Archives of internal medicine最新文献

Background: Initiating antihypertensive drugs in the elderly has been associated with an immediate increased risk of falls. However, it is unknown whether initiation of antihypertensive drugs (eg, thiazide diuretics, angiotensin II converting-enzyme inhibitors, angiotensin II receptor blockers, calcium channel blockers, or β-adrenergic blockers) is associated with an immediate increased risk of hip fractures.

Methods: A population-based, self-controlled case series design using health care administrative databases identifying patients initiating an antihypertensive drug in Ontario, Canada. A cohort of newly treated hypertensive elderly patients was linked to the occurrence of hip fractures from April 1, 2000, to March 31, 2009, to create exposed cases. The risk period was the first 45 days following antihypertensive therapy initiation with control periods before and after treatment in a 450-day observation period. The outcome measure was the first occurrence for a proximal femoral fracture during the risk period. The analysis determined the relative incidence (incidence rate ratio), defined as the hip fracture rate in the risk period compared with control periods.

Results: Among the 301,591 newly treated hypertensive community-dwelling elderly patients, 1463 hip fractures were identified during the observation period. Hypertensive elderly persons who began receiving an antihypertensive drug had a 43% increased risk of having a hip fracture during the first 45 days following treatment initiation relative to the control periods (incidence rate ratio, 1.43; 95% CI, 1.19-1.72).

Conclusions: Antihypertensive drugs were associated with an immediate increased hip fracture risk during the initiation of treatment in hypertensive community-dwelling elderly patients. Caution is advised when initiating antihypertensive drugs in the elderly.

Background: Employment instability is a major source of strain affecting an increasing number of adults in the United States. Little is known about the cumulative effect of multiple job losses and unemployment on the risks for acute myocardial infarction (AMI).

Methods: We investigated the associations between different dimensions of unemployment and the risks for AMI in US adults in a prospective cohort study of adults (N = 13,451) aged 51 to 75 years in the Health and Retirement Study with biennial follow-up interviews from 1992 to 2010. Unadjusted rates of age-specific AMI were used to demonstrate observed differences by employment status, cumulative number of job losses, and cumulative time unemployed. Cox proportional hazards models were used to examine the multivariate effects of cumulative work histories on AMI while adjusting for sociodemographic background and confounding risk factors.

Results: The median age of the study cohort was 62 years, and 1061 AMI events (7.9%) occurred during the 165,169 person-years of observation. Among the sample, 14.0% of subjects were unemployed at baseline, 69.7% had 1 or more cumulative job losses, and 35.1% had spent time unemployed. Unadjusted plots showed that age-specific rates of AMI differed significantly for each dimension of work history. Multivariate models showed that AMI risks were significantly higher among the unemployed (hazard ratio, 1.35 [95% CI, 1.10-1.66]) and that risks increased incrementally from 1 job loss (1.22 [1.04-1.42]) to 4 or more cumulative job losses (1.63 [1.29-2.07]) compared with no job loss. Risks for AMI were particularly elevated within the first year of unemployment (hazard ratio, 1.27 [95% CI, 1.01-1.60]) but not thereafter. Results were robust after adjustments for multiple clinical, socioeconomic, and behavioral risk factors.

Conclusions: Unemployment status, multiple job losses, and short periods without work are all significant risk factors for acute cardiovascular events.

Background: Although the tendency to repeat examinations is a major determinant of the capacity to serve new patients and of the ability to contain health care costs, little research has described the patterns observed in actual practice.

Methods: We investigated patterns of repeat testing in a longitudinal study of a 5% random sample of Medicare beneficiaries, restricted to 743,478 fee-for-service patients who were alive for a 3-year period after their index test between January 1, 2004, and December 31, 2006. Using the 50 largest metropolitan statistical areas as the unit of analysis, we examined the relationship between the proportion of the population tested and the proportion of tests repeated among those tested.

Results: Among beneficiaries undergoing echocardiography, 55% had a second test within 3 years. Repeat testing following other examinations was also common: 44% of imaging stress tests were repeated within 3 years, as were 49% of pulmonary function tests, 46% of chest computed tomography, 41% of cystoscopies, and 35% of upper endoscopies. The proportion of the population tested and the proportion of tests repeated varied across metropolitan statistical areas. The proportion who underwent echocardiography was highest in Miami, Florida (48%, among whom 66% of examinations were repeated in 3 years), and was lowest in Portland, Oregon (18%, among whom 47% of examinations were repeated in 3 years). Across 50 metropolitan statistical areas, the proportion of the population tested was consistently positively correlated with the proportion of tests repeated for echocardiography (Spearman r = 0.87, P < .001), imaging stress test (r = 0.65, P < .001), pulmonary function test (r = 0.62, P < .001), chest computed tomography (r = 0.66, P < .001), cystoscopy (r = 0.21, P = .13), and upper endoscopy (r = 0.59, P < .001).

Conclusions: Repeat testing is common among Medicare beneficiaries. Patients residing in metropolitan statistical areas with high rates of population testing are more likely to be tested and are more likely to have their test repeated.