Curriculum for neurogastroenterology and motility training: A report from the joint ANMS-ESNM task force.

Although neurogastroenterology and motility (NGM) disorders are some of the most frequent disorders encountered by practicing gastroenterologists, a structured competency-based training curriculum developed by NGM experts is lacking. The American Neurogastroenterology and Motility Society (ANMS) and the European Society of Neurogastroenterology and Motility (ESNM) jointly evaluated the components of NGM training in North America and Europe. Eleven training domains were identified within NGM, consisting of functional gastrointestinal disorders, visceral hypersensitivity and pain pathways, motor disorders within anatomic areas (esophagus, stomach, small bowel and colon, anorectum), mucosal disorders (gastro-esophageal reflux disease, other mucosal disorders), consequences of systemic disease, consequences of therapy (surgery, endoscopic intervention, medications, other therapy), and transition of pediatric patients into adult practice. A 3-tiered training curriculum covering these domains is proposed here and endorsed by all NGM societies. Tier 1 NGM knowledge and training is expected of all gastroenterology trainees and practicing gastroenterologists. Tier 2 knowledge and training is appropriate for trainees who anticipate NGM disorder management and NGM function test interpretation being an important part of their careers, which may require competency assessment and credentialing of test interpretation skills. Tier 3 knowledge and training is undertaken by trainees interested in a dedicated NGM career and may be restricted to specific domains within the broad NGM field. The joint ANMS and ESNM task force anticipates that the NGM curriculum will streamline NGM training in North America and Europe and will lead to better identification of centers of excellence where Tier 2 and Tier 3 training can be accomplished.

Perception and Action in Teleoperated Needle Insertion.

We studied the effect of delay on perception and action in contact with a force field that emulates elastic soft tissue with a rigid nonlinear boundary. Such a field is similar to forces exerted on a needle during teleoperated needle insertion. We found that delay causes motor underestimation of the stiffness of this nonlinear soft tissue, without perceptual change. These experimental results are supported by simulation of a simplified mechanical model of the arm and neural controller, and a model for perception of stiffness, which is based on regression in the force-position space. In addition, we show that changing the gain of the teleoperation channel cancels the motor effect of delay without adding perceptual distortion. We conclude that it is possible to achieve perceptual and motor transparency in virtual one-dimensional remote needle insertion task.

Body machine interface: remapping motor skills after spinal cord injury.

The goal of a body-machine interface (BMI) is to map the residual motor skills of the users into efficient patterns of control. The interface is subject to two processes of learning: while users practice controlling the assistive device, the interface modifies itself based on the user's residual abilities and preferences. In this study, we combined virtual reality and movement capture technologies to investigate the reorganization of movements that occurs when individuals with spinal cord injury (SCI) are allowed to use a broad spectrum of body motions to perform different tasks. Subjects, over multiple sessions, used their upper body movements to engage in exercises that required different operational functions such as controlling a keyboard for playing a videogame, driving a simulated wheelchair in a virtual reality (VR) environment, and piloting a cursor on a screen for reaching targets. In particular, we investigated the possibility of reducing the dimensionality of the control signals by finding repeatable and stable correlations of movement signals, established both by the presence of biomechanical constraints and by learned patterns of coordination. The outcomes of these investigations will provide guidance for further studies of efficient remapping of motor coordination for the control of assistive devices and are a basis for a new training paradigm in which the burden of learning is significantly removed from the impaired subjects and shifted to the devices.

Updated fracture incidence rates for the US version of FRAX.

UNLABELLED: On the basis of updated fracture and mortality data, we recommend that the base population values used in the US version of FRAX be revised. The impact of suggested changes is likely to be a lowering of 10-year fracture probabilities. INTRODUCTION: Evaluation of results produced by the US version of FRAX indicates that this tool overestimates the likelihood of major osteoporotic fracture. In an attempt to correct this, we updated underlying fracture and mortality rates for the model. METHODS: We used US hospital discharge data from 2006 to calculate annual age- and sex-specific hip fracture rates and age-specific ratios to estimate clinical vertebral fracture rates. To estimate the incidence of any one of four major osteoporotic fractures, we first summed these newly derived hip and vertebral fracture estimates with Olmsted County, MN, wrist and upper humerus fracture rates, and then applied 10-20% discounts for overlap. RESULTS: Compared with rates used in the current FRAX tool, 2006 hip fracture rates are about 16% lower, with greatest reductions observed among those below age 65 years; major osteoporotic fracture rates are about one quarter lower, with similar reductions across all ages. CONCLUSIONS: We recommend revising the US-FRAX by updating current base population values for hip fracture and major osteoporotic fracture. The impact of these revisions on FRAX is likely to be lowering of 10-year fracture probabilities, but more precise estimates of the impact of these changes will be available after these new rates are incorporated into the FRAX tool.

