Secret History: Return of the Black Death Channel 4, 7-8pm In 1348 the Black Death swept through London, killing people within days of the appearance of their first symptoms. Exactly how many died, and why, has long been a mystery. This Secret History documentary follows experts as they pick through the evidence and reveal why the plague killed on such a scale. And they ask, what might be coming next?

Medscape

The purpose of this report is to provide revised standards and guidelines for the exercise testing and training of individuals who are free from clinical manifestations of cardiovascular disease and those with known cardiovascular disease. These guidelines are intended for physicians, nurses, exercise physiologists, specialists, technologists, and other healthcare professionals involved in exercise testing and training of these populations. This report is in accord with the “Statement on Exercise” published by the American Heart Association (AHA).1

These guidelines are a revision of the 1995 standards of the AHA that addressed the issues of exercise testing and training.2 An update of background, scientific rationale, and selected references is provided, and current issues of practical importance in the clinical use of these standards are considered. These guidelines are in accord with the American College of Cardiology (ACC)/AHA Guidelines for Exercise Testing.3

### The Cardiovascular Response to Exercise

Exercise, a common physiological stress, can elicit cardiovascular abnormalities that are not present at rest, and it can be used to determine the adequacy of cardiac function. Because exercise is only one of many stresses to which humans can be exposed, it is more appropriate to call an exercise test exactly that and not a “stress test.” This is particularly relevant considering the increased use of nonexercise stress tests.

### Types of Exercise

Three types of muscular contraction or exercise can be applied as a stress to the cardiovascular system: isometric (static), isotonic (dynamic or locomotory), and resistance (a combination of isometric and isotonic).4,5 Isotonic exercise, which is defined as a muscular contraction resulting in movement, primarily provides a volume load to the left ventricle, and the response is proportional to the size of the working muscle mass and the intensity of exercise. Isometric exercise is defined as a muscular contraction without movement (eg, handgrip) and imposes greater pressure than volume …

Exercise Standards for Testing and Training A Scientific Statement From the American Heart Association

Meta-analyses of studies yielding sex-specific risk of potentially traumatic events (PTEs) and posttraumatic stress disorder (PTSD) indicated that female participants were more likely than male participants to meet criteria for PTSD, although they were less likely to experience PTEs. Female participants were more likely than male participants to experience sexual assault and child sexual abuse, but less likely to experience accidents, nonsexual assaults, witnessing death or injury, disaster or fire, and combat or war. Among victims of specific PTEs (excluding sexual assault or abuse), female participants exhibited greater PTSD. Thus, sex differences in risk of exposure to particular types of PTE can only partially account for the differential PTSD risk in male and female participants.

/pdf/sex-differences-in-trauma-and-posttraumatic-stress-disorder-2z87gssboo.pdf

Sex differences in trauma and posttraumatic stress disorder: a quantitative review of 25 years of research.

Death is the new sex, last great taboo in Western society and Western medicine, as Richard Smith discusses in his editorial (p 129). In the trinity of births, marriages, and deaths, only death does not have glossy magazines devoted to stylish consumption at the attendant ceremonies. On the web, of course, …

