Effectiveness of community-based screening for depression.

OBJECTIVE: The effectiveness of a voluntary depression screening program was assessed by determining 1) whether participants in the 1994 National Depression Screening Day went for recommended follow-up examinations and 2) the characteristics that differentiated those who did and did not return. METHOD: Randomly selected participants (N = 1,169) from 99 facilities completed a follow-up telephone survey. RESULTS: Of 805 people for whom follow-up was recommended, 56.5% (N = 455) went for an appointment. The severity of depressive symptoms in these subjects ranged from severe (33.4%, N = 152) and marked (41.3%, N = 188) to minimal (17.1%, N = 78) and normal (8.1%, N = 37). Subjects with marked or severe depression were more likely to respond to the screening recommendation than were those with minimal depressive symptoms. However, at each level of symptom severity, subjects who had received previous treatment were more likely to adhere to the screening recommendation than were those with no previous treatment. Of those who returned for a recommended follow-up, 72.1% were diagnosed with depression. Of those who did not return, 29.5% cited lack of insurance, under insurance, or inadequate finances, and 38.0% felt they could "handle" depression on their own. CONCLUSIONS: Voluntary screening for depression is an effective way to bring certain untreated depressed individuals to treatment. Inadequate insurance and the belief that individuals can manage depression on their own continue to be barriers to seeking treatment among some depressed individuals who attend a depression screening program.

Treatment for depression following the 1996 National Depression Screening Day.

OBJECTIVE: Characteristics of the subsequent treatment received by people who screened positive for depression in the 1996 National Depression Screening Day were investigated. METHOD: A follow-up telephone survey was completed by 1,502 randomly selected participants from 2,800 sites. RESULTS: Of 927 people for whom additional evaluation was recommended, 602 (64.9%) obtained evaluations and 503 (83.6%) received treatment. Of these 503, 260 (51.7%) received psychotherapy and medication, 130 (25.8%) received medication only, and 93 (18.5%) received psychotherapy only. Compared with people without health or mental health insurance, individuals with health insurance (66.7% versus 57.5%) and mental health insurance (74.6% versus 55.3%) were more likely to comply with the recommendation to obtain follow-up evaluation. CONCLUSIONS: One-half of the people treated for depression received a combination of psychotherapy and medication. Lack of insurance was associated with not following the recommendation to obtain further evaluation and treatment.

Depression screening as an intervention against suicide.

Depression is a common psychiatric disorder that can disrupt a person's health, work, and relationships, and--in some cases--lead to suicide. Disparity between the prevalence of depression and diagnosis and treatment of the disorder led to the creation in 1991 of National Depression Screening Day (NDSD), an annual nationwide screening program for depression. By raising awareness and reducing the stigma of depression, the national screening program addresses the problems of underdiagnosis and lack of treatment in persons suffering from the depressive disorder. Mental health professionals and colleagues in other specialties must reach out to depressed individuals and make it easier for them to access the health care system. This article discusses the origin and goals of NDSD, the NDSD model for the current community-based program, the results of NDSD screening, and the proposed future expansion of NDSD and the voluntary screening concept.

Outcome of serious blunt cardiac injury.

BACKGROUND: Although serious blunt cardiac injury (BCI) is usually fatal, patients who reach the hospital alive can have a spectrum of abnormalities. We attempted to define the clinical features that helped identify serious BCI and to evaluate outcome. METHODS: Patients with serious BCI at a level I trauma center were identified during a 3-year period. RESULTS: Twelve patients had serious BCI. Six patients had cardiac arrest, and six had unexplained hypotension. Specific injuries included acute myocardial rupture (two patients); valvular disruption (two); myocardial contusion associated with either cardiac failure (two), complex ventricular arrhythmias (two), or delayed myocardial rupture (one), or present at autopsy (two); and coronary artery thrombosis (one). Seven of eight patients who did not have associated fatal injuries survived. Electrocardiography suggested cardiac injury in all nine patients in whom it was done, and echocardiography was useful to establish the diagnosis in four of five patients. Creatine phosphokinase isoenzyme levels did not distinguish serious injuries. CONCLUSIONS: The outcome of serious blunt cardiac injury can be favorable if patients have signs of life on arrival at the hospital, the signs of injury are recognized promptly, and other injuries do not supervene.

Polypropylene mesh closure after emergency laparotomy: morbidity and outcome.

