Aboriginal prisoners and cognitive impairment: the impact of dual disadvantage on Social and Emotional Wellbeing.

BACKGROUND: Negligible information is available regarding the Social and Emotional Wellbeing (SEWB) needs of Aboriginal Australian individuals in custody with cognitive impairment. This is problematic given that Aboriginal people with cognitive impairment often experience dual disadvantage in the context of the justice system. This study sought to ascertain the relationship between cognitive impairment and mental health/cultural needs (SEWB) Aboriginal and Torres Strait Islander people in custody. METHOD: A sample of 122 Aboriginal and Torres Strait Islander people were administered a culturally themed semi-structured questionnaire in custodial settings in Victoria, Australia. The questionnaire included measures of cognitive impairment, SEWB and forensic needs. Analyses were performed to determine differences in the presence of SEWB and unmet custodial needs by level of cognitive impairment. RESULTS: Findings revealed a diminished level of wellbeing for cognitively impaired participants across several factors. Cognitive impairment was associated with poorer coping mechanisms, additional experiences of racism, difficulties handling emotions, discomfort around non-Aboriginal people and reduced access to meaningful activities in custody. All participants regardless of their level of impairment recognised the importance of cultural engagement; however, cognitively impaired participants had greater difficulty accessing/practicing cultural activities. CONCLUSIONS: Culturally responsive disability assistance should be available at all phases of the justice system for Indigenous people with cognitive impairment to ensure that equitable care is accessible and needs are addressed.

Medical clearance of psychiatric patients.

Patients with primarily psychiatric complaints commonly present to emergency departments. The challenges to emergency medicine physicians are to distinguish functional from organic disease and to address any underlying medical comorbidities. The key elements of this medical "clearance" evaluation of psychiatric patients are discussed. The tremendous importance of the history and physical examination are highlighted, as is judicious use of laboratory and radiographic testing. Toxicology testing is specifically addressed.

Primary closure of mammalian bites.

OBJECTIVE: Suturing of bite wounds remains controversial. The authors evaluated the incidence of wound infection in 145 mammalian bite wounds treated with primary closure. METHODS: Consecutive patients with bite wounds receiving primary closure at a university hospital ED had structured closed-question data sheets completed at the time of wound management and suture removal. Infection was determined at the time of suture removal using a previously validated definition. Data included demographics; medical history; time from injury to evaluation; wound characteristics and location; details of wound cleansing methods, debridement, foreign body removal, and wound closure methods; use of antibiotics; and follow-up wound evaluation. Proportions and 95% confidence intervals were calculated. RESULTS: One hundred forty-five mammalian bite patients were enrolled: 88 dog, 45 cat, and 12 human bites. Patients had a mean (+/-SD) age of 21 +/- 20 years; 58% were male; 86% were white; and they presented a mean (+/-SD) of 1.8 +/- 1.2 hours after injury. Bites occurred on the head and neck (57%), upper extremity (36%), and lower extremity (6%). Wounds had a mean length and width of 2.5 cm and 4.8 mm, respectively. Twelve percent involved structures deep to subcutaneous tissue. After primary wound closure, wound infections occurred in eight patients (5.5%; 95% confidence interval = 1.8% to 9.2%). CONCLUSIONS: The data suggest that carefully selected mammalian bite wounds can be sutured with approximately a 6% rate of infection. This infection rate may be acceptable in lacerations where cosmesis is a primary concern.

Poisonings: food, fish, shellfish.

Not every traveler who gets sick away from home has an infection; some are poisoned. This article describes common and dangerous illnesses caused by food-borne toxins. It explores the toxic illnesses acquired from fish or seafood, including scombroid, ciguatera, pufferfish toxicity, and a variety of shellfish poisonings. It also provides a brief overview of plant toxicity. Although gastroenteritis is a common feature of many food poisonings, this article emphasizes those processes associated with neurologic manifestations, as they tend to be more dangerous to patients and less well understood by physicians. It also stresses strategies to prevent food poisoning.

Sulfonamide-induced iritis.

Anterior uveitis is a relatively rare adverse drug reaction when the prescription rate of sulfonamides is considered. Current medications should be included in the differential diagnosis of patients who present with uveitis, because discontinuation of the offending agent is mandatory to resolution of the problem. Lack of recognition and failure to discontinue the medication will increase the patient's risk of ocular injury.

Use of standardised assessment scales in elderly hip fracture patients.

Standardised scales recommended by a joint working party from the Royal College of Physicians (RCP) and The British Geriatrics Society (BGS) in 1992 for the assessment of elderly hospitalised patients were employed in an elderly hip fracture population to investigate their feasibility and usefulness in this group. Patients were assessed at the time of their fracture and one, six and 12 months later. An informant was invited to provide information on behalf of patients (39%) who were classified as having significant memory and cognitive impairment (Abbreviated Mental Test score < 7) or if they had some other communication difficulty. Patients and informants found the format and content of the scales acceptable as well as the administration time of around one hour. Difficulties with the depression (Geriatric Depression Scale) and quality of life (Philadelphia Geriatric Center Morale Scale) scales were due to some patients' digressions, and the fact that little change was noted in the scores over the one-year period of follow-up questions their sensitivity. In the cohort of survivors 31% were classified as being depressed at baseline (score > 5) and this rose to 36% at one year. Ten per cent of the surviving patients were classed as dependent by the Barthel Index at the time of their fracture (score < 12) and this increased to 24% at one year. Despite exhibiting a ceiling effect, this scale was the most responsive of the scales at all time points. The social checklist highlighted important aspects for the management of hip fracture patients.

Management of status epilepticus.

