Aortic Stenosis in the 21st Century

When I was a medical student more than 40 years ago, aortic stenosis was almost invariably the result of rheumatic heart disease. Today, however, rheumatic aortic valve disease has almost vanished in the US. Nevertheless, aortic stenosis is still a common entity in our hospitals. What accounts for this change in the etiology of aortic stenosis and why is it still so common?

To read this article in its entirety, please visit our website.

-- Joseph S. Alpert, MD

This article originally appeared in the October 2010 issue of The American Journal of Medicine.

A Plethora of Protein

Presentation

A 61-year-old man had long been plagued by symptoms of atopy and connective tissue disease when he presented with an 18-month history of soft, compressible nodules on both shins. His past history included atopic eczema since adolescence, asthma, hay fever, and hypertension. Two years earlier he experienced spontaneous venous thrombosis in the right arm. He also had elements of CREST syndrome, a constellation that includes calcinosis, Raynaud's syndrome, esophageal dysmotility, sclerodactyly, and telangiectasias. Our patient had a 10-year history of Raynaud's phenomenon, facial telangiectasias, reduced oral aperture, and esophageal reflux.

Assessment

General examination revealed pitting edema of the face, hands, and lower legs, and bilateral cauliflower ear deformity (Figure 1). This had been present for 10 years, without prior trauma and with no clinical features of chondritis. The patient did not have macroglossia.

What's the diagnosis?

To read this article in its entirety, please visit our website.

-- Diona L. Damian, MBBS, PhD, Jim V. Bertouch, MBBS, MD

This article originally appeared in the October 2010 issue of The American Journal of Medicine.

Adherence to Oral Contraception in Women on Category X Medications

Despite the added risk associated with unintended pregnancy, many women who receive Category X medications have refill patterns suggesting nonadherence to oral contraception. Compared with all women age 18-44, women receiving teratogenic medications do not have better adherence to oral contraception.

Abstract

Background

Over 6% of women become pregnant when taking teratogenic medications, and contraceptive counseling appears to occur at suboptimal rates. Adherence to contraception is an important component in preventing unwanted pregnancy and has not been evaluated in this population. We undertook a pharmacy claims-based analysis to evaluate the degree to which women of childbearing age who receive Category X medications adhere to their oral contraception.

Methods

We evaluated the prescription medication claims for over 6 million women, age 18-44 years, with prescription benefits administered by a pharmacy benefits manager. Women with 2 or more claims for a Category X medication and 2 or more claims for oral contraception were evaluated in further detail. Adherence to oral contraception was measured by analyzing pharmacy claims. Multivariable logistic regression was performed to identify factors associated with adherence.

Results

There were 146,758 women of childbearing age who received Category X medications, of which 26,136 also took oral contraceptive medication. Women who received Category X medications were prescribed oral contraception (18%) at rates similar to others of childbearing age (17%). Women prescribed both Category X and oral contraception demonstrated adherence similar to the overall population. Age, class of Category X medication, number of medications, prescriber's specialty, and ethnicity correlated with lower adherence rates.

Conclusions

Despite added risk associated with unintended pregnancy, many women who receive Category X medications have refill patterns suggesting nonadherence to oral contraception. Compared with all women age 18-44 years, women receiving teratogenic medications do not have better adherence to oral contraception.

To read this article in its entirety, please visit our website.

--Amy Steinkellner, PharmD, William Chen, PhD, MPH, Shannon E. Denison, MA

This article originally appeared in the October 2010 issue of The American Journal of Medicine.