This study estimates that 4.9% of schizophrenics will commit suicide during their lifetimes, usually near illness onset.

The percentage of subjects dead due to suicide (case fatality prevalence) is a more appropriate estimate of suicide risk than the percentage of the dead who died by suicide (proportionate mortality prevalence). More important, it is well established that patients with affective disorders suffer a higher risk of suicide relative to the general population. However, no risk factor, including classification of diagnostic subtype, has been reliably shown to predict suicide. This article demonstrates a hierarchy of risk based on the intensity of the treatment setting. Given that patients with a hospitalization history, particularly when suicidal, have a much elevated suicide prevalence over both psychiatric outpatients and nonpatients, the clinical decision to hospitalize in and of itself appears to be a useful indicator of increased suicide risk.

Psychiatric adverse effects during systemic corticosteroid therapy are common. Two large meta-analyses found that severe reactions occurred in nearly 6% of patients, and mild to moderate reactions occurred in about 28%. Although disturbances of mood, cognition, sleep, and behavior as well as frank delirium or even psychosis are possible, the most common adverse effects of short-term corticosteroid therapy are euphoria and hypomania. Conversely, long-term therapy tends to induce depressive symptoms. Dosage is directly related to the incidence of adverse effects but is not related to the timing, severity, or duration of these effects. Neither the presence nor the absence of previous reactions predicts adverse responses to subsequent courses of corticosteroids. Corticosteroid-induced symptoms frequently present early in a treatment cycle and typically resolve with dosage reduction or discontinuation of corticosterolds. In severe cases or situations in which the dose cannot be reduced, antipsychotics or mood stabilizers may be required. This review offers an approach to identifying and managing corticosteroid-induced psychiatric syndromes based on the type of symptoms and anticipated duration of corticosteroid treatment.

Objective While suicide attempt history is considered to robustly predict completed suicide, previous studies have limited generalizability from using convenience samples of specific methods/treatment settings, disregarding previous attempts, or overlooking first-attempt deaths. Eliminating these biases should more accurately estimate suicide prevalence in attempters. Method This observational retrospective-prospective cohort study using the Rochester Epidemiology Project identified 1,490 (555 males/935 females) Olmsted County residents making index suicide attempts (first lifetime attempts reaching medical attention) between 01-01-1986 and 12-31-2007. The National Death Index identified suicides between enrollment and 12-31-2010 (follow-up 3-25 years). Medical records were queried for sex, age, method, and follow-up care for index attempt survivors. Coroner records yielded data on index attempt deaths. Results During the study period, 81/1490 enrollees (5.4%) died by suicide. Of the 81, 48 (59.3%) perished on index attempt; 27 of the surviving 33 index attempt survivors (81.8%) killed themselves within a year. Males were disproportionately represented: 62/81 (11.2% of men; 76.5% of suicides) vs 19/81 (2.0% of women, 23.5% of suicides). Of dead index attempters, 72.9% used guns, yielding an odds ratio for gunshot death vs all other methods of 140 [95%CI:60,325]. When adjusted for covariates, survivors given follow-up psychiatric appointments had significantly lower likelihood of subsequent suicide (OR=0.212[95%CI:0.089, 0.507]). Conclusions At 5.4%, completed suicide prevalence in this community cohort of suicide attempters was almost 59% higher than previously reported. An innovative aspect of this study explains the discrepancy: by including index attempt deaths—approximately 60% of total suicides—suicide prevalence more than doubled. We contend that counting both index and subsequent attempts deaths more accurately reflects prevalence. Our findings support suicide attempt as an even more lethal risk factor for completed suicide than previously thought. Research should focus on identifying risk factors for populations vulnerable to making first attempts and target risk reduction in those groups.

Although intervention participants maintained and actually improved their QOL during radiation therapy, control participants experienced a significant decrease in their QOL. Thus, a structured multidisciplinary intervention can help maintain or even improve QOL in patients with advanced cancer who are undergoing cancer treatment.

No abstract

Using the principles of sternal wound debridement and early flap coverage, the authors have achieved a significant reduction in mortality after sternal wound infection and have reduced the mean hospital stay after sternal wound closure of these critically ill patients. Further reductions in mortality will depend on earlier detection of mediastinitis, before onset of septicemia, and ongoing improvements in the critical care of patients with multisystem organ failure.

The purpose of this paper is to present the experience at Emory University Hospital with the infected median sternotomy wound and to offer a treatment plan for those patients recalcitrant to the usual therapy of debridement and closed catheter irrigation with antimicrobial agents. When standard treatment fails, we proceed not only with the necessary thorough debridement to convert the wound to a relatively clean one but also concomitant closure by pectoralis major muscle flaps to completely obliterate dead space. Transposition flaps of rectus abdominus muscle or omentum are used when necessary to complete the closure. In the initial phase of this study, there were 3,239 patients who underwent open heart procedures through a median sternotomy approach in the years 1975 through 1978. In the 50 patients who had wound infections (1.54%), there were nine deaths. Three were thought to be unrelated to the sternal wound infection, four patients ruptured the ventricle or aorta, two patients died of generalized sepsis. Of these 50 patients, 22 responded to simple drainage; 28 had involvement of the mediastinum (0.86%). Of the 28 patients, 25 had debridement and closed mediastinal irrigation by catheter. Fourteen of these 25 did not respond. In these failing patients, 12 were treated by further debridement and closure by muscle flaps. Nine of these 12 were rescued. In the past nine months, an additional 1,052 patients had an open heart procedure. Of these, 11 had a median sternotomy infection. There have been no deaths in this latter group of patients, most of whom were treated by the muscle flap procedure. In addition to the improvement in mortality, morbidity has been reduced substantially. This procedure provides for a rational approach that we have found to permit salvage of a high percentage of patients who failed conventional closed irrigation techniques.