Post-traumatic stress disorder in a patient with an implant cardioverter-defibrillator

The authors describe a patient using cardioverter-defibrillator implant therapy (CDIT) after a blood pressure elevation and arrhythmia episode. The CDIT delivered 9 defibrillating discharges in a 24 hour period until a new stabilization was achieved. The patient developed a post-traumatic stress disorder with no improvement with the use of 15 mg of diazepam b.i.d. He was referred to a psychiatrist 4 months later, received Sertraline 100 mg b.i.d., and supportive therapy and achieved a total remission in 6 weeks. This case report illustrates the psychiatric comorbidity in the &#164 survivor' population, a group of patients who survive due to advances in medical technology. The psychiatric study of them is a challenge to the improvement of their quality of life. Assessment and treatment of mental disorder may improve the quality of life for this patient group.     

Practical Operationalizations of Risk Factors for Fracture in Older Women: Results From Two Longitudinal Studies

Several guidelines on osteoporosis have proposed algorithms to identify persons at high risk of fractures. Although these algorithms include well‐known risk factors, it is not clear how they can best be operationalized for use in general practice. The aim of this study was to compare the predictive performance of different operationalizations of four categories of risk factors for fractures that can be used in general practice. This study included 4157 women of ≥60 yr of age (mean ± SD: 74.1 ± 9.1 yr) with a median follow‐up of 8.9 yr of the Rotterdam Study and 762 women of ≥65 yr of age (mean ± SD: 76.0 ± 6.7.yr) with a median follow‐up of 6.0 yr of the Longitudinal Aging Study Amsterdam (LASA). At baseline, information on four categories of risk factors was obtained, including (1) family history of hip fractures, (2) type of prior fractures, (3) low body weight/body mass index (BMI), and (4) mobility impairment. The occurrence of fragility fractures, including hip, pelvic, humerus, and wrist fractures, was used as outcome measure. We quantified the predictive performance of each risk factor by a χ² statistic, calculated as the difference in –2 Log likelihood attributable to the risk factor, with adjustment for age and other risk factors. In the Rotterdam Study, 399 fragility fractures occurred during 31,472 person‐years (PY) of follow‐up. In this study, any prior fracture in the past 5 yr (χ² = 6; p = 0.02), body weight < 64 kg (versus ≥64 kg; χ² = 6.7; p = 0.01), BMI < 22 kg/m² (versus ≥22 kg/m²; χ² = 8.7; p = 0.003), and use of a walking aid (χ² = 7.5; p = 0.004) were the most practical operationalizations of the risk factor categories, after adjustment for age and other risk factors. In LASA, 52 fragility fractures occurred during 3935 PY of follow‐up. Associations were similar as in the Rotterdam Study, except that low body weight and BMI were not associated with fragility fracture. None of the usual operationalizations of family history of hip fractures was independently associated with fragility fracture in either study. Prior osteoporotic fracture, body weight <64 kg, a BMI <22 kg/m², and the use of a walking aid are practical operationalizations of risk factors for fragility fractures. On the basis of the results of this study, a simple, practical algorithm can be developed for use in general practice.     

Skin problems in lower limb amputees: an overview by case reports

The stump in lower limb amputees is prone to skin problems because it is exposed to several unnatural conditions (shear and stress forces and increased humidity) when a prosthesis is used. This study reviews the literature on case reports of lower limb amputees with skin problems on the stump. In total, 56 reports comprising 76 cases were identified in the literature. The main disorders are acroangiodermatitis, allergic contact dermatitis, bullous diseases, epidermal hyperplasia, hyperhidrosis, infections, malignancies and ulcerations.     

Cardiopulmonary resuscitation techniques and instruction: when does evidence justify revision?

[Cummins RO, Hazinski MF: Cardiopulmonary resuscitation techniques and instruction: When does evidence justify revision? Ann Emerg Med December 1999;34:780-784.]     

One-stage Fowler-Stephens orchidopexy for impalpable undescended testis

Background The Fowler-Stephens orchidopexy (FSO) is a well-described treatment for high maldescended testes where the limiting factor for successful placement in the scrotum is short testicular vessels. The operation involves division of these vessels. The testicular blood supply is then dependent on collaterals from the vasal artery. Aims To assess the long-term outcome of patients who underwent this procedure in our institution. Methods The medical records of 20 patients who underwent 22 FSO from 1978 to 1999 by one urologist (HB) were reviewed. Outcome was assessed in terms of testicular position and size. Results Age at operation ranged from 2 to 14 years (mean 5.8 years). All patients had a one-stage FSO and in two of them the procedure was bilateral. In five patients, FSO was preceded by a diagnostic laparoscopy. Mean follow up was 22 months (range 0–121 months). Overall, results were considered good in 18 of 22 testes (82%). Conclusion Our results for the one-stage FSO are comparable with other procedures for the management of high maldescended testis.     

