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The World Health Organization defines sexual health as "a state of physical, emotional, mental and sexual well-being related to sexuality." This broad definition goes beyond simply inquiring about sexual dysfunction and ideally fits the model of patient-centered primary care. As we observe that sexual health and physical health are often closely related, discussions about sexual activity can be very revealing. Sexual intimacy appears positively related to loving relationship satisfaction and stability. Sexual problems have a clear negative impact on both the quality of life and emotional state regardless of age. Learning about specific sexual dysfunctions among men can reveal a variety of as-yet-undiagnosed comorbid pathologic conditions such as: (i) depression and other emotional illnesses; (ii) psychosocial stress; (iii) actual cardiovascular disease as well as related risk factors such as hypertension, diabetes, and/or hyperlipidemia; (iv) hyperprolactinemia; and (v) low serum testosterone. Specific sexual dysfunctions among women can reveal pathologic conditions such as: (i) depression and other adverse imitational and psychosocial conditions; (ii) low serum estrogen or testosterone; and/or (iii) vaginal or pelvic disorders. A discussion about sexual health can be accomplished efficiently in a primary care office with the inquiring clinician having the option to deal with any sexual problems and dysfunctions directly, or to refer the patient to an appropriate specialized care source.
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PMID:Sexual health inquiry and support is a primary care priority. 1640 13

Hyperlipemia in horses is a disorder of lipid metabolism peculiar to ponies. This study reports changes of blood biochemical values from the acute to the postconvalescent phases in 3 Shetland ponies with hyperlipemia in Japan. Diseased ponies (all 7 to 9 years old, in late pregnancy, and obese) were fed in the same farm. The periods of their hospitalizations ranged from 30 to 45 days. Twelve well-conditioned ponies (3 to 13 years old) around parturition were used to establish baseline values for blood test results. Main clinical findings in the affected ponies were depression, dysphagia, anorexia, ventral edema and milky-appearing plasma. Hypertriglyceridemia (40- to 70-fold rise of controls) was found in the acute phase of the disease in the affected ponies, and was derived from increased very-low density lipoproteins. Aspartate transaminase and gamma-glutamyl transpeptidase activities, blood urea nitrogen, and creatinin concentrations were increased in acute ponies compared to controls, suggesting impairment of liver and kidney functions. However, these values gradually recovered until the end of postconvalescent phase. Hyperinsulinemia was observed in the acute phase of the hyperlipemia of all affected ponies. And an exaggerated insulin response to intravenous glucose was observed in the 2 ponies given intravenous glucose tolerance tests. These findings suggest decreased insulin sensitivity in hyperlipemic ponies.
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PMID:Changes of blood biochemical values in ponies recovering from hyperlipemia in Japan. 1667 26

In the case of non-ST-segment elevation acute coronary syndromes (NSTE-ACSs), the acute use of certain antiplatelet agents is complicated by concerns about perioperative bleeding risks in patients requiring coronary artery bypass grafting (CABG) during the index hospitalization. As a result, clinicians often withhold potentially useful agents, such as clopidogrel, before determining patients' coronary anatomy. An accurate predictive model could allow for a better balance of this safety concern with the demonstrated benefits of agents such as clopidogrel. To create an accurate decision-making tool that would assess, at hospital presentation, the need for CABG in patients with NSTE-ACSs, we studied 61,974 high-risk patients with NSTE-ACS admitted to 311 CABG-capable hospitals participating in Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) from 2001 to 2003. A total of 8,395 patients (14%) underwent CABG during their initial hospital stay. A multivariate model was developed and identified 13 presenting clinical characteristics significantly associated with the likelihood of CABG (previous CABG, male gender, previous heart failure, diabetes, hyperlipidemia, renal insufficiency, ST depression and transient ST elevation, age > or = 75 years, previous percutaneous coronary intervention, family history of coronary artery disease, hypertension, trends in CABG rates, and previous stroke). This model had only modest predictive accuracy and calibration (c-index = 0.67). In conclusion, although certain presenting clinical features are associated with an increased likelihood of CABG in patients with NSTE-ACSs during the index hospitalization, it remains difficult to reliably identify, before diagnostic angiography, those who will subsequently undergo surgical revascularization.
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PMID:Challenges in predicting the need for coronary artery bypass grafting at presentation in patients with non-ST-segment elevation acute coronary syndromes. 1692 49

