Patterns and loss of sexual activity in the year following hospitalization for acute myocardial infarction (a United States National Multisite Observational Study).

A multisite observational study of sexual activity-related outcomes in patients enrolled in the TRIUMPH registry during hospitalization for an acute myocardial infarction (AMI) was conducted to identify patterns and loss of sexual activity 1 year after hospitalization for AMI. Gender-specific multivariable hierarchical models were used to identify correlates of loss of sexual activity including physician counseling. Main outcome measurements included "loss of sexual activity" (less frequent or no sexual activity 1 year after an AMI in those who were sexually active in the year before the AMI) and 1-year mortality.

Expanding the safety net of specialty care for the uninsured: a case study.

Objective: To describe core principles and processes in the implementation of a navigated care program to improve specialty care access for the uninsured.

Study Setting: Academic researchers, safety-net providers, and specialty physicians, partnered with hospitals and advocates for the underserved to establish Project Access-New Haven (PA-NH). PA-NH expands access to specialty care for the uninsured and coordinates care through patient navigation.

Project Access-New Haven: improving access to specialty care for patients without insurance.

Background: Poor access to specialty care among uninsured adults threatens the delivery of quality health care and may contribute to the misuse and overuse of emergency departments and hospitals.

Intervention: We sought to improve access to specialty care through a program called Project Access-New Haven (PA-NH),which engages specialty physicians and hospitals to volunteer in a coordinated-care model for the uninsured. Patient navigators guide patients through the health-care network and help to alleviate administrative obstacles.

Statin myopathy: a common dilemma not reflected in clinical trials.

Although statins are remarkably effective, they are still underprescribed because of concerns about muscle toxicity. We review the aspects of statin myopathy that are important to the primary care physician and provide a guide for evaluating patients on statins who present with muscle complaints. We outline the differential diagnosis, the risks and benefits of statin therapy in patients with possible toxicity, and the subsequent treatment options.

What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study.

Background: Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation.

Objective: To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates.

Design: Qualitative study that used site visits and in-depth interviews.

Community-based group aquatic programme for individuals with multiple sclerosis: a pilot study.

Purpose: The purpose of this study was to determine the feasibility of providing a community-based aquatic exercise programme and to examine the effects of a group aquatic exercise programme in individuals with multiple sclerosis. This study illustrates the implementation of a multidisciplinary community-based programme in a university community wellness centre coordinated with a local advocacy group.

Method: Eleven subjects with multiple sclerosis participated in a 5-week community-based aquatic exercise programme.

Beyond insurance coverage: usual source of care in the treatment of hypertension and hypercholesterolemia. Data from the 2003-2006 National Health and Nutrition Examination Survey.

Background: Expanding insurance coverage, while necessary, may not be sufficient to ensure high-quality care for adults with cardiovascular disease. We sought to examine the association between having a usual source of care (USOC) and receiving medication treatment of hypertension and hypercholesterolemia.

Methods: Using the 2003-2006 National Health and Nutrition Examination Survey, we categorized USOC (a place to go when sick or need medical advice) and insurance status in adults >or=35 years old with an indication for medication treatment of hypertension (n = 3,142) and hypercholesterolemia (n = 1,134), determined using the Joint National Committee 7 and Adult Treatment Panel III recommendations, respectively.

Just how stable are escape rhythms after atrioventricular junction ablation?

Background: Atrioventricular (AV) node ablation with implantation of a permanent pacemaker is an established mode of therapy in the treatment of atrial fibrillation. However, concern exists regarding subsequent dependency on an entirely paced rhythm and the possible sequela of unheralded pacemaker failure. Data regarding escape rhythm lability, an important feature of pacemaker dependency, are limited.

From here to JUPITER: identifying new patients for statin therapy using data from the 1999-2004 National Health and Nutrition Examination Survey.

Background: Guidelines for statin use currently focus on patients with elevated low-density lipoprotein levels. Recent findings from the Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin (JUPITER), however, indicate that statin therapy to reduce cardiovascular risk is also effective among older persons with at-goal low-density lipoprotein but elevated high-sensitivity C-reactive protein levels. We estimate the size of and describe this new population for whom statin therapy may now be indicated based on JUPITER's findings.

Aortic dissection with extension to a patent ductus arteriosus.

An 81-year-old woman presented with shortness of breath and fever of 3 days duration. An enhanced CT of the chest revealed a patent ductus arteriosus (PDA) communicating with the true lumen of an aortic arch dissection. Neither the aortic dissection nor the PDA was suspected.

A new approach to developing cross-cultural communication skills.

The need for cross-cultural training (CCT) increases as physicians encounter more culturally diverse patients. However, most medical schools relegate this topic to non-clinical years, hindering skills development. Some residency programs have successfully addressed this deficit by teaching cross-cultural communication skills in a teaching objective structured clinical examination (tOSCE) context.

Role of single photon emission computed tomography and transcranial Doppler ultrasonography in clinical vasospasm.