Persistence with weekly alendronate therapy among postmenopausal women.

INTRODUCTION: Although clinical trials indicate that oral bisphosphonates reduce osteoporotic fracture risk, compliance with bisphosphonate therapy in practice is suboptimal, with 1-year discontinuation rates exceeding 50%. METHODS: We conducted a retrospective cohort study among female members of a large integrated health care delivery system (Kaiser Permanente of Northern California), age 45 years and older, to determine their persistence with weekly alendronate (defined as continuous use, allowing for a refill gap of 60 days), predictors of discontinuation, and subsequent osteoporosis therapy. We also examined the effect of varying the refill gap from 30 to 120 days on the discontinuation rate. From 2002 through 2003, we identified 13,455 women (age 68.8+/-10.4 years) who initiated weekly oral alendronate therapy. RESULTS: Using a 60-day refill gap, the 1-year discontinuation rate was 49.6% [95% confidence interval (CI) 48.8-50.4%]; this increased to 58.0% (CI 57.2-58.8%) with a 30-day gap and decreased to 42.2% (CI 41.1-43.0%) with a 120-day gap. Among those who discontinued therapy, about one-third restarted alendronate or another osteoporosis drug within 6 months. Baseline factors associated with alendronate discontinuation included prior bone mineral density testing [adjusted odds ratio (OR) 0.64, CI 0.60-0.69], prior postmenopausal hormone therapy (OR 0.78, CI 0.73-0.84), prior high-dose oral glucocorticoid therapy (OR 1.26, CI 1.05-1.51), prior gastrointestinal diagnoses (OR 1.21, CI 1.09-1.36), and high number of therapeutic classes of prescriptions filled in the prior year (OR 1.21, CI 1.10-1.32), although the final model had limited explanatory power. CONCLUSIONS: We conclude that apparent discontinuation rates are high within 1 year after treatment initiation, although a subset of women appears to restart bisphosphonate or other osteoporosis therapy. Because intermittent use and/or poor adherence is common, discontinuation rates based on data from administrative databases are sensitive to the refill gap length. In addition, we identified no clinical factors highly predictive of discontinuation.

Outcomes of a disease-management program for patients with recent osteoporotic fracture.

INTRODUCTION: The purpose of this study was to evaluate outcomes of a disease-management program designed to increase rates of bone-mineral-density (BMD) testing and initiation of osteoporosis medication among patients with a recent osteoporotic fracture. STUDY DESIGN: We identified 744 consecutive patients aged>or=55 years who were seen at either of 2 of 14 Kaiser Permanente medical facilities in Northern California (KPNC) after sustaining a fracture of the hip, spine, wrist, or humerus between April 2003 and May 2004. These patients were invited to participate in a study of the Fragile Fracture Management Program, whose protocol used fracture-risk assessment tools to determine treatment recommendations. Postfracture care of study participants was compared with usual postfracture care received by osteoporotic-fracture patients at 12 other KPNC facilities. RESULTS: Of the 744 patients who were invited to participate in the study, 293 (39%) agreed to participate, and 169 (23%) completed the evaluation. Of these 169 patients (127 women, 42 men), 65 (51%) of the women and 7 (17%) of the men qualified for drug treatment; of these 72 patients, 6 (86%) of the men and 41 (63%) of the women accepted the offered treatment. At the two study locations, rates of care (BMD testing or prescribing osteoporosis medication) were about twice as high as rates of usual postfracture care observed at 12 other medical centers in KPNC. CONCLUSIONS: Compared with patients who received usual care for osteoporotic fracture, patients participating in a postfracture disease management program had substantially higher rates of medical attention given for osteoporosis; however, the overall yield of the program was low. This low uptake rate was related to factors not previously appreciated: many patients refused participation in the program; a high proportion of younger women-and men of all ages-did not qualify for treatment; and treatment was refused by one in three study-qualified women and by one in seven study-qualified men. Additional efforts are needed to overcome patient barriers to improved osteoporosis evaluation, treatment and participation in postfracture programs.

