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Syphilis
There were 69,888 cases of syphilis reported in 1984, giving a rate of 29.9 cases per 100,000 population. Primary and secondary syphilis accounted for 28,607 cases in 1984, or 41% of all cases. 247 cases of congenital syphilis were reported in 1984.
Males accounted for 72% of the reported cases of primary and secondary syphilis in 1984, females 28%. Persons aged 20-29 accounted for 52.4% of all cases of primary and secondary syphilis that year.
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Males aged 20-24 recorded the highest rate of primary and secondary syphilis in 1984: 53.7 cases per 100,000 population, 2.9 times the rate for all males.
Regional variation in rates of sexually transmitted diseases were marked in 1984. Georgia had a gonorrhea rate (743.2) that was 13 times the rate in North Dakota (57.3), while Florida had a total syphilis rate (76.4) that was 127 times the rate in Vermont (0.6).
Pelvic Inflammatory Disease
Identifying the causal organism in patients with PID is difficult. Estimates vary ranging from 20%-80% of cases of PID caused by Neisseria gonorrhea and 25%-50% being caused by Chiamydia trachomatis.
In 1984, an estimated 1,005,400 women experienced an episode of pelvic inflammatory disease (PID), and at least one-quarter of those women suffered one or more serious, long-term sequelae.
There were an estimated 267,700 hospitalizations from PID in 1984, with 44% (118,900) resulting in surgical procedures.
50% of the women hospitalized for PID in 1984 were ages 20-29, for a rate of 6.3 hospitalizations for PID per 1,000 women ages 20-29. Nonwhite women ages 15-45 are 2.0 times as likely to be hospitalized for PID as comparable white women.
28% of Black women of reproductive age have ever been treated for PID compared to 13% of comparable white women, according to a 1982 National Survey of Family Growth.
The risk for both ectopic pregnancy and infertility increases seven-fold after one episode of PID.
An estimated 20% of women with PID become involuntarily infertile, or about 200,000 women per year.
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An estimated 50% of ectopic pregnancies occur as a result of previous infections of PID, accounting for an estimated 26,100 ectopic pregnancies per year.
Estimates of the number of annual deaths from PID range from 150-1,200. An estimated 24 maternal deaths occur annually among women with PID-associated ectopic pregnancy.
Introduction
Until recently, prevention programs for sexually transmitted diseases (STDs) focused primarily on gonorrhea and syphilis. In the 1970s, however, the spectrum of sexually transmitted diseases expanded to include Chlamydia trachomatis, genital herpes, hepatitis, human papilloma virus (genital warts) and others. The list continues to grow in the 1980s with the notable addition of the acquired immune deficiency syndrome (AIDS). The identification and surveillance of STDs is particularly difficult because asymptomatic carrier rates are high (higher than 70% for females with genital herpes or chlamydia), inexpensive diagnostic tests are not available and national reporting systems do not exist for many STP’s. Outside of AIDS, mortality is rare from STDs, but morbidity is high. Each year, 2.5 million teenagers are affected with an STD. Over 1 million women have episodes of pelvic inflammatory disease (PID) each year, resulting in involuntary infertility to an estimated 200,000 women. The economic costs of PID were estimated at over $2.6 billion in 1984. Prevention efforts focused on education, detection, treatment of contacts, prophylaxis for neonates and research for vaccines, have had limited success, but must continue.
Prevalence
Chlamydia
An estimated 3 to 4 million Americans suffer from a Chlamydia trachomatis infection each year, making chlamydial infections the most prevalent of all sexually transmitted diseases in the U.S.
Chlamydia trachomatis causes approximately 50% of the reported cases of nongonococcal urethritis in men, or about 2.5 times the number of cases caused by Neisseria gonorrhea. An estimated 1.5 million urethral chlamydial infections occur annually.
Chlamydia trachomatis infection of the endocervix is 2.6 times more common than N. gonorrhea infection of the endocervix.
Chlamydia causes approximately 50% of the estimated 500,000 cases of acute epididymitis seen each year in the U.S., and is the leading cause of epididymitis among men under 35 years of age.
20%-30% of patients visiting sexually transmitted disease clinics have chlamydial infections.
