Physician

Sex After MI: Few Are Counseled, Most Want to Learn

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Few patients report receiving counseling regarding the resumption of sexual activity after an acute MI even when it occurs between the ages of 18 and 55, new research indicates[1].

Of those who do receive counseling, restrictions are commonly given that are not supported by evidence or guidelines, according to the study, published online December 15, 2014 in Circulation.

“This is the first study where we’ve looked specifically at the 18-to-55-year-old group, where about one-fifth of all heart attacks occur. We expected that rates of counseling would be higher for younger people, that there would just be a general bias toward physicians being more open to discuss this issue with younger people,” lead author Dr Stacy Tessler Lindau (University of Chicago, IL) told heartwire .

“But we actually found rates of counseling were lower, if anything, than they were in our prior study that included older adults, and what concerns us is that people are resuming their sexual activity with little information or in some cases misinformation about what’s safe and what to look for. That can cause fear and worry and other problems.”

The prospective longitudinal Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) study was carried out at 127 hospitals in the US and in Spain. It was designed in part to evaluate gender differences in baseline sexual activity, function, and patient experience with physician counseling about sexual activity after an acute MI.

Half the Cohort Younger Than 48 Years

For this analysis, investigators used baseline and 1-month data collected from 2349 women and 1152 men who had experienced an acute MI. The median age of the cohort was 48 years.

Of those who reported sexual activity prior to the MI, 54% of women and 63% of men had resumed sexual activity by 1 month after the MI.

Of interest, 9% of patients who were not sexually active in the year prior to their MI had initiated sexual activity in the month following their attack.

However, only 12% of women and 19% of men overall, not all of them sexually active, had some discussion with a physician about sex in the month after their MI.

Among those who reported having a discussion with their physician regarding sexual activity, 68% were given restrictions to limit sex, take a more passive role during sex, or to keep their heart rate down. Those with poorer physical function were somewhat more likely to receive restrictive recommendations than those in better physical condition.

Rates and frequency of sexual activity were, however, substantially lower in the first month after the MI compared with the prior 12 months, the authors report.

Sexual Behavior 1 Month After AMI: VIRGO Study Participants
Frequency of sex
US
Spain
Women (%) Men (%) Women (%) Men (%)
3-6 times/wk 12 16 7 16
1-2 times/wk 37 46 45 54
2-3 times/mo or less 49 36 47 30
The vast majority of patients agreed that it is appropriate for a physician to discuss sexual health with them and indicated that they felt comfortable discussing this issue with a physician. However, in the US, most patients who had such a discussion reported that they initiated it, whereas in Spain, most discussions were initiated by the physician (P<0.001).
In adjusted analyses, female gender, older age, and sexual inactivity at baseline were all statistically significantly associated with no counseling by physicians about resuming sex after an MI.

Despite restrictions given by physicians, two-thirds of patients who received them indicated that they were “completely satisfied” with the recommendations received.

“I still believe that the power dynamic between doctor and patient puts the doctor in the position of responsibility in terms of raising the topic of sexual function,” Lindau emphasized.

“Having said that, I also believe that if patients have a concern about this issue, it is squarely within the realm of medical care to attend to this concern. Even the guidelines in the US and Europe and elsewhere say this is an important issue to address, and I believe that if patients ask, physicians will have an informative and caring response.”

Patients’ attitudes about the use of placebo treatments: telephone survey.

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Abstract

Objective To examine the attitudes of US patients about the use of placebo treatments in medical care.

Design One time telephone surveys.

Setting Northern California.

Participants 853 members of Kaiser Permanente Northern California, aged 18-75, who had been seen by a primary care provider for a chronic health problem at least once in the prior six months.

Results The response rate was 53.4% (853/1598) of all members who were eligible to participate, and 73.2% (853/1165) of all who could be reached by telephone. Most respondents (50-84%) judged it acceptable for doctors to recommend placebo treatments under conditions that varied according to doctors’ level of certainty about the benefits and safety of the treatment, the purpose of the treatment, and the transparency with which the treatment was described to patients. Only 21.9% of respondents judged that it was never acceptable for doctors to recommend placebo treatments. Respondents valued honesty by physicians regarding the use of placebos and believed that non-transparent use could undermine the relationship between patients and physicians.

Conclusions Most patients in this survey seemed favorable to the idea of placebo treatments and valued honesty and transparency in this context, suggesting that physicians should consider engaging with patients to discuss their values and attitudes about the appropriateness of using treatments aimed at promoting placebo responses in the context of clinical decision making.

