A pilot study: reports of benefits from a 6-month, multidisciplinary, shared medical appointment approach for heart failure patients.

ABSTRACT Heart failure continues to be the leading cause of hospitalization among older adults. Noncompliance with medications, dietary indiscretion, failure to recognize symptoms, and failed social support systems contribute to increased morbidity. Multidisciplinary medical approaches have proven successful for heart failure. In 2004, the Naval Medical Center San Diego started a multidisciplinary shared medical appointment for patients with complicated cases of heart failure. Patients enrolled in the heart failure clinic were monitored prospectively for 6 months. Validated questionnaires concerning satisfaction with care, self-care management, depression, and quality-of-life measures were administered at baseline and 6 months after enrollment. Thirty-nine individuals were enrolled in the clinic, with 33 completing 6 months of follow-up monitoring to date. Hospital admissions for any cause decreased from 11 to eight, whereas congestive heart failure-related admissions decreased from four to two. There was a total of six deaths. During the 6 months of enrollment, use of angiotensin-converting enzyme inhibitors and beta-receptor blockers had absolute increases of 20% and 19%, respectively. Statistically significant improvements were seen in the Beck Depression Inventory and Self-Care Management Index results. A multidisciplinary approach to heart failure patients using the shared medical appointment model can improve patient satisfaction, enhance quality of life, and help reduce hospitalizations while improving provider efficiency.

Limited Use of Outpatient Stress Testing in Young Patients With Atypical Chest Pain.

Low prevalence of coronary artery disease within this population suggests that younger patients may not require stress testing for chest pain evaluations as long as pretest likelihood is low.

Military cardiology under a tent.

As Operation Iraqi Freedom enters its third year, the multinational military force remains engaged in a complex mission based on the military and political climate in the Middle East. As US Navy cardiologists deployed to Kuwait, our experiences proved diverse as we learned to practice in an austere environment. From the evaluation of chest pain to the treatment of coronary artery disease and arrhythmia, patient care was tempered by our ability to use our clinical acumen, physical exam and basic objective data to establish definitive dispositions. Given our younger patient population, involvement in primary prevention efforts was a large focus, allowing us to gain a new perspective on the role of the subspecialist in changing patients' mindsets and lifestyles. By combining the basic tenets of our cardiology training with the practical aspects of diagnosing and treating in a war zone, we developed a great respect for the management of cardiac patients under challenging and often limited conditions. Our experiences as cardiologists in the desert were truly diverse and encompassed virtually every aspect of cardiovascular medicine, involving both current and historic treatment perspectives. Many unique, lifelong lessons were learned.

A novel use of U-500 insulin for continuous subcutaneous insulin infusion in patients with insulin resistance: a case series.

OBJECTIVE: To report our experience with use of U-500 regular insulin (U-500) for continuous subcutaneous insulin infusion (CSII) in four patients with type 2 diabetes requiring high-dose insulin. METHODS: We performed a retrospective review of medical records of four patients with type 2 diabetes and insulin resistance who were using U-500 in a CSII regimen for at least 6 months. Before treatment conversion, two patients were receiving CSII with use of insulin lispro, and two were receiving multiple daily insulin injections. Clinical assessment was monitored with glycosylated hemoglobin (HbA1c) levels. Changes in the insulin volume administered and associated cost savings are analyzed. RESULTS: Three months after conversion to U-500 therapy, the average HbA1c decreased from 10.8% to 7.6%. By 6 months, it declined further to 7.3%. With use of U-500, the absolute volume of insulin infused per day decreased by at least fourfold. This volume reduction led to potential cost savings for insulin of up to $2,600 per year per patient and a savings for pump supplies of up to $3,400 per year per patient. All patients had subjective improvement in quality of life. CONCLUSION: We propose that smaller volumes of insulin with use of U-500 allow for more efficient absorption of large doses of insulin and yield improved glycemic control. In our four patients, the use of U-500 for CSII resulted in improved quality of life, cost savings for treatment, and potential reduction in diabetes-related complications based on the decline in HbA1c. This treatment method may be a novel alternative for patients with type 2 diabetes and insulin resistance who have not met goal glycemic control with standard intensive regimens or who require insulin doses exceeding current insulin pump delivery capacity.

An adult with a sinus venosus atrial septal defect and dilated cardiomyopathy.

Dilated cardiomyopathy, heart failure and atrial septal defects are well-recognised entities in isolation, but are rarely seen together. Now that 90% of children with congenital heart disease survive into adulthood, such combinations of disease are increasingly seen in adult cardiology. While most young patients with dilated cardiomyopathy respond well to medical therapy, some do not, and require more invasive management. We describe a 32 year-old man with dilated cardiomyopathy and a sinus venosus-type atrial septal defect associated with a remarkable pulmonary to systemic flow ratio of 5:1. We propose that the atrial septal defect blunted his heart failure symptoms by serving as a 'pop-off' valve and limiting pulmonary congestion. The patient ultimately failed medical management and received a left ventricular assist device. The case is presented along with a discussion of this unique pathophysiology and a brief review of the literature in this rapidly evolving field.

Pericarditis, thymic hyperplasia, and Graves' thyrotoxicosis: case report and review of the literature.

Graves' thyrotoxicosis with thymic hyperplasia and pericarditis has never been described in the literature. In this case report, we present the clinical, laboratory, and radiographic findings of a 24-year-old active duty male who was admitted for management of nonexertional, positional, pleuritic chest pain. Electrocardiography confirmed pericarditis as the presenting diagnosis. Laboratory findings revealed an undetectable serum thyrotropin level and further evaluation with a contrast chest computed tomography confirmed the presence of a goiter and an anterior mediastinal mass. The patient's pericarditis and thymic hyperplasia resolved with treatment of his Graves' disease.

Overdrive pacing in a patient with incessant torsades de pointes.

A 75-year-old man presented to the emergency department (ED) for syncope and was found to have intermittent runs of torsades de pointes (TdP). The patient had a medical history significant for disseminated coccidiomycosis and was on prophylactic fluconazole. Forty-eight hours prior to presentation, the patient had intractable nausea and vomiting and was unable to take anything orally. He eventually presented to the ED with severe hypokalaemia and hypomagnesaemia with repeat symptomatic runs of TdP, which required overdrive transvenous pacing. During the patient''s admission, his electrolytes were aggressively replete. Fluconazole was discontinued, and prior to discharge, the patient recovered fully with ECGs showing a normalisation of the QT interval.