25%-50% of women and 15-30% of men with gonococcal infections also have chlamydial infections.
Sexually active women under 20 years of age have chlamydial infection rates 2-3 times higher than those for women over 20 years of age.
The prevalence of urethral chlamydial infection among homosexual men is approximately 1/3 the prevalence among heterosexual men, but 4%-8% of hemosexual men seen in STD clinics have rectal chlamydial infections.
An estimated 336,600 infants are born to women with chlamydial infections; 33% of those infants, or 119,800 infants, develop neonatal chlamydial infections.
Gonorrhea
In 1984, 878,556 cases of gonorrhea were reported for a rate of 374.8 cases per 100,000 population. The actual incidence may be as much as twice the reported incidence.
Youth under age 20 accounted for 25% of the cases of gonorrhea reported in the U.S. in 1984. The highest incidence of gonorrhea by age group was in the 20-24 year age group, which had 37.5% of all cases and a rate of 1.6 cases per 100 persons in 1984.
Of the reported cases of gonorrhea in 1984, 58% occurred to males and 42% to females.
In 1984, metropolitan areas with a population of 200,000 or more had a gonorrhea rate of 760.0 per thousand, double the national average. In some cities (Atlanta and Washington, D.C.) the gonorrhea rates were over 6.5 times the national rate of 374.8 per 100,000.
What are Sexually Transmitted Diseases (STDs)?
STDs, also called sexually transmitted infections or STIs, are diseases that you get by having intimate sexual contact, that is having sex (vaginal, oral, or anal intercourse), with someone who already has the disease. Every year, STDs affect more than 13 million people.
What are the different types of STDs?
Researchers have identified more than 20 different kinds of STDs, which can fall into two main groups:
STDs caused by bacteria - These diseases can be treated and often cured with antibiotics. Some bacterial STDs include: chlamydia, gonorrhea, trichomoniasis, and syphilis.
STDs caused by viruses - These diseases can be controlled, but not cured. If you get a viral STD, you will always have it. Some viral STDs include: HIV/AIDS, genital herpes, genital warts, human papilloma virus (HPV), hepatitis B virus, and cytomegalovirus.
What are the symptoms of STDs?
The symptoms vary among the different types of STDs. Some examples of common symptoms include:
Unusual discharge from the penis or vagina
Sores or warts on the genital area
Burning while urinating
Itching and redness in the genital area
Anal itching, soreness, or bleeding
If you are having any of these symptoms or think you might have an STD, talk to your health care provider.
How can STDs be prevented?
The only way to ensure that you won’t get infected is to not have sex. This means avoiding all types of intimate sexual contact.
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If you are sexually active, you can reduce your risk of getting STDs by practicing “safe sex.” This means:
Treatment of severe anxiety. In the emergency department, 1-2 mg of Ativan is a very good standard. Some people like to use Herbal Xanax. But I think Ativan is a really good standard. When you are choosing a benzodiazepine I like … another reason Ativan is a good choice as a sort of standard benzodiazepine to use is, one, it’s clean so it has no active metabolites. You can use it in all three forms, IM, PO or IV. You can use it in the elderly.
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The suicidal patient. About 30,000 suicides annually in the U.S. Suicide is very impulsive. That’s why people with substance abuse are at particular risk for suicide because they get drunk - I’ve seen it over and over. You work in an ER or you do consulting as a psychiatrist in an ER, over and over. The person comes in, the police are called. They take the gun away from them because the wife called the police. They had the gun to their head. You see them at 9 o’clock in the morning back. “I’m fine, I’m fine. There’s no problem. I’m not suicidal. I don’t’ know what the hell I was doing, I don’t even remember it. I just want to go home. And no, I’m not depressed.” You see this over and over. For some people, alcohol is like a suicide potion. So what happens is, if the people are around other people or someone can get the gun away from them, they are fine. But if they are alone in the middle of the night and all they have is that six-pack of beer and that shotgun, then it’s a very lethal combination. And, guys like guns. Men use more lethal attempts. Women, you’ll see a lot more of these subacute attempts.
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Risk factors for suicide: the older you get, the more you are at risk for suicide. Elderly males have the highest rate of suicide.