A double-blind randomized controlled trial showing the analgesic and anesthetic properties of lidocaine E to be equivalent to those of ropivicaine and bupivacaine in carpal tunnel release surgery.

In a three-phase trial, the anesthetic properties of lidocaine, bupivacaine and ropivicaine were compared in carpal tunnel release surgery. In phase I, two groups of 25 sequential patients were injected with either lidocaine plain 2% or lidocaine 2% with adrenaline 1:100,000 (E), as the local anesthetic for outpatient carpal tunnel release surgery. Subjective injection pain, postoperative pain at 2 h increments and the number of analgesic pills taken were recorded. During the first postoperative hours, outcome measures were superior in the lidocaine E group. In phase II, a double-blind randomized design compared 42 patients injected with either lidocaine E or a combination of lidocaine E and bupivacaine. Postoperative pain scores and analgesic pills taken were compared using nonparametric statistical tests. During the first 4 h there was a slight benefit in the duration of the anesthetic and fewer pain pills were used in the bupivacaine group. Phase III was a randomized double-blind comparison of ropivicaine and lidocaine E 2% in 72 patients. There was a slight decrease in pain scores and fewer analgesic pills required during the first 6 h in the ropivicaine group. Lidocaine plain 2% provided significantly inferior analgesic and anesthetic properties compared with lidocaine E 2%, bupivacaine or ropivicaine. Sequential randomized comparisons between lidocaine E and bupivacaine and ropivicaine showed clinical equivalence. The present study showed lidocaine E 2% to be a satisfactory and comparatively cost-effective anesthetic for outpatient carpal tunnel surgery.

Pendant un essai en trois phases, les propriétés anesthésiques de la lidocaïne, de la bupivacaïne et de la ropivicaïne ont été comparées dans le cadre du dégagement chirurgical du canal carpien. Pendant la phase I, deux groupes de 25 patients séquentiels ont reçu une injection de lidocaïne simple à 2 % ou de lidocaïne à 2 % associée à de l'adrénaline 1:100 000 (E), comme anesthésique local pour dégager leur canal carpien par voie chirurgicale sans hospitalisation. La douleur subjective à l'injection, la douleur postopératoire par intervalles de deux heures et le nombre de comprimés analgésiques consommés ont été consignés. Pendant les premières heures postopératoires, les mesures d'issue étaient supérieures au sein du groupe prenant de la lidocaïne E.Pendant la phase II, un essai aléatoire à double insu a permis de comparer 42 patients à qui on avait injecté soit de la lidocaïne E, soit une association de lidocaïne E et de bupivacaïne. Les indices de douleur postopératoire et les comprimés analgésiques consommés ont été comparés au moyen de tests statistiques non paramétriques. Pendant les quatre premières heures, on remarquait un léger avantage dans la durée de l'effet anesthésique et un moins grand nombre de comprimés utilisés au sein du groupe prenant de la bupivacaïne.La phase III était une comparaison aléatoire à double insu de la ropivicaïne et de la lidocaïne E à 2 % chez 72 patients. On remarquait une légère diminution des indices de douleur et un moins grand nombre de comprimés analgésiques nécessaires pendant les six premières heures au sein du groupe prenant de la ropivicaïne.La lidocaïne simple à 2 % avait des propriétés analgésiques et anesthésiques considérablement inférieures à la lidocaïne E à 2 %, à la bupivacaïne ou à la ropivicaïne. Des comparaisons aléatoires séquentielles entre la lidocaïne E, la bupivacaïne et la ropivicaïne démontraient une équivalence clinique. La présente étude révèle que la lidocaïne E à 2 % est un anesthésique satisfaisant et comparativement rentable pour le dégagement chirurgical du canal carpien sans hospitalisation.

Predictors of physical activity in community-dwelling elderly white women.

