Psychosocial difficulties and emergency department use.

OBJECTIVE: To determine whether psychosocial difficulties are more prevalent among ambulatory patients using the ED for nonemergent complaints as compared with ambulatory patients having emergent complaints. METHODS: A survey of noncritical ED patients was performed using anonymous questionnaires addressing psychosocial difficulties: psychiatric illness, educational level, homelessness, alcohol and/or drug dependency (CAGE and DAST surveys), and depression (DSM-III criteria). Three independent physicians ranked each patient's chief complaint as either emergent or appropriate for primary care. The majority ranking was used to determine whether the complaint was emergent. Groups with and without specific psychosocial difficulties were compared for their proportion of emergent vs primary care complaints. RESULTS: Of 700 patients, 367 (52%) met criteria for > or = 1 psychosocial difficulty [acute psychosis-36 (5%), illiteracy-139 (20%), homelessness-45 (6%), alcohol dependency-111 (16%), drug dependency-66 (9%), and depression-130 (19%)]. There were 379 (54%) ED visits considered emergent. Patient groups with vs without > or = 1 psychosocial difficulty had similar rates of emergent visits (58% vs 50%, p = 0.04). Emergent visit rates also were similar for subgroups with vs without specific psychosocial difficulties: psychosis (56% vs 54%, p = 1.00) illiteracy (58% vs 53%, p = 0.89), homelessness (62% vs 54%, p = 0.33), alcohol dependency (62% vs 53%, p = 0.08), drug dependency (59% vs 54%, p = 0.47), or depression (58% vs 53%, p = 0.42). CONCLUSION: Psychosocial difficulties are common among ED patients; however, emergent complaints are just as common in these patients as they are in those without psychosocial difficulties.

Sentenced in sorrow: the role of asylum in the Jean Gianini murder defence.

This paper describes the role played by the notion of asylum in the legal battle over confessed murderer Jean Gianini's mental competence and commitment. Gianini was a 16 year old who murdered his former teacher in a small upstate New York town in 1914. His trial was the first in the US to employ the Binet-Simon intelligence test as a defence and featured a clash of expert witnesses whose credibility was based upon their residence and work in asylums. The verdict of 'not guilty due to criminal imbecility' was due to the defence team's successful portrayal of the asylum as a punishing prison from which the defendant would never be released.

Stroke associated with cardiac surgery. Determinants, timing, and stroke subtypes.

OBJECTIVE: To determine the nature of strokes complicating cardiac surgery. DESIGN: A medical record review was undertaken of all patients who underwent cardiac surgery (either coronary bypass, valvular surgery, or both) between January 1990 and July 1995. Univariate and multivariate analyses were done using odds ratios (ORs) and logistic regression. RESULTS: A total of 2211 patients underwent cardiac surgery. A total of 44 patients (2%) had postoperative strokes. They were compared with 104 surgical controls. Univariate analysis revealed that the patients with stroke were significantly older and had significantly higher rates of transient ischemic attack, congestive heart failure, and peripheral vascular disease by history. A multivariate logistic regression revealed the significant variables associated with stroke were congestive heart failure (OR, 6.8) and transient ischemic attack (OR, 1.2). Analyses of surgical variables revealed that bypass pump time of more than 120 minutes (OR, 1.40) was the only significant predictor. The majority of strokes (61%) had occurred by postoperative day 2, but 39% occurred between postoperative days 3 to 9. Hemispheric syndromes occurred in 70%, brain stem and cerebellar syndromes in 14%, and lacunar syndromes in 16%. Computed tomographic scans revealed that 29 patients had new infarcts, of which 20 (69%) were territorial, 5 (17%) were small deep, and 4 (14%) were border zone. Hemorrhagic infarction was found in 2 cases (5%). One patient (2.5%) had a cardiorespiratory arrest while undergoing computed tomography. Discharge disposition was good in 88% of patients with stroke (12% with poor outcomes) vs 97% of controls with good outcomes (3% with poor outcomes) (P = .04). CONCLUSIONS: Strokes may be delayed following cardiac surgery perhaps because of ongoing risk of embolism or a hypercoagulable state. A surprisingly high proportion of patients have lacunar syndromes or small-deep infarcts shown on computed tomography. Early computed tomographic imaging may be useful to exclude hemorrhage if anticoagulation is considered, but is not without risk in these potentially unstable patients. Greater understanding of risk factors for stroke, timing, and subtypes may ultimately allow identification of patients at particularly high risk for perioperative stroke.

