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An acute myocardial infarction (MI or heart attack) is caused by the occlusion of one or more of the coronary arteries, which supply blood to the heart muscle. Coronary artery occlusion may be due to a thrombus, or blood clot, and intravenous thrombolytic drugs given to break down these clots are an important part of the therapy to reduce the death rate from heart attack. These drugs do not remove occlusive, fatty atherosclerotic plaques within coronary vessels. Consequently, after thrombolytic therapy, MI patients with atherosclerosis are routinely monitored with angiography (which allows X-ray visualization of vessels) to determine if they require surgery to enhance their coronary circulation. Surgical procedures that improve coronary blood flow are coronary artery bypass surgery (CABS) and percutaneous transluminal coronary angioplasty (PTCA). It has not been determined whether follow-up angiography and surgery, as advocated for these patients, are always justified, or simply routine. It is thought that patients with atherosclerosis who have suffered a heart attack should only undergo CABS or PTCA if their angina (chest pain) is severe and when other noninvasive tests of ischemic (inadequate oxygen supply) risk deem them necessary. To explore whether there is an increased need for CABS or PTCA after thrombolytic therapy, seven clinical trials of the two thrombolytic agents approved in North America, tissue plasminogen activator and streptokinase, were evaluated. Results revealed an 80 percent increase in CABS and PTCA procedures among thrombolytic therapy patients within six weeks of their MI, compared with controls who received conventional post-MI therapy. This increase is suggested to represent a reasonable attempt to consolidate the immediate gains from lysing occlusive thrombi in infarct-related coronary arteries, rather than indicative of unnecessary medical intervention or a negative result of thrombolytic therapy. (Consumer Summary produced by Reliance Medical Information, Inc.)

The Simple Calculated Osteoporosis Risk Estimation (SCORE) and the Osteoporosis Risk Assessment Instrument (ORAI) can identify women at risk of osteoporosis who should have dual-energy x-ray absorptiometry testing. This test measures the density of bones but is too costly to use as a general screening tool on all women.

Importance: Falls result in substantial burden for patients and health care systems, and given the aging of the population worldwide, the incidence of falls continues to rise.Objective: To assess the potential effectiveness of interventions for preventing falls.Data Sources: MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Ageline databases from inception until April 2017. Reference lists of included studies were scanned.Study Selection: Randomized clinical trials (RCTs) of fall-prevention interventions for participants aged 65 years and older.Data Extraction and Synthesis: Pairs of reviewers independently screened the studies, abstracted data, and appraised risk of bias. Pairwise meta-analysis and network meta-analysis were conducted.Main Outcomes and Measures: Injurious falls and fall-related hospitalizations.Results: A total of 283 RCTs (159 910 participants; mean age, 78.1 years; 74% women) were included after screening of 10 650 titles and abstracts and 1210 full-text articles. Network meta-analysis (including 54 RCTs, 41 596 participants, 39 interventions plus usual care) suggested that the following interventions, when compared with usual care, were associated with reductions in injurious falls: exercise (odds ratio [OR], 0.51 [95% CI, 0.33 to 0.79]; absolute risk difference [ARD], -0.67 [95% CI, -1.10 to -0.24]); combined exercise and vision assessment and treatment (OR, 0.17 [95% CI, 0.07 to 0.38]; ARD, -1.79 [95% CI, -2.63 to -0.96]); combined exercise, vision assessment and treatment, and environmental assessment and modification (OR, 0.30 [95% CI, 0.13 to 0.70]; ARD, -1.19 [95% CI, -2.04 to -0.35]); and combined clinic-level quality improvement strategies (eg, case management), multifactorial assessment and treatment (eg, comprehensive geriatric assessment), calcium supplementation, and vitamin D supplementation (OR, 0.12 [95% CI, 0.03 to 0.55]; ARD, -2.08 [95% CI, -3.56 to -0.60]). Pairwise meta-analyses for fall-related hospitalizations (2 RCTs; 516 participants) showed no significant association between combined clinic- and patient-level quality improvement strategies and multifactorial assessment and treatment relative to usual care (OR, 0.78 [95% CI, 0.33 to 1.81]).Conclusions and Relevance: Exercise alone and various combinations of interventions were associated with lower risk of injurious falls compared with usual care. Choice of fall-prevention intervention may depend on patient and caregiver values and preferences. [ABSTRACT FROM AUTHOR]

Presents letters to the editor. Response to an article about the use of antidepressant medication for chronic tension headaches; Who should be screened for osteoporosis; Discussion of studies regarding violence in children's films and video games; Others.

Presents a response by C. David Naylor and Susan B. Jaglal to a letter to the editor about their article 'Impact of Intravenous Thrombolysis on Short-Term Coronary Revascularization Rates: A Meta-Analysis,' in the 1990 issue of the 'Journal of the American Medical Association.'