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In This Issue of Archives of Internal Medicine
Arch Intern Med. 2001;161:2287.
Drug-Related Deaths in a Department of Internal Medicine
In a 2-year study it was found that 18.2% of the patients who died in
a department of internal medicine suffered fatal adverse drug events (9.5
per 1000 hospitalized patients). Patients who had fatal adverse drug events
used more drugs and had more diseases then those who did not. Special care
should be taken when changing or adding drug regimens in the event of an emergency
hospitalization.
(SEE ARTICLE)
Sustained-Release Sodium Fluoride in the Treatment of the Elderly With
Established Osteoporosis
Current medical strategies to treat osteoporosis involve the use of
antiresorptive agents. However, the use of a bone-forming or anabolic agent
for treating osteoporosis in the elderly could facilitate treatment because
it targets the senescent decline in osteoblastic activity associated with
decreased bone formation. In this article, Rubin and colleagues carried out
a 3-year double-blind, randomized controlled trial to evaluate the efficacy
and safety of sustained-release sodium fluoride (an anabolic agent) in treating
elderly women with established osteoporosis. The addition of sustained-release
sodium fluoride to a regimen of calcium citrate and cholecalciferol safely
reduced the risk of vertebral fractures compared with calcium citrate and
cholecalciferol alone by 60%.
(SEE ARTICLE)
Acute Precipitants of Congestive Heart Failure Exacerbations
Congestive heart failure (CHF) is characterized by frequent exacerbation
of symptoms, often leading to hospitalization. Knowledge of these factors
could help prevent clinical deterioration. This investigation was a prospective
evaluation of the acute precipitants of CHF conducted as a substudy of the
Randomized Evaluation of Strategies for Left Ventricular Dysfunction Pilot
Study, a randomized trial of candesartan alone, enalapril alone, candesartan
plus enalapril, and metoprolol or placebo in 768 patients over 43 weeks. Investigators
systematically reported all episodes (n = 323) of worsening CHF symptoms.
The factors associated with acute worsening of CHF symptoms were excessive
sodium intake, noncardiac causes (notably pulmonary infections), arrhythmias,
and the use of study medications, antiarrhythmic agents, and calcium channel
blockers. The authors conclude that a wide variety of factors, many of which
are avoidable, are associated with exacerbation of CHF.
(SEE ARTICLE)
Elevated Midlife Blood Pressure Increases Stroke Risk in Elderly Persons
Most strokes occur in older adults, with 72% occurring in subjects older
than 65 years. An elevated blood pressure (BP) is the most important modifiable
risk factor for stroke. However, predictions of stroke risk are traditionally
based on current BP, and the potential impact of a subject's past BP experience
is unknown. Seshadri and colleagues from the Framingham Heart Study address
this question using BP data gathered prospectively over 50 years in more than
5000 subjects. The authors report that past elevations in BP (up to 2 decades
earlier) are a strong predictor of stroke risk in older adults (age, 60-90
years), even after accounting for current BP and even if current BPs are in
a "normal" range. Effective prevention of ischemic stroke in the elderly will
likely require early detection and treatment of hypertension and optimal control
of BP throughout life.
(SEE ARTICLE)
Variation in Routine Electrocardiogram Use in Academic Primary Care
Practice
To evaluate patterns of routine electrocardiogram (ECG) use in primary
care practice, the authors used computerized billing data to examine ECG ordering
by 125 academic internists. Using data on 69 921 patients without cardiac
disease, adjusted rates of ECG ordering were calculated to account for patient
age, sex, and diagnoses. Logistic regression evaluated additional predictors
of ECG ordering. Electrocardiograms were ordered in 4.4% of visits. Variations
in ordering practices were substantial. Group practices had adjusted ECG rates
varying from 0.8% to 8.6%, while individual physicians' rates ranged from
0.0% to 24%. Significant patient predictors of ECG use were older age, male
sex, and the presence of clinical conditions. Nonclinical factors related
to financial incentives also seemed to have an impact on ECG ordering. These
findings suggest a need for greater consensus about screening ECG testing
in primary care.
(SEE ARTICLE)
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