BACKGROUND: Alternative methods for abdominal wall closure may be necessary after emergency laparotomy. The purpose of this study was to determine the morbidity and outcome of emergency fascial closure with polypropylene mesh. METHODS: A retrospective review was performed of all patients undergoing emergency fascial closure with polypropylene mesh from January 1990 to March 1994. RESULTS: Seventy patients were identified. Indications for mesh placement included visceral edema (40), infected/necrotic fascia (21), and planned reexploration (7). Enteric fistulas developed in five patients (7.1%). When omentum was interposed between intestine and mesh, the incidence of fistula was significantly reduced (0 of 51 vs 5 of 19, p < 0.01). Forty-two patients (60%) survived with wound closure, accomplished by skin flaps in 19 (45%), skin grafting in 11 (26%), and secondary healing in 6 (14%). The mesh was removed in six patients (14%). Complications of mesh extrusion and hernia occurred less often after skin flap closure compared with skin grafting or secondary healing (1 of 19 vs 9 of 17, p < 0.01). No mesh infection occurred. CONCLUSIONS: Polypropylene mesh placement is an effective alternative for abdominal closure after emergency laparotomy, even when intraabdominal sepsis is present. Fistulas associated with its use may be effectively eliminated by the interposition of omentum between bowel and mesh. Wound closure with full-thickness skin flaps is the preferred method for soft tissue coverage when mesh is used.

Antibiotic prophylaxis for injured patients.

Infection is the major cause of serious complication in injured patients. This article addresses antibiotic use in the injured patient and clarifies the limitations of antimicrobials in the prevention of infection.

Bedside insertion of inferior vena cava filters in the intensive care unit.

BACKGROUND: Several authors have showed that bedside insertion of inferior vena cava filters (IVCF) is feasible and cost effective, with the additional benefit of not having to transport a critically ill patient to the operating room or radiology department. The objective of this study was to examine our experience of 158 IVCF insertions at the bedside in the intensive care unit. STUDY DESIGN: A prospective, observational study of bedside IVCF insertion performed by the authors from February 1996 through August 2000 was undertaken. RESULTS: One hundred fifty-eight patients underwent bedside IVCF insertion in the intensive care unit. The mean age was 42.2 years (SD 17.5 years). The mean Injury Severity Score of the trauma patients was 27.3 (SD 14.5). The majority of patients (90%) had a prophylactic indication for IVCF insertion using our institutional guidelines for venous thromboembolic prophylaxis for trauma patients. All IVCF insertions were successfully performed at the bedside after iodinated contrast or carbon dioxide cavography. The mortality was 11% (n = 18), none attributable to the IVCF insertion or cavagram. There was one asymptomatic cava occlusion and one postinsertion pulmonary embolus in a patients with a subclavian vein thrombosis. CONCLUSIONS: Our results demonstrate the safety and efficacy of IVCF insertion at the bedside in the ICU. This method offers less resource use and more safety for critically ill patients, avoiding the hazards of intrahospital transport.

Safety and accuracy of bedside carbon dioxide cavography for insertion of inferior vena cava filters in the intensive care unit.

BACKGROUND: Bedside insertion of inferior vena caval filters (IVCFs) avoids risks associated with transporting these critically ill patients to the operating room or to the radiology suite. But because IVCF insertion requires preinsertion caval imaging, the risk of contrast-induced renal failure remains a concern. Carbon dioxide (CO2) as a contrast agent does not cause renal failure, but its accuracy in determining vena caval diameter (a critical factor in filter selection) and its safety in the critical care population are unknown. This study is designed to assess the safety of using CO2 as a contrast agent in this patient population and to evaluate its accuracy in determining the diameter of the inferior vena cava when used at the bedside. STUDY DESIGN: A prospective study comparing CO2 with iodinated contrast (IC) material was performed in critically ill patients undergoing vena cavography before bedside IVCF placement. CO2 cavagrams were performed with one or more hand injections of 60 mL of CO2; a single injection of 40 mL of IC material was used. Digital subtraction techniques were used for all of the studies. Blood pressure, pulse rate, and arterial oxygen saturation, end-tidal CO2, and intracranial pressure (when available) were recorded before, during, and after contrast injection. Statistical analysis was performed using the paired t-test, with p < 0.05 being considered significant. Data are expressed as mean +/- SD. RESULTS: Twenty-three patients were studied. Mean transverse inferior vena cava (IVC) diameters measured 20.4 +/- 0.7mm (IC) and 20.0 +/- 0.7mm (CO2); p = 0.003. The difference in the measurements was 0.4 +/- 0.1 mm, with the largest difference being 1.7mm. In the remaining 10 patients, CO2 differed from IC in determining IVC diameter by only 0.4mm, a statistically significant (p < 0.05) but clinically insignificant difference. No adverse effects on blood pressure, pulse, arterial oxygen saturation, end-tidal CO2, or intracranial pressure were noted with the use of CO2. CONCLUSIONS: Carbon dioxide as a contrast agent is safe and provides accurate determination of vena caval diameter and anatomy. Carbon dioxide should be considered the contrast agent of choice in critically ill patients.