Death and dying

BIOMEDICAL RESEARCH POLICY COMMITTEE REPORT WAS PUBLISHED AS A SUPPLEMENT TO THE AUGUSTJOURNAL OF MEDICAL EDUCATION. A REPRINT IS ENCLOSED. REQUESTS FOR ADDITIONAL COPIES SHOULD BE ADDRESSED TO THISOFFICE. -COPIES ARE BEING SENT TO MEMBERS OF CONGRESS AND THE KEY MEMBERS OF THE ADMINISTRATION. CALLING UPON-YOUR SENATORSAND CONGRESSMEN TO TELL THE STORY OF THE ROLE. OF MEDICAL SCHOOLS IN BIOMEDICAL RESEARCH AND HEALTH CARE IS IMPORTANT.I STRONGLY URGE THAT YOU MAKE AN 411 APPOINTMENT TO SEE YOUR CONGRESSIONAL REPRESENTATIVES WHILE YOU ARE IN WASHINGTON FOR THE COUNCIL MEETINGON OCTOBER 29. UPON REQUEST WE CAN SUPPLY THE NAMES OF APPOINTMENT SECRETARIES AND PHONE NUMBERS OF YOUR SENATORS AND CONGRESSMEN. APPROPRIATIONS COMMITTEE ACTED WITH EXTRAORDINARY ALACRITY THIS YEAR. THE-NIH APPROPRIATION WAS INCREASED BY 242 MILLION DOLLARSOVER 1971, REPRESENTING A 142 MILLION DOLLAR INCREASE OVER. THE ADMINISTRATION BUDGET, THE BLUE SHEET ASCRIBES APPROPRIATIONS OUTCOME TO THE EFFECTIVENESS OF THE COALITION FOR HEALTH FUNDING UNDER THE LEADERSHIP OF JOHN A. D. COOPER.

The Association of American Medical Colleges

Objective The authors review their experience with laparoscopic adrenalectomy in patients with benign adrenal neoplasms. Efficacy, safety, and cost effectiveness of the procedure are examined. Background Laparoscopic adrenalectomy is replacing open adrenalectomy in some medical centers as the standard surgical approach for uncomplicated tumors. However, laparoscopic adrenalectomy often is considered more difficult and more expensive than traditional open surgery. Methods Perioperative and postoperative records as well as hospital charges from the first 19 patients undergoing laparoscopic unilateral adrenalectomies at the authors' medical institutions were examined and compared with 19 patients who underwent open unilateral adrenalectomies. Results None of the 19 patients undergoing unilateral laparoscopic adrenalectomy required conversion to open adrenalectomy. Mean operative times as well as total hospital charges were similar in those patients undergoing ether laparoscopic or open adrenalectomy. However, the morbidity and postoperative length of hospital stay were significantly less in those patients undergoing laparoscopic adrenalectomy. Conclusions Laparoscopic adrenalectomy can be performed safety and with the benefits associated with minimally invasive surgery. In addition, the procedure is cost effective. These factors suggest that laparoscopic adrenalectomy should be the preferential surgical technique for benign adrenal disease.

Laparoscopic Adrenalectomy: A New Standard of Care

OBJECTIVE: The war in Bosnia has had a tremendous impact on civilians. Little is known about the impact of modern warfare on children. This survey documents the nature and frequency of war-related experiences among Bosnian children and describes their manifestations of selected psychological sequelae. METHODS: A cross-sectional survey of 364 internally displaced 6- to 12-year-old children and their parents living in central Bosnian collectives was conducted during the war. Parents were surveyed for their children's war experiences; the children were surveyed for war-related distress symptoms. RESULTS: The children were exposed to virtually all of the surveyed war-related experiences. The majority had faced separations from family, bereavement, close contact with war and combat, and extreme deprivation. The prevalence and severity of experiences were not significantly related to a child's gender, wealth, or age, but were related to their region of residence, with children from the region of Sarajevo having the highest prevalence of experiences. Almost 94% of the children met Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria for posttraumatic stress disorder. Significant life activity affecting sadness and anxiety were reported by 90.6% and 95.5% of the children, respectively. High levels of other symptoms surveyed were also found. Children with greater symptoms had witnessed the death, injury, or torture of a member of their nuclear family, were older, and came from a large city. CONCLUSIONS: The war-related experiences of the children studied were both varied and severe, and were associated with a variety of psychological sequelae. This experience underscores the vulnerability of civilians in areas of conflict and the need to address the effects of war on the mental health of children. Language: en

War experiences and distress symptoms of Bosnian children.

