Irritability is associated with anxiety and greater severity, but not bipolar spectrum features, in major depressive disorder.

OBJECTIVE: Irritability is common during major depressive episodes, but its clinical significance and overlap with symptoms of anxiety or bipolar disorder remains unclear. We examined clinical correlates of irritability in a confirmatory cohort of Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study participants with major depressive disorder (MDD). METHOD: Logistic regression was used to identify features associated with presence of irritability on the clinician-rated Inventory of Depressive Symptomatology. RESULTS: Of 2307 study participants, 1067(46%) reported irritability at least half the time during the preceding week; they were more likely to be female, to be younger, to experience greater depression severity and anxiety, and to report poorer quality of life, prior suicide attempts and suicidal ideation. Bipolar spectrum features were not more common among those with irritability. CONCLUSION: Irritable depression is not a distinct subtype of MDD, but irritability is associated with greater overall severity, anxiety comorbidity and suicidality.

Pretreatment frontal EEG and changes in suicidal ideation during SSRI treatment in major depressive disorder.

OBJECTIVE: We investigated frontal quantitative EEG (QEEG) as predictor of changes in suicidal ideation (SI) during SSRI treatment in major depressive disorder (MDD). METHOD: Eighty-two subjects meeting DSM-IV criteria for MDD entered an 8-week, prospective, open-label treatment with flexible dose SSRIs and completed at least 4 weeks of treatment. We assessed MDD severity with the 17-item Hamilton Depression Rating Scale (HAM-D-17); change in SI was measured with HAM-D item no. 3. We recorded four-channel EEGs (F7-Fpz, F8-Fpz, A1-Fpz, A2-Fpz) before treatment. RESULTS: During the first 4 weeks of treatment 9 (11%) subjects experienced worsening SI. Left-right asymmetry of combined theta + alpha power correlated significantly with change in SI from baseline, even when adjusting for changes in depression severity (HAM-D-17) and for the SSRI utilized. CONCLUSION: Frontal QEEG parameters before treatment may predict worsening SI during SSRI treatment in MDD.

African-American patients with cancer Talking About Clinical Trials (TACT) with oncologists during consultations: evaluating the efficacy of tailored health messages in a randomised controlled trial-the TACT study protocol.

INTRODUCTION: Low rates of accrual of African-American (AA) patients with cancer to therapeutic clinical trials (CTs) represent a serious and modifiable racial disparity in healthcare that impedes the development of promising cancer therapies. Suboptimal physician-patient consultation communication is a barrier to the accrual of patients with cancer of any race, but communication difficulties are compounded with AA patients. Providing tailored health messages (THM) to AA patients and their physician about CTs has the potential to improve communication, lower barriers to accrual and ameliorate health disparities. OBJECTIVE: (1) Demonstrate the efficacy of THM to increase patient activation as measured by direct observation. (2) Demonstrate the efficacy of THM to improve patient outcomes associated with barriers to AA participation. (3) Explore associations among preconsultation levels of: (A) trust in medical researchers, (B) knowledge and attitudes towards CTs, (C) patient-family member congruence in decision-making, and (D) involvement/information preferences, and group assignment. METHODS AND ANALYSIS: First, using established methods, we will develop THM materials. Second, the efficacy of the intervention is determined in a 2 by 2 factorial randomised controlled trial to test the effectiveness of (1) providing 357 AA patients with cancer with THM with 2 different 'depths' of tailoring and (2) either providing feedback to oncologists about the patients' trial THM or not. The primary analysis compares patient engaged communication in 4 groups preconsultation and postconsultation. ETHICS AND DISSEMINATION: This study was approved by the Virginia Commonwealth University Institutional Review Board. To facilitate use of the THM intervention in diverse settings, we will convene 'user groups' at 3 major US cancer centres. To facilitate dissemination, we will post all materials and the implementation guide in publicly available locations. TRIAL REGISTRATION NUMBER: NCT02356549.

Myocardial infarction redefined--a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction.

