In This Issue of Archives of Internal Medicine FREE

DeCarolis et al conducted a retrospective study of the manufacturer's recommended therapeutic doses of enoxaparin sodium in patients with normal renal function, defined as estimated creatinine clearance greater than 80 mL/min, and moderate renal function, defined as an estimated creatinine clearance between 30 and 50 mL/min. Major outcomes were major bleeding, defined as any bleeding resulting in hospital admission or death, lengthened hospital stay, or an emergency department visit, and recurrent thrombosis. The results showed significantly higher bleeding in the moderate renal impairment group (22.0% vs 5.7%), as well as a higher bleeding rate in patients receiving enoxaparin as bridge therapy.

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Butt et al report on the association between antihypertensive drugs and immediate hip fracture risk during the initiation of treatment in hypertensive community-dwelling elderly patients living in Ontario, Canada. Some studies indicate that antihypertensive drugs can increase the risk of falls during the first few weeks of therapy. However, there is no evidence to support an increased risk of hip fracture during this period. Using a self-controlled case series analysis, the authors found a 43% increased risk of hip fracture during the first 45 days of initiation of antihypertensive drug therapy.

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Using data recorded in an inpatient electronic Medication Administration Record system, Zhou et al reported patients' actual acetaminophen exposure and identified important factors associated with supratherapeutic dosing of acetaminophen. Among hospitalized patients, 60.7% received acetaminophen, and of these, 6.6% exceeded the 4-g/d recommended maximum. Patients receiving greater doses of acetaminophen tended to have significant elevations in alkaline phosphatase level, although a causal relationship cannot be concluded. A significantly higher risk of supratherapeutic dosing was observed in patients who received scheduled administrations (hazard ratio [HR], 16.6; 95% CI, 13.5-20.6), multiple product formulations (HR, 2.4; 95% CI, 2.0-2.9), or the 500-mg strength formulation (HR, 1.9; 95% CI, 1.5-2.3). Interventions to reduce the incidence of these risk factors may prevent supratherapeutic acetaminophen dosing in hospitalized patients.

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In this analysis of nationally representative survey data, Frank et al examined trends in the prevalence and management of substance use disorders in ambulatory visits between 2001 and 2009, a period during which several new pharmacologic treatment options became available. Visits involving substance use disorders increased 70%, from an estimated 10.6 million in 2001 through 2003 to 18.0 million in 2007 through 2009 (P = .006). Visits for opioid use disorders increased 6-fold during this period (P = .004). Pharmacotherapy prescribing, defined as provision of buprenorphine, methadone, acamprosate, disulfiram, or naltrexone, rose from 6% of visits in 2001 through 2003 to 22% in 2007 through 2009 (P < .001).

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Dupre et al investigate the cumulative impact of multiple dimensions of unemployment on risks of acute myocardial infarction (AMI). Using 18 years of prospective cohort data of US adults aged 51 to 75 years, the authors found that AMI risks were significantly higher among the unemployed than the employed and that risks increased incrementally from 1 job loss (hazard ratio [HR], 1.22; 95% CI, 1.04-1.42) to 4 or more cumulative job losses (HR, 1.63; 95% CI, 1.29-2.07). Risks of AMI were particularly elevated within the first year of unemployment, and the results were robust after adjustments for multiple socioeconomic, behavioral, psychological, and clinical risk factors. These data show that unemployment status, multiple job losses, and short periods without work were significant risk factors for acute cardiovascular events.

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