An Aberrant Internal Carotid Artery in the Mouth

To the Editor:

The cervical internal carotid artery normally runs straight to the skull base without branching.(1) However, aberrant courses of the extracranial internal carotid artery are not rare and may place the vessel in close relationship with the pharyngeal wall.(2, 3) We present this clinical observation to draw the readers' attention on a probably underappreciated anatomic variation.

A 77-year-old woman had long-standing moderate dysphagia and right-sided foreign body sensations in the throat. She had no history of alcohol or tobacco abuse. On examination, smooth irritation-free mucous membranes were found, but a funicular pulsatile mass was detected on the posterior pharyngeal wall on the right (Figure 1A). Endoscopy displayed that the mass continued down to the hypopharynx. It was finally attributed to an aberrant course of the internal carotid artery (Figure 1B). The patient was instructed to advise every treating physician of this anatomic variation and to abstain from sharp-edged food such as chicken bones and fish.

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-- Jens Pfeiffer, MD, Gerd J. Ridder, MD

This article was originally published in the March 2009 issue of The American Journal of Medicine.

Alcohol and Illicit Drug Use as Precipitants of Atrial Fibrillation in Young Adults: A Case Series and Literature Review

Abstract
Background

Atrial fibrillation in young patients (≤45 years) is uncommon. There is the perception that the precipitant in such cases is alcohol, but we also have noted cases related to illicit drug abuse. There are no clear guidelines on the treatment of atrial fibrillation in patients presenting with “lone atrial fibrillation” precipitated by alcohol or illicit drugs.

Methods

We retrospectively analyzed young (defined as ≤45 years) patients with “lone” atrial fibrillation who were admitted to the hospital with electrocardiographically confirmed diagnosis of atrial fibrillation or atrial flutter, precipitated by either alcohol or illicit drugs, over a 6-year period.

Results

Eighty-eight patients aged ≤45 years were admitted with atrial fibrillation or atrial flutter. In 22 patients, (mean [SD] age 33.6 [8.4] years; 20 male), alcohol (n = 19) and/or illicit drugs (n = 3) were found to be the precipitant. One patient required electrical cardioversion, with the remaining patients cardioverting back to sinus rhythm either pharmacologically or spontaneously. Twelve (54.5%) were investigated for atrial fibrillation burden by 24-hour Holter monitoring and the majority also underwent a transthoracic echocardiogram (81.8%). At discharge, 14 (63.6%) patients were treated with anti-arrhythmic drugs and 10 received either antiplatelets or anticoagulants. Most (85%) patients were followed-up for at least 12 months, during which time 6 had further paroxysms; all of whom continued to abuse either alcohol or illicit drugs.

Conclusions

Alcohol and illicit drugs are arrhythmogenic and are associated with atrial fibrillation. Apart from abstinence, the optimal management of such patients and the long-term effects of these substances on the heart and atrial fibrillation recurrences are still unclear.

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-- Suresh Krishnamoorthy, MRCP, Gregory Y.H. Lip, MD, Deirdre A. Lane, PhD

This article was originally published in the September 2009 issue of The American Journal of Medicine.

Incidence of Thrombocytopenia in Hospitalized Patients with Venous Thromboembolism

Although heparin-associated thrombocytopenia is uncommon, the incidence can be minimized by use of low molecular weight heparin, particularly if extended prophylaxis or extended treatment is required.

Abstract
Purpose
To determine the incidence of heparin-associated thrombocytopenia in patients receiving prophylaxis or treatment for venous thromboembolism.

Methods
We assessed the database of the National Hospital Discharge Survey from 1979 through 2005 and complemented this with a meta-analysis of published literature.

Results
Among 10,554,000 patients discharged from short-stay hospitals throughout the US with venous thromboembolism during the 27 years of study, secondary thrombocytopenia was coded in 38,000 patients (0.36%). From 1979 through 1992, secondary thrombocytopenia was coded in only 0.15% of hospitalized patients with venous thromboembolism. The frequency increased sharply to 0.54% from 1993 through 2005. Secondary thrombocytopenia was rarely diagnosed among 1,446,000 patients aged <40 years and among 77,000 women who had venous thromboembolism with deliveries. Meta-analysis of published literature showed a higher incidence among patients who received unfractionated heparin (UFH) for prophylaxis than those who received low-molecular-weight heparin (LMWH) for prophylaxis. Treatment resulted in smaller differences of the incidence between UFH and LMWH.

Conclusion
Heparin-associated thrombocytopenia is rare among patients aged <40 years and women following delivery. The risk of heparin-associated thrombocytopenia is more duration-related than dose-related, and higher with UFH when used for an extended duration. Our findings and those of the literature suggest that although heparin-associated thrombocytopenia is uncommon, the incidence can be minimized by use of LMWH, particularly if extended prophylaxis or extended treatment is required.