OBJECTIVE: To describe patterns of physical activity and to determine factors associated with engaging in regular exercise, especially walking, in elderly white women. DESIGN: Cross-sectional study of 9,442 independently living elderly white women aged 65 years and over participating in the Study of Osteoporotic Fractures. MEASUREMENTS AND MAIN RESULTS: We studied the association between lifestyle habits, social factors, health status and self-reported physical activity (assessed by modified Paffenbarger scale) during the past twelve months. Walking was the most common form of exercise: 4,837 (51%) women reported doing so a mean of 12 (SD = 10) blocks per day, 3.9 (SD = 2.9) times per week. Other common activities were gardening (35%), swimming (16%), and bicycling (13%). Less than a third of women reported engaging in medium- or high-intensity exercise in the past year. In a multivariate age-adjusted analysis, factors independently (P < .01) associated with walking for exercise included greater than high school education (52% vs 48%), history of physical activity for exercise at ages 30 years (51% vs 46%) and 50 years (51% vs 45%), and stronger social network (51% vs 47%). Women who were current smokers, obese, or depressed were less likely to take walks for exercise. Marital status, self-reported arthritis, current estrogen use, and a history of falls in the past year were not independently associated with taking walks for exercise. CONCLUSIONS: In this healthy cohort, walking for exercise is associated with other positive health behaviors. Given the mounting evidence about the health benefits of walking, and since many of these community dwelling women can and do walk for exercise, but rarely engage in other common prescribed physical activities, clinicians might best focus their efforts on encouraging walking.

Low-dosage esterified estrogens opposed by progestin at 6-month intervals.

OBJECTIVE: To estimate incidence of endometrial hyperplasia, vaginal bleeding, and menopausal symptoms in women who changed from standard monthly cyclic hormone replacement therapy (HRT) to half-strength estrogen opposed by medroxyprogesterone acetate (MPA) at 6-month intervals. METHODS: We identified 138 women aged 55-75 years who had regularly used HRT at a standard dosage (equivalent to 0.625 mg conjugated estrogen) opposed by cyclic monthly MPA. Each subject's HRT regimen was changed to 0.3 mg/day esterified estrogens (Estratab; Solvay Pharmaceuticals, Marietta, GA) combined with 14-day courses of MPA, 10 mg/day, every 6 months. Endometrial biopsy was repeated after 1 year of the new regimen. Any vaginal bleeding was reported in each patient's daily diary. Menopause symptoms were evaluated using the Greene Menopause Symptom Index. RESULTS: Among 125 women who had biopsy after 1 year of the new regimen, endometrial hyperplasia was found in two (1.6%, 95% confidence interval 0.3%, 6.2%). Of the 125 women, 44% had scheduled bleeding, and 9.4% had unscheduled bleeding. Relative to baseline vasomotor score (range 0-6), an increase of at least 2 U was reported by 20% of subjects at 6 months and by 17% of subjects at 12 months. CONCLUSION: Most women aged at least 55 years can safely switch their HRT regimen from standard dosage HRT to low-dosage estrogen opposed by MPA at 6-month intervals. Moreover, this new HRT regimen causes little vaginal bleeding while maintaining adequate control of menopausal symptoms.

Postmenopausal hormonal support: discontinuation of raloxifene versus estrogen.

OBJECTIVE: To determine possible differences in continuation among women initiating treatment with the selective estrogen receptor modulator raloxifene, versus those initiating treatment with estrogen-containing regimens. DESIGN: A pharmacy prescription database search for refill patterns. The study subjects were members of Kaiser Foundation Health Plan, a large health maintenance organization; 1,394 women age >or=60 years who filled index prescriptions for either raloxifene (n = 331) or systemic estrogens (n = 1,063) between April 1998 and March 1999. The main outcome measure was discontinuation based on prescription refill patterns through December 2000. RESULTS: At 24 months, the probabilities of discontinuing were 56% for women starting raloxifene compared to 72% for women starting estrogens. The likelihood of discontinuation was significantly less among women starting raloxifene than among those starting estrogen (hazard ratio = 0.75; 95% confidence interval = 0.64-0.88). Adjustments for age and prescriber specialty did not affect the risk. CONCLUSIONS: We conclude that discontinuation of estrogen by women well beyond the age of menopause is high; more than two-thirds discontinue within 2 years of starting. Women starting therapy with raloxifene are 25% percent less likely to discontinue their medication than those starting estrogen, providing some promise that long-term benefits of raloxifene may be more easily achieved than those of estrogen.

Acute perforated neonatal appendicitis associated with chorioamnionitis.