Discussion

The opinions of US patients have been missing from debates over the use of placebo treatments in clinical practice and deliberate efforts by physicians to enhance patient care by promoting placebo responses. Our data show that patients are open to the idea of placebo treatments. Most (50-84%) judged it acceptable for doctors to recommend placebo treatments under conditions that varied according to the doctor’s level of certainty about the benefits of the treatment, the purpose of the treatment (for example, to address a patient’s need to receive a treatment), and the transparency with which the treatment was described to patients. Fewer than a quarter stated that it was never acceptable for doctors to recommend placebo treatments. In addition, many respondents indicated a willingness to try placebo treatments in different scenarios. This is generally compatible with trends reported in previous patient surveys in other countries regarding willingness to try placebo treatments.16 17 18 20

Our findings also underscore the importance of honesty and trust in the prescription of placebo treatments. Respondents indicated that the use of placebo treatments could have a negative impact on the doctor-patient relationship if patients learnt that a doctor had recommended a placebo to placate patient’s expectations for treatment–especially if it did not work. Respondents said that doctors should be honest about an intervention being a placebo treatment when patients ask specific questions about the treatment, and they disagreed about whether it is acceptable for physicians to call a placebo treatment “real medicine.” Interestingly, some respondents thought that doctors should not disclose that a treatment is a placebo if it is working, suggesting some support for the non-transparent use of placebo treatments, a finding not reported in previous surveys.

Although clinical practice guidelines recommend against the use of placebo treatments to mollify patients,10 most participants in this survey judged their use to be acceptable to address patients’ need to feel like they received some treatment. Patients did, however, specify limits on how far physicians should go to placate patients, with over 90% judging it inappropriate for doctors to prescribe antibiotics for a cold, even when patients ask for it. Yet recent surveys suggest that a small proportion of physicians would indeed prescribe antibiotics to some patients in this situation, and that they had done so at least once within the past year.4 21 Taken together, these findings hint at a disconnect between clinical practice guidelines, patients’ opinions, and physicians’ practices that should be further explored.

Although our data indicate a general acceptance of placebo treatments by patients, responses to different questions about the effectiveness of such treatments varied. While most thought when asked directly that placebo treatments are only effective when patients do not know they are receiving them, the responses to the more nuanced scenarios indicated a general acceptance of transparently prescribed “open” placebo treatments—both a belief that they are effective (62%) and a willingness to take them (61-65%). This discrepancy prompts questions about how well patients understand the concept of placebo treatments in general and whether providing additional detail in the scenarios adds to their understanding such that their answers to the corresponding questions are more accurate.

The study sample was representative of the population of Northern California but may not be representative of US patients in general. Our sample was more highly educated (≥44% college graduates) than the general population, had health insurance coverage through Kaiser Permanente Northern California, and had seen a physician within the past six months for a chronic medical condition. Although we constructed our definition of placebo treatments based on feedback from focus groups and pretest interviews, respondents may none the less have variable or limited understandings of the concepts of the placebo effect and placebo treatments. This is perhaps not surprising, given the variable understandings of these concepts among the placebo research community.5In view of the widespread variability in definitions and conceptions of placebo in the literature, we endeavored to employ a pragmatic definition of the placebo effect in our questionnaire that would be useful in the context of a patient survey. While there may be some vagueness and ambiguity in the concept of placebo treatments, the pattern of survey responses and our experience in exploring placebo treatments with focus groups indicate that patients are able to understand the difference between treatments that work on the basis of their inherent pharmacologic properties and those that may produce benefit primarily by means of positive expectations. We observed some variability in answers to analogous questions that were asked in different ways (for example, directly versus in contextualized scenarios), and it is difficult to know which formulation of the questions is likely to reflect attitudes more accurately. Furthermore, the survey captures patients’ opinions about a series of plausible hypothetical scenarios rather than actual behaviors and experiences.

Researchers of one study have argued that models of shared decision making need to include conversations between physicians and patients about the role of the placebo effect in clinical care,22 and clinical practice guidelines leave the door open for the use of placebo treatments when presented to patients transparently.10 Researchers of another study further suggest that attitudinal data can help develop and foster the use of effective and non-deceptive placebo treatment techniques.20 That many patients in this survey seem favorable to the idea of placebo treatments suggests that physicians should consider engaging with patients to discuss their values and attitudes concerning the appropriateness of using placebos in the context of clinical decision making. Such conversations could allow physicians to determine which patients might be open to the use of placebo treatments and could help physicians tailor their description of placebo treatments according to patients’ preferences and level of understanding. Further research is needed to determine how physicians can optimally promote placebo responses in clinical practice and to guide the appropriate use of placebo treatments.

What is already known on this topic

  • The use of placebo treatments by physicians in clinical practice has been documented in recent surveys
  • Attitudinal surveys in other countries suggest that patients are open to the use of placebo treatments in specific circumstances
  • This study provides data on US patients’ attitudes about the use of placebo treatments in clinical practice
  • These data suggest that many patients are favorable to the idea of placebo treatments

What this study adds

 

Source: BMJ

 

If Your Doctor Is Healthy, You Probably Are Too.

