Finding hope in the midst of despair: my decade with Parkinson's disease and Lewy body dementia.

Living for 10 years with Parkinson's disease (PD) and Lewy body dementia (LBD) author Thomas B. Graboys, MD recounts the various losses - physical, emotional, social and intellectual - that ultimately add up to a loss of self inflicted by these progressive neurological diseases. No longer able to practice medicine, engage in athletics, or engage fully with his extended family, soon to include 11 grandchildren, Graboys nevertheless writes that there is one aspect of self PD and LBD cannot steal: the soul.

Long-term outcomes of optimized medical management of outpatients with stable coronary artery disease.

The objective of this study was to assess long-term clinical outcomes and their correlates in medically managed outpatients with stable angina pectoris, healed myocardial infarction (MI), or documented asymptomatic coronary artery disease (CAD). Management strategy emphasized maximally tolerated medical therapy and modification of coronary risk factors. Referral to invasive coronary interventions followed stricter criteria than standard published guidelines. Primary study outcomes were all-cause mortality or nonfatal myocardial infarction. Secondary study outcomes included cardiac death, unstable angina, or coronary revascularization. A total of 693 men and women with proved CAD (mean age 67 years at entry, 85% men, 41% with history of MI) were enrolled. The annual incidence of nonfatal MI, cardiac mortality, and total mortality was 2.2%, 0.8%, and 1.4%, respectively, during an average follow-up of 4.6 years. Coronary revascularization was performed in 24% of subjects; unstable or progressive anginal symptoms were the most common reasons for revascularization. In patients with documented stable CAD, a management strategy based on intensive medical therapy and modification of established coronary risk factors was associated with excellent long-term outcomes. Thus, coronary interventions can be safely delayed until clinical instability ensues, without increased risk of MI or death. This treatment approach represents a viable alternative to invasive strategies.

Hand to hand.

Examination of the hands has the potential to transform the encounter between physician and patient. Taking the hands conveys a sense of warmth and connectedness and is a means to communicate the physician's mindfulness. The hands can focus the examination on the individual patient as a complete human being, and not merely a disease or a collection of symptoms. The hands provide readily accessible information that may not be available through other evaluations, and they offer clues to a patient's physical and mental health. Commonplace observations, such as those revealed in the hands, can unravel medical mysteries and provide profound clinical insights.

Sildenafil in the cardiologist's office: patients' attitudes and physicians' practices toward discussions about sexual functioning.

Sildenafil is a medication increasingly prescribed to improve sexual function in patients who have erectile dysfunction. Because a major contraindication to the use of sildenafil is a history of coronary disease and the concomitant use of nitrates, it becomes increasingly important for cardiologists to prescribe this medication. We evaluated the nature of discussions in all 70 patients for whom sildenafil was prescribed in a cardiology practice between April and July 1998. We used a standardized questionnaire to determine the patients' perspective on the sexual history and the extent to which they wanted their physicians to take a detailed history about sexuality. A separate chart review evaluated the nature of physicians' discussions about sexual functioning before sildenafil was prescribed. Fifty-five of the 70 patients (79%) responded to the survey. The majority of patients (98%) felt that physicians should talk with patients about sexual functioning. However, only 73% of patients believed their doctor was comfortable talking with them about this subject. Sixty percent of patients reported that their doctor had ever talked with them about erectile function and only 15% had ever had a discussion with their doctors about specific difficulties during intercourse. Based on the results of the chart review, only 24% of the patients ever specifically discussed the used of sildenafil with their physician prior to the time that it was prescribed. The results of the study suggest that patients with coronary disease erectile dysfunction are comfortable talking with their physicians about sexual functioning, but these conversations occur infrequently.