Guidelines For Medical Treatment Research Articles

Circulation: Cardiovascular Interventions Editors’ Picks

<i>Circulation: Cardiovascular Interventions</i> Editors’ Picks

Progress on the road to better medical care for transgender patients

In order to improve transgender individuals' access to healthcare, primary care physicians and specialists alike should be knowledgeable about transgender medicine. This review is intended to provide concise transgender hormone treatment guidelines. Transgender individuals report that the lack of knowledgeable providers represents the greatest barrier to transgender medical care. Hormone treatments are generally well tolerated and greatly benefit transgender patients. After physicians recognize that gender identity is stable, hormone treatments for transgender patients are often straightforward. A practical target for hormone therapy for transgender men (female to male) is to increase testosterone levels to the normal male physiological range (300-1000 ng/dl) by administering testosterone. A practical target for hormone therapy for transgender women (male to female) is to decrease testosterone levels to the normal female range (30-100 ng/dl) without supra-physiological levels of estradiol (<200 pg/ml) by administering an antiandrogen and estrogen. Patients should be monitored every 3 months for the first year and then every 6-12 months for hormonal effects. Although more studies are required, recently published transgender medical treatment guidelines provide a good start toward making care of transgender patients more generalized and accessible to healthcare providers.

Categorising methadone: Addiction and analgesia

While methadone was first developed as an analgesic, and used for this purpose before it was adopted as a therapy for drug dependence, it is this latter use which has saturated its identity. Most of the literature and commentary on methadone discusses it in the context of methadone maintenance therapy (MMT). But one of the effects of the liberalization of opiate prescription for chronic pain which took place in the 1990s was the re-emergence of methadone as a painkiller. This article examines the relationship between methadone the painkiller and methadone the addiction treatment as it is constituted in recent medical research literature and treatment guidelines. It highlights the way medical discourse separates methadone into two substances with different effects depending on the problem that is being treated. Central to this separation is the classification of patients into addicts and non-addicts; and pain sufferers and non-pain sufferers. The article argues that despite this work of making and maintaining distinctions, the similarities in the way methadone is used and acts in these different medical contexts complicates these categories. The difficulties of keeping the ‘two methadones’ separate becomes most apparent in cases of MMT patients also being treated for chronic pain.

Hormones and Nocturia: Guidelines for Medical Treatment?

Nocturnal polyuria (NP) is an important cause of nocturia and it is related to an imbalance in water and/or sodium homeostasis. Antidiuretic hormone (ADH) and atrial natriuretic peptide (ANP) are believed to play an important role in this excessive urine production overnight, however, many other hormones are involved. ADH and ANP are both directly and indirectly influenced by the renin-angiotensin-aldosterone system (RAAS), prostaglandins antagonize both ADH and RAAS and sex hormones have a predominantly antidiuretic effect by stimulating ADH and RAAS, meaning that any disturbance can lead to an imbalance in diuresis. Since nocturia is a condition affecting sleep, melatonin secretion can also be affected, leading to a decrease in the antidiuretic effect and to an increase of nocturnal urine production. Depending on the underlying condition affecting any of these hormones, a more specific therapeutic approach might lead to a restoration of the normal diuresis cycle and to a good night’s sleep. The characteristics of each of these hormones, the pathophysiology in NP and the therapeutic implications are set out in this review.

NYS Workers’ Compensation Medical Treatment Guidelines: Variance Tracking and Guidelines Amendment Program

In December of 2010 the New York State Insurance Department drafted medical treatment guidelines, including those for the care of the back and neck, utilizing input from physicians who were representatives of labor unions or medical directors of workers’ compensation carriers. None of the members of the task force were orthoapedic surgeons nor neurosurgeons.

Systematische Literaturrecherche für die S1-Leitlinie zur sequenziellen medikamentösen Therapie der rheumatoiden Arthritis

On behalf of the German association of Rheumatology national experts developed guidelines for the medical treatment of rheumatoid arthritis (RA) based on the EULAR recommendations for the management of RA published in 2010. Current evidence was provided with an update of the systematic literature review (SLR). The methods and results of the SLR are presented in this article. An update of the EULAR SLR for the medical treatment of RA was performed from January 2009 to August 2011. The SLR assessed all controlled studies dealing with the outcome in clinical aspects, function and structure of disease modifying treatment of RA. Out of 6,869 screened publications, 138 articles and 56 abstracts were considered in the development of the German guidelines on the treatment of RA. A modified set of recommendations was approved in a consensus of national experts. A systematic literature research provided current evidence for the German recommendations on the sequential medical treatment of RA.