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Story at-a-glance

  • When a physician was perceived to be overweight or obese, patients viewed him or her as less credible and trustworthy, and they were less inclined to follow the given medical advice.
  • Patients whose physicians were compliant with certain preventative health practices were more likely to have undergone these procedures themselves.
  • Research has also shown that physicians with healthy lifestyles are more likely to discuss healthful personal habits to motivate you to do the same
  • Choosing a physician shouldn’t only be about credentials and educational background, but also about their personal lifestyle choices
  • If your physician leads a healthy lifestyle there’s a good chance these positive habits will get passed on to you.
  • healthy-doctor

If your physician is overweight or obese, does it make him or her less able to give you sound medical advice?

Logically you would say no, yet a new study published in the International Journal of Obesity1 found that excess body weight impacts patients’ views of their physician.

When a physician was perceived to be overweight or obese, patients viewed him or her as less credible and trustworthy, and they were less inclined to follow the given medical advice.

This bias may not be fair; as mentioned, body weight obviously has little bearing on a physician’s ability to practice medicine. However, are such reservations justifiable?

It is most unfortunate that the vast majority of physicians who finish medical school are not highly motivated to follow truly healthy lifestyles, but more or less succumb to the powerful brainwashing influence of Big Pharma in their curriculum.

Research Shows Healthier Doctors Have Healthier Patients

You probably wouldn’t knowingly take driving lessons from an instructor who had carelessly totaled his car. Likewise, you may be less inclined to accept health advice from someone you perceive to be unhealthy.

An overweight physician may still be healthy but is likely to be perceived as less so than a physician who is fit. According to the recent study, overweight physicians were less trusted by both normal weight and overweight patients alike. The study’s lead author told the New York Times:2

“The bias against overweight people is so socially accepted that despite all the doctor’s training and expertise, it can jeopardize the doctor’s ability to have a conversation about health care with the patient.”

It’s a harsh finding, but there may be some reason to seek out the healthiest physicians. Separate research has shown, in fact, that healthier physicians tend to have healthier patients.3

Unfortunately, that particular study used practices like mammography and annualvaccinations, which are poor measures of true health as the markers, finding that patients whose physicians were compliant with these practices were more likely to have undergone these procedures themselves.

This suggests that other preventive measures practiced by physicians, such as healthful eating and exercise, may also transfer over to patients as well.

So the secret to finding the best health care provider for you may lie in seeking someone who is like-minded, more inclined to use natural therapies and lifestyle strategies before medicine, if that is important to you, as well as someone who practices what they preach. The study’s author noted:4

“It’s human nature. People usually preach what they practice. Personal adoption of a practice suggests that the doctors are sufficiently convinced of the importance of the intervention that they are motivated enough to even do it themselves, and perhaps they’ve figured out how to overcome access barriers that can enable patients, as well.”

Healthy Personal Behaviors Improve Physicians’ Credibility

Research has shown not only that physicians with healthy lifestyles are more likely to discuss such practices with their patients, but also that talking about these healthful personal habits improves their credibility and ability to motivate their patients to do the same.5 The correlation was so strong that researchers concluded:

“Educational institutions should consider encouraging health professionals-in-training to practice and demonstrate healthy personal lifestyles.”

Another study similarly found that healthy physicians can help motivate positive change for entire communities, noting:6

“Physician-directed interventions that advance these [health] principles are most effective when directed by clinicians who regularly participate in such healthy behaviors themselves.”

What does this mean for you? Choosing a physician shouldn’t only be about credentials and educational background but also about their personal lifestyle choices. Does your physician exercise? Does he or she embrace healthy eating habits and stress-reduction techniques? If so there’s a good chance these positive habits will get passed on to you.

You Don’t Need a Doctor to Learn How to Take Control of Your Health

It may be especially motivating to have your physician tell you to eat more vegetables or get more exercise, but you don’t need a physician to learn some of the most important variables to reaching optimal health.

The vast majority of deaths in wealthier countries like our own are due to chronic, not acute, disease. And most chronic diseases, including cancer, heart disease, diabetes, and obesity, are largely preventable with simple lifestyle changes. Even infectious diseases like the flu can often be warded off by a healthy way of life.

The added bonus to this is that the healthier you are, the less you will need to rely on conventional medical care, which is aleading cause of death. So while it’s a good idea to choose a doctor who leads a healthy lifestyle, it’s even better to lead one yourself! So what does a “healthy lifestyle” entail?

  • Proper Food Choices

For a comprehensive guide on which foods to eat and which to avoid, see my nutrition plan. It’s available for free, and is perhaps one of the most comprehensive and all-inclusive guides on a healthy lifestyle out there. Generally speaking, you should be looking to focus your diet on whole, ideally organic, unprocessed foods that come from healthy, sustainable, ideally local, sources.

For the best nutrition and health benefits, you will want to eat the majority of your food raw. Nearly as important as knowing which foods to eat more of is knowing which foods to avoid, and topping the list is fructose. Sugar, and fructose in particular, can have a multitude of toxic effects when consumed in excess, not the least of which is insulin resistance, a major cause of accelerated aging and a crucial factor in driving virtually all chronic disease.

