Bizarre Paranoid Delusions Associated With an Implanted Surgical Device.

We describe a case involving bizarre paranoid delusions following implantation of a sacral nerve stimulator, and review the literature regarding psychotic symptoms related to surgical implants. A 64-year-old female developed bizarre paranoid delusions regarding a sacral nerve stimulator that had been implanted two years previously for dysfunctional voiding. The patient believed that the wires from the sacral nerve electrodes had grown up her spine and were affecting her vision as well as controlling her thoughts. The delusions developed in the setting of profound anxiety and feelings of loss after the death of her mother. The patient initially demanded that the implant be removed emergently. The delusions gradually abated as she adjusted to the loss of her mother. Fortunately the symptoms abated entirely with supportive care. We suspect that given the frequency of surgical implants that the association with delusional thoughts might be much higher than suggested by a literature review.

Gun Violence, mental health, and Connecticut physicians.

While there is a public perception that gun violence is associated with mental illness we present evidence that it is a complex public health problem which defies simple characterizations and solutions. Only a small percentage of individuals with mental illness are at risk for extreme violence and they account for only a small percentage of gun-related homicides. Individuals who are at risk for gun violence are difficult to identify and successfully treat. The incidence, and perhaps the demographics, of gun violence vary substantially from state to state. We make a case for Connecticut physicians to study gun violence at the state level. We recommend that Connecticut physicians promote and expand upon the American Academy of Pediatrics' recommendation for creating a "safe home environment. "We suggest that guns be secured in all homes in which there are children. In addition we suggest that guns be voluntarily removed from homes in which there are individuals with a history of violence, threats of violence, depression, drug and/or alcohol abuse, and individuals with major mental illnesses who are not cooperating with therapy.

Inter-rater concordance of wound classifications in patients undergoing appendectomy.

BACKGROUND: Despite the widespread utilization of a four-stage wound classification system to risk-adjust operations for surgical site infection (SSI) rates, we are not aware of any study evaluating the definitions of the wound classes for clarity. We limited our study of wound classifications to appendectomies and posed the question whether different reviewers classify individual cases differently. METHODS: We evaluated the wound classifications of 105 consecutive appendectomies in our community hospital. Four reviewers graded retrospectively the wound classifications, first after reading the description of the appendix in the operative report and again after reading the pathology report. The wound classifications of the four reviewers were evaluated for concordance with the original operating room nurse (ORN) assignment. RESULTS: The kappa scores for inter-observer concordance of wound classifications among the four reviewers based on their interpretation of the operative report and the ORN who originally classified the operation ranged from 0.1028 to 0.1597. By conventional standards, this represents no better than "slight agreement" for any of the reviewers. We found that 19%, 50%, 94%, 95%, or 96% of our appendectomies would be considered "high risk," Class 3 or 4, operations depending on which rater classified the operation. The additional information contained in the pathology reports did not change the distribution of wound classifications of the four reviewers significantly. CONCLUSIONS: Our study demonstrated considerable differences in the distribution of wound classifications of appendectomies among our ORNs and retrospective reviewers. A review of the surgical literature supports our finding that the incision classification system utilized commonly lacks precision, at least in the rating of appendectomies. We recommend that further studies be performed to determine whether changes in the definitions of wound classes are warranted.

Are complications of transrectal ultrasound-guided biopsies of the prostate gland increasing?

Although transrectal ultrasound-guided biopsies (TRUSB) of the prostate gland are generally considered to be low-risk procedures, a study from Canada reported that there had been a significant increase in the percentage of hospital admissions following TRUSBs between 1996 and 2005 (1.0% to 4.1%). The authors speculated that the increase may be secondary to the emergence of antibiotic-resistant enteric bacteria or the result of an increasing number of cores taken with each TRUSB. In a chart review, we retrospectively evaluated complications from 2,080 consecutive TRUSBs performed by one urology group in Connecticut between January 2003 and August 2010. We identified seven patients (0.34%) who were admitted to an acute-care hospital for infectious complications and three patients (0.14%) who were admitted for bleeding. The risk of serious infections and bleeding did not significantly rise during the study period despite a significant increase in the mean number of biopsy cores taken.

Adaptation of adults to uncorrected hypospadias.

OBJECTIVES: Surgery has been advocated for children with hypospadias to improve the appearance of the penis, allow voiding in the standing position, and improve the chance of fertility. We undertook a survey of adults with hypospadias to determine their adaptation to this congenital anomaly without surgical correction. METHODS: In a 2-year prospective study, six urologists in the general practice of urology identified 56 adult patients from their practices with hypospadias. The urethral meatus was glanular in 21 patients, subcoronal in 23, distal penile in 7, mid-penile in 4, and proximal penile in 1. Nine patients had undergone failed or incomplete hypospadias repairs as children. Seven patients had mild to moderate chordee. RESULTS: Only 1 patient presented with a complaint referable to the hypospadias, and only 3 (5%) of the 56 patients expressed dissatisfaction with the appearance of their penis. Of the 56 patients, 18 (32%) stated that they were unaware that they had a congenital anomaly. The 2 patients who were known to be infertile were believed to be infertile on the basis of oligospermia. Although 20 (36%) of the 56 patients described angulation or spraying of the urinary stream, only 3 (5%) stated that they preferentially sat to void. No patient pursued an interest in corrective surgery. CONCLUSIONS: Of the adults we surveyed with hypospadias, most stated that they were satisfied with the appearance of the penis, voided in the standing position, and did not have infertility associated with the abnormal position of the urethral meatus.