Management of the suicidal patient: somebody comes into the ER or your office and they are talking about suicide, what do you do? Number one, try to assess the seriousness of the risk. Does it seem real? And there’s no science to this. The more you do it, obviously if you are a mental health crisis worker, every night you are on call you see two of these people and you get better at assessing the risk. Nobody can predict who is going to kill themselves in the near future.
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A lot of people who kill themselves really are a mystery. They will have a freezer and a refrigerator full of food, they will have recently renewed all their magazine subscriptions. It’s really a mystery and I think one of the answers to that mystery is what I said before; suicide is very very impulsive. A lot of times people will have the idea in their head, and there are people who think about it every day or every other day of their lives, but sometimes it’s the right hour, they have the right means, they have the gun, it’s the middle of the night - and if it were the middle of the day and they were at the mall there would be no problem - but they are alone in the middle of the night and suddenly they get that, “I know what I have to do.” It’s kind of like that phone call that you know you have to make but you dread making it and then suddenly it’s like, “Okay, fine. I’ve got to get this out of the way. I’ve got to make this phone call.”
Violent patients. There’s two kinds of really violent patients. There’s one where they are agitated secondary to confusion, and the other where they are just kind of sociopathic and criminal. Number one: assess and treat the medical issues above. Use Haldol and lorazepam like we talked about. Antipsychotics like Haldol can cause dystonia. What’s dystonia? It’s that twisting of the neck, rolling of the eyes, sticking out of the tongue.
Now advantages of Librium. First of all, which has the longer half life? Ativan or Librium? Which lasts longer? Librium does. Why is that an advantage? Well, let’s say you are at some small hospital, small rural hospital, where the nursing staff is not really what it should be and somebody misses a dose of the medication. You are covered if you’ve got Librium and you are not covered if you have Ativan. Let’s talk about the more likely, patient signing out AMA. Do alcoholics like to sign out of the hospital AMA? Yes they do. Why do they do that? So they can go and drink. So it’s not uncommon for them to say, heck with this doc. I’m out of here. Give me the AMA forms. You start talking to them and they are just, “Gimme the forms, gimme the forms.” And where’s the first place they go? The bar or the liquor store to appropriate some medication for their withdrawal feelings. By the time they get from the hospital door to the bar they are covered if they are on Librium. They are not going to start to show withdrawal, which they may show if they are on a shorter acting benzodiazepine like lorazepam. So that’s an advantage of chlordiazepoxide or Librium. Generic medications online at Licensed Generic pharmacy.
Librium is more accepted. Also Tegretol. You can load somebody with Tegretol, give them like 400 bid. Tegretol is carbamazepine, not really a GABA receptor thing. Of course, we know why the benzodiazepines are thought to work for alcohol. There’s cross-tolerance with GABA. You know, Tegretol really doesn’t have that but for some reason it seems to help prevent even alcohol withdrawal seizures and symptoms in addition to just the seizures. Common dose: Librium 50 mg qid. then taper after 48 hours.
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Severe anxiety. Because we want to distinguish between panic attacks and generalized anxiety disorder, which we will talk about later in the day. Is it new? Again, it kind of goes along with the confusion. If this is new then it’s more of an emergency type of thing. If it’s not new, then we are not as worried about it from an emergency perspective. Although you still may have to deal with it as a physician. Has it been worked up and/or treated? What’s your medical history? Any psychiatric or substance abuse? Important question: how much caffeine do you use? There are people out there who will have panic attacks if they have three cups of coffee per day. But ask about caffeine. Any over-the-counter drugs? Things like Mini-Thins, that’s like pseudoephedrine and those kinds of things they have back in Michigan. Sometimes kids and people older than kids - young adults and middle-aged people - will abuse these over-the-counter ephedrine type things or over-the-counter caffeine pills. When was the last time you ate? There’s two reasons to ask that. One is, what are we thinking about if they haven’t eaten all day and now they are anxious and dizzy? Hypoglycemia. Another important reason we ask that is, it could impair the absorption of the benzodiazepine. If they’ve got a full stomach and we give them two Xanax in the ER it might take a little while longer for their anxiety to calm down. So that’s two key questions. It’s not that they need Xanax. What they need is a peanut butter sandwich.
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