Disrupting the Adverse Interplay Between Psychiatric and Medical Illnesses.

Psychiatric illnesses increase the morbidity and mortality of comorbid medical disease, and current research targets the identification of specific mechanisms that account for this association. Psychotic illness complicates the management of chronic diseases where self-care activities often play a major role, such as in the regulation of blood glucose levels in diabetes. In this issue, Wykes et al. describe an interactive relationship between cognitive functioning and negative symptoms, self-efficacy, and diabetic control in patients with psychotic illnesses and Type 1 diabetes. Although high self-efficacy was associated with better hemoglobin A1C levels in patients with mild negative symptoms and higher cognitive function, in patients with more severe negative symptoms and lower cognitive function, high-self-efficacy was linked to higher A1C levels. These findings point to the need for designing diabetes management plans based on careful assessments of specific psychiatric symptomatology in this population. Severe mental illness is also associated with poor general physical health and higher rates of somatic complaints. Madan and colleagues describe in this issue an integrated model of psychiatric and medical care that substantially reduced physical symptoms in patients with severe mental illness during an 8-week hospitalization, with striking improvements in those presenting with substance abuse and sleep disorders. If these findings are shown to persist after discharge, then accountable care organizations should be encouraged to incorporate this more aggressive approach to caring for this vulnerable population. Such targeted approaches are likely to result in decreased utilization of outpatient medical services and improved long-term outcomes.

Rural Surgery--A Crisis in Wisconsin.

Recruitment of general surgeons to practice in rural environments is challenging. We believe that innovative training programs focusing on the specific needs and experiences of rural surgical practice can play an important role in addressing this clinical workforce issue. For practical reasons, our program will start out small, but if 50 centers around the nation were to establish a similar rural track, we could see a substantial collective impact over time. We hope our new program will serve as a model for the development of other university-based residency training programs with similar opportunities. We are grateful to have received state funding to support the development and early implementation of this program (see Table). We commend the state for understanding the importance of primary care surgery, and we look forward to measuring and reporting the impact of our rural training program on rural surgical care in Wisconsin.

Intermediate-term outcomes for floating elbow and floating elbow variant injuries.

BACKGROUND: There are limited outcome studies describing floating elbow injuries. The purpose of this report is to describe patient outcomes after floating elbow injury using the American Shoulder and Elbow Surgeons (ASES) elbow assessment form. MATERIALS AND METHODS: From 1994 to 2004, 19 patients were retrospectively identified at 3 Level I trauma centers and returned for follow-up evaluation after treatment of their floating elbow injury. Patient outcomes were assessed based on physical examination and the ASES elbow form. RESULTS: The 19 patients were evaluated at a mean of 6.7 years (range, 2.3-13.4 years) after treatment of their floating elbow injuries. The mean ASES elbow score was 89 (range, 13-99), and the mean visual analog scale satisfaction with elbow surgery was 8.7 (range, 7-10). Fifteen of 19 patients reported continued pain in the elbow. Patient age, arm dominance, type of humeral fixation, type of forearm fixation, open fracture, multiple surgeries, and fracture pattern were not significantly associated with outcomes. Nerve injury was associated with lower ASES elbow scores (P = .03). There was also a significant correlation between the ASES elbow score and follow-up time, indicating that patients with a longer duration of follow-up had better subjective outcomes (Spearman coefficient = 0.55; P = .02). CONCLUSION: Floating elbow fractures represent high-energy trauma and have significant associated injuries. Nerve injury is correlated with lower subjective outcomes. Patients continue to improve for several years with acceptable mid-term results.

Learners With Disabilities: An Important Component of Diversity, Equity, and Inclusion in Medical Education.

The population of people with physical or sensory disabilities is growing, yet they are underrepresented in the medical and other health professions. At the same time, there is a clear need to enhance didactic curricular content and clinical training experiences that explicitly address the full scope of medical needs that individuals with disabilities have. These gaps represent missed opportunities to advance the health of an important, underserved, and growing population. Based on the authors' experience, the inclusion of people with physical or sensory disabilities in medical education greatly enhances the education of all learners and the professional development of faculty and staff, providing invaluable perspectives on the significant abilities of individuals with diverse physical or sensory disabilities. There are additional efforts and costs associated with the education of a medical student who is blind, is deaf, uses a wheelchair, or has another disability. But based on the authors' experience, it is clear that the societal return on investment is enormous, and the costs associated with a failure to embrace full inclusivity are much greater. Medical education institutions should recognize the population of people with disabilities as a vital component of their commitment to diversity, equity, and inclusion and strive to provide inclusive education for learners with disabilities.

Identifying an indoor air exposure limit for formaldehyde considering both irritation and cancer hazards.

