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Background and Objectives: The extent to which greater frailty among American compared with European women reflects individual-level characteristics has not been well studied. To test the hypothesis that cardiometabolic conditions and depression and anxiety confound the relationship between region and incident prefrailty and frailty in American compared with European women. Materials and Methods: The Global Longitudinal Study of Osteoporosis in Women (GLOW) is a 5-year observational cohort study of women aged ≥55 years. A total of 19,674 participants from the United States and Europe were nonfrail at baseline and provided information on characteristics, including body mass index, depression and anxiety, and cardiovascular disease. We used multivariable Cox proportional hazards models to examine the relationship between region and incident frailty and prefrailty. Results: Over 40% of respondents became prefrail or frail during follow-up. Adjusting for age, body mass index, depression and anxiety, cardiovascular disease, and other health-related characteristics, European respondents had a decreased risk of developing prefrailty (2-year hazard ratio [HR]: 0.78, 95% confidence interval [CI]: 0.73-0.84; 3-year HR: 0.74, 95% CI: 0.67-0.81) and frailty (2-year HR: 0.65, 95% CI: 0.56-0.76; 3-year HR: 0.82, 95% CI: 0.68-0.99) compared with American respondents. Risk of incident frailty and prefrailty did not vary by region at 5 years of follow-up. Conclusions: Cardiometabolic conditions and depression and anxiety did not account for increased frailty and prefrailty onset among American compared with European women. Differences in smaller regions and environmental characteristics may contribute to frailty and prefrailty. [ABSTRACT FROM AUTHOR]

Background: Anticoagulants reduce the risk of venous thromboembolism (VTE) after total joint replacement. However, concern remains that pharmacologic VTE prophylaxis can lead to bleeding, which may impact on postoperative complications such as infections and reoperations. Methods and Findings: From the Global Orthopedic Registry (GLORY), we reviewed 3,755 patients in US who elected for primary total hip or knee arthroplasty, received either warfarin or low molecular weight heparin (LMWH) as VTE prophylactics, and had up-to-90-day follow-up after discharge. We compared incidence rates of VTE, infections and other complications between LMWH and warfarin groups, and used multivariate analyses with propensity score weighting to generate the odds ratio (OR). Patients receiving LMWH tended to be older and higher in the American Society of Anesthesiologists grade scores. In contrast, warfarin was used more frequently for hip arthroplasty with longer duration among patients with more pre-existing comorbidity (all P<0.02). A weight variable was created with propensity score to account for differences in covariate distributions. Propensity score-weighted analyses showed no differences in VTE complications. However, compared to warfarin, LMWH was associated with significantly higher rates of bleeding (6.2% vs. 2.1%; OR = 3.82, 95% confidence interval [CI], 2.64 to 5.52), blood transfusion (29.4% vs. 22.0%; OR = 1.75, 95% CI, 1.51 to 2.04), reoperations (2.4% vs. 1.3%; OR = 1.77, 95% CI, 1.07 to 2.93) and infections (1.6% vs. 0.6%; OR = 2.79, 95% CI, 1.42 to 5.45). Similar results were obtained from compliant uses of warfarin (26%) and LMWH (62%) according to clinical guidelines. While surgical site infections were mostly superficial, current study was underpowered to compare incidence rates of deep infections (<1.0%). Conclusions: Surgical site infections and reoperations in 3 months following primary total joint arthroplasty may be associated with anticoagulant use that exhibited higher bleeding risk. Long-term complications and deep wound infections remain to be studied. [ABSTRACT FROM AUTHOR]

The article presents a study which aims to analyze the cumulative incidence of venous thromboembolism (VTE) in acutely ill hospitalized medical patients. The study reveals that 67 patients had lower-extremity deep vein thrombosis (DVT) and 76 had pulmonary embolism of the 184 patients developing symptomatic VTE. The study shows a 1.0% in cumulative VTE incidence, with 45% of events happened after discharge.

Background The time course of events after acute coronary syndromes might influence the timing and duration of therapeutic interventions. We investigated the impact of risk status and ST-segment category at presentation. Methods The timing of death; reinfarction, stroke and major bleeding within 6 months of acute coronary syndromes was determined in 46,829 patients enrolled in the Global Registry of Acute Coronary Events (GRACE). Acute coronary syndromes were classified by elevation (n = 17,668), depression (n = 8,542), or neither (n = 20,619) in the ST segment. GRACE risk scores and hazard ratios (HR) were determined for three time periods: 0-4, 5-15 and 16-180 days. Results ST-segment elevation was associated with a higher early risk of death than was ST-segment depression (0-4 days, HR 1.89, 95% CI 1.60- 2.24 versus 5-15 days, HR 1.26, 95% CI 1.05-1.50), but after 15 days the risk was reversed (16-180 days, HR 0.85, 95% CI 0.75-0.97). Throughout the study, patients with ST-segment deviation had a higher mortality risk than those without. Within each ST category, the highest GRACE risk scores were associated with a 10--40-fold greater risk of death than the lowest scores (all categories P<0.0001). Most deaths occurred after day 4 (57%, 74%, and 78% for ST-segment elevation, depression and neither, respectively). Conclusion The timing of events after acute coronary syndromes was affected by ST category and influenced by GRACE risk score within each electrocardiographic category of acute coronary syndromes. Risk stratification should, therefore, include multiple risk factors rather than ST shift alone. [ABSTRACT FROM AUTHOR]