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-- Paul D. Stein, MD, Russell D. Hull, MBBS, MSc, Fadi Matta, MD, Abdo Y. Yaekoub, MDc, Jane Liang, MSc

This article was originally published in the October 2009 issue of The American Journal of Medicine.

The Patient–Physician–Industry–Government Partnership: A Societal Good

I recently celebrated the 40th anniversary of my graduation from medical school at a class reunion in Boston. While reminiscing with my former classmates about the joys and tribulations of living as a student during the 1960s, a discussion arose regarding what was available to us then in the area of pharmacotherapeutics compared with what is now available for practicing physicians. In regard to treatments for cardiovascular disease, my area of internal medicine subspecialty, we had nitrates for angina pectoris; digitalis preparations and furosemide for heart failure; hydrochlorothiazide, reserpine, guanethidine, hydralazine, and alpha-methyldopa for hypertension; quinidine, lidocaine, and procainamide for arrhythmias; and bile acid resins for hypercholesterolemia. Since 1969, with the advances in basic research supported by the National Institutes of Health (NIH) and the development of new drugs by the pharmaceutical industry, we now have available for clinical use the beta-adrenergic blockers and calcium-entry blockers for the treatment of angina pectoris; angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for heart failure; new drugs for systemic and pulmonary hypertension; thrombolytics for myocardial infarction; statins for hypercholesterolemia; and new antiplatelet drugs. These newer therapies have favorably affected both the prevention and treatment of cardiovascular disease.

As examples, over the past 40 years, major reductions have occurred in the numbers of acute myocardial infarctions, in part related to innovative drug therapies for cholesterol elevations, hypertension, and smoking addiction.

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- William H. Frishman, MD

This article was originally published in the October 2009 issue of The American Journal of Medicine.

Mortality after Hospitalization with Mild, Moderate, and Severe Hyponatremia

Hyponatremia is present on admission in almost 15% of hospitalized patients. Even mild hyponatremia carries a significantly increased risk of death in hospital. The risk of death associated with hyponatremia appears to be particularly strong in patients with cardiovascular disease, cancer, and those undergoing orthopedic procedures.

Abstract
Background
Hyponatremia is the most common electrolyte abnormality in hospitalized individuals.

Methods
To investigate the association between serum sodium concentration and mortality, we conducted a prospective cohort study of 98,411 adults hospitalized between 2000 and 2003 at 2 teaching hospitals in Boston, Massachusetts. The main outcome measures were in-hospital, 1-year, and 5-year mortality. Multivariable logistic regression and Cox proportional hazards models were used to compare outcomes in patients with varying degrees of hyponatremia against those with normal serum sodium concentration.

Results
Hyponatremia (serum sodium concentration <135 mEq/L) was observed in 14.5% of patients on initial measurement. Compared with patients with normonatremia (135-144 mEq/L), those with hyponatremia were older (67.0 vs 63.1 years, P<.001) and had more comorbid conditions (mean Deyo-Charlson Index 1.9 vs 1.4, P <.001). In multivariable-adjusted models, patients with hyponatremia had an increased risk of death in hospital (odds ratio 1.47, 95% confidence interval [CI], 1.33-1.62), at 1 year (hazard ratio 1.38, 95% CI, 1.32-1.46), and at 5 years (hazard ratio 1.25, 95% CI, 1.21-1.30). The increased risk of death was evident even in those with mild hyponatremia (130-134 mEq/L; odds ratio 1.37, 95% CI, 1.23-1.52). The relationship between hyponatremia and mortality was pronounced in patients admitted with cardiovascular disease, metastatic cancer, and those admitted for procedures related to the musculoskeletal system. Resolution of hyponatremia during hospitalization attenuated the increased mortality risk conferred by hyponatremia.

Conclusion
Hyponatremia, even when mild, is associated with increased mortality.

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-- Sushrut S. Waikar, MD, MPH, David B. Mount, MD, Gary C. Curhan, MD, ScD

This article was originally published in the September 2009 issue of The American Journal of Medicine.

Seriously Stressed

Presentation
Substance abuse—or more likely, its abrupt cessation—was a likely trigger for an unusual cardiac syndrome. A 25-year-old woman was brought to the emergency department from home after a seizure episode. En route to the hospital, the patient lost consciousness, and the emergency medical team discovered that she was in torsades de pointes, which then progressed to ventricular fibrillation. The patient was defibrillated to sinus tachycardia with a monophasic waveform shock of 360 J. She was successfully resuscitated, regained consciousness, and denied any chest pain or shortness of breath. On further questioning, she denied any past history of arrhythmia or family history of sudden cardiac arrest or unexplained death.