Talisman or taboo: the controversy of the suicide-prevention contract.

The suicide-prevention contract is a widely used but overvalued clinical and risk-management technique. The scant information on this topic in the psychiatric and mental health literature is reviewed, along with the literature on collateral subjects including suicide prediction, medicolegal aspects of treating suicidal patients, the therapeutic alliance, and countertransference with suicidal patients. A group of 112 psychiatrists and psychologists was surveyed about their use of suicide-prevention contracts; the majority of them had never received any formal training on the topic. A combination of factors--the unpredictability of suicide, the many different antecedents to completed suicides, the complex psychological reactions of clinicians (including fear of litigation), the incongruity between clinical and legal usages of the contract concept, and the hazards that come of collapsing a complex treatment process into a few words--limit the applicability of suicide-prevention contracts. We reason that the use of these contracts is based upon subjective belief rather than on objective data or formal training. We recommend an alternative approach to suicide risk management rooted in the well-known and well-defined principles of informed consent.

Potential of laparoscopy to reduce non-therapeutic trauma laparotomies.

Standard diagnostic methods used to evaluate patients sustaining abdominal trauma result in non-therapeutic laparotomy rates ranging from 5 to 40 per cent depending upon the clinical situation. The purpose of this study was to assess the safety and efficacy of diagnostic laparoscopy in the identification of intra-abdominal injuries in stable trauma patients. Twenty-one hemodynamically stable adult patients underwent laparoscopy prior to laparotomy for blunt (n = 10) or penetrating (n = 11) trauma, and the findings from each procedure were directly compared. Laparoscopy was 100 per cent accurate in detecting the need for laparotomy, although a number of specific injuries were not identified. There were no complications related to the procedure. Emergency laparoscopy is safe and should be considered in hemodynamically stable trauma patients with indications for laparotomy based on standard diagnostic criteria in order to minimize the incidence of non-therapeutic laparotomy.

Idiopathic necrotizing fasciitis: recognition, incidence, and outcome of therapy.

Early recognition and treatment of necrotizing fasciitis (NF) is essential for survival. The diagnosis of primary or idiopathic NF may be particularly challenging because it occurs in the absence of a known causative factor or portal of entry for bacteria. Patients with NF treated between 1989 and 1993 were reviewed to determine the incidence, clinical features, bacteriology, and results of treatment in patients with idiopathic NF. Idiopathic NF occurred in nine (18%) of 51 patients, five men and four women, ranging in age from 21 to 67 years. Associated conditions included diabetes mellitus (4), alcoholism (3), remote infection (3), and pregnancy (2). NF affected the lower extremity in eight and the perineum in one patient. Pain and tenderness occurred in all patients, soft tissue gas was recognized in two, and the presence of erythema and edema was variable. Idiopathic NF was monomicrobial in seven (78%) patients, compared to 21 per cent of patients with secondary NF (P = 0.003). S. pyogenes was the causative organism in five of seven monomicrobial infections. Time from admission to operation was significantly longer (62.3 +/- 54.8 hours) in patients with idiopathic NF compared to patients with secondary NF (17.0 +/- 16.6 hours) (P = 0.001). Treatment included operative debridement (means = 3.3) and limb amputation (n = 1) to control infection. Three patients (33%) with idiopathic NF died. Primary or idiopathic NF is principally a monomicrobial infection usually caused by S. pyogenes that most commonly occurs in the extremities. Mortality is high but is comparable to secondary NF. It is important to recognize that NF may occur spontaneously, and it should be suspected in patients with unexplained soft tissue pain and tenderness.

Transcranial gunshot wounds: cost and consequences.

Poor outcomes following transcranial gunshot wounds (TC-GSW) and the perception of significant financial loss have led some institutions to adopt a fatalistic attitude towards these patients. This study was undertaken to define those factors predictive of mortality following TC-GSW as well as to determine the costs and benefits associated with providing care to these individuals. We reviewed the medical records of 57 TC-GSW patients seen at our Level I Trauma Center between January 1990 and December 1992. Overall mortality was 75 percent, and was statistically associated with an admission Glasgow Coma Score of 4 or less, a respiratory rate of less than 10, and self-inflicted wounds. Complete financial information was available for 37 of the 57 patients. Reimbursements for this group were $306,156 and exceeded costs by $62,257. Organ donation efforts were successful in 44.2 per cent of the nonsurvivors (19/43), yielding 60 organs and 29 tissues for transplantation. Nonsurvivors who became organ donors were clinically and demographically indistinguishable from those in whom organs/tissues could not be retrieved. Despite the poor outcome following TC-GSW, vigorous resuscitation and stabilization is justified in all patients, in that nearly one half of nonsurvivors will become organ and/or tissue donors. Concerns regarding excessive monetary looses by treating facilities are unfounded.