The article discusses the study which aims to examine the clinical practices for venous thromboembolism (VTE) prophylaxis in acutely ill hospitalized medical patients. The patient management was determined the by the treating physicians, in which it reflects to their approach to prevent VTE. It concludes that physicians need to improve their medical practices through the implementation of current evidence-based guidelines in hospitals.

This article presents the result of the study "Decline in Rates of Death and Heart Failure in Acute Coronary Syndromes, 1999-2006." The basis for the study was that although trials have provided evidence that pharmacological and intervention treatments in patients with ST-segment elevation and non-ST-segment elevations acute coronary syndromes seem to work, the ability to translate these findings into clinical practice is unknown. The objective was the determine if changes in hospital management of these patients would improve their clinical outcome. The design, setting and patients are identified. The results are listed with the conclusion of the study which is that improvements in the management of acute coronary patients were associated with significant reductions in the rates of new heart failure and mortality as well as in rates of stroke at six months.

The article presents a study concerning the external validity of clinical trials in acute myocardial infarction (AMI). The study aims to compare patients who are not enrolled but eligible for enrollment in randomized clinical trials (RCTs) of reperfusion therapy with RCT ineligible patients as well as with AMI patients who participate in RCTs. The study concludes that AMI patients who join RCTs experience lower mortality and lower baseline risk compared to RCT eligible and ineligible patients.

Objective To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome. Design Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation. Setting Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand. Population 43,810 patients (21,688 derivation set; 22,122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005. Main outcome measures Death and myocardial infarction. Results 1,989 patients died in hospital, 1,466 died between discharge and six month follow-up, and 2,793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries). Conclusions This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assess [ABSTRACT FROM AUTHOR]

Background: The Hip and Knee Registry is an observational database comprising data on practices of US orthopedic surgeons during 1996 to 2001. We examined trends in the use of prophylaxis for venous thromboembolism (VTE) among patients who underwent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). Methods: Data on 9,327 THA and 13,846 TKA patients were submitted between 1996 and 2001 by 464 orthopedic surgeons from 319 hospitals in 42 of the United States. Results: During 1996 to 2001, 44% of THA patients and 38% of TKA patients were male, and 93% and 92% were white, respectively. The median age of THA and TKA patients increased from 66 to 68 years and 68 to 69 years, respectively, between 1996 and 2001 (p < 0.001), while the mean length of hospital stay decreased from 4.7 to 3.7 days and 4.5 to 3.7 days, respectively (p < 0.001). Use of spinal or epidural anesthesia increased from 34 to 46% for THA and 43 to 54% for TKA patients (p < 0.001). One or more types of thromboprophylaxis were administered to 99% of patients. The following were the most common types of thromboprophylaxis: elastic stockings (61% and 58%), warfarin (56% and 53%), low-molecular-weight heparin (38% and 40%), and intermittent pneumatic compression (35% and 32%) in THA and TKA patients, respectively. Aspirin was used for thromboprophylaxis in 4% of THA and 7% of TKA patients. One or more type of in-hospital prophylaxis matching the 2001 American College of Chest Physicians (ACCP) recommendations were administered to 89% of THA and 91% of TKA patients between 1996 and 2001. During this period, in-hospital use of ACCP prophylaxis recommendations increased from 88 to 94% following THA (p < 0.001). This increase was also observed for prophylaxis administered to TKA patients, although this did not reach statistical significance. Conclusions: Recent trends in the management of patients undergoing THA and TKA in the United States, including shorter lengths of hospital stay and increased use of spinal/epidural anesthesia, present a challenge to orthopedic surgeons who wish to provide their patients with effective prophylaxis for VTE. Despite these challenges, nearly all surgeons participating in the Hip and Knee Registry are providing types of prophylaxis consistent with evidence based consensus recommendations. Although there are concerns regarding increased bleeding risk due to the use of anticoagulants in patients receiving spinal/epidural anesthesia, there was a significant increase in the use of spinal/epidural anesthesia between 1996 and 2001. During this same period, the proportion of patients receiving spinal/epidural anesthesia who were also administered anticoagulants as prophylaxis increased significantly. [ABSTRACT FROM AUTHOR]

Presents letters to the editor on issues related to internal medicine. Usefulness of cytomegalovirus cultures in patients with HIV infection; Description of a case in which the investigation of isolated persistent singultus led to the diagnosis of herpetic esophagitis; Benefits from determining serum ferritin levels.

