WHEN FEMALE VETERANS RETURN HOME
Some bring the enduring effects of trauma with them.
More female veterans of the U.S. military have experienced combat during the past fifteen years than have ever before in our nation's history, and their experience, complete with physical and psychological trauma, is beginning to unfold.
In a large survey, it was revealed that 22% of them had experienced enough symptoms of posttraumatic stress disorder (PTSD) within the preceding month to meet the criteria for the diagnosis. In addition to reporting trauma related to combat, 23% of female veterans reported having been sexually assaulted while in military service. The survey administrators found that, compared with other female veterans, those with PTSD suffered from an overall poorer-quality of life, in respect of health, characterized by depression, substance abuse, smoking, obesity, multiple sexual partners, sexually transmitted diseases, domestic violence, fibromyalgia, irritable bowel syndrome, panic disorder, and eating disorders.
The study confirms the findings of others that have revealed higher rates of concurrent illnesses among people with PTSD in a general sample. Conclusions about causation cannot be drawn from the study, but the association between PTSD and depression is believed to be great, and the association between depression and poor health is well-documented.
Contrary to the common assumption, nearly twice as many women as men suffer from PTSD, and the prevalence of the disorder is twice as great in female veterans as it is in other women. When such veterans present with significant physical or mental illness, or both, they should be screened for symptoms of PTSD as well as for functional impairment; the quality of their lives, in terms of both physical and mental health, should be assessed. A tactful assessment for a history of severe trauma, physical or otherwise, can help guide the treatment plan for many female military veterans and other patients who present with one or more seemingly intractable medical problems.
Dobie DJ, et al. Arch Intern Med 2003;164 (4):394-400.
SUDDEN CARDIAC DEATH
The use of antipsychotic medication is a significant risk factor.
Initially, antipsychotic medications were prescribed for the treatment of schizophrenia, providing, in many cases, such dramatic relief of symptoms that patients who had spent decades in institutions were able to return to life in the community. Antipsychotic medication now is used to relieve the symptoms of other psychiatric disorders, and newer such agents have fewer adverse effects.
However, during the past four decades, some studies and case reports have associated antipsychotic drug use with sudden cardiac death among people diagnosed with schizophrenia. How safe, then, is the use of antipsychotic medication in the general population?
Sudden cardiac death occurs three times more often among people taking antipsychotic medication, according to the findings of a population-based case-control study in which the medical records of 250,000 people in the Netherlands from 1995 to 2001 were analyzed. Only one-fourth of victims who had been taking antipsychotic medication took it for schizophrenia or schizoaffective disorder, three-fourths having been prescribed an antipsychotic agent for the treatment of organic psychosis, dementia, bipolar depression, anxiety, stress, or other psychiatric disorders. Therefore, sudden cardiac death appears to be related to the use of antipsychotic medication, not to schizophrenia itself. Higher dosages of antipsychotic medication were associated with higher rates of sudden cardiac death, which was more likely to occur within the first three months of therapy, with the risk remaining significantly elevated as long as medication use continued.
The ability of antipsychotic agents to prolong the QT interval has been proposed as an explanation for the apparent causal connection. However, at which point prolongation becomes clinically significant is not known, and its role in sudden cardiac death is uncertain-it may be a sign of cardiac toxicity, generally. If there's a causal connection, the mechanism remains to be defined, and conclusions regarding which antipsychotic agents pose the greatest risk could not be drawn from the study data.
Because sudden cardiac death isn't a rare phenomenon, a threefold greater risk of it posed by antipsychotics would seem to be highly significant and of great concern, particularly in view of the fact that that risk subsists among people taking even low doses of antipsychotic agents, and often for psychiatric disorders other than schizophrenia.
Straus SM, et al. Arch Intern Med 2004;164(12):1293-7.
PREVENTING POSTOPERATIVE MISERY
Various antiemetic strategies effective but prevention best in patients at high risk.