Formaldehyde is a well-studied chemical and effects from inhalation exposures have been extensively characterized in numerous controlled studies with human volunteers, including asthmatics and other sensitive individuals, which provide a rich database on exposure concentrations that can reliably produce the symptoms of sensory irritation. Although individuals can differ in their sensitivity to odor and eye irritation, the majority of authoritative reviews of the formaldehyde literature have concluded that an air concentration of 0.3 ppm will provide protection from eye irritation for virtually everyone. A weight of evidence-based formaldehyde exposure limit of 0.1 ppm (100 ppb) is recommended as an indoor air level for all individuals for odor detection and sensory irritation. It has recently been suggested by the International Agency for Research on Cancer (IARC), the National Toxicology Program (NTP), and the US Environmental Protection Agency (US EPA) that formaldehyde is causally associated with nasopharyngeal cancer (NPC) and leukemia. This has led US EPA to conclude that irritation is not the most sensitive toxic endpoint and that carcinogenicity should dictate how to establish exposure limits for formaldehyde. In this review, a number of lines of reasoning and substantial scientific evidence are described and discussed, which leads to a conclusion that neither point of contact nor systemic effects of any type, including NPC or leukemia, are causally associated with exposure to formaldehyde. This conclusion supports the view that the equivocal epidemiology studies that suggest otherwise are almost certainly flawed by identified or yet to be unidentified confounding variables. Thus, this assessment concludes that a formaldehyde indoor air limit of 0.1 ppm should protect even particularly susceptible individuals from both irritation effects and any potential cancer hazard.

Weight of evidence evaluation of potential human cancer risks from exposure to polychlorinated biphenyls: an update based on studies published since 2003.

Drawing on all data available in 2003, the WoE of the human epidemiological data for polychlorinated biphenyls (PCBs) demonstrates that exposure to a mixture of PCBs (i.e. Aroclors) did not pose a cancer risk to humans ( Golden et al. (2003) . This evaluation was based on criteria established by the US Environmental Protection Agency (EPA) as well as on a different methodology used by the Agency for Toxic Substances and Disease Registry (ATSDR). Subsequently, at least 15 more studies on the potential cancer risks (both incidence and mortality) of PCBs have been published. All studies published since 2003 are critically reviewed using the criteria established by the EPA (2005) and ATSDR (2000) . None of the studies published since 2003 change the conclusions drawn by Golden et al. (2003) : "that the weight of evidence does not support a causal association for PCBs and human cancer". This conclusion pertains to all cancers combined, as well as to the various cancers that have been sporadically reported in the occupational cohort mortality studies. With respect to breast cancer risk, the WoE is compelling that environmental exposure to PCBs is not etiologically implicated in breast-cancer risk. This conclusion is supported by the consistently negative findings for increased breast-cancer mortality in occupational studies, which now involve almost 9,000 women occupationally exposed to PCBs. Similarly, the incidence studies in which PCB background levels are reported to be associated with increased risk of non-Hodgkin's lymphoma or prostate, testicular, and intestinal cancer are not corroborated by occupational cohort studies with PCB exposures far in excess of environmental exposures. The most likely explanation for these discordant findings is discussed in this review. Finally, the recent elucidation of the mode of action by which PCBs promote liver tumors in rats, combined with the demonstration that none of the key events in the mode of action occurred until substantial tissue accumulation of total PCBs had occurred, casts further doubt that PCB exposure at environmental or occupational levels poses a carcinogenic risk to humans. The dramatic differences between rodents and humans in sensitivity to PCB-mediated induction of CYP1A1 suggests that even occupational exposures to PCBs have never resulted in PCB body burdens approaching the levels required to initiate the sequence of events involved in the promotion of liver tumors in rodents.

Mood and anxiety disorders in females with the FMR1 premutation.

Fragile X syndrome (FXS) is a model for studying the relative contributions of genetic and environmental factors to psychiatric disorders in mothers of children with disabilities. Here, we examine the frequency and predictors of mood and anxiety disorders in mothers with the FMR1 premutation. Ninety-three females with the FMR1 premutation were in the study and were compared to 2,159 women from the National Comorbidity Survey Replication (NCS-R) dataset. Mood and anxiety disorders were assessed using the SCID-I. Our data reflect elevated lifetime major depressive disorder (MDD), lifetime panic disorder without agoraphobia and current agoraphobia without panic disorder in the FMR1 premutation sample. Also, we found a low frequency of lifetime social phobia, specific phobia, and post-traumatic stress disorders and current specific phobia in the FMR1 premutation sample. The profile of MDD in the FMR1 premutation sample was not episodic or comorbid with an anxiety disorder, as in the NCS-R dataset. Never having been married and smaller CGG repeat length were associated with increased likelihood of MDD while increased children with FXS in the family and greater child problem behaviors were associated with increased likelihood of an anxiety disorder in the FMR 1 premutation group. Major depression in females with the FMR1 premutation may not be characterized as an episodically chronic recurrent disorder as it is in community samples and may have a genetic basis given the relationship with CGG repeat length and lack of association with all child and most demographic factors.