Lessons learned from a lipid lowering trial in adolescents with type 1 diabetes

Herein, we describe recruitment efforts for a trial of lipid-lowering medications in adolescents with type 1 diabetes, age 12–21 years. Based on our experience, future studies will require multiple centers to enroll a sufficient number of participants for adequate data to direct dyslipidemia medication treatment guidelines for adolescents with type 1 diabetes.

Insight Into Evidence-Based Return to Work Guidelines

Ingrid Pederson, BA, is a Senior Account Executive for Work Loss Data Institute (WLDI). Ingrid has been with WLDI since 2007. Ingrid has worked with the editorial and technical staff at WLDI in the web-based presentation of disability duration and medical treatment guidelines for Official Disability Guidelines and ODG Treatment in Workers' Comp (the ODG product line). Through extensive training and applied experience, she has gained a thorough knowledge of the Official Disability Guidelines with specific regard to the development process and how to most effectively implement the guidelines to maximize outcomes. Before working for WLDI, Ingrid was a consultant with Stay Well Health Management. Address correspondence to Ingrid Pederson, BA, 169 Saxony Road, Suite 101, Encinitas, CA 92024 ([email protected]). The author reports no conflicts of interest.

Abstract 2319: Improving Inter-facility Transfer Times for Acute Ischemic Stroke Patients: The Stroke Rescue Program

Background and Purpose: The inter-facility transfer of acute ischemic stroke (AIS) patients to a comprehensive stroke center (CSC) must be rapid. Transfer delays increase the likelihood of exclusion from endovascular stroke therapy and therefore are an obstacle to time sensitive stroke treatments. Reducing transport times and improving transfer efficiency is integral to the success of a comprehensive stroke network. Methods: The Stroke Rescue Program was created within a large metropolitan health system to facilitate the rapid transfer of AIS patients from regional (both health system (n=8) and non-system (n=4)) primary stroke centers (PSC) to the network's CSC. Program interventions included creation of a transfer center and stroke rescue hotline with a new priority dispatching protocol; standing order medical treatment guidelines with paramedic, referring physician and staff education; and the development of transport time elements and targets. Selected time elements included Transport 1 (Tr-1, initial phone call to EMS arrival at PSC), ED Time (PSC arrival to PSC departure), and Transport 2 (Tr-2, PSC departure to CSC arrival). Total transport time target was set at &lt;60 min and to achieve this we aimed at decreasing ED Time. Results: Between January 1, 2010 and June 30, 2011, 128 patients underwent Stroke Rescue. The median PSC to CSC distance was 14.4 miles (range 3.0 to 32.1 miles). Ischemic stroke was confirmed in 116 (91%) patients and 65 (51%) patients were “drip and ship” transports (intravenous tPA infusion during Tr-2). Overall, median total transport time was 48 min (ED Time 18 min). Comparing first quarter 2010 (baseline quarter, n=21) to second quarter 2011 (most recent quarter, n=31), the percent transported within 60 min increased from 57% to 81%. Statistically significant improvement was seen for both median ED Time (23 min versus 14 min; U = 171, p &lt;.01, r = .40) and median total transport time (56 min versus 44 min; U = 199, p &lt;.05, r = .33). Conclusion: Process organization with inter-facility stroke transfer protocols that minimize the time paramedics spend in a PSC emergency department can significantly reduce transport duration making transfer for time limited stroke therapies practical. Further study is needed to determine whether improved stroke network efficiency translates into better clinical outcomes, but the concept of “time is brain” supports this approach.

Rhinologic Issues in Pregnancy

The diagnosis and treatment of rhinitis, sinusitis, and epistaxis during pregnancy present unique challenges to the otolaryngologist. Poorly controlled sinonasal disease may have significant adverse effects on the mother's quality of life and pregnancy outcomes and the lack of adequately controlled safety data limits the clinician's ability to make informed decisions about management. At the conclusion of this discussion, the reader should be familiar with the available literature and evidence-based guidelines regarding the safety and indications for radiographic imaging, clinical testing, medical intervention, and surgical treatment of sinonasal disease in pregnant patients. A review was performed of pertinent guidelines regarding the management of gestational rhinitis, sinusitis, and epistaxis, including the diagnostic and therapeutic limitations and physiological changes specific to pregnancy. A study population of four patients was analyzed to highlight the steps of management by reviewing the patient charts including pertinent history, physical examination, clinical course, and operative reports. Two patients with epistaxis and two patients with rhinosinusitis ranging from 27 to 38 years of age and between 16 and 35 weeks gestation were analyzed. The treatment of sinonasal disease during pregnancy is challenging and a thorough knowledge of the available medical evidence and treatment guidelines is necessary to optimize pregnancy outcomes. When the severity of disease precludes the possibility of delaying treatment, the clinician should provide a limited intervention that optimizes the mother's health without placing the fetus at significant risk.