This study asks parents who have children with Down syndrome how they feel about their lives so that such information could be shared with expectant couples during prenatal counseling sessions. A valid and reliable survey instrument was mailed to 4,924 households on the mailing lists of six non-profit Down syndrome organizations. Of the 2,044 respondents, 99% reported that they love their son or daughter; 97% were proud of them; 79% felt their outlook on life was more positive because of them; 5% felt embarrassed by them; and 4% regretted having them. The parents report that 95% of their sons or daughters without Down syndrome have good relationships with their siblings with Down syndrome. The overwhelming majority of parents surveyed report that they are happy with their decision to have their child with Down syndrome and indicate that their sons and daughters are great sources of love and pride.

/pdf/having-a-son-or-daughter-with-down-syndrome-perspectives-1mut0t8gec.pdf

Having a son or daughter with Down syndrome: Perspectives from mothers and fathers†‡

This study asks people with Down syndrome, ages 12 and older, about their self-perception so that their information could be shared with new and expectant parents of children with Down syndrome. We analyzed valid and reliable survey instruments from 284 people with Down syndrome on the mailing lists of six non-profit Down syndrome organizations around the country. Among those surveyed, nearly 99% of people with Down syndrome indicated that they were happy with their lives; 97% liked who they are; and 96% liked how they look. Nearly 99% people with Down syndrome expressed love for their families, and 97% liked their brothers and sisters. While 86% of people with Down syndrome felt they could make friends easily, those with difficulties mostly had isolating living situations. A small percentage expressed sadness about their life. In our qualitative analysis, people with Down syndrome encouraged parents to love their babies with Down syndrome, mentioning that their own lives were good. They further encouraged healthcare professionals to value them, emphasizing that they share similar hopes and dreams as people without Down syndrome. Overall, the overwhelming majority of people with Down syndrome surveyed indicate they live happy and fulfilling lives.

/pdf/self-perceptions-from-people-with-down-syndrome-bx2h8hvzq1.pdf

Self-perceptions from people with Down syndrome.

OBJECTIVES: From among physiological attributes commonly targeted in rehabilitation, to identify those in which changes led to clinically meaningful differences (CMDs) in mobility outcomes.

DESIGN: Secondary analysis of data collected for a randomized controlled trial of exercise using binary outcomes defined by recording a large CMD (Short Physical Performance Battery (SPPB)=1 unit; gait speed (GS)=0.1 m/s). Iterative models were performed to evaluate possible confounding between physiological variables and relevant covariates.

SETTING: Outpatient rehabilitation centers.

PARTICIPANTS: Community-dwelling mobility-limited older adults (n=116) participating in a 16-week randomized controlled trial of two modes of exercise.

MEASUREMENTS: Physiological measures included leg power, leg strength, balance as measured according to the Performance-Oriented Mobility Assessment (POMA), and rate pressure product at the maximal stage of an exercise tolerance test. Outcomes included GS and SPPB. Leg power and leg strength were measured using computerized pneumatic strength training equipment and recorded in Watts and Newtons, respectively.

RESULTS: Participants were 68% female, had a mean age of 75.2, a mean of 5.5 chronic conditions, and a baseline mean SPPB score of 8.7. After controlling for age, site, group assignment, and baseline outcome values, leg power was the only attribute in which changes were significantly associated with a large CMD in SPPB (odds ratio (OR)=1.48, 95% confidence interval (CI)=1.09�2.02) and GS (OR=1.31, 95% CI=1.01�1.70).

CONCLUSION: Improvements in leg power, independent of strength, appear to make an important contribution to clinically meaningful improvements in SPPB and GS.

Richard D. Goldstein

Papers

Laparoscopic Adrenalectomy: A New Standard of Care

War experiences and distress symptoms of Bosnian children.

Having a son or daughter with Down syndrome: Perspectives from mothers and fathers†‡

Self-perceptions from people with Down syndrome.

Are Changes in Leg Power Responsible for Clinically Meaningful Improvements in Mobility in Older Adults