This report described an interim analysis of a investigator-driven multicenter trial in renal transplant recipients: the Prospective Quality of life Renal Transplantation Switch Study; Tacrolimus-based immunosuppression ("PQRST study"). Patients included in the trial initially treated with cyclosporine-based immunosuppression after renal transplantation who experienced side effects, such as hypertension, hyperlipidemia, hypertrichosis, or other adverse reactions, were converted to a tacrolimus-based immunosuppressive regimen (n = 31). Steroids were subsequently discontinued between 3 and 6 months after the conversion. As of today 19/31 (50%) patients have been successfully weaned off steroids with the remaining patients in this process. In this interim analysis, with a follow-up ranging from 1 to 18 months both patient and graft survivals were 100%. No patient experienced an acute rejection episode; none of the grafts were lost. Blood pressure decreased in 22/31 (71%) of the patients. No patient developed de novo diabetes or other serious side effect related to the conversion. Three patients were withdrawn from the trial because of side effects: bleeding, depression, and proteinuria. However, none of these adverse events were felt to be directly related to the change of the immunosuppressive regimen to tacrolimus monotherapy. In conclusion, conversion from cyclosporine to tacrolimus-based therapy was safe and well tolerated; it may improve the cardiovascular risk profile after kidney transplantation.
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PMID:Steroid-free immunosuppression in kidney transplant recipients and prograf monotherapy: an interim analysis of a prospective multicenter trial. 1709 29

We report a case of severe citrate toxicity during volunteer donor apheresis platelet collection. The donor was a 40-year-old female, first-time apheresis platelet donor. Past medical history was remarkable for hypertension, hyperlipidemia, and depression. Reported medications included bumetanide, pravastatin, and paroxetine. Thirty minutes from the start of the procedure, the donor noted tingling around the mouth, hands, and feet. She then very rapidly developed acute onset of severe facial and extremity tetany. Empirical treatment with intravenous calcium gluconate was initiated, and muscle contractions slowly subsided over approximately 10 to 15 minutes. The events are consistent with a severe reaction to calcium chelation by sodium citrate anticoagulant resulting in symptomatic systemic hypocalcemia. Upon additional retrospective analysis, it was noted that bumetanide is a loop diuretic that may cause significant hypocalcemia. We conclude that careful screening for medications and underlying conditions predisposing to hypocalcemia is recommended to help prevent severe reactions due to citrate toxicity. Laboratory measurement of pre-procedure serum calcium levels in selected donors may identify cases requiring heightened vigilance. The case also illustrates the importance of maintaining preparedness for managing rare but serious reactions in volunteer apheresis blood donors.
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PMID:Severe citrate toxicity complicating volunteer apheresis platelet donation. 1711 19

ST-segment depression (ST-D) on the admission electrocardiogram of patients with non-ST-elevation acute coronary syndromes (NSTEACSs) is associated with higher mortality. However, few studies have evaluated the effect of location of ST-D and T-wave polarity on long-term prognosis of patients with NSTEACS. Electrocardiographic (ECG) and clinical data from 6,770 patients with NSTEACS randomly assigned in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIB trial were analyzed retrospectively. One-year mortality was correlated with location of ST-D (leads I and aVL; II, III, and aVF; V1 to V3; or V4 to V6) and T-wave polarity. ST-D in any of the ECG locations was associated with higher mortality compared with patients without ST-D. Patients with ST-D and T-wave inversion in leads V4 to V6 had the highest 1-year mortality rate of all groups (16.2%), significantly higher compared with patients with ST-D without T-wave inversion in those leads (9.0%, p=0.001). Logistic regression analysis showed that age, hyperlipidemia, Killip class>I, history of myocardial infarction, history of heart failure, history of angina pectoris, systolic blood pressure, heart rate, sum of ST-D (odds ratio 1.061, 95% confidence interval 1.035 to 1.087, p<0.001), and ST-D with T-wave inversion in leads V4 to V6 (odds ratio 1.374, 95% CI 1.023 to 1.844, p=0.035) were independent predictors of 1-year mortality. Conversely, ST-D without T-wave inversion in leads V4 to V6 or other ECG presentations were not independent predictors of high 1-year mortality. In conclusion, ST-D with T-wave inversion in leads V4 to V6 on the admission electrocardiogram in patients with NSTEACS identifies those with higher 1-year mortality than for patients with any other ECG presentation.
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PMID:Usefulness of ST depression with T-wave inversion in leads V(4) to V(6) for predicting one-year mortality in non-ST-elevation acute coronary syndrome (from the Electrocardiographic Analysis of the Global Use of Strategies to Open Occluded Coronary Arteries IIB Trial). 1739 87

