Dissociation, Posttraumatic Symptomatology, and Sexual Revictimization: A Prospective Examination of Mediator and Moderator Effects

Using prospective data gathered from a sample of 323 college women over a 10-week academic quarter, the present study examined whether dissociation and posttraumatic symptomatology mediate or moderate sexual revictimization. Results indicated that posttraumatic symptomatology, but not dissociation, moderated the link between previous and subsequent sexual victimization. Neither posttraumatic symptomatology nor dissociation mediated revictimization.     

The use of transesophageal echocardiography to avoid left atrial thrombus during percutaneous mitral valvuloplasty

During mitral balloon valvuloplasty, transesophageal echocardiography (TEE) has been employed for the accurate placement of the transseptal needle, guide wires, and balloon catheters and to provide an immediate evaluation of the results of the procedure. We describe a case demonstrating that TEE can be used to avoid a left atrial appendage thrombus during the placement of wires and catheters. With TEE guidance, we feel left atrial appendage thrombi are no longer an absolute contraindication to percutaneous mitral valvuloplasty. © 1993 Wiley-Liss, Inc.     

Disproportionate increase in prevalence of diabetes among patients with congestive heart failure due to systolic dysfunction

BACKGROUND: Despite new therapies, the prevalence of heart failure continues to escalate. The prevalence of diabetes, a risk factor for heart failure, also continues to rise. To further understand the increasing prevalence of heart failure, we compared trends in the prevalence of diabetes among individuals with diagnosed heart failure versus those in the general population. METHODS: Fourteen randomized trials between 1989 and 1999 including subjects with heart failure (n = 34,633) were reviewed. For each trial, the enrollment date was used to estimate the yearly prevalence of diabetes among study participants with heart failure. The prevalence of diabetes in the general population was estimated based on United State's Center for Disease Control statistics from 1989 to 1999. The prevalence of diabetes between heart failure subjects and the general population was compared using a two-sample t-test for independent samples with unequal variances. RESULTS: The prevalence of diabetes increased from 2.6% to 4.0% from 1989 to 1999 in the general U.S. population. Among patients with heart failure, the prevalence of diabetes increased from 13% to 47%. Diabetes prevalence estimates varied significantly (p < 0.001) between the general population and individuals with heart failure during the study period. CONCLUSIONS: The rising prevalence of diabetes may partially explain the growing epidemic of heart failure. Increased efforts targeting diabetes and other cardiovascular risk factors are warranted in attenuating the rising prevalence of heart failure.     

Nicotine reduces antisaccade errors in task impaired schizophrenic subjects

Nicotine and/or smoking have been shown to reduce various cognitive deficits associated with schizophrenia. Here, we examine the effects of nicotine gum on repeated performance on a simple eye movement task. Eight schizophrenic subjects and eight controls participated in three days of testing on saccade (S) and antisaccade (AS) tasks. On each testing day, subjects participated in four testing sessions and received both of two nicotine gum treatments (4 and 6 mg) and both of two control conditions (placebo gum and no gum), each followed by a recovery period. Overall, schizophrenics showed significant impairments on the AS task. However, upon individual examination only four schizophrenics showed significant differences in AS errors or reaction times (RTs) when compared to controls. The other four schizophrenic subjects showed control level performance. All schizophrenic subjects showed normal and better than control level performance on the simple S task. Furthermore, no effects of nicotine were seen on the simple S task. There were significant treatment effects on the AS task. Nicotine treatment significantly decreased errors in the task impaired schizophrenic group and this effect was most pronounced at the 6 mg level. No nicotine effects were demonstrated for non-impaired schizophrenic subjects or controls. This study demonstrates a benefit of short exposure to nicotine in cognitively impaired schizophrenic subjects. These results support previous findings of cognitive benefits of nicotine in schizophrenics.     

Effect of Time to Titration to Maximum Dose of Statins on Cardiovascular Outcomes

Background

Recent trials have shown that high-dose HMG-CoA reductase inhibitor (statin) therapy reduces cardiovascular events in high-risk subjects within weeks of initiating therapy. We investigated the effect of time to titration to maximum dose of statin therapy on cardiovascular events.

