Risk marker associations with venous thrombotic events: a cross-sectional analysis.

OBJECTIVE: To examine the interrelations among, and risk marker associations for, superficial and deep venous events-superficial venous thrombosis (SVT), deep venous thrombosis (DVT) and pulmonary embolism (PE). DESIGN: Cross-sectional analysis. SETTING: San Diego, California, USA. PARTICIPANTS: 2404 men and women aged 40-79 years from four ethnic groups: non-Hispanic White, Hispanic, African-American and Asian. The study sample was drawn from current and former staff and employees of the University of California, San Diego and their spouses/significant others. OUTCOME MEASURES: Superficial and deep venous events, specifically SVT, DVT, PE and combined deep venous events (DVE) comprising DVT and PE. RESULTS: Significant correlates on multivariable analysis were, for SVT: female sex, ethnicity (African-American=protective), lower educational attainment, immobility and family history of varicose veins. For DVT and DVE, significant correlates included: heavy smoking, immobility and family history of DVEs (borderline for DVE). For PE, significant predictors included immobility and, in contrast to DVT, blood pressure (BP, systolic or diastolic). In women, oestrogen use duration for hormone replacement therapy, in all and among oestrogen users, predicted PE and DVE, respectively. CONCLUSIONS: These findings fortify evidence for known risk correlates/predictors for venous disease, such as family history, hormone use and immobility. New risk associations are shown. Striking among these is an association of PE, but not DVT, to elevated BP: we conjecture PE may serve as cause rather than consequence. Future studies should evaluate the temporal direction of this association. Oxidative stress and cell energy compromise are proposed to explain and predict many risk factors, operating through cell-death mediated triggering of coagulation activation.

The older the better: are elderly study participants more non-representative? A cross-sectional analysis of clinical trial and observational study samples.

OBJECTIVE: Study participants can differ from the target population they are taken to represent. We sought to investigate whether older age magnifies such differences, examining age-trends, among study participants, in self-rated level of activity compared to others of the same age. DESIGN: Cross-sectional examination of the relation of participant age to reported 'relative activity' (ie, compared to others of the same age), a bidirectionally correlated proxy for relative vitality, in exemplars of randomised and observational studies. SETTING: University of California, San Diego (UCSD) PARTICIPANTS: 2404 adults aged 40-79 including employees of UCSD, and their partners (San Diego Population Study, observational study). 1016 adults (aged 20-85) not on lipid medications and without known heart disease, diabetes, cancer or HIV (UCSD Statin Study, randomised trial). MEASUREMENTS: Self-rated activity relative to others' age, 5-point Likert Scale, was evaluated by age decade, and related via correlation and regression to a suite of health-relevant subjective and objective outcomes. RESULTS: Successively older participants reported successively greater activity relative to others of their age (greater departure from the norm for their age), p<0.001 in both studies. Relative activity significantly predicted (in regression adjusted for age) actual activity (times/week exercised), and numerous self-rated and objective health-predictors. These included general self-rated health, CES-D (depression score), sleep, tiredness, energy; body mass index, waist circumference, serum glucose, high-density lipoprotein-cholesterol, triglycerides and white cell count. Indeed, some health-predictor associations with age in participants were 'paradoxical,' consistent with greater apparent health in older age-for study participants. CONCLUSIONS: Study participants may not be representative of the population they are intended to reflect. Our results suggest that departures from representativeness may be amplified with increasing age. Consequently, the older the age, the greater the disparity may be between what is recommended based on 'evidence, ' and what is best for the patient. TRIAL REGISTRATION: UCSD Statin Study-Clinicaltrials.gov # NCT00330980 (http://ClinicalTrials.gov).

Reduction of suboptimal prescribing and clinical outcome for dementia patients in a senior behavioral health inpatient unit.

BACKGROUND: Suboptimal prescribing in older psychiatric patients causes iatrogenic morbidity. The objectives of this study were to compare the prevalence of suboptimal prescribing before and after admission to a geropsychiatry inpatient unit and to evaluate a possible correlation between optimal medication use and functional improvement in patients with dementia. METHODS: The study sample comprised 118 consecutively admitted patients to a 14-bed university hospital-based geropsychiatry inpatient unit over a period of 20 months who met the DSM-IVTR criteria for an Axis I psychiatric illness and co-morbid dementia. At admission demographic information, Mini-mental State Examination (MMSE) Score, Mattis Dementia Rating Scale Score (DRS), and number of active medical illnesses were recorded. At admission and discharge the number and type of medications, number of Revised Beers Criteria (RBC) medications (a published list of potentially inappropriate medications in older adults independent of diagnoses or conditions), Global Assessment of Functioning (GAF) scores, and Scale of Functioning (SOF) scores were tabulated. chi2 tests, paired t-tests and Pearson correlations were used to test the medication prevalence and associations between measures of clinical function and other variables. RESULTS: The mean age (standard deviation) of the sample was 81.5 (6.2) years. The mean scores on the MMSE and DRS were 22.1 (6.2) and 116.6 (18.7), respectively. From admission to discharge, the mean number of RBC medications per patient decreased significantly from 0.8 (1.1) to 0.4 (0.6). There was also a significant correlation between reduction in Beers criteria medications and improved SOF score from time of admission to time of discharge. CONCLUSION: Suboptimal medication use is a potential source of decreased function in older patients with dementia.

Comparison of two models for delivery of services in psychiatric emergencies.

OBJECTIVE: To evaluate the benefits of the psychiatric emergency service (PES) model, in comparison to the model of the psychiatric consultant to the emergency department (the consultation model). METHODS: A retrospective chart review of 100 involuntary PES patients and 100 involuntary patients of the consultation model were matched for age, sex, ethnicity and primary diagnosis. Baseline characteristics, demographics and various outcomes of the two groups were compared. RESULTS: After establishment of the psychiatric emergency service, there were improvements in the following categories: (1) timely rendering of psychiatric emergency care (330 vs. 639 min, P<.01), (2) completion of mental status exam (95% vs. 49%, P<.01), (3) pregnancy testing (73% vs. 52%, P<.05), (4) safety in the form of seclusion (6% vs. 15%, P<.05) and elopement (5% vs. 13%, P<.05). There were no statistical significant differences in urine toxicology ordered, follow-up care provided and readmission rate after 30 days. CONCLUSION: The PES is a multidisciplinary system that can be beneficial to psychiatric emergency patients by providing timely rendering of care, improving access to care, and ensuring safety and better assessment.