Perforation of the appendix is rare in term neonates and even more rare in prematures. In most of the reported cases it is a complication of necrotizing enterocolitis (NEC) but can also complicate Hirschsprung's disease (HD), cystic fibrosis (CF) or acute appendicitis (AA). We present a pre-term newborn, born to a mother who had bacteriaemia associated with chorioamnionitis. On his sixth day of life he had clinical and radiological signs of perforated abdominal viscus. Laparotomy and histologic findings indicated acute perforated appendicitis. The association of acute perforated appendicitis with chorioamnionitis points to the role of maternal foetal infection in the aetiology of neonatal acute appendicitis.

Initiation of osteoporosis treatment after bone mineral density testing.

The aim of the study was to describe initiation of osteoporosis drug therapy after bone mineral density (BMD) testing and to determine any association with BMD test results obtained, physician factors, or both. The setting was the Kaiser Foundation Health Plan (KFHP), a large health maintenance organization (HMO) in Northern California. Data were collected from bone densitometry centers at four KFHP medical centers sites in Sacramento, San Rafael, Fresno, and Oakland. We identified 17,290 women aged > or = 45 years who had BMD testing between January 1, 1997 and June 30, 1999. After excluding those for whom any osteoporosis drugs were prescribed in the year before testing, 8020 women were available for analysis. Using logistic regression, we examined the association between BMD diagnosis (i.e., osteoporosis or osteopenia versus normal) and initiation of drug therapy, for osteoporosis (including hormone replacement therapy (HRT), alendronate, etidronate, raloxifene and calcitonin) within 6 months after the test. Among the 8020 women, 1934 (24%) filled a prescription for an osteoporosis drug within 6 months after BMD testing. Compared with women who had a normal BMD test result, women diagnosed with osteopenia were nearly 4 times more likely (OR = 3.7; CI = 3.0-4.4), and women diagnosed with osteoporosis were 15 times more likely (OR = 15.0; CI = 12.5-18.1), to fill a prescription for an osteoporosis drug within 6 months after BMD testing. Women with high exposure to corticosteroid agents were twice as likely (OR = 2.1; CI = 1.7-2.7) to start osteoporosis drug therapy compared with women who were not similarly exposed; women diagnosed with recent osteoporotic fractures were 50% more likely (OR = 1.5; CI = 1.2-1.9) to begin therapy than women without such fractures. Despite the strong association between BMD and initiating treatment, nearly half the osteoporotic women did not initiate treatment. In addition, we found that age strongly influenced choice of osteoporotic drug. Compared with osteoporotic women aged 45-54 years, women aged 55-64 years who started drug therapy were 40% more likely (OR = 1.4; CI = 1.0-2.2) and women aged > or = 65 years were twice as likely (OR = 2.0; CI = 1.4-2.8) to start non-HRT drugs. BMD test results indicating osteoporosis were thus strongly associated with increased likelihood of beginning drug therapy, and half of such women initiated therapy. Drug initiation was also associated with other factors, including age, use of corticosteroid agents, recent fracture, and physician characteristics. However, these factors showed much weaker associations than those found for BMD. Health care providers must consider whether test results will influence treatment decisions, and our data indicate that results of BMD testing do influence management decisions regarding osteoporosis drug use for women.

Prevalence and determinants of osteoporosis drug prescription among patients with high exposure to glucocorticoid drugs.

OBJECTIVE: To investigate use of osteoporosis drugs among patients with high exposure to glucocorticoid drugs. STUDY DESIGN: Retrospective review of pharmacy records. METHODS: We identified patients aged > or = 20 years who received prescriptions for > or = 2 g of prednisone (or equivalent) during any 12-month period between January 1, 1998, and December 31, 1999, and who initiated use of osteoporosis-specific drugs (alendronate sodium, etidronate disodium, and calcitonin) during that period. RESULTS: Among 8807 patients who met study criteria, 772 (8.8%) received prescriptions for osteoporosis drugs. Prevalence of osteoporosis drug prescriptions increased linearly during the study and differed markedly by patient sex, age, and exposure to glucocorticoid drugs. Osteoporosis drugs were prescribed for 16.3% of women aged > or = 65 years, for 6.1% of women aged < 50 years, for 6.5% of men aged > or = 65 years, and for 2.2% of men aged < 50 years. Higher glucocorticoid exposure was also associated with higher rate of osteoporosis drug prescription (11.2% of patients exposed to > 4 g/y and 5.6% exposed to 2 to 3 g/y received such therapies). Osteoporosis drugs were 50% more likely to be prescribed by clinicians who prescribed glucocorticoid drugs to > 18 patients than by providers who prescribed glucocorticoid drugs to < 4 patients. CONCLUSIONS: Despite ready availability of bone-specific osteoporosis drugs, few patients with high exposure to glucocorticoid drugs received such therapy. Likelihood of an osteoporosis drug being prescribed for such patients strongly depends on patient sex, age, and exposure to glucocorticoid drugs and on level of practitioner experience in prescribing glucocorticoid drugs.

