clinical trial, 68 participants randomly assigned to the intervention group which took 500 mg carrot seed three times a day for 12 weeks versus placebo. Participants in two groups filled Female Sexual Function Index (FSFI) questionnaire at baseline, week six and 12. Repeated measure analysis of variance (ANOVA) test was used for statistical analysis.ResultsThirty women in carrot seed group and thirty women in placebo group completed 12 weeks of the study. In general, carrot seed compared to placebo improved the total score of FSFI 7.329 ± 0.830 (p < 0.001), desire 4.1±0.7 (p < 0.001), lubrication 4.7±0.4 (p = 0.019), arousal 4.1±0.08 (p < 0.001), satisfaction 4.8±1.1 (p < 0.001), orgasm 3.9±0.9 (p < 0.001) and pain 5.4±1(p < 0.001). No adverse event was reported in this study.ConclusionsWomen with HSDD may benefit from six weeks' treatment with carrot seed for improvement of sexual dysfunction. Further large clinical studies are warranted to confirm efficacy of this herbal drug.     

Five-year mortality in men and women with atrial fibrillation

Objective - Five-year mortality in men and women with atrial fibrillation (AF). Design - A follow-up of the medical records of patients with AF registered on September 30, 1993. Setting - One community health centre in Stockholm County. Subjects - 129 patients (76 men and 53 women). Main outcome measures - Observed and expected, age- and sexstandardised, 5-year mortality rates. Significant risk factors by multiple logistic regression. Results - Women had a higher mean age (77.5 vs 72.8 years) and more often suffered from heart failure and hypothyreosis. Five-year mortality rate for men was 30% vs expected 27% in Sweden and 24% in the community; for women it was 43% vs expected 29% (p &lt;; 0.05) and 23% in the community (p &lt;; 0.001), i.e. an excess mortality of 49% and 88%, respectively. Significant factors predicting death by logistic regression among women were: age (odds ratio 1.39, p &lt; 0.001), levothyroxine treatment (odds ratio 27.87, p &lt;; 0.05) and diabetes (odds ratio 20.75, p &lt;; 0.05). Conclusions - AF is related to an excess sex- and age-standardised, 5-year mortality in women but not in men, with levothyroxine treatment as one significant factor.