Incidence of hepatocellular carcinoma among individuals with hepatitis B virus infection identified using an automated data algorithm

The purpose of this study was to develop an algorithm for identifying patients with chronic hepatitis B virus (HBV) using automated data sources from two US health systems and evaluate the algorithm's performance by quantifying the incidence of hepatocellular carcinoma (HCC) among chronic HBV patients. To allow comparisons with estimates from automated databases that may not contain all data elements used in this algorithm, we created three definitions of chronic HBV infection and used these definitions to create three overlapping cohorts. We compared the incidence of HCC in each cohort with the incidence of HCC in a matched general population comparison cohort with no evidence of HBV. Patients who met the most stringent criteria for chronic HBV infection (based on the standard definition of 6 months of infection using repeat laboratory tests and record review) were 146 times more likely to develop HCC than matched comparison patients (adjusted hazard ratio = 146.5, 95% CI: 74.0-289.8). Those not meeting the stringent criteria, but who met the criterion of at least one positive hepatitis B surface antigen test were 30 times more likely to develop HCC than comparison patients (adjusted hazard ratio = 29.8, 95% CI: 16.5-53.6). Finally, patients who met the criterion based on at least one HBV diagnosis were 38 times more likely to develop HCC than matched comparison patients (adjusted hazard ratio = 37.8, 95% CI: 25.9-55.1). The magnitude of the relative increase in HCC risk seen using different criteria used to define HBV infection indicate that these automated data algorithms can identify patients with chronic HBV infection.

Low back pain in Mozambican adolescents

Recent literature shows that the prevalence of low back pain (LBP) in adolescents living in Western countries approaches that of adults 18-55 years of age. Moreover, epidemiological studies have also shown that the frequency of different rheumatic disorders in developing countries is similar to that found in Western industrialized regions. The purpose of this study was to ascertain the prevalence of LBP and to explore some risk factors among adolescents living in different zones of Mozambique. A previously validated questionnaire was distributed to schoolchildren of grades 6 and 7 living in three different residential/social regions of the country. Two hundred four (204) children participated in the survey. Median age was 13 years (age range 11-16 years) and 46% were boys. Several episodes of LBP interfering with usual activities during the previous year were reported by 13.5% of the sample. Living in the wealthier urban center (as compared with the peripheral regions) and walking >30 min per day to and from school were associated with an increased risk of LBP (OR 3.1, 95% CI 0.99-9.48, and OR 4.8, 95% CI 1.61-14.28, respectively).

Recovery of impaired muscle function in severe sciatica

This is a prospective cohort study of patients with acute treated severe sciatica. The objectives of the study are, firstly, to describe the recovery of muscle performance by manual and isokinetic muscle testing in patients with acute severe sciatica over 1 year, and secondly, to discuss the potential clinical relevance of the isokinetic testing of the ankle for patients with acute sciatica. In clinical daily practice, muscle performance is evaluated by means of isometric manual tests. Different authors using manual muscle tests have reported the long-term outcome of the muscle function in patients with sciatica. Overall, the results are good in terms of the recovery of muscle strength. However, it is not clear whether the isometric strength is sufficiently relevant to evaluate the more complete muscle performance of the affected muscles in patients with sciatica. This study presents data on the muscle recovery measured with manual testing and isokinetic testing of patients with severe sciatica. Consecutive patients admitted to the Cantonal Hospital for conservative management of severe acute sciatica were eligible for inclusion in the study. Patients were evaluated at admission, discharge, and follow-up at 3, 6, and 12 months. All the visits included a standardized clinical examination and the completion of questionnaires. Imaging and electromyography were conducted at the first visit. Isokinetic muscle tests at 30 degrees/s and 120 degrees/s were performed at discharge and follow-up visits. Manual and isokinetic tests were performed on foot and ankle flexor and extensor muscles. Eighty-two consecutive patients (66% men), with a mean age of 43 (+/-10.3) years, entered the study. The prevalence of major muscle weakness was low, with 7% of patients unable to perform toe walking and 11% unable to walk on the heel at visit one. Moreover, motor deficit defined as a score of 4 or less (out of 5) was found in 15% of subjects at the first evaluation. Such severe deficits were not found during the last three visits. The isokinetic tests showed a higher prevalence of muscle function impairment. At visit 5, the isokinetic test showed impaired muscle function recovery from 23% to 32%, while the manual test showed almost full recovery. The issues of agreement between manual and isokinetic muscle testing are discussed. In this selected and homogeneous cohort of patients, the prevalence of motor deficit was rather low and the outcome excellent according to the results of the manual testing. Isokinetic muscle tests showed a higher prevalence of deficit and a much slower recovery. The manual muscle test is a crude clinical test. For more indepth muscle performance evaluation, additional testing may be necessary, especially for those patients with physically demanding jobs or activities.