The North American Menopause Society 1998 menopause survey: Part II. Counseling about hormone replacement therapy: association with socioeconomic status and access to medical care.

OBJECTIVE: The purpose of this study was to examine two predictors of women's obtaining hormone replacement therapy (HRT) counseling: socioeconomic status and access to health care. DESIGN: During May-July 1998, by means of random-digit telephone dialing, 749 postmenopausal women who were living in the United States and aged 50-65 years were interviewed. On average, they were 56.8 years and 11.8 years postmenopausal. Most (86.0%) were Caucasian, and their median annual income was approximately $40,000. Nearly all (90.8%) had medical insurance coverage; 47.6% of those insured received care from a managed care organization. Access to medical care was evidenced by 92.3% being under the care of a primary care physician, 92.3% ever having had a mammogram, 96.9% ever having had a pelvic examination, and 91.1% ever having had a serum cholesterol determination. RESULTS: Of these 749 women, 75.4% reported that they had received counseling about post-menopausal HRT from healthcare providers. Both level of education and level of income were associated with an increased likelihood that HRT counseling would be obtained. Having a personal physician, and particularly receiving care from a gynecologist, increased the likelihood that counseling would be available. There were no substantial differences in counseling frequency between women in managed care plans and those having other types of health insurance. In a multivariate model, adjusted odds ratios for receiving HRT counseling were 2.9 (95% confidence interval [CI] = 1.7-4.8) for having an annual income of $50,000 or more versus less than $30,000, 2.8 (95% CI = 1.7-4.5) for receiving care from a gynecologist versus other primary care physician, 1.9 (95% CI = 1.1-3.2) for being Caucasian versus not, and 1.5 (95% CI 1.0-2.2) for having a hysterectomy versus not. CONCLUSIONS: Three quarters of a sample of US postmenopausal women aged 50-65 years reported that they had been counseled about HRT. However, women of lowest socioeconomic status and those who did not have a primary care physician were least likely to have received counseling. No differences were observed in prevalence of counseling between women in managed care settings and those with other types of health insurance. The findings suggest that special efforts are necessary to provide menopause education and counseling to underserved women.

Diagnosis of symptomatic postmenopausal women by traditional Chinese medicine practitioners.

OBJECTIVE: To learn more about the way that practitioners of traditional Chinese medicine (TCM) diagnose women who have menopausal symptoms. DESIGN: We assembled a cohort of 23 postmenopausal women who had hot flushes and were otherwise healthy. Each woman was examined independently by nine practitioners of TCM on the same day. Examination consisted of medical history and physical examination. Diagnoses were recorded and counted. RESULTS: The most frequent diagnosis made by the practitioners of TCM was kidney yin deficiency, which was the diagnosis made after 168 of 207 visits (81%); 23 women seen by nine TCM practitioners. Practitioners showed good agreement regarding presence of kidney yin deficiency: in 12 women (52%), this diagnosis was made by eight of nine practitioners; in 16 women (70%), seven of nine practitioners made this diagnosis; and in all 23 women (100%), at least five of nine practitioners made this diagnosis. CONCLUSIONS: Practitioners of TCM who diagnose postmenopausal women with vasomotor symptoms are likely to make a diagnosis that includes kidney yin deficiency.

Effect of age on reasons for initiation and discontinuation of hormone replacement therapy.