The problem of typological thinking in mental retardation.

Despite the acceptance of evolutionary theory in the biological and social sciences, typological thinking--the belief that individual differences diverge around an underlying type or essence--has persisted. The most egregious example is J. H. Langdon Down's "ethnological classification of idiocy," taken seriously in the field for almost 80 years after its origin in 1866. Past and present controversies over the definition of mental retardation have turned on an unacknowledged typological axis. Some contemporary research on Down syndrome indicates that the allure of typology is still an obstacle to the appreciation of individual differences and human dignity in the field of mental retardation.

The beast in man: degenerationism and mental retardation, 1900-1920.

It is widely believed that the eugenics movements was largely responsible for the turn of the century perception that individuals with mental retardation were a social menace. However, that explanation fails to account for the vast corpus of 19th century degeneration theory, which, in the Progressive era, became the lens through which mental retardation was viewed. In this paper I have described the chain of theological and scientific reasoning that led to the linkage of mental retardation with the evolutionary "mark of the beast," a development that not only helped fuel the notorious myth of the "menace of the feeble-minded" but also cast a long shadow into this century.

Ibuprofen and acetaminophen in the relief of acute pain: a randomized, double-blind, placebo-controlled study.

To determine the relative analgesic efficacy of ibuprofen 400 mg and acetaminophen 1000 mg, we conducted a single-dose, double-blind, placebo-controlled, randomized clinical trial using a standard assay for analgesic agents, the dental pain model. At regular intervals over 6 hours, 184 patients who had undergone dental impaction surgery rated pain intensity and relief on categorical scales and pain half-gone on a dichotomous nominal scale; a categorical overall evaluation was completed at the end of 6 hours. Both active agents were effective compared to placebo. Ibuprofen 400 mg was more effective than acetaminophen 1000 mg for Sum Pain Intensity Difference (SPID), Total Pain Relief (TOTPAR), sum pain half-gone, and overall evaluation (P less than .05 to P less than .001). The time-effect curves demonstrated a greater peak effect and longer duration of action for ibuprofen 400 mg compared to acetaminophen 1000 mg. Side effects were reported in five ibuprofen patients, 11 acetaminophen-treated patients, and seven placebo patients. Based on the results of this clinical study, we conclude that ibuprofen 400 mg is a safe and more effective analgesic than acetaminophen 1000 mg for patients with acute pain.

Spirometric abnormalities among asbestos insulation workers.

We studied the prevalence of spirometric changes among asbestos insulation workers to investigate when functional abnormalities appear during the course of asbestos employment and the influence of cigarette smoking. Of 1,249 eligible asbestos insulation workers in the New York-New Jersey metropolitan area, 1,117 (89.4%) were examined in the year 1963 to provide baseline pulmonary function status for long-term prospective observation. Forced vital capacity (FVC) was measured in all 1,117 workers and forced expiratory volume in 1 second (FEV1) in 613 workers (55%). Of 353 workers examined in the first 10 years after onset of exposure, 26 (7.4%) had FVC below 70% of predicted, a prevalence similar to that reported in nonexposed general populations. Prevalence increased with time from onset of exposure. Of the 117 workers examined 40 or more years after onset of exposure, 76 (55%) had FVC below 70% of predicted. A similar trend with time was shown for FEV1 and FEV1/FVC. Cigarette smoking had little influence on the prevalence of pure restrictive impairment. Cigarette smokers and non-cigarette smokers had much the same prevalence (28%) of moderate to severe reduction of FVC while the FEV1/FVC was normal. None of the non-cigarette smokers and five of the cigarette smokers had a predominantly obstructive pattern. One non-cigarette smoker and eight cigarette smokers showed reduction of both FVC and FEV1/FVC, consistent with a mixed ventilatory abnormality. The data demonstrate that asbestos alone without the additional effect of cigarette smoking has no measureable effect on the function of the large airways.