At the Edge of Viability: Moral and Ethical Guideline Proposals

The paper proposes moral and ethical guidelines for medical treatment at the edge of viability. The proposed principles are defended on the grounds of a general conceptual framework presented by elucidating the notions of viability, the edge of viability, person, sanctity of human life, dignity, and the slope of dignity protection, as well as the distinction between ethics and morality.

Hispanic Women's Health Care Provider Control Expectations: The Influence of Fatalism and Acculturation

In order to understand how culture influences Hispanic women's views about their health care provider (HCP), we examined the relationship between acculturation and fatalism in the HCP control expectations of Hispanic women. (A HCP control expectation is the extent to which an individual believes that her HCP has control over her health.) We predicted that acculturation would be negatively associated with HCP control expectations, and fatalism would be positively associated with HCP control expectations. A group of 1,027 young Hispanic women (mean age 21.24 years; SD=2.46) who were University of Texas Medical Branch clinic patients completed a comprehensive survey. Structural equation modeling was employed and, as predicted, acculturation was negatively associated with HCP control expectations (p<.001) and fatalism was positively associated (p<.001). Understanding fatalism, acculturation, and their influence on HCP control expectations will help us understand this population's perceptions of their HCPs. This knowledge will assist HCPs in providing culturally competent care which will increase adherence to medical treatment and screening guidelines.

Early Aggressive Medical Treatment Associated with Selective Prophylactic Aortic Stent-Grafting for Aortic Intramural Hematoma

Although recent studies suggest that medical treatment is appropriate for patients with aortic intramural hematoma (IMH), the outcomes of supportive medical treatment alone have not been satisfactory, and clear guidelines for medical treatment are not yet available. We assessed whether a management protocol of combined early aggressive medical treatment and selective prophylactic aortic stent-grafting would benefit patients with IMH. Nineteen patients with IMH were prospectively studied; after initial clinical and radiological evaluation, 13 underwent early aggressive medical therapy (group 1), and 6 underwent early aggressive medical therapy and prophylactic endovascular stent-grafting (group 2). In group 1, one patient with type A IMH died prior to surgical consultation because of cardiac tamponade; another patient with type A IMH underwent replacement of the ascending aorta at the 6-month follow-up. The condition of the other 11 patients stabilized during hospitalization and after discharge. The disease spontaneously regressed in 10 patients, and the intramural hematoma completely resolved in 5 patients. In group 2, follow-up imaging revealed complete coverage of the penetrating aortic ulcers and regression of the intramural hematoma; endovascular leaks have not yet occurred. Our protocol may be used as an alternative approach for patients with IMH. After initial clinical and radiological evaluation, the condition of patients without complications can be stabilized with medical treatment; frequent follow-up imaging is required in such cases. Early aggressive medical treatment combined with prophylactic aortic stent-grafting is a safe and effective treatment modality for IMH patients with penetrating aortic ulcers in the descending aorta.

Survey on geriatricians' experiences of adverse drug reactions caused by potentially inappropriate medications: Commission report of the Japan Geriatrics Society

The Japan Geriatrics Society (JGS) developed the guidelines for medical treatment and its safety in the elderly and the list of potentially inappropriate medication use, a Japanese version of the Beers list, in 2005. The JGS working group in collaboration with the Japan Broadcasting Corporation conducted the survey to geriatricians to investigate their experiences of adverse drug reactions (ADR) caused by potentially inappropriate medications. In September 2008, the survey mails were sent to all the JGS certified geriatricians (n=1492). The questionnaire consisted of 1 year of experiences of ADR of any type, past experiences of ADR by the use of antipsychotic benzamides, hypnotic benzodiazepines, digoxin (≥0.15 mg/day), vitamin D3 (alfacalcidol≥1.0 µg/day) and additional drugs, and their attitudes to reduce the dose/number of drugs for the prevention of ADR. A total of 425 geriatricians responded (response rate 29%). Seventy-two percent experienced ADR within 1 year. Past experiences of ADR were reported by 79% for antipsychotic benzamides, 86% for hypnotic benzodiazepines, 70% for digoxin and 37% for vitamin D3. Free responses included frequent ADR by non-steroidal anti-inflammatory, antihypertensive, antiplatelet, anti-arrhythmic, antidiabetic and antidepressant drugs. Reduction of drugs for ADR prevention was attempted by 93%. This survey showed that most geriatricians experience ADR and take preventive measures for ADR. The results can be used for education and the development of new guidelines.