OBJECTIVE: The purpose of this study was to examine age-related differences in reasons that postmenopausal women began and stopped hormone replacement therapy (HRT). DESIGN: Two identical telephone surveys were conducted of women members of Kaiser Foundation Health Plan who had begun HRT within the previous 3 years. The first, in 1997, was of 604 older women aged 65 years or older; the second, in 1998, was of 866 younger women aged 50-55 years. Prescription records for both groups provided the means for determining continuation of therapy. RESULTS: Among older women, 35% reported prevention or treatment of osteoporosis as the primary reason for starting HRT. Younger women were less likely (14%) to report this (p < 0.001). Relief of vasomotor menopausal symptoms was the most frequently reported reason that younger women gave for starting HRT; it was the primary reason in 34%. In contrast, only 7% of older women reported relief of vasomotor symptoms as the primary reason for starting HRT (p < 0.001). Older women were more likely than younger women to discontinue HRT; after 12 months, the probabilities of discontinuation were 62% and 48% (relative risk = 1.4; 95% confidence interval = 1.2-1.6). Treatment-related side effects were most often the reason given for stopping HRT; 87% of older women and 64% of younger women who stopped reported that a treatment side effect was their primary reason (p < 0.001). Among treatment side effects, vaginal bleeding was the most frequently reported reason for stopping HRT; it was the primary reason for stopping in 52% of older women and 29% of younger women (p < 0.001). CONCLUSIONS: Older women differ from younger women in their reasons for starting and stopping HRT. Whereas osteoporosis is the predominant reason that older women begin HRT, relief of vasomotor symptoms is the major reason that younger women begin. Early discontinuation of HRT is common and is greater among older women. Intolerance of treatment, particularly vaginal bleeding, is the predominant reason for stopping HRT.

Continuation of postmenopausal hormone replacement therapy in a large health maintenance organization: transdermal matrix patch versus oral estrogen therapy.

OBJECTIVE: To determine possible differences in continuation of postmenopausal estrogen replacement therapy among women initiating treatment with transdermal estradiol versus those initiating treatment with oral estrogen. STUDY DESIGN: A retrospective database search. PATIENTS AND METHODS: We analyzed estrogen use among 45- to 74-year-old women who filled index prescriptions for estrogen during 1996 for either once-a-week transdermal estradiol or daily oral estrogen. Prescription use was analyzed separately for each of 2 groups: 276 hysterectomized women who filled prescriptions for estrogen alone (ERT) and 4182 women who filled prescriptions for medroxyprogesterone acetate (MPA) with estrogen (HRT) on the same day. RESULTS: Risk of discontinuing therapy after 12 months ranged from 59% to 76% among the 4 subgroups: ERT with unopposed transdermal estradiol; ERT with unopposed oral estrogen; HRT with MPA-opposed transdermal estradiol; and HRT with MPA-opposed oral estrogen. The relative risk (RR) of discontinuation was significantly greater among women starting HRT with transdermal estradiol than among women starting oral estrogen (RR = 1.5; 95% confidence interval [CI] = 1.3 to 1.8). RR of discontinuation among women starting ERT with transdermal estradiol compared with women starting oral estrogen therapy was 1.3 (95% CI = 1.0 to 1.8). CONCLUSIONS: Approximately 2 of 3 women who start either ERT or HRT discontinue therapy within a year, regardless of hysterectomy status. Furthermore, women who start ERT or HRT with a transdermal estradiol system are more likely to discontinue therapy.

Osteoarthritis and risk of falls, rates of bone loss, and osteoporotic fractures. Study of Osteoporotic Fractures Research Group.