Patients often report that nausea and vomiting are worse than pain is during the first 24 hours after surgery, and postoperative vomiting heightens the risk of several severe complications, including esophageal rupture and bilateral pneumothorax. The problem has been studied extensively, but more than 1,000 randomized, controlled trials investigating the prevention and treatment of postoperative nausea and vomiting could not produce a consensus.
Patients at high risk-those with two or more of the following characteristics: female sex, not smoking, a history of postoperative nausea and vomiting or motion sickness, and anticipated use of postoperative opioids-suffer the misery of postoperative nausea and vomiting, a leading cause of unanticipated hospital admission after planned outpatient surgery, at the cost of several hundred million dollars each year in the United States.
More than 5,000 of such patients were enrolled in a randomized, controlled trial that used a factorial design to evaluate 64 possible combinations of pharmacologic preventive strategies, the results of which indicate that each intervention works about as well as the others, and all work additively, rather than synergistically, when used in combination. Six well-established antiemetic interventions were tested independently and in the combinations-ondansetron (a serotonin antagonist) or no ondansetron, dexamethasone (a glucocorticoid) or no dexamethasone, droperidol (a neuroleptic agent) or no droperidol, either propofol or a volatile anesthetic, either nitrogen or nitrous oxide, and either remifentanil or fentanyl for analgesia. Approximately one-third of the patients experienced nausea and vomiting within the first 24 hours after surgery, the rate being highest (59%) in patients who received volatile anesthetic, nitrous oxide, fentanyl, and no antiemetics, and lowest (17%) in those who received propofol, nitrogen, remifentanil, ondansetron, dexamethasone, and droperidol. Each of the three antiemetics-ondansetron, dexamethasone, and droperidol-reduced the risk of nausea and vomiting by about 26%. Substituting propofol for a volatile anesthetic reduced nausea by about 19%, and nitrogen for nitrous oxide by about 12%; total intravenous anesthesia resulted in a 26% reduction in risk. No reduction in postoperative nausea and vomiting resulted from the substitution of remifentanil for fentanyl. The only surgical procedures that were found to carry a greater risk of postoperative nausea and vomiting despite the use of the interventions were hysterectomy and, possibly, cholecystectomy; patient factors (sex, and a history of postoperative nausea and vomiting, for example) determine the baseline risk in the vast majority of surgical procedures.
If a 100% absolute risk is reduced by a 25% relative risk, it becomes 75%; reducing that 75% absolute risk by another 25% relative risk results in a 56% absolute risk; and reducing that 56% absolute risk by another 25% relative risk results in a 42% absolute risk, and so on. The authors report that a 70% reduction in the relative risk is the best result that can be achieved with any combination of the interventions studied. That means that the patient's baseline risk remains a critical factor in determining whether or not postoperative nausea and vomiting occur, and that patients at highest risk are likely to need more interventions to bring the absolute risk of nausea and vomiting close to the lowest rate achieved, 17%.
Total intravenous anesthesia and dexamethasone cannot be used once symptoms have begun, and both are relatively safe, so the authors suggest that they be used preventively in patients who are at high risk for nausea and vomiting, or who are at high risk for complications should vomiting occur. The antiemetics droperidol and ondansetron can then be reserved for use as rescue agents if nausea and vomiting occur in spite of preventive treatment. There is controversy concerning the possibility that droperidol, a neuroleptic, prolongs the QT interval and leads to arrhythmias, and while that may not occur at antiemetic doses, some hospitals have eliminated its use in response to a recent warning issued by the Food and Drug Administration. Additionally, the drug seems to work in women but not in men. Ondansetron, one of a new class of serotonin antagonists, is expensive. For the latter reasons, as well as for the patient's comfort, prevention is the preferred strategy for postoperative nausea and vomiting in high-risk patients.
Apfel CC, et al. N Engl J Med 2004;350 (24):2441-51; White PF. N Engl J Med