This report presents our experience with Transcranial Doppler (TCD) ultrasonography and Single Photon Emission Computed Tomography (SPECT) in the assessment of patients with aneurysmal subarachnoid haemorrhage (SAH). It was designed to evaluate clinical vasospasm with both TCD and SPECT and determine their diagnostic value. Twenty-eight consecutive patients were examined with both TCD and SPECT, performed within 24 hours of each other.

Continuous intrathecal baclofen infusion delivered by a programmable pump for the treatment of severe spasticity following traumatic brain injury.

The aim of this study was to determine the efficacy and safety of intrathecal baclofen (ITB) delivered by a programmable pump for the chronic treatment of severe spasticity due to traumatic brain injury (TBI). Eight patients with severe spasticity following TBI, refractory to oral baclofen or who experienced intolerable side effects, were screened. The first five patients were enrolled in a research protocol that was approved by the Institutional Review Board for Human Research at Boston University Medical Center.

Continuous intrathecal baclofen infusion by a programmable pump in 131 consecutive patients with severe spasticity of spinal origin.

We began this study to determine the efficacy and safety of intrathecal baclofen (ITB) delivered by a programmable pump for the treatment of severe spasticity of spinal cord origin. One hundred fifty two patients with severe spasticity of spinal origin, refractory to oral baclofen, or who experienced intolerable side-effects were given a test dose of ITB. Only those who had a satisfactory response were considered to be appropriate for pump implantation.

Testosterone replacement therapy for hypogonadal men with major depressive disorder: a randomized, placebo-controlled clinical trial.

Background: Symptoms of male hypogonadism include low libido, fatigue, and dysphoria and are alleviated with testosterone replacement. The prevalence of major depressive disorder (MDD) in hypogonadal men is not known, nor is the antidepressant efficacy of testosterone replacement in depressed, hypogonadal men.

Method: A 6-week double-blind, placebo-controlled clinical trial was conducted in 32 men with DSM-IV MDD and a low testosterone level, defined as total serum testosterone < or = 350 ng/dL.

Dysesthesia perceived as painful spasticity: A report of 3 cases.

Lesions of the central nervous system often involve the pyramidal tracts and the sensory pathways to produce spasticity, paresthesias, and dysesthesia. Three patients with intractable spasticity were treated with intrathecal baclofen. Two had an implanted Medtronic SynchroMed pump for long-term delivery of the muscle relaxant.

Brain pH monitoring during ischemia.

Background: Brain tissue acidosis can result from ischemia when cerebral blood flow reduction reaches a critical value. The portable, battery-operated Khuri pH monitor has been used previously in a large number of patients undergoing cardiopulmonary bypass surgery to monitor the intramyocardial pH during aortic clamping. It was found to be easy to use, reliable, and a strong predictor of myocardial preservation.

Treatment of depression in patients with heart disease.

Patients with depression are more likely than patients without depression to develop ischemic heart disease and suffer cardiac-related death. Recent evidence suggests that the association between depression and increased cardiac mortality may in part be due to an increase in platelet activity and an imbalance in sympathetic and parasympathetic activity that makes the patient more susceptible to ventricular fibrillation. Available data suggest that the tricyclic antidepressants (TCAs) may increase the risk of mortality in patients with ischemic heart disease.

Treating depression in patients with ischaemic heart disease: which agents are best to use and to avoid?

There are a number of dimensions to the complex relationship between cardiovascular disease and affective disorders including: (i) patients with depression are at an increased risk of dying from sudden cardiovascular death compared with the general population; (ii) patients with depression over the course of a lifetime have a higher rate of symptomatic and fatal ischaemic heart disease compared with a control group without depression; and, (iii) patients after either a myocardial or a cerebrovascular infarction who are depressed have a higher mortality rate than their medically comparable nondepressed counterparts. The deleterious impact of depression on the prognosis of cardiac disease and the suggestion that treatment of depression may reduce cardiac mortality has led clinicians to seek safe and effective treatment for patients with comorbid depression and ischaemic disease. Though they are robustly effective, the tricyclic antidepressants are type 1A antiarrhythmic agents and presumably carry the same risk in patients with ischaemic disease as treatment with other type 1 antiarrhythmics such as moricizine.

Lymphocytic hypophysitis.

A male patient with lymphocytic hypophysitis is reported on. Lymphocytic hypophysitis is a rare disease that may mimic pituitary adenoma and occurs mostly in women in the peripartum period. Only six other cases have been reported in men.

Chronic intrathecal delivery of baclofen by a programmable pump for the treatment of severe spasticity.

The aim of this study was to determine the efficacy, safety, and cost-effectiveness of intrathecal baclofen delivered by a programmable pump for the chronic treatment of severe spasticity. Sixty-six patients with severe spasticity of spinal cord origin that was refractory to oral baclofen or who experienced intolerable side effects with this form of the drug were screened. The first nine participated in a double-blinded, randomized, placebo (normal saline)-controlled trial to determine response to a bolus dose of intrathecal baclofen.