Assessment
The patient admitted to daily heavy alcohol consumption, and 3 days before hospitalization, she had used cocaine. Her potassium and magnesium levels on admission were 3.2 mEq/L and 1.4 mg/dL, respectively. An electrocardiogram (ECG) performed 3 hours after resuscitation revealed a narrow complex sinus tachycardia with deep, inverted T waves in leads II, III, AVF, and V3-V6, and a remarkably prolonged QTc interval of more than 660 msec (Figure 1). She was not taking any medications known to prolong the QT interval.

Serial cardiac enzymes remained within the normal range. A chest X-ray and computed tomography of the head were normal. However, a transthoracic echocardiogram disclosed an anteroapical regional wall motion abnormality and a reduced left-ventricular ejection fraction of 35-40%. Coronary angiography was normal. Left ventriculography showed basal hyperkinesis with apical ballooning, a finding consistent with takotsubo cardiomyopathy. The condition also is known as stress cardiomyopathy, because it can be induced by short-term emotional or physiologic stress.

Diagnosis
Our patient's diagnosis of takotsubo cardiomyopathy was based on the following criteria: transient hypokinesis, akinesis, or dyskinesis of the left ventricular apical and mid-ventricular segments; absence of obstructive coronary artery disease; ECG changes, either ST-segment elevation and/or T-wave inversion; and absence of head trauma, intracranial bleeding, pheochromocytoma, hypertrophic obstructive cardiomyopathy, or myocarditis.(1, 2)

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-- Nishant Kalra, MD, Prashant Khetpal, MD, MPH, Vincent L. Sorrell, MD

This article was originally published in the August 2009 issue of The American Journal of Medicine.

Mild Hyponatremia Carries a Poor Prognosis in Community Subjects

Abstract
Objective
Hyponatremia has been shown to predict adverse outcome in congestive heart failure and pneumonia among other common clinical entities, but its significance in the general population is elusive.

Methods
The population-based Copenhagen Holter Study included 671 men and women aged 55 to 75 years with no history of cardiovascular disease, stroke, or cancer. Baseline evaluation included 48-hour ambulatory electrocardiogram monitoring, blood tests, and a questionnaire. Hyponatremia was defined as s-Na ≤ 134 mEq/L or s-Na ≤ 137 mEq/L according to previously accepted definitions. An adverse outcome was defined as deaths or myocardial infarction. Median follow-up was 6.3 years.

Results
Fourteen subjects (2.1%, group A) had s-Na ≤ 134 mEq/L, and 62 subjects (9.2%, group B) had s-Na ≤ 137 mEq/L. No subject had s-Na < 129 mEq/L. An adverse outcome occurred in 43% of group A, 27% of group B, and 14% of subjects with s-Na >137mEq/L (controls) (P <.002). Adjusted hazard ratio for adverse outcome was 3.56 (95% confidence interval [CI], 1.53-8.28, P <.005) in group A compared with controls and 2.21 (95% CI, 1.29-3.80, P <.005) in group B after controlling for age, gender, smoking, diabetes, low-density lipoprotein cholesterol, and blood pressure. The hazard ratios were robust for additional adjusting for variables showing univariate association to hyponatremia (ie, beta-blocker and diuretic use, heart rate variability, creatinine, C-reactive protein, and NT-pro brain natriuretic peptide). By excluding diuretic users (18% of subjects), the adjusted hazard ratio for adverse outcome was 8.00 (95% CI, 3.04-21.0, P <.0001) in group A and 3.17 (95% CI, 1.76-5.72, P = .0001) in group B compared with controls.

Conclusion
Hyponatremia is an independent predictor of deaths and myocardial infarction in middle-aged and elderly community subjects.

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-- Ahmad Sajadieh, MD, DMSc, Zeynep Binici, MD, Mette Rauhe Mouridsen, MD, Olav Wendelboe Nielsen, MD, PhD, DMSc, Jørgen Fischer Hansen, MD, DMSc, Steen B. Haugaard, MD, DMSc

This article was originally published in the July 2009 issue of The American Journal of Medicine.

Psychiatric Comorbidity and Other Psychological Factors in Patients with “Chronic Lyme Disease”

This study found that misdiagnosis of Lyme disease was common, resulting in repeated and unnecessary antibiotic treatment. Psychiatric comorbidity and other psychological factors were associated with functional outcomes.

Abstract
Background
There is no evidence of current or previous Borrelia burgdorferi infection in most patients evaluated at university-based Lyme disease referral centers. Instead, psychological factors likely exacerbate the persistent diffuse symptoms or “Chronic Multisymptom Illness” (CMI) incorrectly ascribed to an ongoing chronic infection with B. burgdorferi. The objective of this study was to assess the medical and psychiatric status of such patients and compare these findings to those from patients without CMI.

