A five-year study on the interactive effects of depression and physical illness on psychiatric unit length of stay.

OBJECTIVE: Previous research has shown that hospital length of stay among medical patients is significantly increased by comorbid mental illness, in particular depression. However, few studies have examined the length of stay effect of comorbid physical and mental illness among psychiatric patients. METHOD: The present study examined the effect of comorbid physical and psychiatric illness on hospital length of stay among 2323 psychiatric inpatient admissions over a 5-year period. Patients were grouped into seven diagnostic categories. RESULTS: Average length of stay was significantly longer for patients with comorbid physical diagnoses (mean = 20.01 days) than for patients with no physical diagnoses (mean = 16.63 days). Analyses of the psychiatric categories revealed that the average length of stay for depressed patients was significantly greater for those with comorbid physical diagnoses (mean = 19.73 days) than for depressed patients with no comorbid physical diagnoses (mean = 13.96 days). No other psychiatric group evidenced a significant increase in length of stay for comorbid physical illness. CONCLUSIONS: Results suggest that comorbid physical diagnosis increases length of stay among psychiatric patients overall, with increased hospitalization stay for depressed patients, in particular.

Impact of the interaction of depression and physical illness on a psychiatric unit's length of stay.

Prior literature suggests that length of stay (LOS) on medical inpatient units is increased by the coexistence of depression and physical illness. The present study examined 532 psychiatric inpatient admissions to determine if physical illness increased LOS for patients grouped by diagnostic categories of psychosis, depression, personality disorder, anxiety disorder, adjustment disorder, bipolar disorder (not depressed), and other psychiatric disorders. LOS for depressed patients was significantly longer for those with any physical final diagnosis (mean = 20.08 days) than for depressed patients with no physical diagnosis (mean = 11.48 days). LOS was also longer for all patients with physical diagnoses (mean = 19.31 days) than all patients with no physical diagnosis (mean = 13.13 days). No other specific diagnostic group (psychosis, personality disorder, and so forth) showed significant differences in LOS for any associated physical illness vs no physical illness. The study results tend to indicate that physical illness is associated with increased LOS for depressed psychiatric patients but not for other specific diagnostic groups. Depressed patients may 1) mask physical illness by depression-generated physical complaints; 2) prioritize mood symptoms over physical symptoms; and/or 3) may suffer from feelings of hopelessness or be pessimistic that their physical symptoms will be effectively treated and, therefore, not report their physical symptoms.

Low-dose oral medroxyprogesterone acetate in the management of the paraphilias.

BACKGROUND: There are no reports on the use of low-dose oral medroxyprogesterone acetate (MPA) in the treatment of the paraphilias. High-dose depot MPA treatment (500-800 mg i.m. weekly) has proven to control the behavioral manifestations of the paraphilias when testosterone levels decrease from pretreatment to prepubescent levels, but at the price of significant morbidity. METHOD: Oral MPA (60 mg/day for an average of 15.33 months) was given in an open nonblind trial to seven patients who met criteria for DSM-III-R paraphilias. Four of the subjects had shown inadequate improvement after 1 year of psychotherapy. RESULTS: Six subjects responded at 60 mg/day. Testosterone levels decreased by 50% to 75% (range, 100-400 ng/dL). No patient displayed significant side effects. All patients described significantly fewer paraphilic fantasies, and no patient reported engaging in paraphilic behaviors during oral MPA treatment. CONCLUSION: Double-blind placebo and phallometrically controlled tumescence studies need to be carried out to test the results of this study.

Tuberculosis of the upper limb joints.

Seventy-four cases of tuberculosis of the upper limb joints (sterno-clavicular 1; shoulder 12; elbow 42; wrist 10 and fingers 9), treated by two of the authors, were reviewed. Eighty-seven percent presented at an advanced stage of destruction. The diagnosis was proved in 71 our of 74 cases. In most, the treatment was 6-12 months of chemotherapy, plaster immobilization (in order to prevent or correct deformity) and functional rehabilitation whenever possible. The sterno-clavicular and finger joints were not immobilized. Response to chemotherapy was favourable in 66 of the patients followed up. One relapse occurred at the 18th month. The affected shoulder joints healed with loss of movement, but were not painful. At the elbow, ten patients developed spontaneous bony fusion in the right-angle position, 27 had a useful range of motion and 19 had more than 70 degrees of flexion-extension movement. One patient had an arthrodesis. At the wrist, two patients healed with painful stiffness and an arthrodesis was performed. All the finger lesions healed with painless stiffness which did not interfere much with function because rehabilitation had been started early. The authors believe that conservative management usually gives better results than arthrodesis or excision of the joint.