Survival experience in the Breast Cancer Detection Demonstration Project.

Very high survival rates have been observed in four through 11 years of follow-up in 4,240 women with a histologically confirmed diagnosis of breast cancer in the Breast Cancer Detection Demonstration Project (BCDDP). The relative five, eight, and 10-year survival rates were 88, 83, and 79 percent, respectively. Allowances were made for lead-time bias among cancers detected through screening, and the validity of the findings was supported by internal analyses, which showed that length-time bias was of little, if any, importance, and that any possible "overdiagnosis" of cancer cases was also of small relevance. In view of current interest in the value of screening women before age 50, intensive analyses were made comparing the BCDDP data for women in their 40s with women in their 50s. In terms of kinds of breast cancers found, modality of finding them, and survival rates once they have been found, the parallel results for the two groups show that screening was virtually as effective in the younger as in the older women. Some authorities are of the opinion that the benefits of mammography after age 50 are well documented, but at younger ages the evidence is still inconclusive. The findings in this study show there is no doubt of the very successful results of screening for breast cancer with mammography in younger as well as older women. In comparing relative five-year and eight-year survival rates for women with invasive breast cancers detected through screening in the BCDDP, with those for cases diagnosed in the National Cancer Institute's Surveillance, Epidemiology and End Results (NCI SEER) program from 1977 to 1982, it is seen that for individual subcategories by tumor size and nodal class, the survival rates are about the same. However, for overall invasive cancers, the five-year and eight-year survival rates were 87 and 81 percent, respectively, for the BCDDP compared with 74 and 65 percent for SEER. Thus the substantial gains in survival followed the large shift toward a high proportion of cancers being diagnosed and treated in more favorable stages through the screening accomplishments. With respect to the relative case fatality rates, the complements of the relative survival rates, the eight-year rate of 19 percent for the BCDDP versus that of 35 percent for SEER connotes 46 percent fewer women dying in the BCDDP group.

Mortality experience of amosite asbestos factory workers: dose-response relationships 5 to 40 years after onset of short-term work exposure.

A cohort of 820 men in a Paterson, New Jersey, amosite asbestos factory which began work during 1941-1945 was observed from 5 to 40 years after start of work. Most of the cohort had limited duration of work experience (days, weeks, months), though some men worked for several years until the factory closed in 1954. With white males of New Jersey as the control population, Standardized Mortality Ratios (SMRs) of 500 are evident for the cohort for lung cancer and for noninfectious pulmonary diseases (including asbestosis), while being almost 300 for total cancer and about 170 for all causes of death. A statistically significant SMR of almost 200 is seen for colon-rectum cancer. Mesothelioma incidence initially shows a strong relationship with advancing time since onset of exposure and then tails off. The main concern of the study is with dose-response patterns. Response is measured by the mortality for relevant causes of death, while the direct asbestos dosage was measured in two ways. One way was the length of time worked in the factory and the other was the individual's accumulated fiber exposure, calculated by multiplying the aforementioned length of time worked by the estimated fiber exposures associated with the particular job that the worker had in the factory. Whichever measure of dosage is used, it was found that, in general, the lower the dose, the longer it took for adverse mortality to become evident and, also, the smaller the magnitude of that adverse mortality.

Clinical findings among asbestos workers in U.S.: influence of cigarette smoking.

All members of a large union were invited to participate in a study of potentially adverse effects of asbestos exposure. Clinical findings among 1,117 workers (90% of those eligible for examination) are presented in this study. Cough was much less common among those without a history of cigarette smoking, although duration from onset of employment did not appreciably affect the prevalence of cough among the smokers. Rhonchi present among nonsmokers were limited in extent, but were marked and diffuse among cigarette smokers. Although dyspnea was as prevalent among nonsmokers as in smokers forty years and more after onset of exposure, it was relatively uncommon and found only among smokers when examined shortly after onset of exposure. Cigarette smoking had less influence on the prevalence of râles among asbestos workers; both smokers and nonsmokers showed this finding when examined 30 years and more after onset of asbestos exposure. Analysis of powerhouse work experience and mask use as possible confounders indicated no difference in prevalence of these characteristics between the smokers and nonsmokers.