Methods

From a list of all patients actively taking simvastatin 80 mg/day as of April 2003 at our hospital, two clinical pharmacists reviewed 213 electronic medical records including pharmacy records from November 1992 to April 2003. Data on cardiovascular risk factors, laboratory results, titration schedules, and outcomes were extracted from the electronic database. Titration period time frames were compared between patient groups using a Student t-test and multiple-variable logistic regression to account for other risk factors.

Results

Titration schedules and time frames to attain a regimen of simvastatin 80 mg/day were available for 154 (73%) subjects. Titrations ranged from 1 to 8 and averaged 2.3± 1.3 titrations per patient (median titrations = 2) over 1 month to 8.4 years. On follow-up, 47 patients experienced 80 cardiovascular-related outcomes. The average time to titration to maximum dose of statin therapy was longer for patients who experienced a cardiac event than for those who did not (3.5 ± 2.2 vs 2.1 ± 1.8 years; p = 0.0004). After accounting for other risk factors, the titration period was still significantly related to the presence of a cardiac event (p = 0.0060, odds ratio per month increase in the titration period 1.3, 95% CI 1.08, 1.58).

Conclusions

Despite potential limitations, the results of our study show that an excessive delay in titrating statin therapy to the optimal dose may lead to an increased risk of atherosclerosis-related events in high-risk patients.     

Stroke Mortality and Race: Does Access to Care Influence Outcomes?

BACKGROUND: Stroke is the third leading cause of death in the United States. We investigated racial differences in death after hospital discharge for ischemic stroke in a large cohort of Veterans Health Affairs (VHA) stroke patients. We hypothesized that having access to VA care would ameliorate the excess stroke mortality rates in African-Americans (AA) reported in non-VA studies. METHODS: Hospital administrative data were used to identify all patients discharged from any VA hospital between October 1990 and September 1997 with a primary discharge diagnosis of ischemic stroke (ICD-9-CM codes 434 and 436). We obtained demographic data and clinical data recorded during the index hospitalization and after discharge, including deaths, from VA clinical and administrative databases. The Charlson comorbidity index was constructed for each patient from the index admission's discharge diagnoses. Patients were followed through 1998. RESULTS: Of 55,094 VHA stroke patients discharged after ischemic strokes, 34,579 (63%) were white and 11,530 (21%) were AA. Charlson index was similar between the groups. One-year mortality rate was significantly higher for whites: Adjusting for demographic and clinical differences, being white remained predictive of higher mortality rates (multivariable hazard ratio, 1.06; 95% CI, 1.02 to 1.10). From Kaplan-Meier estimates, the probability that whites would survive for 1 year was 0.86 compared with 0.87 for AA. CONCLUSIONS: Despite having similar severity of illness and adjusting for other clinical differences, mortality rate was marginally lower in AA after being discharged from VA hospitals after ischemic strokes. This is contrary to prior reports from non-VA hospitals and suggests the possibility of access to care playing a role in stroke deaths.     

Family therapy in the treatment of adolescents.

A family with an adolescent must transform itself from a predominantly nurturant unit to one that can tolerate and encourage the adolescent's need to separate. When an adolescent presents with symptoms that disrupt the developmental process, the clinician who is familiar with several models of family therapy is better able to select a therapeutic and cost-effective intervention. For family assessments, the authors recommend a biopsychosocial approach, which has replaced the outdated view that families cause psychiatric problems and which acknowledges the family as a potential source of healing. The authors describe several models of family therapy--Satir's communication model, the structural model of Minuchin, Bowen's cross-generational model, and psycho-education--and examine features of these approaches useful for working with adolescents. Illustrative vignettes and some guiding principles for matching model and problem are offered.     

"Perilous pearl"--papillary fibroelastoma of aortic valve: a case report and literature review

Papillary fibroelastomas of the heart valves are benign, slow-growing, rare tumors of the heart. These lesions are primarily responsible for embolic events that can clinically manifest with neurological and cardiovascular symptoms. Early diagnosis is very important, as surgical excision of these tumors can prevent cerebrovascular and cardiovascular complications. The case of a 60-year-old man who presented with a neurological deficit caused by a papillary fibroelastoma of the noncoronary cusp of the aortic valve is described. Diagnosis was made by transesophageal echocardiogram, and the tumor was resected surgically.