For most people (although there are clearly individual differences), a diet high in healthful fats (as high as 50-70 percent of the calories you eat), moderate amounts of high-quality protein, which is far less than the average amount most people eat, with the bulk of carbohydrates coming from high-nutrient, low-carbohydrate vegetables and very little carbohydrates from grains and sugars, will set you on the right track toward health.

  • Comprehensive Exercise Program, including High-Intensity Exercise

Even if you’re eating the healthiest diet in the world, you still need to exercise to reach the highest levels of health, and you need to be exercising effectively, which means including not only core-strengthening exercises, strength training, and stretching but also high-intensity activities into your rotation. High-intensity interval-type training like Peak Fitness boosts human growth hormone (HGH) production, which is essential for optimal health, strength and vigor.

  • Stress Reduction and Positive Thinking

You cannot be optimally healthy if you avoid addressing the emotional component of your health and longevity, as your emotional state plays a role in nearly every physical disease — from heart disease and depression to arthritis and cancer. Effective coping mechanisms are a major longevity-promoting factor in part because stress has a direct impact on inflammation, which in turn underlies many of the chronic diseases that kill people prematurely every day. Meditation, prayer, energy psychology tools such as the Emotional Freedom Technique (EFT), social support and exercise are all viable options that can help you maintain emotional and mental equilibrium.

  • Optimize Vitamin D with Proper Sun Exposure

We have long known that it is best to get your vitamin D from appropriate sun exposure during times when UVB rays are present. Vitamin D plays an important role in preventing numerous illnesses ranging from cancer to the flu. The important factor when it comes to vitamin D is your serum level, which should ideally be between 50-70 ng/ml year-round.

Sun exposure, or failing that, a safe tanning bed is the preferred method for optimizing vitamin D levels, but a vitamin D3 supplement can be used when necessary. Most adults need about 8,000 IU’s of vitamin D a day to achieve serum levels above 40 ng/ml, which is still just below the minimum recommended serum level of 50 ng/ml. Be aware that if you take supplemental vitamin D, you also need to make sure you’re getting enough vitamin K2, as these two nutrients work in tandem to ensure calcium is distributed into the proper areas in your body.

  • High Quality Animal-Based Omega-3 Fats

Animal-based omega-3 fat like krill oil is a strong factor in helping people live longer, and some experts believe that it may be one reason why the Japanese are the longest lived race on the planet.

  • Avoid as Many Chemicals, Toxins, and Pollutants as Possible

This includes tossing out your toxic household cleaners, soaps, personal hygiene products, air fresheners, bug sprays, lawn pesticides, and insecticides, just to name a few, and replacing them with non-toxic alternatives.

Source: mercola.com

 

 

 

Physician-Assisted Suicide.

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John Wallace is a 72-year-old man with metastatic pancreatic cancer. At time of diagnosis, the cancer was metastatic to his regional lymph nodes and liver. He was treated with palliative chemotherapy, but the disease continued to progress. Recently he has become jaundiced, and he has very little appetite. He has been seeing a palliative care physician and a social worker on an ongoing basis. His abdominal pain is now well controlled with high-dose narcotics, but the narcotics have caused constipation. In addition to seeing the social worker, he has also been seeing a psychologist to help him to cope with his illness.

Mr. Wallace has been married to his wife, Joyce, for 51 years, and they have three children and six grandchildren. He and his wife have lived in Salem, Oregon, for the past 23 years, and most of his family lives nearby. He understands the prognosis of the disease, and he does not wish to spend his last days suffering or in an unresponsive state. He discusses his desire for euthanasia with his wife and family members, and they offer him their support. The next day, he calls his physician and asks for information about physician-assisted suicide.

TREATMENT OPTIONS

Do you believe that Mr. Wallace should be able to receive life-terminating drugs from his physician? Which one of the following approaches to the broader issue do you find appropriate? Base your choice on the published literature, your own experience, and other sources of information.

To aid in your decision making, each of these approaches is defended in the following short essays by experts in the field. Given your knowledge of the patient and the points made by the experts, which option would you choose? Make your choice and offer your comments at NEJM.org.

  • Option 1: Physician-Assisted Suicide Should Not Be Permitted
  • Option 2: Physician-Assisted Suicide Should Be Permitted

 

 

OPTION 1

Physician-Assisted Suicide Should Not Be Permitted

J. Donald Boudreau, M.D., Margaret A. Somerville, A.u.A. (pharm.), D.C.L.

We recognize that a patient in Mr. Wallace’s situation is in a state of grief. We appreciate his desire to be of sound mind at the end of his life and not to have to suffer as death approaches. We also recognize the obligations of physicians to respect a patient’s refusal of treatment, to relieve pain and suffering, and to provide palliative care. However, we believe that the art of healing should always remain at the core of medical practice, and the role of healer involves providing patients with hope and renewed aspirations, however tenuous and temporary. Within the realm of palliative care, there exists a well-recognized paradox that one can die healed.1 Physicians have a duty to uphold the sacred healing space — not destroy it. Therefore, physicians must hear Mr. Wallace’s request for death but never carry it out.

