An overview of systematic reviews on the public health consequences of social isolation and loneliness.

OBJECTIVES: Social isolation and loneliness have been associated with ill health and are common in the developed world. A clear understanding of their implications for morbidity and mortality is needed to gauge the extent of the associated public health challenge and the potential benefit of intervention. STUDY DESIGN: A systematic review of systematic reviews (systematic overview) was undertaken to determine the wider consequences of social isolation and loneliness, identify any differences between the two, determine differences from findings of non-systematic reviews and to clarify the direction of causality. METHODS: Eight databases were searched from 1950 to 2016 for English language reviews covering social isolation and loneliness but not solely social support. Suitability for inclusion was determined by two or more reviewers, the methodological quality of included systematic reviews assessed using the a measurement tool to assess systematic reviews (AMSTAR) checklist and the quality of evidence within these reviews using the grading of recommendations, assessment, development and evaluations (GRADE) approach. Non-systematic reviews were sought for a comparison of findings but not included in the primary narrative synthesis. RESULTS: Forty systematic reviews of mainly observational studies were identified, largely from the developed world. Meta-analyses have identified a significant association between social isolation and loneliness with increased all-cause mortality and social isolation with cardiovascular disease. Narrative systematic reviews suggest associations with poorer mental health outcomes, with less strong evidence for behavioural and other physical health outcomes. No reviews were identified for wider socio-economic or developmental outcomes. CONCLUSIONS: This systematic overview highlights that there is consistent evidence linking social isolation and loneliness to worse cardiovascular and mental health outcomes. The role of social isolation and loneliness in other conditions and their socio-economic consequences is less clear. More research is needed on associations with cancer, health behaviours, and the impact across the life course and wider socio-economic consequences. Policy makers and health and local government commissioners should consider social isolation and loneliness as important upstream factors impacting on morbidity and mortality due to their effects on cardiovascular and mental health. Prevention strategies should therefore be developed across the public and voluntary sectors, using an asset-based approach.

Review of vaginal pessaries.

Pessaries have been used to treat pelvic organ prolapse throughout history, although with advances in the field of anesthesia and in surgical technique during the past century, pessary use declined. Current indications for pessary use include women awaiting definitive surgical repair, treatment for an unsuccessful surgical repair, treatment for women who are not surgical candidates, and for those who prefer medical management. In addition pessary use is gaining popularity among women with stress urinary incontinence, as well as in younger women interested in maintaining child bearing capabilities. Neonatal pelvic organ prolapse has also been treated successfully with pessaries. Many physicians have limited experience with pessary selection and fitting. This review article attempts to provide a basic overview of pessary selection and management.

Trauma and pregnancy.

Trauma and/or accidental injury complicates 6-7% of all pregnancies. The management protocols for trauma in pregnancy are based largely on case reports and small series. The purposes of this study were to: describe the demographics of pregnant trauma patients at a tertiary care center and a large community hospital; identify variables predictive of fetal outcome including an examination of Kleihauer-Betke and nonstress testing; and recommend an evaluation and management protocol after trauma based on empirical data rather than anecdotal reports. Data from pregnancies complicated by trauma from July 1987 through October 1993 were retrospectively reviewed. Statistical analysis included Chi-square and Kruskall-Wallis testing. There were 476 medical records available for review. Of the trauma cases, 54.6% were motor vehicle accidents, 22.3% were domestic abuse and assaults, 21.8% were associated with falls, and 1.3% were secondary to burns, puncture wounds, or animal bites. Mean maternal age was 24 years, 49.9% were Caucasian, and 43% were primigravid. Mean gestational age at occurrence of trauma was 25.9 weeks and mean gestational age of delivery was 37.9 weeks. Domestic abuse occurred most frequently before 18 weeks, falls between 20-30 weeks' gestation, and motor vehicle accidents occurred with equal frequency throughout gestation. Uterine contractions occurred in 39.8% of patients and as often as every 1 to 5 min in 18% of patients. Preterm labor occurred in 11.4%, preterm delivery in 25%, and abruptions in 1.58% of the trauma population. Fetal heart rate monitoring was abnormal in 3% of cases. Twenty-seven perinatal deaths were noted and in 14 pregnancies the deaths were related to trauma. Eight of these perinatal deaths were associated with motor vehicle accidents, four with domestic violence, and two with falls. The only preventable perinatal deaths were a twin pregnancy transferred with nonreassuring fetal heart tones. Early warning symptoms of vaginal bleeding, uterine contractions, and/or abdominal and/or uterine tenderness were not predictive of either preterm delivery or adverse pregnancy outcome, sensitivity 52%, specificity 48%. Abnormal monitoring and positive Kleihauer-Betke tests were also not predictive of adverse pregnancy outcome. However, there were no adverse outcomes directly related to trauma when monitoring was normal and early warning symptoms were absent (negative predictive value 100%). Two hundred eighty-nine Kleihauer-Betke tests were performed and only one affected management. Repetitive monitoring over several days did not uncover any patients whose heart rate tracings evolved from normal to abnormal monitoring. Given our findings that prolonged monitoring was not helpful in management of pregnant trauma patients, we support the recommendation that initial external fetal monitoring be performed for 4 hr, and, if reassuring, the patient may be sent home with precautions. We also recommend an Rh-immunoglobulin work-up for all Rh-negative pregnant trauma patients, but do not recommend Kleihauer-Betke testing for Rh-positive women. Given the frequency with which trauma affects pregnancy and the difficulty encountered with identifying variables predictive of pregnancy outcome, there may be great benefits of incorporating trauma prevention into routine prenatal care.