A Review of Evidence-Based Biopsychosocial Laws Governing the Treatment of Pain and Injury

The impact of scientific findings on medical, psychological, and legal concepts has led to the adoption of laws and regulations that do not easily fit into the established legal categories of medical law or mental health law. Instead, this convergence of forces has resulted in laws and regulations mandating biopsychosocial treatment guidelines, where both medical and psychological cares are integrated within the framework of a single paradigm. Laws and regulations of this type have been adopted by a number of US states and Canadian provinces, and could be considered to represent a new category, for which we offer the term “biopsychosocial law.” Biopsychosocial laws currently pertain to medical treatment guidelines for workers’ compensation, a medical treatment system noted for high costs, high levels of litigation, and psychological involvement. There are a number of examples of biopsychosocial laws, but the most noteworthy are based on guidelines developed by the Colorado Division of Workers’ Compensation, the American College of Occupational and Environmental Medicine, the Work Loss Data Institute, and The Reed Group. These guidelines differ significantly with regard to features, conditions covered, and strength of evidence basis. However, all of these guideline systems were developed with the intent of providing good care while controlling costs, are evidence based, integrate the practice of medicine and psychology, and are legally mandated in certain jurisdictions. Taken together, these guidelines represent a growing convergence of scientific evidence, professional society positions, payor policies, and legal regulations. These forces are propelling a broad societal shift away from Cartesian assumptions that the body and mind are separate, and toward a biopsychosocial paradigm for the treatment of injury and illness.

Second hip fracture and patients’ medication after the first hip fracture: A follow-up of 221 hip fracture patients in Finland

The national Finnish guidelines for medical treatment of hip fracture patients are: anti-osteoporotic drugs and the daily concomitant use of calcium plus vitamin D supplements. We investigated the incidence, the fracture type and the side of all second hip fractures among 221 consecutive hip fracture patients who were followed up for 5 years. The medication of the patients and the time interval between the first and second hip fracture were analyzed. Of the patients 12% (26/221) sustained a second hip fracture. The type of fracture was in most cases (76%) the same as in the first case, more often in trochanteric and subtrochanteric fractures than in cervical fractures. The mean interval between the fractures was 4 ± 4.2 years (±S.D.); 3.2 ± 3.5 years in men and 4.4 ± 4.4 years in women. The number of patients using polypharmacy (5 or more drugs daily) was 9/25 (36%) at the time of the first hip fracture and 17/25 (68%) at the time of the second hip fracture. The use of at least one psychotropic drug regularly rose from 9/25 (36%) to 16 (64%) between the two fractures. Concomitant use of calcium plus vitamin D and anti-osteoporotic drugs was insufficient among the patients. More effort should be focused on the secondary prevention following the first hip fracture.

Post-Fracture Prescribed Calcium and Vitamin D Supplements Alone or, in Females, with Concomitant Anti-Osteoporotic Drugs is Associated with Lower Mortality in Elderly Hip Fracture Patients