Supporters of physician-assisted suicide justify their position by placing the value of individual autonomy above all other values and ethical considerations. Giving individual autonomy absolute priority runs roughshod over competing values, protections, and needs and ignores the harmful effects on other people, societal institutions (the medical profession in particular), and the general community.

Permitting physician-assisted suicide creates a slippery slope that unavoidably leads to expanded access to assisted suicide interventions — and abuses. Advocates of euthanasia deny that slippery slopes exist, arguing that legal constraints and administrative safeguards are effective in preventing them. But the evidence is clearly to the contrary, as the High Court of Ireland recently affirmed. In upholding the constitutionality of the prohibition on assisted suicide, the justices wrote, “. . . the fact that the number of LAWER (`life-ending acts without explicit request’) cases remains strikingly high in jurisdictions which have liberalised their law on assisted suicide . . . speaks for itself as to the risks involved.”2 Vulnerable communities in our societies — persons who are old and frail and those who are disabled or terminally ill — perceive themselves to be threatened.3Physicians must not be willfully blind to these serious dangers.

Many aspects of physician-assisted suicide breach physicians’ long-standing ethical norms. For instance, the 2011 annual report on the Death with Dignity Act in Oregon shows that physicians were present at fewer than 10% of “assisted deaths.”4 Why might they want to disconnect themselves from what they have enabled? Perhaps they have a moral intuition that intentionally facilitating or inflicting death is wrong. Patients expect an empathic presence from their physicians, and authentic healers commit to accompanying patients throughout the illness trajectory.

Referring to physician-assisted suicide as “treatment” is a new rhetorical tool that is used by the advocates of euthanasia. The goal is to make assisted suicide seem less alarming to the public and to promote the idea that legalizing the practice is just another small step along a path already taken and ethically approved. By intentionally confusing physician-assisted suicide with legitimate palliative care, pro-euthanasia advocates hope that the public will conclude that it is a medically and ethically accepted end-of-life treatment.5

For palliative care to remain a healing intervention, it cannot include “therapeutic homicide.”6Euthanizing and healing are intrinsically incompatible. Involvement of physicians in such interventions is unethical and harms the fundamental role of the doctor as healer.

 

 

OPTION 2

Physician-Assisted Suicide Should Be Permitted

Nikola Biller-Andorno, M.D., Ph.D.

To many of us — physicians and nonphysicians alike — death appears as a menace, as something we fear and want to avoid at all cost. At the same time, most of us know someone for whom death has come as a relief. These deaths were sometimes long-awaited or they were actively sought out, prepared for in secrecy, and endured alone. For those persons, the opportunity to ask a competent professional for assistance in ending their lives in a legally and socially accepted way would be a clear improvement. Mr. Wallace is fortunate that this is an option in the state in which he lives and that he can discuss it openly with his family and his physician.

The role of physicians is not simply to preserve life but also to apply expertise and skills to help improve their patients’ health or alleviate their suffering. The latter includes providing comfort and support to dying patients. Such patients may, after careful consideration, come to the conclusion that in their particular situation, asking a physician for assistance in suicide best reflects their interests and preferences. Responding to such a carefully considered request can be compatible with the goals and ethos of medicine, as well as with a trusting patient–physician relationship.

There is broad consensus about the importance and desirability of palliative medicine and hospice care, and physician-assisted suicide is in no way a repudiation of those practices.7 Yet in some cases, symptoms cannot be sufficiently controlled; in many other instances, what is at stake is a perceived loss of autonomy and dignity.8 Some patients wish to proactively shape the end of their life; to those patients, taking action to end their life is better than passively waiting for death to occur.

Physician-assisted suicide is now legal in a number of states in the United States, including Oregon and Washington State, as well as in Switzerland and in the Netherlands. The data from these places show that the implementation of physician-assisted suicide, when it is accompanied by certain safeguards (including comprehensive screening and informed consent processes), does not lead to uncontrolled expansion or abuse. In Switzerland, the number of assisted suicides has risen steadily over the past decade, but the total number of suicides has declined.9 The data from Oregon and Washington show that the majority of persons who request physician-assisted suicide are white, educated men — not a population that would be considered particularly vulnerable. Also, only a minority of persons who inquire about suicide assistance actually complete the process; this indicates that the option is perceived as a choice that can be abandoned.10

Even in societies with broad public support for physician-assisted suicide, a certain uneasiness and ambivalence remain, particularly among physicians who have to carry the emotional burden and moral responsibility of having enabled someone to end his or her life.11,12 The decision to provide suicide assistance cannot be forced on physicians but needs to be left to their individual conscience. However, if a physician is prepared to respond to a request for assistance in suicide, there are no compelling ethical reasons not to allow that physician to do so. In any case, careful regulation, comprehensive monitoring, and an ongoing critical debate are required to ensure that physician-assisted suicide remains a choice that is based on caring relationships among the patient, the family, and health care professionals.