Methods
There were 240 consecutive patients who underwent medical evaluation and were screened for clinical disorders (eg, depression and anxiety) with diagnoses confirmed by structured clinical interviews at an academic Lyme disease referral center in New Jersey. Personality disorders, catastrophizing, and negative and positive affect also were evaluated, and all factors were compared between groups and with functional outcomes.

Results
Of our sample, 60.4% had symptoms that could not be explained by current Lyme disease or another medical condition other than CMI. After adjusting for age and sex, clinical disorders were more common in CMI than in the comparison group (P <.001, odds ratio 3.54, 95% confidence interval, 1.97-6.55), but personality disorders were not significantly more common. CMI patients had higher negative affect, lower positive affect, and a greater tendency to catastrophize pain (P <.001) than did the comparison group. Except for personality disorders, all psychological factors were related to worse functioning. Our explanatory model based on these factors was confirmed.

Conclusions
Psychiatric comorbidity and other psychological factors are prominent in the presentation and outcome of some patients who inaccurately ascribe longstanding symptoms to “chronic Lyme disease.”

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-- Afton L. Hassett, PsyD, Diane C. Radvanski, MS, Steven Buyske, PhD, Shantal V. Savage, BA, Leonard H. Sigal, MD

This article was originally published in the September 2009 issue of The American Journal of Medicine.

“Common Sense Is Not So Common” (What We All Need to Remember) – Part Two

Common Sense Is Not So Common.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764

This essay is the second of 2 dealing with clinical aphorisms that I have derived during many years of clinical experience. The first part contained 8 items and was published in the August issue of The American Journal of Medicine.

Rule # 9: Physician, heal thyself. The physician should be a model of good health habits for 2 reasons. First, patients are unlikely to follow the advice of someone who they believe is hypocritical. A doctor who smokes cigarettes will hardly be believed when informing patients that they have to stop smoking. Secondly, physicians with poor health habits eventually become patients themselves; it is difficult to be an effective health care provider when one's own health is impaired.

Rule # 10: Respect your fellow health care workers; they are your most important clinical asset. Just as no man is an island, no physician works in isolation. The health care team consists of nurses, physician assistants, technicians, laboratory staff, administrators, and many other individuals who make the health care system run smoothly. It is essential that the physician, as the leader of the clinical team, establish smooth working relationships with the many individuals in that unit. Friction, irritation, and bad humor in the environment lead to poor performance and, in the end, harm the patient. When I was a medical student, Judah Folkman informed my classmates and me that if we had a negative relationship with the nurses in the hospital during our clinical rotations then we would be better off selecting a profession other than medicine (personal communication, Judah Folkman, 1967).

Rule # 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient. Proof of this aphorism can be obtained easily if one takes an objective and uninvolved look at patients in an intensive care unit setting. Many of these individuals are tied to the bed and connected to a variety of tubes that emerge from nearly every natural orifice as well as many iatrogenic orifices. Patients are often unable to communicate with caregivers because of tracheal intubation. Usually they are given periodic doses of mind-altering substances and often are left by themselves for periods of time even in the intensive care environment. Therefore, it is imperative that we periodically take a step back from the bedside and decide what our goals are for these patients. Is there a reasonable chance that all that is being done to them will result in meaningful survival? If the answer to this last question is “no” or “probably not,” then the time has come to start discussing plans with the patient's family for discontinuing life support.

An important corollary to this aphorism is that many patients in the United States undergo excessive testing in the name of defensive medicine. One example is the excessive numbers of brain computed tomography scans that are performed on patients with minimal head trauma or vague histories of headache. In a similar vein, many patients with atypical chest pain are admitted to coronary care units. Much of this excessive utilization of diagnostic services could be eliminated if physicians took the care to obtain a comprehensive history from the patient and spent a few minutes explaining to the patient why certain tests are being performed and why others are not indicated. Many malpractice lawsuits arise as a result of poor communication between the doctor and the patient and not because of medical errors. Establishing rapport with the patient by taking a careful history—the “careful listening” referred to by William Carlos Williams (1883-1963)—is the physician's best defense against liability risk.

Rule # 12: True, true, and unrelated. This phrase refers to a commonly used form of question on medical knowledge examinations. A series of possibly related entities are presented, and the examinee is asked to pair them and state whether they are related or not with respect to causation. Situations often arise in clinical medicine in which one event or one physical finding occurs in close proximity to a second event or finding. However, these 2 events may be related to each other, or they may have occurred spontaneously without any relationship.

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-- Joseph S. Alpert, MD

This article was originally published in the September 2009 issue of The American Journal of Medicine.