Several studies have shown excess mortality among hip fracture patients compared with the normal population of the same age. Finnish guidelines for medical treatment of hip fracture patients recommend anti-osteoporosis medication and the daily concomitant use of prescribed calcium and vitamin D supplements. However, whether post-fracture use of calcium and vitamin D supplements is associated with survival in such patients has not been evaluated. To study the association between survival in hip fracture patients and patients' sex and age, pre-fracture vitamin D status, American Society of Anesthesiologists - Physical Status (ASA-PS) class, type of fracture and post-fracture use of prescribed calcium plus vitamin D and anti-osteoporotic medication. The study population was 221 hip fracture patients primarily treated in acute care for a new hip fracture in 2003-4 in two Finnish hospitals. After a median of 27.5 months from the fracture, a questionnaire was sent to all patients who were still alive at the time (n = 137). The patients were queried about their use of prescribed calcium plus vitamin D supplementation and of anti-osteoporotic drugs. The follow-up time for use of anti-osteoporotic medication and prescribed calcium and vitamin D was 19.5-36 months (median 27.5 months). Data on the use of prescribed calcium plus vitamin D supplementation and anti-osteoporotic drugs were checked against information on reimbursement of drug prescriptions held by the Finnish Social Insurance Institution. A total of 4 years' (48 months') survival data for all patients in the study population was also obtained, with the dates of patient deaths being checked against Official National and Regional population statistics. Patient survival was analysed using both the Bayesian multivariate analysis and the life table method. In the multivariate analysis, the combination of variables that best explained post-fracture survival was as follows: age <80 years; ASA-PS class 1-2 (ASA-PS class 1 and 2 data were combined in calculations); post-fracture use of prescribed calcium plus vitamin D supplements concomitantly with anti-osteoporotic drugs; post-fracture use of prescribed calcium plus vitamin D supplements; post-fracture use of anti-osteoporotic drugs only; and type of fracture (femoral neck or subtrochanteric). This model correctly predicted 74% of cases. At 36 months, we observed a 36% reduction in deaths in females who used prescribed calcium plus vitamin D supplementation and a corresponding 43% reduction in males. Survival of females who used anti-osteoporotic drugs concomitantly was even greater (43% reduction in deaths) over the entire follow-up period. Excess mortality was highest in females and males who used neither anti-osteoporotic drugs nor prescribed calcium and vitamin D. Our results indicate a potential relationship between reduced mortality and post-fracture use of prescribed calcium plus vitamin D supplementation and, in females, concomitant use of anti-osteoporotic drugs. However, further investigations are needed to understand the reason for the reduction in the risk of death. Population-based, randomized, placebo-controlled trials with total mortality as the main endpoint should be conducted to verify our results.

Care of the Very Low-birthweight Infant

1. Robert Angert, MD 1. Albert Einstein College of Medicine Children's Hospital at Montefiore Bronx, NY 1. Henry M. Adam, MD, Editor, In Brief Medical Staff Guidelines for Periviability Pregnancy Counseling and Medical Treatment of Extremely Premature Infants. Kaempf JW, Tomlinson M, Arduza C, et al. Pediatrics. 2006:117 :22– 29[OpenUrl][1][Abstract/FREE Full Text][2] The S.T.A.B.L.E. Program: Post-resuscitation/Pre-transport Stabilization Care of Sick Infants . 5th ed. Karlsen KA, ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006 Care of the Extremely Low-birth-weight Infant. Eichenwald EC. In: Taeusch HW, Ballard RA, Gleason CA, eds. Avery's Diseases of the Newborn. 8th ed. Philadelpia, Pa: Elsevier Saunders; 2005:410– 426 Textbook of Neonatal Resuscitation. 5th ed. Elk Grove Village, Ill; Dallas, Tex: American Academy of Pediatrics and American Heart Association; 2006. Hospital Discharge of the High-risk Neonate–Proposed Guidelines . American Academy of Pediatrics. Committee on Fetus and Newborn. Pediatrics. 1998;102 :411– 417[OpenUrl][3][Abstract/FREE Full Text][4] Motor and Executive Function at 6 Years of Age after Extremely Preterm Birth. Marlow N, Hennessy EM, Bracewell MA, Wolke D. EPICure Study Group. Pediatrics. 2007;120 :793– 804[OpenUrl][5][Abstract/FREE Full Text][6] Increasing survival among extremely preterm infants has focused more attention on these babies, who are smaller in birthweight and lower in gestational age. Technological and therapeutic advances have improved during the past 2 decades, increasing survival among the smallest, most immature infants, some as young as 22 to 23 weeks’ gestation. Successful resuscitation and stabilization of the extremely preterm infant requires clinicians trained in delivery room preparation and management as well as immediate newborn care needs of such infants. Particular attention must be paid to the prevention of hypothermia, maintenance of glucose homeostasis, and provision of appropriate nutrition support, as well as the prevention of lung injury, retinopathy of prematurity (ROP), and infection. Once alerted that a preterm baby will be born, a member of the neonatal team should meet with the expectant family. The … [1]: {openurl}?query=rft.jtitle%253DPediatrics%26rft.stitle%253DPediatrics%26rft.issn%253D0031-4005%26rft.aulast%253DKaempf%26rft.auinit1%253DJ.%2BW.%26rft.volume%253D117%26rft.issue%253D1%26rft.spage%253D22%26rft.epage%253D29%26rft.atitle%253DMedical%2BStaff%2BGuidelines%2Bfor%2BPeriviability%2BPregnancy%2BCounseling%2Band%2BMedical%2BTreatment%2Bof%2BExtremely%2BPremature%2BInfants%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2004-2547%26rft_id%253Dinfo%253Apmid%252F16396856%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=117/1/22&atom=%2Fpedsinreview%2F30%2F1%2F32.atom [3]: {openurl}?query=rft.jtitle%253DPediatrics%26rft.stitle%253DPediatrics%26rft.issn%253D0031-4005%26rft.aulast%253DCommittee%2Bon%2BFetus%2Band%2BNewborn%26rft.auinit1%253D%2B%26rft.volume%253D102%26rft.issue%253D2%26rft.spage%253D411%26rft.epage%253D417%26rft.atitle%253DHospital%2BDischarge%2Bof%2Bthe%2BHigh-Risk%2BNeonate--Proposed%2BGuidelines%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.102.2.411%26rft_id%253Dinfo%253Apmid%252F9685443%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [4]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=102/2/411&atom=%2Fpedsinreview%2F30%2F1%2F32.atom [5]: {openurl}?query=rft.jtitle%253DPediatrics%26rft.stitle%253DPediatrics%26rft.issn%253D0031-4005%26rft.aulast%253DMarlow%26rft.auinit1%253DN.%26rft.volume%253D120%26rft.issue%253D4%26rft.spage%253D793%26rft.epage%253D804%26rft.atitle%253DMotor%2Band%2BExecutive%2BFunction%2Bat%2B6%2BYears%2Bof%2BAge%2BAfter%2BExtremely%2BPreterm%2BBirth%26rft_id%253Dinfo%253Adoi%252F10.1542%252Fpeds.2007-0440%26rft_id%253Dinfo%253Apmid%252F17908767%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [6]: /lookup/ijlink?linkType=ABST&journalCode=pediatrics&resid=120/4/793&atom=%2Fpedsinreview%2F30%2F1%2F32.atom