Definition of MI. Criteria for acute, evolving or recent MI. Either one of the following criteria satisfies the diagnosis for an acute, evolving or recent MI: 1) Typical rise and gradual fall (troponin) or more rapid rise and fall (CK-MB) of biochemical markers of myocardial necrosis with at least one of the following: a) ischemic symptoms; b) development of pathologic Qwaves on the ECG; c) ECG changes indicative of ischemia (ST segment elevation or depression); or d) coronary artery intervention (e.g., coronary angioplasty). 2) Pathologic findings of an acute MI. Criteria for established MI. Any one of the following criteria satisfies the diagnosis for established MI: 1) Development of new pathologic Q waves on serial ECGs. The patient may or may not remember previous symptoms. Biochemical markers of myocardial necrosis may have normalized, depending on the length of time that has passed since the infarct developed. 2) Pathologic findings of a healed or healing MI.

Accumulation of radioiodinated 15-(p-iodophenyl)-6-tellurapentadecanoic acid in ischemic myocardium during acute coronary occlusion and reperfusion.

The myocardial uptake of 15-(p-iodophenyl)-6- tellurapentadecanoic acid ( TPDA ) was studied in dogs during coronary occlusion and after reperfusion. In eight dogs with a 3 hour occlusion (Group A) with (n = 5) and without (n = 3) 30 minutes of reperfusion, iodine-125 TPDA uptake correlated well with microsphere myocardial blood flow over a wide range of flow levels (n = 111, r = 0.94). In six dogs with a 20 minute occlusion of the left anterior descending coronary artery and 1 hour of reperfusion (Group B), iodine-125 TPDA uptake correlated equally well with myocardial blood flow (n = 37, r = 0.90). There was no difference between the slopes of regression lines for Groups A and B, indicating no release from the myocardium of radioiodinated TPDA . Dual radiolabeling of TPDA was employed in five Group A animals by intravenous injection of iodine-125 TPDA during coronary occlusion and iodine-131 TPDA after reperfusion. In 63 myocardial samples, microsphere reperfusion flow and iodine-131 TPDA uptake were closely correlated (r = 0.91). As with monovalent cations, at myocardial flows higher than control flows, iodine-131 TPDA uptake was flow-limited. It is concluded that: 1) radioiodinated TPDA accurately reveals severely ischemic areas of myocardium without myocardial release of the radionuclide in coronary occlusions lasting 20 to 180 minutes and followed by reperfusion, and 2) double radiolabeled TPDA allows assessment of both occlusion and reperfusion flows. This compound may find an application in the measurement of infarct size and the evaluation of interventional therapies in acute myocardial infarction.

Myocardial infarction with angiographically normal coronary arteries.

More than 30 years ago, when the techniques and indications for coronary arteriography were being defined, the entity of myocardial infarction with angiographically normal coronary arteries (MINC) was first reported. These first reports already noted that the few patients with MINC tended to be different from the much larger group of individuals with myocardial necrosis and coronary atherosclerosis. Since these early case reports and subsequent small collected series, there have been significant advances in our understanding of the pathophysiologic features of acute myocardial infarction. This review seeks to reexamine MINC in light of this new information.

Diastolic function of the heart in clinical cardiology.

During the last six years, there has been increased interest in the detection of abnormalities of left ventricular diastolic function in patients with heart disease. Before 1981, most studies on diastolic function were performed in the catheter laboratory using invasive techniques and complex methods. Recently, radionuclide angiograms and Doppler echocardiography have been employed to measure the dynamics of filling in normal individuals and in patients with heart disease. These methods are noninvasive, easy to perform, accurate, and reproducible. It is now clear that diastolic function may be altered globally and regionally, at rest and perhaps during exercise, in many patients with ischemic heart disease, hypertension, and hypertrophic cardiomyopathy. Interestingly, these diastolic abnormalities may even appear before systolic abnormalities are identified in these patients. Thus, diastolic abnormalities may permit assessment of presence of disease early in its evolution. Whether detection and quantitation of diastolic abnormalities will permit grading of disease severity or evaluation of therapeutic efficacy remains an important research question. At the present time, it appears that the decision to employ either radionuclide angiography or Doppler echocardiography for the assessment of diastolic abnormalities will depend on the local expertise to carry out the investigation. Both diagnostic modalities require standardization of accuracy and reproducibility with proper selection of control values from the appropriate populations of normal individuals. It is also important to remember that left ventricular diastolic abnormalities have to be identified after the elimination of the confounding influence of variables such as ejection fraction, heart rate, age, and preload (end-diastolic volume). Automation of the derivation of indexes of diastolic filling should provide an objective assessment of the dynamics of left ventricular filling. Although the value of measurement of diastolic filling in the individual patient remains controversial, we believe that the practice of cardiology is incomplete without consideration of the second half of cardiac function.