Vitamin D: Bone and Beyond, Rationale and Recommendations for Supplementation

Abstract
Adequate vitamin D status is necessary and beneficial for health, although deficiency plagues much of the world's population. In addition to reducing the risk for bone disease, vitamin D plays a role in reduction of falls, as well as decreases in pain, autoimmune diseases, cancer, heart disease, mortality, and cognitive function. On the basis of this emerging understanding, improving patients' vitamin D status has become an essential aspect of primary care. Although some have suggested increased sun exposure to increase serum vitamin D levels, this has the potential to induce photoaging and skin cancer, especially in patients at risk for these conditions. Vitamin D deficiency and insufficiency can be both corrected and prevented safely through supplementation.

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-- Sarah A. Stechschulte, BA, Robert S. Kirsner, MD, PhD, Daniel G. Federman, MD

This article was originally published in the September 2009 issue of The American Journal of Medicine.

Medical Bankruptcy in the United States, 2007: Results of a National Study

In 2001 in 5 states sampled, it was found that medical problems contributed to at least 46.2% of all bankruptcies. Since then, health costs and the numbers of un- and underinsured have increased, and bankruptcy laws have tightened. Despite these factors, medical related bankruptcy increased to 62.1% of all bankruptcies in 2007. Illness and medical bills contribute to a large and increasing share of US bankruptcies.

Abstract
Background
Our 2001 study in 5 states found that medical problems contributed to at least 46.2% of all bankruptcies. Since then, health costs and the numbers of un- and underinsured have increased, and bankruptcy laws have tightened.

Methods
We surveyed a random national sample of 2314 bankruptcy filers in 2007, abstracted their court records, and interviewed 1032 of them. We designated bankruptcies as “medical” based on debtors' stated reasons for filing, income loss due to illness, and the magnitude of their medical debts.

Results
Using a conservative definition, 62.1% of all bankruptcies in 2007 were medical; 92% of these medical debtors had medical debts over $5000, or 10% of pretax family income. The rest met criteria for medical bankruptcy because they had lost significant income due to illness or mortgaged a home to pay medical bills. Most medical debtors were well educated, owned homes, and had middle-class occupations. Three quarters had health insurance. Using identical definitions in 2001 and 2007, the share of bankruptcies attributable to medical problems rose by 49.6%. In logistic regression analysis controlling for demographic factors, the odds that a bankruptcy had a medical cause was 2.38-fold higher in 2007 than in 2001.

Conclusions
Illness and medical bills contribute to a large and increasing share of US bankruptcies.

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-- David U. Himmelstein, MD, Deborah Thorne, PhD, Elizabeth Warren, JD, Steffie Woolhandler, MD, MPH

This article was originally published in the August 2009 issue of The American Journal of Medicine.

Only in America: Bankruptcy Due to Health Care Costs

The article by Himmelstein et al in the August 2009 issue of the The American Journal of Medicine documents that health care expenses were the most common cause of bankruptcy in the United States in 2007, accounting for 62% of US bankruptcies compared with 8% in 1981.

Most bankruptcies occurred in middle-class citizens with health insurance, further evidence that our current health care system, based on for-profit, employment-based health insurance, is not working. Millions of Americans have limited access to health care because they cannot afford health insurance. Millions of others, such as those who have to file for bankruptcy because of health care costs, have inadequate health insurance. It is estimated that 1 in 5 Americans goes without health insurance or has inadequate health insurance.

Why is the United States, one of the richest countries in the world, the only major industrial nation that is unable to provide access to health care to all its citizens? Are there any other nations whose citizens have to declare bankruptcy because of health care expenses?

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-- James E. Dalen, MD, MPH

This article was originally published in the August 2009 issue of The American Journal of Medicine.

“Common Sense Is Not So Common” (What We All Need to Remember)—Part One

Common Sense Is Not So Common.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764

This editorial is the second time I have discussed clinical aphorisms that have proved useful for me during more than 30 years of inpatient and outpatient attending at 4 US medical schools. The last time I put this list of aphorisms together, it contained 10 items. The current commentary will be published sequentially in 2 parts with 8 aphorisms in part I and 7 additional items in part II for a total of 15.

Rule 1: Common things occur commonly. I make this point continuously to medical students and residents. Sometimes young clinicians will suggest an unusual diagnosis for a patient with the hope of being the only doctor to make the correct diagnosis. More experienced clinicians believe the correct diagnosis is usually something common. For example, consider a patient with an enlarged spleen. In North America, splenomegaly rarely results from entities such as primary lymphoma of the spleen or malaria. Rather, splenomegaly is often caused by portal hypertension or mononucleosis. One of my first, and best, residents during my internship told me “If it looks like a horse, whinnies like a horse, and smells like a horse, don't expect a zebra to appear” (Stone N, MD, personal communication, 1970).