Undertreatment of osteoporosis following hip fracture in the elderly

The national Finnish guidelines for medical treatment of hip fracture patients are: osteoporosis medication and the daily concomitant use of vitamin D and calcium supplements. We investigated the post-fracture medical therapy for osteoporosis and the calcium and vitamin D therapy among hip fracture patients in two Finnish hospitals. The pre-fracture osteoporosis medication and use of calcium and vitamin D supplements of the patients were inquired on admission. The patient-specific use of osteoporosis medication and of prescribed calcium and vitamin D therapy during the follow-up time were checked from The Finnish Social Insurance Institution. At the end of the follow-up, those who were alive were inquired about the use of medication at the time. Eight percent of the 223 patients used osteoporosis medication and 8% used prescribed calcium and vitamin D supplements before the fracture. During the follow-up, the figures were 39% (52/133) and 53% (70/133), respectively, and at the end of the follow-up, correspondingly, 25% (29/114) and 44% (50/114). The follow-up time was 19.5–35 months. The post-fracture medical therapy for osteoporosis was insufficient. More effort should be focused on the secondary prevention following hip fracture in order to ensure the recommended treatment of osteoporosis.

Autonomous Medical Care for Exploration Class Space Missions

The US-based health care system of the International Space Station contains several subsystems, the Health Maintenance System, Environmental Health System and the Countermeasure System. These systems are designed to provide primary, secondary and tertiary medical prevention strategies. The medical system deployed in low Earth orbit for the International Space Station is designed to support a "stabilize and transport" concept of operations. In this paradigm, an ill or injured crewmember would be rapidly evacuated to a definitive medical care facility (DMCF) on Earth, rather than being treated for a protracted period on orbit. The medical requirements of the short (7 day) and long duration (up to 6 months) exploration class missions to the moon are similar to low Earth orbit class missions but also include an additional 4 to 5 days needed to transport an ill or injured crewmember to a DMCF on Earth. Mars exploration class missions are quite different in that they will significantly delay or prevent the return of an ill or injured crewmember to a DMCF. In addition the limited mass, power and volume afforded to medical care will prevent the mission designers from manifesting the entire capability of terrestrial care. National Aeronautics and Space Administration has identified five levels of care as part of its approach to medical support of future missions including the Constellation program. To implement an effective medical risk mitigation strategy for exploration class missions, modifications to the current suite of space medical systems may be needed, including new crew medical officer training methods, treatment guidelines, diagnostic and therapeutic resources, and improved medical informatics.