Significant advances in our understanding of the pathophysiology and evaluation and management of the patient in status epilepticus have markedly decreased associated morbidity and mortality in the last two decades. Any type of seizure can progress to status epilepticus. Identification and management of the cause is of particular importance for those patients for whom initial pharmacologic management fails. This subgroup of individuals tends to have important underlying metabolic, structural, toxic, or infectious causes that must be addressed. Those episodes associated with CNS pathology tend to have a more serious prognosis. Cause aside, appropriate, organized, and timely care will significantly effect outcome. Treatment goals are fourfold: (1) rapid stabilization of the individual, (2) expeditious termination of both clinical and electrical seizure activity, (3) determination and management of life-threatening precipitants, and (4) timely recognition and minimalization of any adverse physiologic sequelae of seizure activity. Benzodiazepines, phenytoin, and phenobarbital remain the most effective first-line and second-line pharmacologic agents. If these agents prove ineffective, appropriately monitored pentobarbital anesthesia appears to be the modality of choice and should be rapidly instituted.

The Edinburgh randomised trial of breast cancer screening: results after 10 years of follow-up.

The Edinburgh Randomised Trial of Breast Cancer Screening recruited 44,288 women aged 45-64 years into the initial cohort of the trial during 1978-81, and 10 years of follow-up is now complete. A total of 22,944 women were randomised into the study group and were offered screening for 7 years; the remaining women formed the control group. After 10 years, breast cancer mortality is 14-21% lower in the study group than in the controls depending on the precise definition of the end point. These differences are not statistically significant; for breast cancer as the underlying cause of death the relative risk is 0.82 (95% confidence interval 0.61-1.11). Rates of locally advanced and metastatic cancer were substantially lower in the study group, but screening has failed to achieve marked reductions in rates of small node-positive cancers. Those women who accepted the final invitation to screening have been monitored over the 3 year period prior to their first screen under the UK service screening programme. Interval cases, expressed as a proportion of the control incidence, increased from 12% in the first year to 67% in the third year. The reduction in breast cancer mortality for older women (aged at least 50 years) is the same as that for the total study group for this duration of follow-up. For analyses of breast cancer mortality in younger women updates recruited to the trial from 1982 to 1985 (10,383 women with 6-8 years' follow-up) have been included. The reduction in breast cancer mortality for women aged 45-49 years at entry was 22% (relative risk = 0.78, 95% confidence interval = 0.46-1.31).

Thrombolytic therapy in review.

The use of thrombolytic agents for both coronary and noncoronary indications is a rapidly progressing field. There has been substantial debate over which disease processes ultimately benefit from the use of thrombolytic agents. In addition, many recent studies have focused on comparing different thrombolytic agents and dosing regimens in an attempt to gain optimal therapeutic benefit with minimal risk. This paper discusses the current status of thrombolytic therapy for coronary artery disease, pulmonary embolus, peripheral vascular thrombosis, and cerebrovascular infarction.

Marine trauma, envenomations, and intoxications.

When humans encounter marine creatures a variety of maladies may occur, ranging from dermatitis to life-threatening trauma, allergy, envenomations, or intoxications. The emergency physician should be prepared to recognize quickly and address appropriately the potential life threats, which are primarily neurologic, respiratory, and cardiovascular. A high degree of suspicion for these illnesses is needed. Intoxications may be especially confusing. Although most of the syndromes are self-limited and treatment supportive, time is of the essence if neuromuscular paralysis, hypotension, or respiratory compromise is present. Much folklore exists regarding detection and prevention of these entities and should be regarded as such. The last several decades have seen a marked increase in our knowledge base regarding these fascinating envenomations and intoxications. Research in the next several decades probably will produce a variety of diagnostic and therapeutic tools, which will further our understanding of, and ability to specifically manage, these syndromes.

Cervical anterior spinal artery syndrome associated with cardiopulmonary arrest.

Nontraumatic spinal cord ischemia is uncommon, especially when the cervical cord is involved. We present an elderly man who sustained acute occlusion of the anterior spinal artery at a high cervical level. This was followed by a respiratory arrest due to the paralysis of the diaphragm and chest wall muscles. A review of the vascular supply to the cord and of nontraumatic ischemic myelopathy is provided.

Evaluation of the traveler. An introduction to emporiatrics for the emergency physician.

Travel medicine, or emporiatrics, presents an additional challenge to the practicing emergency physician. In this time of increased travel for business and pleasure, travel history should become a routine part of patient evaluation. While the emergency physician may not need to become facile with specific details concerning immunizations and prophylaxis, he or she should have a good working knowledge of these in order to provide the potential traveler with some basic information and to be able to adequately evaluate the returned traveler who becomes ill and seeks care. Air travel allows many travelers to arrive back in the United States before manifesting symptoms and signs of illness acquired abroad. Many of these illnesses are not usually found in the United States. Late diagnosis of certain illnesses, such as falciparum malaria, may increase the morbidity and mortality. As such, travel history should become a routine part of patient evaluation, and the physician should have a good working knowledge of illnesses that may be acquired abroad.

Other infectious complications in intravenous drug users. The compromised host.

This article deals with the infectious entities, excluding acquired immunodeficiency syndrome and endocarditis, the physician is likely to encounter in the intravenous drug abuser on presentation to the Emergency Department. Multiple factors may suppress the usual diagnostic indicators. Awareness of the common infectious problems in this population and a high index of suspicion are needed to render quality care in the Emergency Department.

Immersion injury. Drowning and near drowning.

Near drowning remains one of the most frequently encountered environmental injuries in the United States. Physicians can do much to educate their patients on prevention. Both at the scene and in the emergency department, physicians should direct initial attention to aggressive respiratory management, because hypoxia is the primary cause of mortality and morbidity in the near-drowning victim. An apparently lifeless victim of cold-water immersion may go on to full recovery with such management. In patients who survive the initial insult, the degree of hypoxic encephalopathy is the major determinant of outcome.