Asbestosis: interstitial pulmonary fibrosis and pleural fibrosis in a cohort of asbestos insulation workers: influence of cigarette smoking.

A cohort of 1,117 asbestos insulation workers was established in 1963 and has been prospectively followed since then. Chest X-ray abnormalities detected at the initial medical examination, and interpreted according to the International Labour Office Classification of Radiographs of Pneumoconioses are reported in this paper. The prevalence of all radiographic abnormalities (pleural and pulmonary) increased with duration from onset of asbestos exposure. A positive smoking history was associated with a significantly higher prevalence of small irregular opacities indicating interstitial pulmonary fibrosis. Such an association was not found for pleural fibrosis. The possible mechanisms which underlie the effect of smoking on asbestos-induced interstitial fibrosis seem to be of much less importance in the development of pleural fibrosis. Progression of radiographic changes over the 20-year interval 1963-1983 will be separately reported as will the predictive significance of these changes.

Probabilities of eventually developing or dying of cancer--United States, 1985.

The usual measures of the magnitude of the cancer problem are annual incidence and mortality data. We present another measure of the magnitude of the cancer problem. We computed the probabilities at birth and at various ages of developing or dying of the disease within 10 years, 20 years, or total lifetime and show the trends that have occurred in these data since 1975. These probabilities were computed for males and females and among whites and blacks for 1975 and 1980, and projected to 1985. The data indicate a continuing, albeit modest, increase in the probabilities of eventually developing cancer in each of the four sex-race groups, both excluding and including carcinoma in situ. White males now show the highest probability at birth of eventually developing cancer, and black females, the lowest, with the figures for the other two groups being intermediate. Larger increases were seen for males between 1980 and 1985 (more than three percent) than for females (two percent or less). A child born in the US in 1985 has more than one in three chances of eventually developing invasive cancer (exclusive of epidermoid skin cancer). By site, for males the largest probabilities and the largest increases in the probabilities are for eventually developing lung and prostate cancer. For women, the largest eventual probabilities are for breast cancer, almost one in 10 for white females and one in 14 for black females. The largest increases are seen for lung cancer and cancer of the colon-rectum. The probability of eventually dying of cancer is increasing among the four sex-race groups and is now greater for males of both races than for their female counterparts. For males born in 1985, the chances of eventual death from cancer are almost one in four, and for females, almost one in five. With the long-term, downward trends in terms of other causes of death--most specifically, decreases in mortality from cardiovascular diseases--the effect on the population at large is greater longevity. This situation, in turn, leaves more people longer time to be exposed to cancer risks. Thus, while the probabilities of developing or dying of cancer are seen to increase, the increases should be viewed in light of the increasing numbers of people available for such an occurrence.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparative efficacy of fenoprofen calcium and zomepirac sodium in postsurgical dental pain.

The relative analgesic efficacy of zomepirac sodium 100 mg and fenoprofen calcium 200 mg was evaluated in patients with pain due to surgical removal of dental impactions. This is the first study to make a direct comparison of their effectiveness. This study is especially important since zomepirac sodium was recently removed from the market as an analgesic for acute pain. Zomepirac sodium was extremely popular among clinicians and was considered the most effective of the peripherally acting analgesics. Patients were requested to take a single dose of study medication when they had moderate to severe pain. The study medications were identical in appearance and randomly allocated under double-blind conditions. The medication was evaluated over the next 4 hours according to subjective analgesic measurement scales. The primary measures of efficacy included total pain relief ( TOTPAR ), sum pain intensity difference ( SPID ), overall evaluation, and time to remedication . Of the 136 patients entered, 117 were included in the efficacy analysis. Both active agents demonstrated marked superiority to placebo (p less than 0.001) for all efficacy measures but were inseparable from each other. The mean analgesic efficacy values for both zomepirac sodium and fenoprofen calcium were almost identical. The nineteen subjects who reported side effects were evenly distributed among the three groups. No serious side effects occurred. The results of this study indicate that fenoprofen calcium 200 mg and zomepirac sodium 100 mg are equally efficacious, with similar onset, peak, and total analgesic effects.