Domestic violence in America.

Domestic violence is an underrecognized problem of immense cost. It is a crime; its victims must be identified and protected. The medical and judicial communities share responsibility in addressing this issue and providing support for victims. The role of health care workers in recognizing and preventing domestic violence cannot be overestimated. Direct questioning of patients, especially about the source of any injuries and about safety at home, is the first step in uncovering abuse. Educational programs for health care providers and the general public can change society's view and tolerance of this problem. Physicians must take an active role in changing community attitudes about domestic violence and in instituting programs to reduce its incidence. Medical treatment of the injuries resulting from domestic violence is not sufficient. Abused women need the care of a team of professionals who can address psychological, emotional, and physical injuries. They must also be provided with safe housing and financial and legal assistance in order to escape the abusive relationship. Physicians and legislators must work together to effect change. Domestic violence is a public health menace. We need to break the cycle of abuse that has become an integral part of our society.

Psychosomatic diseases and the Rorschach test.

Despite numerous efforts to identify a Rorschach profile uniquely associated with and helpful in diagnosing psychosomatic conditions, none has been demonstrated to exist. Although certain Rorschach characteristics have been consistently observed in studies of patients with psychosomatic diseases and can shed light on personality features of these individuals, similar characteristics are encountered in a variety of other conditions as well. This state of affairs is attributable not to short-comings in the Rorschach test, but rather to inadequate conceptualization and categorization of psychosomatic disease.

Epidemiology of psychosomatic disorders in Iran.

Psychiatric-epidemiological surveys executed from 1963 to 1976 in Iran with the help of the WHO sampled all three principal components (rural, urban, tribal) of the population greater than or equal to 6 years. The surveys employed questionnaires and tests in a first screening phase and individual psychiatric examinations of all suspects in a second. They were based partly on census studies, partly on random samples. Prevalencies per 1,000 for all psychiatric cases were: rural 149, urban 166, tribal 21; for all psychoreactive cases (included in the foregoing) rural 87, urban 98, tribal 12; for all psychosomatic cases (included in the psychoreactive) rural 17, urban 23, tribal 9. All tribal rates were significantly lower. Reactive cases thus accounted for 59% of the total psychiatric morbidity, psychosomatic cases for 14% of it. Significant sex differences were found only in the poorer strata. The distribution of types of psychosomatic disorder differed from what Cremerius has reported for Munich, with more psychosomatic headache and less pulmonary/cardiovascular and gastrointestinal disturbance.

[Epileptic patients in the psychiatric clinic. From twilight attacks to psychosis]. / Epileptiker in der psychiatrischen Klinik. Von der Dämmerattacke zur Psychose.

Cases of epilepsy at the University Psychiatric Clinic of Bern during the decade 1968 to 1977 are analysed, and of 203 such cases 122 were psychotic. In comparison to the non-psychotic cases those with psychosis showed significantly more females, more kryptogenesis, more combined hereditary taint with epilepsy and other neuropsychiatric diseases (excluding neuroses and psychopathies) and more alteration of character, but not more intellectual deterioration. Psychomotor epilepsies were over-represented among the psychotic cases. They did not differ from other forms of epilepsy as regards kryptogenetic origin or number of first degree relatives with epilepsy, but this group did contain all 3 cases in our material who had first degree relatives with schizophrenia. The striking similarity between results of stimulation through deeply implanted electrodes in the limbic system and familiar symptoms of schizophrenia is indicated and discussed in this light.

[Sex character of human movement answers in the Rorschach test in transsexual and transvestite patients]. / Der Geschlechtscharakter der Mensch-Bewegungsantworten im Rorschach-Versuch bei Transsexuellen und Transvestiten.

As a complement to a former study on the sexual character of the kinaesthetic human movement responses in the Rorschach tests of healthy and neurotic men and women, the same characteristic was investigated in Rorschach records of transsexuals and transvestites from the Psychiatric Out-Patient Department of the University Hospital of Zurich. In none of these groups was the distribution of masculine, feminine and neuter movement responses congruent with that in one of the preceding groups. The anatomically male transsexuals who desired a change of sex to female (TXmw) gave considerably more interpretations of the opposite or goal sex than did the anatomically female (TXwm). The two transsexual groups TXmw and TXwm do not constitute mirror images of each other. Whereas the mean experience type of most groups was not far from ambiequality, the TXmw and the male transvestites (TVmw) were decidedly introverted. All three of the newly studied groups gave more space responses than would be expected in a "normal" Rorschach record, especially the TXwm and the TVmw. The difference in the frequency of space responses between the TXmw and TXwm was statistically significant.

Masters of shadows.

The interchange of views between Hans Binder and Bruno Klopfer regarding their evaluation and scoring systems for shading responses is traced and their single personal meeting much later is described.