 

Source: Nejm

Job Stress a Major Factor in High Rates of Physician Suicide.

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Job stress, coupled with inadequate treatment for mental illness, may account for the higher than average rate of suicide among US physicians, new research suggests.

Investigators at the University of Michigan in Ann Arbor found that among individuals who died by suicide, having a mental health disorder or a job problem was significantly associated with being a physician.

They also found that physicians who died by suicide were much more likely than their nonphysician counterparts to have antipsychotics, benzodiazepines, and barbiturates, but not antidepressants, present on toxicology testing.

“This [study] paints a more detailed picture of external events and risk factors in a physician’s life before a suicide, rather than just looking at a death certificate,” lead author Katherine J. Gold, MD, MSW, said in a statement.

The study was published online November 5 in General Hospital Psychiatry.

Lack of Action

The researchers point out that the suicide rate among physicians is significantly higher than that of the general population, and although there has been some previous research looking at mental health issues in medical students, relatively few studies have examined mental illness and suicide risk among practicing physicians.

“We’ve seen a number of studies now that show a high rate of anxiety, depression, and burnout among both medical students and physicians, but we haven’t done very much to develop programs to reduce or treat these factors and to increase mental health–seeking among physicians,” said Dr. Gold.

To investigate risk factors and comorbidities associated with physician suicide and to compare potential differences between physician and nonphysician suicide victims, the researchers used data from the National Violent Death Reporting System (NVDRS).

The NVDRS, they note, offers “rarely-available data on psychosocial, psychiatric, mental health care, medical comorbidity and substance abuse variables associated with suicide.”

The study included data on 31,636 suicide victims aged 18 years and older from 17 states. Of these, 203 were physicians.

The researchers found that there were no significant differences in current mental health disorders between physicians and persons in other occupations (46% vs 41%) or in persons with current depression (42% vs 39%).

In addition, there was no difference between physician and nonphysician groups with respect to comorbid current depression, substance or alcohol abuse disorder, or known mental illness.

At 48% for physicians and 54% for nonphysicians, firearms were the most common method of suicide for both groups. For physicians, this was followed by poisoning (23.5%), blunt trauma (14.5%), and asphyxia, which included hanging (14%).

After firearms, the most common cause of death in nonphysicians was asphyxia (22%), followed by poisoning (18%) and blunt trauma (6%).

Need for Change

Among suicide victims, having a known mental illness was mildly associated with higher odds of being a physician (odds ratio [OR], 1.34; confidence interval [CI], 1.01 – 1.82; P = .045). However, among physicians, the greater likelihood of having a known mental illness was not matched by a greater likelihood of antidepressant therapy, the investigators note.

However, having a job problem that contributed to the suicide significantly predicted the likelihood of being a physician (OR, 3.12; CI, 2.10 – 4.63; P < .0005).

Toxicology testing revealed that physicians were significantly more likely than nonphysicians to have antipsychotics (OR, 28.7; CI, 7.94 – 103.9; P < .0005), benzodiazepines (OR, 2:10; CI, 11.4 – 38.6; P < .0005), or barbiturates (OR, 3.95; CI, 15.8 – 99.0; P< .0005) present.

“There needs to be greater effort to address the stigma, underdiagnosis, and treatment of depression among physicians and understand how we can reduce the stress related to work. We need to make mental health treatment more available, safe, and confidential,” said Dr. Gold.

In an accompanying editorial, Olaf Gjerløw Aasland, MD, PhD, from the Institute of Health and Society, University of Oslo in Norway, describes the study as “an impressive piece of work.”

Dr. Aasland notes that the findings highlight the need for “good management of mental imbalance and psychiatric disorders, reduce[d] workplace and work—home balance stressors, and restriction of access to means for physicians who are in situations in which the two other factors are acute.”

Source: Medscape.com

Placenta accreta associated with submucosal fibroid polyp.

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  1. Papa Dasari

+ Author Affiliations

1.      JIPMER, Puducherry, India
  1. Correspondence to Papa Dasari, dasaripapa@gmail.com

Summary

A 35-year-old para 1, whose child birth was 5 years ago, was on barrier contraception and safe period. She was diagnosed to have a small submucosal posterior wall fibroid when she planned for her second child now. She conceived spontaneously during the next cycle after consultation. Her first trimester ultrasonography revealed placental implantation on the fibroid. She developed severe pre-eclampsia at 32 weeks of pregnancy and suffered from uncontrolled hypertension. and pulmonary oedema. Pregnancy was terminated at 33+4 weeks by elective lower segment caesarean section (LSCS) because of severe pre-eclampsia, pulmonary oedema and unfavourable cervix. At LSCS, placenta was found to be adherent to the pedunculated fibroid polyp which was removed by clamping, cutting and ligating the pedicle. Histopathological examination revealed placenta accreta and hyaline change of leiomyomatous polyp. Fetus was preterm, weighed 2.1 kg and survived.