Patient satisfaction with doctor–patient interaction in a radiotherapy centre during the severe acute respiratory syndrome outbreak

An outpatient radiotherapy department assessed how precautions implemented during the severe acute respiratory syndrome (SARS) outbreak affected patient satisfaction with doctor–patient interaction and explored variables potentially influencing satisfaction. The information obtained would help prepare us for future infectious disease outbreaks. Outpatients seen during the outbreak completed a validated questionnaire assessing satisfaction with doctor–patient interaction. Additional items assessed included patients’ perception of SARS measures and patient demographics. Of 149 patients, 97% had heard of SARS, 92% believed SARS precautions necessary, and 54% believed contracting SARS was possible despite the precautions. Patients were satisfied with doctors wearing masks (97%), temperature checks (97%), and patients wearing masks (96%). Despite the high satisfaction levels with SARS precautions, 24% believed it had adversely affected doctor–patient interaction. With regards to doctor–patient interaction, 94% of patients were satisfied. Patients were most satisfied with the ‘information exchange’ domain (mean score 3.23 out of 4) compared to other domains (P < 0.0001, 100.00% confidence) and were less satisfied with the ‘empathy’ domain compared to other domains (P < 0.0001, 100.00% confidence). Patients were most satisfied with understanding their treatment plan (100%), doctor being honest (97%) and being understood (96%). Patients were least satisfied with information about caring for their illness (61%), that the visit could be better (59%), and the doctor showing more interest (58%). On multivariate analysis, patients who were less satisfied with SARS measures were significantly less satisfied with doctor–patient interaction (P = 0.0001). Dissatisfaction with SARS measures was associated with significant dissatisfaction for questions in all domains. Older age and non‐breast cancer patients were also less satisfied with doctor–patient interaction. Most (94%) of patients were satisfied with doctor–patient interaction, despite implementation of infectious disease prevention measures. However, patients who were dissatisfied with the SARS precautions had poorer satisfaction. In particular, physician empathy appeared to be most adversely affected. The results have relevance to any radiotherapy department preparing contingency plans in the event of infectious disease outbreaks.     

Annual summary of vital statistics--1996

Several recent trends in the vital statistics of the United States continued in 1996, including an increase in life expectancy and declines in infant mortality, births to teenage mothers, age-adjusted death rates, and death rates for children and adolescents. In 1996, there were an estimated 3 914 953 births in the United States. The preliminary birth rate remained unchanged at 14.8 births per 1000 population, and the fertility rate, births per 1000 women 15 to 44 years of age, was essentially the same at 65.7. Fertility rates rose slightly for most racial and ethnic groups except black women, for whom the rate hit a historic low of 70.8. Overall, fertility remains particularly high for Hispanic women, although there is considerable variation within this heterogenous group. For the fifth consecutive year, birth rates dropped for teenagers. Birth rates for women >/=30 years of age continued to increase. The birth rate for unmarried women declined 1% in 1996 to 44.6 births per 1000 unmarried women, continuing the decline noted in 1995 for the first time in 2 decades. The percentage of women who began prenatal care in the first trimester rose in 1996 to 81.8%, whereas the percentage with late (third trimester) or no care dropped to 4.1%. The rise in timely prenatal care was greatest for black and Hispanic women. The percentage of low birth weight (LBW) infants reached 7.4% in 1996, its highest level since 1975. The very low birth weight rate remained unchanged at 1.4%. The rise in LBW occurred primarily among white women, whereas the LBW rate for black women dropped to 13.0%, the lowest rate reported since 1987. The rise among white women is only partially a result of increases in multiple births, because LBW rates have also risen among white singleton births. The multiple birth ratio rose again in 1996 by 2%, as it has since 1980. The rise was particularly large for higher-order multiple births. Infant mortality reached an all time low level of 7.2 deaths per 1000 births, based on preliminary 1996 data. Neonatal and postneonatal rates declined, as did rates for both black and white infants. National birth weight specific mortality rates are reported here for the first time. In 1995, 63% of infant deaths occurred to the 7.3% of the population that was born LBW. The four leading cause of infant death were congenital anomalies, disorders relating to short gestation and unspecified birth weight, sudden infant death syndrome, and respiratory distress syndrome, accounting for more than half of infant deaths in 1996. Despite the declines in infant mortality, the United States continues to rank poorly in international comparisons of infant mortality. Expectation of life at birth reached a new high in 1996 of 76.1 years for all gender and race groups combined. Age-adjusted mortality rates declined in 1996 for diseases of the heart, malignant neoplasms, cerebrovascular diseases, accidents and adverse effects, chronic liver disease and cirrhosis, and suicide. They rose, as in the past several years, for chronic obstructive pulmonary diseases, diabetes mellitus, and pneumonia and influenza. For the first time since human immunodeficiency virus infection was created as a special cause-of-death category in 1987, death rates for human immunodeficiency virus infection declined from 15.6 in 1995 to 11.6 in 1996. The homicide rate also declined, as it has since 1991. Death rates for children between 1 and 19 years of age declined in 1996, with an estimated 29 183 deaths to children. Unintentional injury mortality has dropped by approximately 50% among children and adolescents since 1979, although it remains the leading cause of death for all age groups of children from 1 to 19 years. Homicide was the fourth leading cause of death for children 1 to 4 and 5 to 9 years of age, the third leading cause for children 10 to 14, and the second leading cause for 15 to 19 year olds.