A 63-year-old African American man presented with severe epigastric pain of 1 day's duration. The pain was sharp and continuous and radiated toward the left flank. There were no aggravating or relieving factors or previous similar episodes.

Mortality data released by the CDC in January show that between 1999 and 2005, the age-adjusted death rate for coronary heart disease decreased by 25.8%, from 195 to 144 deaths per 100,000 persons per year. The new data also indicate that since 1999, the death rate for stroke has decreased by 24.4%, from 61 to 47 deaths per 100,000 persons per year. The reduction in mortality rates in 2005 resulted in approximately 160,000 fewer deaths from coronary heart disease and stroke, 2 of the 3 leading causes of death in the United States.

An estimated 46.4 million US adults, or approximately 21% of the adult population, self-reported a physician-diagnosed form of arthritis, which is the leading cause of disability in the United States, according to 2005 data collected by the National Arthritis Data Work group. The work group estimates that by 2030, the number of US adults aged 18 years and older with arthritis or other rheumatic conditions will jump to nearly 67 million (25% of the adult population)-an increase of about 40% (Figure 1).

The idea that “you are what you eat” in terms of influencing one’s overall health may soon be tested in a unique way. Increasingly, employers seeking to reduce health care expenses are targeting employees’ unhealthy lifestyle practices. But will these programs cross the line and invade employees’ privacy?

An analysis of data from the National Comorbidity Survey, a nationally representative sample of persons aged 15 to 54 years (N = 8098), suggests that those who exercise regularly are less likely to report being depressed or having an anxiety disorder.1 The association between regular physical activity and lower prevalence of major depression (odds ratio [OR], 0.75) is fairly specific. Dysthymia, for example, was only minimally responsive to exercise, and there was no correlation between regular exercise and reduced risk of bipolar disorder. Psychotic disorders and substance abuse also were not substantially affected by regular physical activity. However, certain anxiety disorders, particularly panic attacks and phobias, were found to be less prevalent among self-reported exercisers.

Heart failure (HF) is a complex clinical syndrome in whichthe heart is unable to deliver adequate cardiac output at normal fillingpressures. There are proven pharmacological and clinical management strategiesthat can improve care and reduce associated health care costs, but these areunderutilized. The Advanced Heart Failure Program (AHFP) was developed at theDorn Veterans Administration Medical Center to provide a comprehensivemultidisciplinary management approach to persons with advanced HF. Beforeenrollment in the AHFP, the average annual all-cause hospital admission rate was3.2 for the 217 HF patients. After enrollment in the AHFP and stabilization, themean all-cause hospital admission rate was 1.2. HF patients had an averageannual hospitalization cost of $28,936.32 before enrollment in the AHFP. Afterenrollment, average hospitalization cost dropped to $10,851.12 per patient.Taking into account the 50-week cost of $3036.14 for a patient enrolled in theclinic, participation in the AHFP was associated with a significant decrease inthe number of HF-related admissions, saving an average of $15,049.06 perpatient. (Drug Benefit Trends. 2008;20:54-59)

Diabetes is a destructive disease that kills thousands eachyear in the United States and disables thousands more, and its incidence hasbeen rising dramatically. Glycemic control is imperative to forestallcomplications; however, it can be difficult for patients to achieve glycemicgoals.

The American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP) renewed their 2004 call for a mandatory public clinical trial registry to be established and overseen by the federal government. This is in response to a study that showed that research on antidepressants is published selectively-effectively suppressing trials deemed negative and overstating the benefits of antidepressant therapy. The study was published in the January 17 issue of the New England Journal of Medicine.

Consumer-directed health plans (CDHPs) are attracting new interest as a result of a ruling by the Internal Revenue Service (IRS) over what constitutes preventive services. CDHP benefit designs take various forms, but in general, these are low-premium, high-deductible plans that provide full or close to full coverage for enrollees once the deductible is met and are typically tied to a health savings account (HSA).

A proposal by the Centers for Medicare & Medicaid Services (CMS) published in the January 8 issue of the Federal Register would allow stand-alone Part D plans to offer reduced premiums to enrollees with limited incomes and resources-a rule intended to give such enrollees in each Medicare prescription drug benefit region at least 5 options with no monthly premium.

Health care spending in the United States increased 6.7% in 2006 to $2.1 trillion or $7026 per person. Prescription drug costs increased faster, up 8.5% to $216.7 billion from 5.8% in 2005, and were spurred in part by the launch of the Medicare Part D prescription drug benefit in 2006 (Cover Figure).

According to a survey published in January by the International Foundation of Employee Benefit Plans (IFEBP), Brook field, Wis (http://www.ifebp.org), US employers are increasingly covering alternative/complementary therapies and medical tourism as part of their health benefit cost-containment efforts. Currently, chiropractic care is covered by 80.5% of employers, and 33.5% of employers cover acupuncture or acupressure expenses. The IFEBP survey found that medical tourism-a practice in which US residents travel to other nations, such as India, Mexico,and Thailand, to obtain lower-cost treatment (Figure), including heart bypass surgery and hip or knee replacement surgery-is covered by 11% of employers. 

Dr Thomas Fekete's recent article on emerging infections (CONSULTANT, October 2007) was timely, given recent evidence that the incidence of methicillin-resistant Staphylococcus aureus (MRSA) infection, both hospital-acquired and community-acquired, has assumed pandemic proportions.

 NEARLY A THIRD (31%) of personsliving with tuberculosis (TB) are unawareof their HIV status, accordingto a study highlighted in the CDC'sMorbidity and Mortality Weekly Report(Reported HIV status of tuberculosispatients-United States, 1993-2005.MMWR. 2007;56:1103-1106). Thestudy evaluated retrospective healthdata from 49 states and the Districtof Columbia and found that eventhough reporting status of personswith TB increased from 35% in 1993to 68% in 2003, it has remainedrelatively unchanged since then.

HIV infection continues to exact a devastating toll worldwide.Advances in antiretroviral therapy have helped bring theHIV/AIDS epidemic under control in developed countries.Antiretroviral drugs, however, are not widely available inthose developing countries where HIV poses a catastrophicthreat. Effective strategies for HIV prevention are thereforecrucial to curbing the global epidemic. Vaccination, microbicideuse, and male circumcision are 3 key preventive interventions.Current research is focused on developing effective vaccinesand microbicides and on determining the extent to whichcircumcision helps prevent HIV acquisition and transmission.[Infect Med. 2008;25:63-72]

Critical ViewsinInfectiousDiseaseMedicine A

Several reports have documented an increased incidence of smooth muscle tumors in patients with AIDS and in those with other immunocompromised conditions.

Recently the CDC released a report of a study on coinfection with HIV and Mycobacterium tuberculosis that found that many US patients with tuberculosis (TB) are still not being tested for HIV.

Reviewing just a 2-month interval of HIV/AIDS-related publications and announcements, from mid-September to mid-November of 2007, produced discouraging news in 3 key areas: vaccine development, female-initiated barrier protection, and HIV treatment in the resource-poor world.

We evaluated a cohort of persons with late-stage HIV infection currently enrolled in a longitudinal tracking study to determine whether coinfection with hepatitis C virus (HCV) is associated with a greater prevalence and/or severity of HIV-associated cognitive-motor complex and distal predominantly sensory peripheral polyneuropathy compared with persons with HIV infection alone