Background

Complications are greater in cases of submucosal pedunculated intrauterine fibroid polyps associated with pregnancy. Adherent placenta is to be expected in cases of submucosal fibroid of uterus when placenta is seen anterior to it on ultrasonogram. Posterior wall fibroids may not be visualised in advanced pregnancy.

It is easy to remove the fibroid polyp at lower segment caesarean section (LSCS) and prevent the complications of postpartum haemorrhage and inversion which may result in case of vaginal birth.

Case presentation

A 35-year-old para 1 whose child birth was 5 years ago consulted for planning for second pregnancy. The couple were using male condom and safe period for contraception till she came for consultation. She gave history of menorrhagia (which did not make her anaemic) for the past 6 months . She was found to have a posterior wall fibroid of 3×2 cm size which appeared as submucosal in location on transvaginal ultrasound. She was advised to take folic acid tablet and was asked to return after 3 months if conception does not occur.

She conceived the following month after consultation. Her first trimester ultrasound showed posterior implantation with a single live fetus. The placenta was implanted posteriorly overlying the fibroid but there was an anechoic space between the placenta and the fibroid which was visualised up to second trimester (18 weeks scan) of pregnancy (figure 1). At 32 weeks, she developed severe pre-eclampsia and was hospitalised for the same at 32+3 days as her blood pressure (BP) was not controlled with tablet, –methyl Dopa given 500 mg 8 hourly on outpatient basis. She had severe pedal oedema extending up to knee joints. It was planned to manage her conservatively till 34 weeks of pregnancy and inj. Dexamethasone 6 mg was given intramuscularly 12 hourly for two doses for fetal lung maturity. She was also started on antioxidants, viz, vitamin A, vitamin C and vitamin E, along with sedatives. Five days after admission, that is, at 33+1 day she developed cough and difficulty in breathing. Respiratory system examination revealed fine crepitations. BP was within 150/100 mm of Hg. She was given injection Morphine and tab. Lasix 40 mg 8 hourly with which she had partial relief from dyspnoea. After 2 days the BP was on the rise >160/100 mm Hg and her output started decreasing and a decision to terminate pregnancy was taken. She was decided for elective LSCS in view of pulmonary oedema and unfavourable cervix at 33+4 weeks of gestation. On the operation table, her BP was 170/105 mm of Hg and there were bilateral crepitations. Oxygen saturation was 89%, hence LSCS was done under general anaesthesia with careful fluid administration, and injection magnesium sulphate was started prophylactically soon after the surgery. At surgery, the lower segment was not well formed and the fetal head was high floating and hence delivered with the help of forceps. The liquor was meconium stained and the placenta could not be removed by controlled cord traction though signs of placental separation were present. On intrauterine examination, the placenta was found to be adherent to the posterior wall and hence it was attempted to remove manually. When it was being removed, the upper part of the placenta was found to be attached to the posterior uterine wall by a pedunculated firm structure which was clamped cut and ligated with No-1 vicryl. After removal it was recognised to be the fibroid polyp of 3×4 cm on which the placenta was implanted. Placenta along with polyp was sent for histopathological examination. Uterine incision was closed in two layers with No-1 vicryl, and tubectomy was performed as per the patient’s wish. Fetus was preterm, alive with an Apgar of 6/10 at 1 min and 8/10 at 5 min and weighed 2.1 kg.

She was monitored in RICU (respiratory intensive care unit) and was on continuous oxygen by mask. She developed hypertensive crisis which was controlled by inj. Labetalol for 24 h. Magnesium sulphate was discontinued after 24 h. She was shifted out of RICU after 36 h when she maintained Sp O2 of 96% with room air. She was started on tab. Amlodepine 5 mg twice daily after the Physician’s opinion. She was discharged on the 8th postoperative day along with the baby and advised to continue the antihypertensives for 2 weeks.

Investigations

Her complete haemogram performed after admission at 33 weeks of gestation was normal except for low platelet counts of 156 000/mm3. Renal function, liver function tests and glucose tolerance test were normal. Fundus examination showed grade I hypertensive changes. Ultrasonography (USG) at 32+4 weeks showed biometry corresponding to 31 weeks with estimated fetal weight of 1.8 kg. Placenta was posterior and the fibroid could not be visualised properly at this time. Amniotic fluid index was 16 cm.

The histopathological examination of placenta with polyp was reported as leiomyomatous polyp with hyaline change and placenta accreta

Treatment

  • ▶ Injection Dexamethasone for fetal lung maturity.
  • ▶ Antihypertensives for pre-eclampsia.
  • ▶ Prophylactic magnesium sulphate for imminent eclampsia.
  • ▶ Inj. Morphine and Lasix for pulmonary oedema.
  • ▶ LSCS polypectomy with bilateral tubectomy.