The experienced clinician is aware of the relative incidence of various illnesses in his/her community, and, unless there are unusual features in a particular patient's clinical picture, one should always seek one of the diagnoses most common in the community where one practices. For example, on moving to Arizona, I was amazed to discover how common coccidiomycosis pneumonia was in our hospital population. I had learned about this illness while studying and working in Boston. However, I had never seen an example of this disease entity and thought that it was a rarity. This is definitely not the case in Arizona where coccidiomycosis pneumonitis is common and should always be considered in the differential diagnosis of a pulmonary infiltrate.

Rule 2: Common sense occurs uncommonly. This aphorism is usually attributed to Voltaire. Over the years, I have seen many violations of this important rule in clinical medicine. Physicians should exercise common sense before ordering tests or performing therapeutic interventions. Examples abound in support of this rule. Recently, I saw a 60-year-old diabetic woman in my office. She had been admitted to our hospital several weeks earlier with a single bout of rest angina. Her cardiac catheterization revealed modest coronary arterial stenoses, and she was placed on medical therapy with brand name medications by another cardiologist: a statin, an angiotensin receptor blocker, and clopidogrel. Subsequently, I first saw her in my office. At that time, she and her family told me that they had paid more than $500 for 1 month's supply of the medicines that had been prescribed in the hospital. I quickly altered her regimen to include generic forms of a statin and an angiotensin-converting enzyme inhibitor, as well as 325 mg of aspirin. These new generic prescriptions would cost the patient less than $20 per month. Common sense should have been used earlier by the inpatient attending physician simply by informing the patient that generic brands cost less than brand name pharmaceuticals. As noted by Harvey Cushing (1869-1939), “Three-fifths of the practice of medicine depends on common sense, knowledge of people and of human reactions.” I would add knowledge of the patient's ability to pay for the medicines prescribed.

Rule 3: The less a procedure is indicated the more likely that its use will be accompanied by complications. This rule advises clinicians to ensure that every procedure or test ordered has a reasonable probability of altering patient management. An example of this aphorism in practice involved a healthy 55-year-old man without coronary heart disease risk factors. He became anxious when a neighbor had an acute myocardial infarction. His doctor suggested that he undergo a coronary calcium computed tomography scan. This test revealed modest coronary calcifications. The patient became more anxious when he heard the results of his computed tomography scan, and he convinced his physician that he needed a coronary angiogram. The angiogram was unremarkable, but the catheterization resulted in a large groin hematoma and pseudoaneurysm that required vascular surgical repair. If I had been involved in this patient's initial care, reassurance or, at most, a Bruce protocol electrocardiographically monitored exercise test, would have been my approach.

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-- Joseph S. Alpert, MD

This article was originally published in the August 2009 issue of The American Journal of Medicine.

It's Time to Bail Out Seniors Trapped in the Medicare Donut Hole!

Medicare D, which became effective in January of 2006, was a major step forward in providing prescription drug coverage to one segment of our population: those age 65 and older. As of 2009, 90% of all seniors (Medicare beneficiaries) had signed up for Medicare D, which is voluntary, or had other insurance coverage for prescription drugs.

The Medicare population accounts for one third of all prescription drug use in the US. The vast majority (87%) of seniors have at least one chronic condition that requires life-long medication, and more than 45% have 3 or more chronic conditions. The average number of prescription drugs for seniors with one of the commonest chronic conditions, congestive heart failure, was 7.5 with an annual cost of $3823 in 2001. The health of our Medicare population is dependent on their being able to afford prescription drugs.

Unfortunately, 2 features of the Medicare D legislation jeopardize the ability of seniors to afford the drugs they require. The legislation forbids Medicare from negotiating drug prices with drug manufacturers. Unlike the Department of Defense, the Veterans Administration, and Medicaid, which are able to negotiate discounts of 30 to 50%, Medicare is forced to pay the manufacturers' asking price. As a result, Medicare and Medicare beneficiaries pay more for prescription drugs than the citizens of any other country. Medicare pays 30% more for prescription drugs than Medicaid pays. In 2 years (2006 and 2007) Medicare paid $3.7 billion more than Medicaid would have paid for the same prescription drugs.

The second feature of the legislation that jeopardizes the ability of seniors to afford prescription drugs is the infamous “donut hole.” Once a deductible of $250 has been paid by the senior, Medicare pays 75% of the cost of drugs and the senior pays 25% until the total amount paid by Medicare and the patient reaches $2250. At that point, the senior pays 100% out of pocket until the total amount paid by the patient and Medicare reaches a catastrophic limit of $5100. After that point has been reached, the senior is freed from the donut hole and Medicare pays 95% of further prescription costs. In one study, only 3%, and in another study, only 4% of seniors falling into the donut hole emerged to receive catastrophic coverage.