OBJECTIVE: To examine the association between osteoarthritis (OA), as defined by radiographic evidence and self report, and osteoporotic fractures, falls, and bone loss in a cohort of elderly white women. METHODS: A cohort of 5,552 elderly women from the Study of Osteoporotic Fractures was followed up prospectively for a mean of 7.4 years. Self-reported, physician-diagnosed OA was recorded at interview, and radiologic OA of the hip and hand were defined from pelvis and hand radiographs obtained at baseline by validated techniques. Prevalent and incident vertebral fractures were detected by vertebral morphometry, and data on incident fractures and falls were collected by postcard surveys; fractures were confirmed by radiography. Bone mineral density (BMD) was measured on 2 occasions at the hip, lumbar spine, and calcaneus, and rates of bone loss were calculated. RESULTS: Women with radiographic hip OA had a reduced risk of recurrent falls in the first year (relative risk [RR] 0.7, 95% confidence interval [95% CI] 0.5-0.95). However, those with self-reported OA had an increased risk of falls (RR 1.4, 95% CI 1.2-1.5). Radiographic hip OA was associated with reduced bone loss in the femoral neck compared with controls (mean +/- SD -0.29+/-0.09%/year versus -0.51+/-0.03%/year; P = 0.018). However, radiographic hip OA showed nonsignificant trends toward increased bone loss at the calcaneus and lumbar spine. There was no significant association between self-reported OA or radiographic hand OA with bone loss. No definition of OA was associated with incident nonvertebral fracture, hip fracture, or vertebral fracture. CONCLUSION: Despite having increased BMD compared with controls, subjects with OA did not have a significantly reduced risk of osteoporotic fracture, although there was a trend toward a reduced risk of femoral neck fractures in subjects with severe radiographic OA. The failure of the observed increase in BMD to translate into a reduced fracture risk may be due, in part, to the number and type of falls sustained by subjects with OA. Patients with OA should not be considered to be at a lower risk of fracture than the general population. Physicians should be aware that a high BMD in patients with OA may be falsely reassuring.

Recreational physical activity and the risk of osteoarthritis of the hip in elderly women.

OBJECTIVE: The relationship between recreational physical activity and the risk of osteoarthritis (OA) of the hip in women is uncertain. We examined the cross sectional association of radiographic OA of the hip and past recreational and sports related physical activity in elderly women who are participants in the Study of Osteoporotic Fractures. METHODS: An anteroposterior pelvic radiograph of 5818 subjects was assessed for hip OA using reliable measurements of individual radiographic features. Hips were graded on a summary scale of 0 (no findings) to 4 (severe OA) based on the number and type of radiographic features present. Logistic regression was used to examine the association of self-reported recreational physical activity (times/week) as a teenager, at age 30, and at age 50 with hip OA. All analyses were adjusted for age and body mass index at age 25 years. RESULTS: The risk of moderate to severe radiographic hip OA in elderly women was modestly increased in elderly women who were in the highest quartile for all physical activities performed as a teenager (odds ratio 1.7, 95% confidence interval 1.1, 2.4), at age 50 (OR 1.4, 95% CI 1.0, 1.9) and weight bearing activities at age 30 (OR 1.4, 95% CI 1.0, 1.9) compared to women in the lowest quartile of activity. The risk of symptomatic hip OA (grade > or =2 hip OA + hip pain) was modestly increased in women who were in the highest quartile for all physical activities as a teenager (OR 2.0, 95% CI 1.2, 3.4), at age 50 (OR 1.6, 95% CI 1.0, 2.4), and weight bearing activities at age 30 (OR 1.6, 95% CI 1.0, 2.4) compared to women in the lowest quartile of activity. CONCLUSION: Recreational physical activities performed by women before menopause may increase the risk of radiographic and symptomatic hip OA.

Association between serum fructosamine and mortality in elderly women: the study of osteoporotic fractures.

Serum fructosamine levels can be used to estimate long-term serum glucose values and can be measured in frozen serum. The authors examined whether fructosamine levels were associated with mortality in a cohort of 9,704 white women (> or = 65 years of age) recruited from September 1986 to October 1988 at four clinical centers in the United States. A random sample of women who had died during a mean of 6 years of follow-up (n = 55) was compared with randomly selected controls (n = 276, 54 of whom had died). Fructosamine assays were performed blinded to vital status. Hazard ratios with 95% confidence intervals were adjusted for age, clinical center, smoking, hypertension, and serum albumin and cholesterol levels. Each standard deviation (46 micromol) increase in fructosamine level was associated with a 1.3-fold (95% confidence interval (CI) 1.0-1.6, p = 0.04) increased rate of all-cause mortality, including a 1.5-fold (95% CI 1.0-2.1, p = 0.03) increase in cardiovascular disease mortality. Elevated fructosamine levels (>285 micromol/liter) were associated with a 4.3-fold (95% CI 1.6-12, p = 0.004) increased rate of cardiovascular mortality; in women without a history of diabetes, the hazard ratio was 4.6 (95% CI 1.3-16, p = 0.02). Fructosamine level, or another indicator of glycemia, should be included when the risk of cardiovascular disease among older patients is evaluated.