[Conservative treatment of osteoarticular tuberculosis of the elbow]. / Traitement conservateur des tuberculoses ostéo-articulaires du coude.

Thirty-six cases of tuberculosis of the elbow have been treated by chemotherapy and plaster cast immobilisation followed by rehabilitation. The overall results were satisfactory with restoration of useful mobility and flexion in 26 cases. The ranges of movement in pronation and supination were less satisfactory.

Proposal of a new classification for established Volkmann's contracture.

The multiple contributory aspects of the claw deformity seen in 115 cases of established Volkmann's contracture has been analyzed. This has given rise to a clinically oriented 5-Stage classification. Clinical and electrical motor nerve deficits in the median, ulnar and radial distributions have shown considerable variability between patients. The individual pattern of nerve damage has been outlined. The measurement of passive extension deficits (PED) illustrates the degree of extrinsic muscle contracture. The PED is increased proportionally to nerve damage. Secondary stigmata of chronic ischemia (ie chronic changes, sensory deficits,stiff joints, web-space and intrinsic contractures) are increased proportionally to muscle and motor nerve damage. Staging in these five groups has permitted the establishment of rapid diagnosis, severity of injury, prognostic evaluation and management modalities according to stage.

Multiple stapling for wrist arthrodesis in the nonrheumatoid patient.

Twenty-five out of 26 consecutive wrist fusions carried out by means of staple fixation alone had follow-up for an average of 40 months. This technique avoids corticocancellous bone grafting, achieves good stability in variable wrist positions with minimal splintage, and seems to avoid serious complications. Fusion occurred in 25 cases in an average of 3 1/5 months with complications in three cases and uneventful results in 22 cases (88%). Two patients were operated on a second time. Fifty-six percent of this patient population requested removal of the staples. This technique does not shorten the time to fusion, but it does obviate extensive plaster immobilization and the morbidity rate of bone grafting.

Skeletal tuberculosis of the wrist and hand: a study of 27 cases.

The 27 cases of skeletal tuberculosis in the hand and wrist reported represented 6.9% of the skeletal tuberculosis seen at our hospital and 32% of the skeletal tuberculosis found in the upper extremity. In a majority of these patients a single bone or joint was involved and 18.5% of the patients had bone and/or joint involvement outside the hand. Pulmonary tuberculosis was present in 10.7% of these cases. The clinical picture of tuberculosis is similar to that of other infections and tumorous conditions, but a history of absent bacille Calmette Guérin protection and positive tine test should arouse one's suspicion to the condition. Eight-six percent of our patients had x-ray findings that included bone atrophy, bone or joint destruction with discrete periostitis, or the presence of the typical spina ventosa. We found no case of resistance to various combinations of the usual drugs in any patients. Supportive orthopaedic splints were used over short periods (3 months) and surgery was used for diagnostic purposes (biopsies) and in treatment by fusion of two wrists in this patient series. Finger joint involvement responded satisfactorily to drug and conservative orthopaedic treatment and in no case were these joints fused or replaced by a prosthesis.

Results of conservative treatment in tuberculosis of the elbow.

The authors have used conservative treatment in 29 cases of tuberculosis of the elbow with 12 months of specific chemotherapy regim and 1--2 months of plaster immobilisation followed by rehabilitation. Seven elbows were ankylosed at the end of the period of treatment, 20 elbows had a useful range of joint movement, and 14 had more than 70 degrees of free movement. The results were not so satisfactory regarding pronation and supination. The authors believe that conservative management gives better results than classical arthrodesis or excision of the elbow joint.

[Conservative treatment of osteoarticular tuberculosis of the elbow]. / Traitement conservateur des tuberculoses ostéo-articulaires du coude.

The authors have applied conservative treatment in 21 cases of tuberculosis of the elbow with 12 months of specific chemotherapy and antibiotics and plaster immobilization for 3 montths followed by rehabilitation. Four elbows were ankylosed at the end of treatment. Seventeen elbows had useful joint mobility. In thirteen cases, there was more than 70 degrees of movement in flexion but the results were not so satisfactory as regards pronation and supination. The authors believe that conservative management gives better results than surgery by arthrodesis or resection.