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-- James E. Dalen, MD, MPH

This article was originally published in the July 2009 issue of The American Journal of Medicine.

“Hey, Doc, Is It OK for Me to Drink Coffee?”

Many of my patients with coronary artery disease, diabetes, or hypertension have been warned at various times in their lives to avoid caffeinated coffee because they had been informed that drinking caffeinated coffee could result in increased blood pressure, worsening of diabetic control, and might even trigger a myocardial infarction. Some of my patients also worry that drinking caffeinated coffee might cause cancer. This editorial will briefly cite the now-voluminous evidence that caffeinated coffee in moderate doses (1-3 cups per day in some studies and more in other investigations) is not associated with clinically relevant increases in blood pressure, serum cholesterol levels, myocardial infarction, or various malignancies.

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-- Joseph S. Alpert, MD

This article was originally published in the July 2009 issue of The American Journal of Medicine.

The Effect of a Hypertension Self-Management Intervention on Diabetes and Cholesterol Control

Although most chronic disease self-management programs target specific disease outcomes, they may have unintended but beneficial effects on other comorbid chronic conditions.

Abstract
Background
Most patient chronic disease self-management interventions target single-disease outcomes. We evaluated the effect of a tailored hypertension self-management intervention on the unintended targets of glycosylated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C).

Methods
We evaluated patients from the Veterans Study to Improve the Control of Hypertension, a 2-year randomized controlled trial. Patients received either a hypertension self-management intervention delivered by a nurse over the telephone or usual care. Although the study focused on hypertension self-management, we compared changes in HbA1c among a subgroup of 216 patients with diabetes and LDL-C among 528 patients with measurements during the study period. Changes in these laboratory values over time were compared between the 2 treatment groups using linear mixed-effects models.

Results
For the patients with diabetes, the hypertension self-management intervention resulted in a 0.46% reduction in HbA1c over 2 years compared with usual care (95% confidence interval, 0.04%-0.89%; P = .03). For LDL-C, there was a minimal 0.9 mg/dL between-group difference that was not statistically significant (95% confidence interval, −7.3-5.6 mg/dL; P = .79).

Conclusions
There was a significant effect of the self-management intervention on the unintended target of HbA1c,but not LDL-C. Chronic disease self-management interventions might have “spill-over” effects on patients' comorbid chronic conditions.

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-- Benjamin J. Powers, MD, Maren K. Olsen, PhD, Eugene Z. Oddone, MD, MHS, Hayden B. Bosworth, PhD

This article was originally published in the July 2009 issue of The American Journal of Medicine.

Depression and Clinical Outcomes in Heart Failure: An OPTIMIZE-HF Analysis

Abstract
Background

Depression is a risk factor of excessive morbidity and mortality in heart failure. We examined in-hospital treatment and postdischarge outcomes in hospitalized heart failure patients with a documented history of depression from the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure.

Methods

We identified patient factors associated with depression history and evaluated the association of depression with hospital treatments and mortality, and early postdischarge mortality, emergency care, and rehospitalization.

Results

In 48,612 patients from 259 hospitals, depression history was present in 10.6% and occurred more often in females, whites, and those with common heart failure comorbidities, including chronic pulmonary obstructive disease (36% vs 27%), anemia (27% vs 16.5%), insulin-dependent diabetes mellitus (20% vs 16%), and hyperlipidemia (38% vs 31%), all P <.001. Patients with depression history were less likely to receive coronary interventions and cardiac devices, all P <.01; or be referred to outpatient disease management programs, P <.001. Length of hospital stay was longer with depression history (7.0 vs 6.4 days, P <.001). In 5791 patients followed-up at 60-90 days postdischarge, those with depression history had higher mortality (8.8% vs 6.4%; P=.025). After multivariable modeling, depression history remained a predictor of length of hospital stay, P <.001 and postdischarge mortality, P=.02.

Conclusions

Depression history at heart failure hospitalization may be a predictor of prolonged length of hospital stay, less use of cardiac procedures and postdischarge disease management, and increased 60-90 day mortality. Patients with depression might represent a vulnerable group in which improved use of evidence-based treatment should be considered.

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Nancy M. Albert, PhDa, Gregg C. Fonarow, MDb, William T. Abraham, MDc, Mihai Gheorghiade, MDd, Barry H. Greenberg, MDe, Eduardo Nunez, MDf, Christopher M. O'Connor, MDg, Wendy G. Stough, PharmDh, Clyde W. Yancy, MDi, James B. Young, MDj

This article was originally published in the April 2009 issue of The American Journal of Medicine.

Vascular Endothelial Growth Factor in Systemic Capillary Leak Syndrome

Systemic capillary leak syndrome is a rare disorder characterized by acute attacks of severe vascular hyperpermeability causing hypotension and shock. All patients have a paraproteinemia. There is a rarer variant of this syndrome in which the same symptoms appear in a chronic form. The diagnosis is made by exclusion of other causes. The cause has not been elucidated, and no treatment has been shown effective.