Objective: To determine the rate of use of prophylaxis for venous thromboembolism in high-risk hospital patients.Design: A retrospective medical record review.Setting: A community-wide study in 16 short-stay hospitals in central Massachusetts.Patients: A total of 2017 patients with multiple risk factors for venous thromboembolism.Measurements and Main Results: On the basis of age, length of hospitalization, and the presence of at least one additional major risk factor, 17% of 151,349 discharges (25,410 patients) were identified as being at high risk for venous thromboembolism. Eight percent of these discharges were randomly selected for medical record review. Prophylaxis for venous thromboembolism was received by 32% of these high-risk patients. Prophylaxis use among the 16 study hospitals varied widely, ranging from 9% to 56%, and was higher in teaching hospitals than in nonteaching hospitals (44% compared with 19%; P less than 0.001). One or more of the following methods of prophylaxis was used: low-dose heparin (78%), intermittent calf compression (13%), warfarin (12%), and inferior vena caval filter (3%). Use of prophylaxis increased with the number of risk factors identified (P less than 0.001).Conclusion: Prophylaxis for venous thromboemobolism is underused, particularly in nonteaching hospitals. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine several dimensions of health-related quality of life (HRQL) in postmenopausal women who report previous fractures, and to provide perspective by comparing these findings with those in other chronic conditions (diabetes, arthritis, lung disease) - PATIENTS AND METHODS: Fractures are a major cause of morbidity among older women. Few studies have examined HRQL in women who have had prior fractures and the effect of prior fracture location on HRQL. In this observational study of 57,141 postmenopausal women aged 55 years and older (enrollment from December 2007 to March 2009) from 17 study sites in 10 countries, HRQL was measured using the European Quality of Life 5 Dimensions index (EQ-5D) and the health status, physical function, and vitality questions of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). RESULTS: Reductions in EQ-5D health-utility scores and SF36-measured health status, physical function, and vitality were seen in association with 9 of 10 fracture locations. Spine, hip, and upper leg fractures resulted in the greatest reductions in quality of life (EQ-5D scores, 0.62, 0.64, and 0.61, respectively, vs 0.79 without prior fracture). Women with fractures at any of these 3 locations, as well as women with a history of multiple fractures (EQ-5D scores, 0.74 for 1 prior fracture, 0.68 for 2, and 0.58 for ≥3), had reductions in HRQL that were similar to or worse than those in women with other chronic diseases (0.67 for diabetes, 0.69 for arthritis, and 0.71 for lung disease). CONCLUSION: Previous fractures at a variety of bone locations, particularly spine, hip, and upper leg, or involving more than 1 location are associated with significant reductions in quality of life. [ABSTRACT FROM AUTHOR]

The article discusses a study created to determine the risk of venous thromboembolism (VTE) in hospital care and the application of prophylaxis treatment. Evidence-based guidelines regarding the administration of prophylaxis to treat VTE such as pulmonary embolism have been established by the American College of Chest Physicians (ACCP). Risk of VTE for patients in hospitals was examined based on ACCP guidelines and the resulting data processed by statistical analysis. Prophylaxis treatments such as anticoagulants and pneumatic compression were analyzed as well.

Preexisting or new-onset atrial fibrillation (AF) commonly occurs in patients with an acute coronary syndrome (ACS). However, it is currently unknown if previous or new-onset AF confers different risks in these patients. To determine the prognostic significance of new-onset and previous AF in patients with ACS, we evaluated all patients with ACS enrolled in the multinational Global Registry of Acute Coronary Events (GRACE) between April 1999 and September 2001. We compared clinical characteristics, management, and hospital outcomes in patients with ACS and new-onset and previous AF with those without AF. Of a total of 21,785 patients with ACS enrolled in GRACE, 1,700 (7.9%) had previous AF and 1,221 (6.2%) had new-onset AF. Patients with any AF were older, more likely to be women, had more co-morbid conditions, and worse hemodynamic status. Most in-hospital adverse events (reinfarction, shock, pulmonary edema, bleeding, stroke, and mortality) were significantly higher in patients with any AF than those without AF. Only new-onset AF (not previous AF) was an independent predictor of all adverse in-hospital outcomes. We conclude that compared with patients with ACS without any AF, previous and new-onset AF are associated with increased hospital morbidity and mortality. However, only new-onset AF is an independent predictor of in-hospital adverse events in patients with ACS. [Copyright &y& Elsevier]