Outcome and follow-up

Normal at 6weeks.

Discussion

Fibroids are diagnosed in 4–5% of women undergoing prenatal ultrasound. Submucosal fibroids are the least common type of uterine fibroids (5%) and the pedunculated type account for only 2.5%.1 Uterine fibroid polyps (pedunculated submucous fibroids) can interfere with implantation causing infertility or they can cause miscarriage or preterm labour. The outcome of a pregnancy in a case of submucosal posterior wall fibroid is reported here.

The symptoms of submucous fibroids include abnormal uterine bleeding (most often menorrhagia, less commonly metrorrhagia), pain lower abdomen, dysmenorrhoea and increased vaginal discharge. Rarely they prolapse out of cervix into the vagina and occasionally cause inversion of uterus. This case was, however, asymptomatic except for mild menorrhagia (which did not make her anaemic). Hysteroscopic myomectomy is feasible and effective for submucous fibroids and it should be considered in women with intracavitary submucous fibroids suffering from infertility, pregnancy loss and abnormal uterine bleeding.2 But hysteroscopic myomectomy is associated with significant complications like bleeding, perforation, burns, electrolyte imbalance, possibility of hysterectomy and even death. Data describing the fertility and pregnancy outcomes following hysteroscopic myomectomy is limited.3 A pregnancy rate of 60% was reported in patients with infertility after hysteroscopic myomectomy.4 In this case, hysteroscopic resection was not considered as she was asymptomatic. A prospective study which assessed the positional affect of fibroids on pregnancy rates revealed 43.3% pregnancy rate in patients with submucosal fibroids who underwent myomectomy compared to 27.2% in those who did not undergo surgery.5 The affect of submucosal fibroids may not be purely positional as it was found that polyps and leiomyomas produce excess glycodelin, a glycoprotein, in the uterus which impairs fertilisation and implantation.6

Pregnancy has a variable and unpredictable effect on myoma growth, majority do not increase and in those that grow, the greatest growth usually occurs before 10 weeks of gestation.7 The pregnancy outcome differs from those who do not have fibroid only in the rate of caesarean section, which was significantly higher in those with fibroid uterus.8 Although most pregnancies are unaffected by fibroids, large submucosal and retroplacental fibroids seem to impart greater risk for complications including degeneration, abruptio placentae, preterm labour and delivery.9 This case did not suffer from abruptio placentae despite pre-eclampsia, and the fibroid polyp underwent degeneration without significant growth. However, adherent placenta was the result because of its implantation on the fibroid polyp. Submucosal fibroids have long been recognised as one of the causes for placenta accreta as mentioned by Fox.10 Both hyaline degeneration and placenta accreta were evident in this case.

The sonographic appearance of myomas is generally characteristic but as they can undergo various kinds of degeneration, the sonographic appearance can vary mimicking other cystic conditions. MRI is more accurate and specific in diagnosing the various changes that occur in a fibroid.11 The fibroid could not be visualised during the later half of pregnancy by USG in this case because of its posterior location and it’s small size and most probably because of hyaline degenerative change reported on histopathological examination. MRI would have been useful in delineating the fibroid in such a situation.

The pedicle could be easily felt on the posterior wall of the uppersegment and clamped and ligated at LSCS in this case. If she had a vaginal delivery, retained placenta with primary postpartum haemorrhage (PPH) would have been the result as there is partial adherence of placenta, that is, on the polyp, and attempts at manual removal would not be successful because of pedunculated polyp and she would have required a laparotomy for the same. A case of pedunculated submucosal myoma that prolapsed during 26 weeks of pregnancy causing preterm labour was reported to be successfully managed by vaginal myomectomy.12 Postnatal complications of pedunculated uterine polyp include PPH, infection, necrosis, prolapse of the polyp and inversion of uterus if the polyp is large. A case of pedunculated submucosal fibroid of lower segment causing PPH is recently reported13 and two cases of infection and necrosis and prolapse were reported in older literature.14

This case illustrates the outcome of pregnancy when the placenta is implanted on the submucosal pedunculated fibroid polyp. Placenta accreta and hyaline change of the fibroid polyp were the outcome. Postpartum haemorrhage and inversion of uterus were prevented in this case because of recognition and prompt action in removing the adherent placenta along with fibroid polyp at LSCS.

Learning points

  • ▶ Placenta can get implanted on the pedunculated submucosal fibroid and can become morbidly adherent.
  • ▶ Fibroid polyp can undergo degenerative change during pregnancy.
  • ▶ Posterior submucous fibroids may not be visualised during late pregnancy.
  • ▶ Pedunculated submucosal fibroids can safely be removed at caesarean section.
  • Competing interests None.
  • Patient consent Obtained.

Footnotes

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Source: BMJ