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-- Willem Joost Lesterhuis, MD, Alexander J. Rennings, MD, William P. Leenders, PhD, Arjan Nooteboom, PhD, Cornelis J. Punt, MD, PhD, Fred C. Sweep, PhD, Peter Pickkers, MD, Anneke Geurts-Moespot, MS, Hanneke W. Van Laarhoven, MD, PhD, Johan Van der Vlag, PhD, Jo H. Berden, MD, PhD, Cor T. Postma, MD, Phd, Jos W. Van der Meer, MD, PhD

This article was originally published in the June 2009 issue of The American Journal of Medicine.

The Association of Inhaled Corticosteroid Use with Serum Glucose Concentration in a Large Cohort

Abstract

Background

Inhaled corticosteroids (ICSs) are widely used in the treatment of obstructive lung disease. ICSs have been shown to be systemically absorbed. The association between ICS and serum glucose concentration is unknown.

Methods
To explore the association of ICS dosing with serum glucose concentration, we used a prospective cohort study of US veterans enrolled in 7 primary care clinics between December 1996 and May 2001 with 1 or more glucose measurements while at least 80% adherent to ICS dosing. The association between ICS dose from pharmacy records standardized to daily triamcinolone equivalents and serum glucose concentration was examined with generalized estimating equations controlling for confounders, including systemic corticosteroid use.

Results
Of the 1698 subjects who met inclusion criteria, 19% had self-reported diabetes. The mean daily dose of ICS in triamcinolone equivalents was 621 μg (standard deviation 555) and 610 μg (standard deviation 553) for subjects with and without diabetes, respectively. After controlling for systemic corticosteroid use and other potential confounders, no association between ICS and serum glucose was found for subjects without diabetes. However, among subjects with self-reported diabetes, every additional 100 μg of ICS dose was associated with an increased glucose concentration of 1.82 mg/dL (P value .007; 95% confidence interval [CI], 0.49-3.15). Subjects prescribed antiglycemic medications had an increase in serum glucose of 2.65 mg/dL (P value .003; 95% CI, 0.88-4.43) for every additional 100 μg ICS dose.

Conclusion
Among diabetic patients, ICS use is associated with an increased serum glucose concentration in a dose-response manner.


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Christopher G. Slatore, MD, Chris L. Bryson, MD, MS, David H. Au, MD, MS

This article was originally published in the May 2009 issue of The American Journal of Medicine.

Adherence to Healthy Lifestyle Habits in US Adults, 1988-2006

Lifestyle choices are associated with cardiovascular disease and mortality. Comparing healthy lifestyle habits in adults between 1988 and 2006, the authors found adherence to 5 healthy habits decreased from 15% to 8% in the US, as obesity increased.

Abstract
Background
Lifestyle choices are associated with cardiovascular disease and mortality. The purpose of this study was to compare adherence to healthy lifestyle habits in adults between 1988 and 2006.

Methods
Analysis of adherence to 5 healthy lifestyle trends (≥5 fruits and vegetables/day, regular exercise >12 times/month, maintaining healthy weight [body mass index 18.5-29.9 kg/m2], moderate alcohol consumption [up to 1 drink/day for women, 2/day for men] and not smoking) in the National Health and Nutrition Examination Survey 1988-1994 were compared with results from the National Health and Nutrition Examination Survey 2001-2006 among adults aged 40-74 years.

Results
Over the last 18 years, the percent of adults aged 40-74 years with a body mass index ≥30 kg/m2 has increased from 28% to 36% (P <.05); physical activity 12 times a month or more has decreased from 53% to 43% (P <.05); smoking rates have not changed (26.9% to 26.1%); eating 5 or more fruits and vegetables a day has decreased from 42% to 26% (P <.05), and moderate alcohol use has increased from 40% to 51% (P <.05). Adherence to all 5 healthy habits has gone from 15% to 8% (P <.05). Although adherence to a healthy lifestyle was lower among minorities, adherence decreased more among non-Hispanic Whites over the period. Individuals with a history of hypertension/diabetes/cardiovascular disease were no more likely to be adherent to a healthy lifestyle than people without these conditions.

Conclusions
Generally, adherence to a healthy lifestyle pattern has decreased during the last 18 years, with decreases documented in 3 of 5 healthy lifestyle habits. These findings have broad implications for the future risk of cardiovascular disease in adults.

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-- Dana E. King, MD, MS, Arch G. Mainous III, PhD, Mark Carnemolla, BS, Charles J. Everett, PhD

This article was originally published in the June 2009 issue of The American Journal of Medicine.