Growth and development in patients operated on for islet cell dysplasia.

Neonatal hypoglycemia caused by islet cell dysplasia (ICD), sometimes called nesidioblastosis, may lead to psychomotor retardation and neurologic dysfunction in up to 50% of patients who are not given early aggressive treatment. In 1979, we adopted a more aggressive protocol for treating this condition that consists of the following steps: immediate insertion of a silastic central venous line for reliable venous access; continuous intravenous infusion of glucose and glucagon to maintain euglycemia; oral diazoxide; and near total pancreatectomy if the first steps fail to overcome the hypoglycemia or the patient cannot be weaned off intravenous therapy. Twelve consecutive patients who underwent pancreatectomy for control of hypoglycemia between 1979 and 1984 were recalled and evaluated for growth delay, neurologic dysfunction, and psychomotor retardation using the Revised Yale Developmental Schedules, the Peabody Picture Vocabulary, and the Draw a Man Test. Follow-up ages ranged from 1.2 to 6.0 years with a median of 3.6 years. No significant growth abnormalities were identified. No patient exhibited focal neurologic dysfunction, although some demonstrated soft neurologic signs, which did not appear to be related to their earlier hypoglycemia. Psychomotor function for the group as a whole was normal, with a mean developmental quotient (DQ) of 99.2. The DQ was average for five patients and above average for four; no patient had a DQ in the frankly subnormal range. Psychomotor development correlated better with the family's socioeconomic and educational status than with the neonatal hypoglycemia. These children are developmentally and neurologically normal despite severe neonatal hypoglycemia. Continued follow-up will be necessary to detect any late sequelae.(ABSTRACT TRUNCATED AT 250 WORDS)

Injury severity, whole body protein turnover, and energy expenditure in pediatric trauma.

The purpose of this study was to quantify the changes in energy expenditure and protein turnover imposed by blunt trauma in children and to correlate them with the Injury Severity Score (ISS). We studied 19 children (mean age 10 +/- 1 year, mean ISS 20 +/- 2). Basal metabolic rate (BMR) was measured in the postabsorptive state by open-circuit indirect calorimetry. Whole body protein turnover (Q) and synthesis (S) were determined by the 15N enrichment of urinary ammonia in a 12-hour collection following a single dose of 15N glycine. Twelve-hour total urinary nitrogen excretion (E) was also determined. Because nitrogen intake was 0 during the study period, Q was equivalent to protein breakdown (B). Eleven patients were restudied at 3- to 5-day intervals during hospitalization and eight were restudied after discharge (mean 34 +/- 6 days post injury). There was a significant increase in BMR, Q, S, and E following injury, when compared with post injury baseline values. However, while BMR increased by 14%, there were 93% and 82% increases in Q (B) and S, respectively. Negative nitrogen balance resulted from the fact that protein breakdown increased more than protein synthesis. The initial increase in BMR varied directly with the severity of injury, as reflected in the ISS (r = 0.56, P less than .02). There was no significant correlation between ISS and any of the parameters of protein metabolism. These results suggest that the metabolic response of pediatric patients to multiple trauma may differ from that of adults. In addition, they imply that the ISS may not be a reliable indicator of the severity of tissue injury.

Antibiotic prophylaxis for intracranial pressure monitors.

To determined the safety and efficacy of prophylactic antibiotics in head-injured patients requiring intracranial pressure monitors, the files of 30 consecutive patients with isolated, severe head injuries admitted over a 1-year period were reviewed. Patients .15 years with severe closed-head injury who did not have severe concomitant, extracranial injury (Abbreviated Injury Score, 3) and survived .48 hours following hospital admission were included. Fourteen patients underwent intracranial pressure monitor placement and received prophylactic antibiotics for the duration of monitoring and the remaining 16 patients were neither monitored nor given prophylactic antibiotics. Length of hospital stay, length of intensive care stay, overall and septic complication rate, and death rate were compared for the two treatment groups. The groups were similar with regard to patient characteristics, associated injuries, and injury severity. Patients who received prophylactic antibiotics demonstrated statistically higher septic morbidity rates (78.6% versus 31.3%) and statistically higher pneumonia rates (57.1% versus 18.8%) compared with patients who did not. No patient developed central nervous system infection related to the monitor itself. These results indicate that the administration of prophylactic antibiotics to head-injured patients for the duration of intracranial pressure monitoring is unnecessary and potentially detrimental. Antibiotics, if given at all, should be limited to the period immediately surrounding intracranial pressure monitor placement.