BACKGROUND: Atrial fibrillation is the most common cardiac arrhythmia associated with significant medical complications. We examined trends in the medical therapy of atrial fibrillation in the United States from 1991 through 2000. METHODS: Data from 1355 visits among patients with atrial fibrillation were obtained from the National Ambulatory Medical Care Survey, a nationally representative assessment of office-based practice. We assessed trends in medication use for ventricular rate control (digoxin, beta-blockers, and calcium channel blockers), sinus rhythm maintenance (class IA, IC, and III antiarrhythmics), and thromboembolism prevention (oral anticoagulants and aspirin). RESULTS: Overall rate control medication use decreased from 72% of visits in 1991-1992 to 56% in 1999-2000 (P =.01 for trend) due to declining digoxin use (64% to 37%, P.001 for trend). beta-Blocker and calcium channel blocker use remained unchanged. Although there was no change in overall sinus rhythm medication use over time, amiodarone hydrochloride use increased from 0.2% to 6.4% (P.001 for trend), while quinidine use decreased from 5.0% to 0.0% (P =.01 for trend). Oral anticoagulant use increased (28% to 41%, P =.01 for trend), with the greatest increase in patients aged 80 years and older (14% to 48%, P.001 for trend). Despite this, only 46.5% of patients at high risk for stroke were taking anticoagulants in 1999-2000. CONCLUSIONS: Digoxin use in atrial fibrillation decreased over time, without concomitant increases in beta-blocker or calcium channel blocker use. Miodarone replaced quinidine as the dominant sinus rhythm medication. Although oral anticoagulant use increased over time, particularly in the oldest patients, fewer than half of the patients at high risk for stroke were anticoagulated.

Medical providers often fail to treat depression. We examined whether treatment is more aggressive in a setting with accessible mental health resources, the Veterans Health Administration (VA). VA and non-VA primary care physicians and medical specialists viewed a videotape vignette portraying a patient meeting criteria for major depression and then answered interviewer-administered questions about management. We found that 24% of VA versus 15% of non-VA physicians would initiate guideline-recommended treatment (antidepressants or mental health referral, or both) (P = .09). Among those who identified depression as likely, 42% of VA versus 19% of non-VA physicians would treat (P = .002): 23% versus 3% recommended mental health referral (P .001) and 21% versus 17% an antidepressant (P = .67). Although many patients with major depression may not receive guideline-recommended management, VA physicians do initiate mental health referral more often than do non-VA physicians. Access to mental health services may prove valuable in the campaign to increase physician adherence to depression clinical guidelines.

Drug-eluting stents are quickly replacing bare-metal stents as the arterial revascularization device of choice. Because nearly all of the information we have about patient outcomes with drug-eluting stents is from trials designed for U.S. Food and Drug Administration approval, we are missing some of the information critical to a more comprehensive understanding of how these new devices will perform at the population level.

Helicobacter pylori (HP) infection can cause hypochlorhydria, a positive risk factor for Mycobacterium tuberculosis (MTB) infection. This study examined the association between HP and MTB infections among persons attending the Policlinico Peruano Japones Gastrointestinal Clinic in Lima, Peru. From 23 June 2000 to 18 August 2000, consenting 18-55 year olds who attended the clinic for gastric biopsy gave blood for HP serologic testing, underwent tuberculin skin testing (TST) and completed a social and medical history. Of 128 participating patients, 78 (61%) were TST positive for MTB, and 107 (84%) were infected with HP by serology. Of the patients who were HP positive, 67 (63%) developed positive TST reactions compared to 11 (52%) of 21 HP-seronegative subjects (OR 1.29; 95% CI 0.54-3.11; P = 0.6). There was no association after adjusting for covariates of H. pylori infection (OR 0.78; 95% CI 0.23-2.71; P = 0.7). However, study power was limited by high prevalence of the two infections.

Chronic conditions are among the most common causes of death and disability in the United States. Patients with such conditions receive disproportionate amounts of health care services and therefore cost more per capita than the average patient. This study assesses the prevalence among the Department of Veterans Affairs (VA) health care users and VA expenditures (costs) of 29 common chronic conditions. The authors used regression to identify the marginal impact of these conditions on total, inpatient, outpatient, and pharmacy costs. Excluding costs of contracted medical services at non-VA facilities, total VA health care expenditures in fiscal year 1999 (FY1999) were $14.3 billion. Among the 3.4 million VA patients in FY1999, 72 percent had 1 or more of the 29 chronic conditions, and these patients accounted for 96 percent of the total costs ($13.7 billion). In addition, 35 percent (1.2 million) of VA health care users had 3 or more of the 29 chronic conditions. These individuals accounted for 73 percent of the total cost. Overall, VA health care users have more chronic diseases than the general population.

In a random assignment study, substance-abusing patients with HIV/AIDS in a public general hospital received a brief contact condition or received 12 months of case management delivered by paraprofessionals. Patient outcomes included substance use, HIV transmission risk, physical health, psychological status, and quality of living situation. In both conditions, a significant decrease occurred in a range of problems from Intake to the 6-month interview, followed by no significant pattern of change at 12- and 18-month interviews. On major outcome variables, there were no significant differences between the brief contact and case management conditions. Sixteen percent had died by the 18-month interview. Process data indicated wide variation in the amount of case management received by participants, and the amount of case management was not related to improvement in the outcome measures. The study has limitations yet does not support the hypothesis that case management improves outcomes better than brief contact for this population.

Trauma and Substance Abuse explores the underrecognized connection between trauma, substance use, and posttraumatic stress disorder. Patients with trauma related distress such as posttraumatic stress disorder (PTSD) often have comorbid substance use disorders (SUDs). This book presents cutting-edge research on how often the two disorders co-occur and why. Authors describe models of comorbidity and explore how specific PTSD and substance use symptoms are functionally related to each other. In addition, they suggest assessment approaches and practice guidelines to facilitate proper diagnosis and treatment. Particularly valuable are descriptions of several new treatment approaches that have been developed specifically for PTSD-SUD, including cognitive-behavioral and exposure therapy. This is the first book to evaluate and synthesize the two fields of PTSD and substance use disorder research and treatment. This volume is indispensable for researchers and clinicians seeking a full understanding of the etiology, assessment, and treatment of this challenging dual diagnosis.