Erectile dysfunction (ED) is a common condition with a significant effect on quality of life. The prevalence of ED increases with age and other risk factors (hypertension, diabetes, smoking, coronary heart disease, dyslipidemia and depression). Nitric oxide (NO) activity is adversely affected, in penile and vascular tissue, by these risk factors. Endothelial dysfunction and a reduced generation or bioavailability of NO have emerged as major pathophysiological mechanisms in ED. Hyperlipidemia may impair erectile function by affecting endothelial and smooth muscle cells of the penis. Oxidized low-density lipoprotein is a causative factor for the impaired relaxation response of the corpus cavernosum. Elevated serum cholesterol and reduced high density lipoprotein cholesterol levels are associated with an increased risk of ED. It follows that treating dyslipidemia could have a beneficial effect on ED. Phosphodiesterase type 5 inhibitors are now considered as first line treatment for ED. There is evidence that statins improve responses to these drugs. ED is considered as a warning sign of silent or early vascular disease. The use of statins may be beneficial in these patients.
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PMID:Dyslipidemia as a risk factor for erectile dysfunction. 1762 14

Blood pressure dynamicity during tilt table measurement is discussed. We analyzed ECG and BP parameters from 14 normotensive young healthy volunteers, 15 old healthy volunteers, and two groups of hypertensive patients--20 non-medicated hypertensive subjects with no other known complications and 21 hypertensive non-medicated subjects with confirmed obesity (according to waist circumference), hyperlipidemia or diabetes mellitus. The dynamic parameters, such as pulse pressure, maximum of derivative BP, difference between maximum and minimum of derivative BP and SBP peak--DBP depression time were obtained from derivative continuous blood pressure signal recordings. We have found that the age factor plays a more significant role in dynamic parameters change and in inter-group differentiation than additional risk factors of hypertensive subjects.
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PMID:Blood pressure dynamics in hypertensive subjects during tilt table test. 1800 12

We report the case of a 32-year-old man who presented at the emergency department with severe chest pressure, left arm pain, and dizziness. These symptoms were described as intermittent, occurring after exercise and at rest. He had undergone several stress tests during the past 8 years, but no objective evidence of ischemia was produced. His history of hyperlipidemia and increasing frequency of symptoms prompted us to perform coronary angiography, which showed a single coronary artery with an ostium at the right sinus of Valsalva. The vessel had an initial, mixed common trunk that gave rise to both the right coronary artery proper and to the left coronary artery. The left main trunk followed a prepulmonic course. The anatomic features were eventually confirmed by computed tomographic angiography. The left main stem had a fixed 50% to 60% area narrowing, at baseline study. A treadmill stress myocardial perfusion study showed no evidence of ischemia. The patient was referred to a 2nd facility, where intravascular ultrasonography, at baseline, revealed 63% left main narrowing without evidence of atherosclerosis. Acetylcholine provocation demonstrated worsening of the stenosis to about 80%, with reproduction of angina and ST-segment depression, which indicated that medical management of spasm might provide symptomatic relief.
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PMID:Single coronary artery with prepulmonic coursing left main coronary artery manifesting as prinzmetal's angina. 1817 28

Fixed combination psychotropics, such as a combination of a tricyclic and a typical antipsychotic, were widely prescribed a generation ago. These products were plagued by a number of problems, including serious side effects, which caused them to fall out of favor. More recently, a fixed combination of the atypical antipsychotic olanzapine and the serotonin selective reuptake inhibitor (SSRI) fluoxetine has been approved in the US for the treatment of bipolar I depression. Although the combination produced a robust clinical response relative to placebo or olanzapine alone, the response from practitioners has been mixed. The reasons for this are likely to be varied. Some practitioners who remember the earlier era of fixed combinations may simply be resistant to using products of this type. Moreover, the two constituents are available and many clinicians prescribe them independently. Finally, adverse events associated with olanzapine may make practitioners hesitant. For example, weight gain is a common side effect with olanzapine, and may be associated with hyperlipidemia or type II diabetes. Aggressive management of this problem appears to be helpful in preventing or reversing weight gain. It is not clear how weight gain is going to impact the uptake of this effective treatment.
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PMID:The return of fixed combinations in psychiatry: fluoxetine and olanzapine combination. 1836 May 92


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