The future of academic medical centers in the United States: passing through the valley of the shadow of death.

The last 2 decades witnessed remarkable events in the life of academic medical centers (AMCs) in the United States. Twenty years ago, AMCs were thriving as the era of fee-for-service medicine came to a close: clinical departments were expanding, hiring new faculty members, purchasing new equipment as necessary, and funding research projects and protected research time with the abundant clinical revenues. The subsequent 20 years since that golden era came to a close witnessed teh disappearance of these expansionary trends. Departments have contracted, protected research time and start-up funds have declined precipitously, and many faculty members are infected with a sense of malaise and fear for the future.

Increasing frequency of staphylococcal infective endocarditis. Experience at a university hospital, 1981 through 1988.

To determine the characteristics of infective endocarditis in our hospital, we reviewed all patients with that diagnosis at the University of Massachusetts Medical Center, Worcester, between 1981 and 1988. Of 113 patients with infective endocarditis, 56 (50%) had staphylococcal endocarditis. Despite aggressive medical and surgical therapy, in-hospital mortality was 25%. Forty-five (80%) of the 56 cases of staphylococcal endocarditis involved Staphylococcus aureus with a mortality of 28% vs 9% in the non-S aureus group. Mortality was higher in patients with congestive heart failure (35%), atrioventricular block (45%), atrial fibrillation (42%), and prosthetic valve endocarditis (50%). Seventy-six percent of the patients with congestive heart failure required surgery. Patients with congestive heart failure and S aureus infection had a mortality of 45%. Thirty-six patients (64%) were alive at late follow-up (mean, 28.6 months). Mortality was highest (23%) during the first 3 months following diagnosis of staphylococcal endocarditis. Staphylococcal endocarditis represents an increasingly large proportion of patients with infectious endocarditis. Mortality rates remain high despite aggressive management of the patient's condition.

The increased use of diagnostic procedures in patients with acute myocardial infarction. A community-wide perspective.

As part of a community-wide study examining time trends in the incidence and case-fatality rates of 3263 patients hospitalized with validated acute myocardial infarction (MI) during the years 1975, 1978, 1981, and 1984, we examined changes over time in the use of various noninvasive and invasive diagnostic tests during hospitalization for acute MI. In terms of the noninvasive procedures, exercise testing before hospital discharge increased from only 0.1% of patients in 1975 to 40.3% in 1984, while use of echocardiography (2.5%, 1975; 15.3%, 1984), Holter monitoring (1.0%, 1975; 34.0%, 1984), and radionuclide ventriculography (2.6%, 1975; 52.7%, 1984) also increased dramatically. Concerning the invasive procedures, use of coronary arteriography in patients with acute MI increased from 3.1% in 1975 to 9.8% in 1984. A more striking increase was noted in the use of pulmonary artery catheterization (7.2%, 1975; 19.9%, 1984). Examination of patient characteristics associated with the use of these tests demonstrated that the increased use of these diagnostic procedures was not due to changes in the clinical characteristics of patients hospitalized with acute MI; rather, it was the result of changes in physician practice patterns. If the practice patterns seen in this community-based study are similar to those seen throughout the United States, the charges for these diagnostic tests in 1984 are estimated to approach 600 million dollars. Given current interest in cost-containment and evaluation of clinical practices, these results suggest the need for further observational studies and clinical trials to assess the cost-effectiveness of these diagnostic tests. To assess the cost-effectiveness, it will be necessary to determine if the use of these tests improves the short-term or long-term prognosis of patients hospitalized with acute MI.