Visually-guided irrigation in patients with early knee osteoarthritis: a multicenter randomized, controlled trial

OBJECTIVE

To determine if visually-guided arthroscopic irrigation is an effective therapeutic intervention in patients with early knee osteoarthritis.

DESIGN

Ninety patients with knee osteoarthritis were randomized in a double-blind fashion to receive either arthroscopic irrigation with 3000 ml of saline (treatment group) or the minimal amount of irrigation (250 ml) required to perform arthroscopy (placebo group). The primary outcome variable was aggregate WOMAC score.

RESULTS

The study did not demonstrate an effect of irrigation on arthritis severity as measured by aggregate WOMAC scores, the primary outcome variable; the mean change in aggregate WOMAC score at 12 months was 15.5 (95% CI 7.7, 23.4) for the full irrigation group compared to 8.9 (95% CI 4.9, 13.0) for the minimal irrigation group (P=0.10). Full irrigation did have a statistically significant effect on patients' self-reported pain as measured by the WOMAC pain subscale and by a visual analog scale (VAS) (the secondary outcome variables). Mean change in WOMAC pain scores decreased by 4.2 (95% CI -0.9, 9.4) for the full irrigation group compared with a mean decrease of 2.3 (95% CI -0.1, 4.7) in the minimal irrigation group (P=0.04). Mean VAS pain scores decreased by 1.47 (95% CI -1.2, 4.1) in the full irrigation group compared to a mean decrease of 0.12 (95% CI 0.0, 0.3) in the minimal irrigation group (P=0.02). A hypothesis-generating post-hoc analysis of the effect of positively birefrigent intraarticular crystals showed that patients with and without intraarticular crystals had statistically significant improvements in pain assessments and aggregate WOMAC scores at 12 months; patients with crystals had statistically greater improvements in pain.

CONCLUSIONS

Visually-guided arthroscopic irrigation may be a useful therapeutic option for relief of pain in a subset of patients with knee OA, particularly in those who have occult intraarticular crystals.

A functional recovery score for elderly hip fracture patients: I. Development

OBJECTIVE

To develop a Functional Recovery Score for ambulatory elderly hip fracture patients related to independent functioning to assess restoration of function to prefracture status.

STUDY DESIGN/METHODS

The phases of this effort consisted of: (a) identification of five relevant components represented by sixteen specific functional capacities; (b) assessment of the importance independent community-dwelling elderly gave to the sixteen functional capacities; (c) pilot testing of a sixteen-item preliminary questionnaire in recovering elderly hip fracture patients; and (d) modification of the questionnaire to an eleven-item score.

RESULTS

The resulting eleven-item Functional Recovery Score is comprised of three main components: basic activities of daily living (BADL) assessed by four items, instrumental activities of daily living (IADL) assessed by six items, and mobility assessed by one item. Basic activities of daily living comprise 44 percent of the score; instrumental activities of daily living comprise 23 percent, and mobility comprises 33 percent. Complete independence in basic and instrumental activities of daily living and mobility results in a score of 100 percent.

A functional recovery score for elderly hip fracture patients: II. Validity and reliability

OBJECTIVE

To assess predictive and discriminant validity and responsiveness of the Functional Recovery Score, a disease-specific health assessment tool.

STUDY DESIGN

Prospective, consecutive.

METHODS

Six hundred eighty-two elderly patients who sustained a hip fracture were prospectively followed and evaluated by using the Functional Recovery Score at three, six, and twelve months after surgery

RESULTS

The Functional Recovery Score (FRS) was found to be responsive to change: scores after hip fracture were significantly lower at three months than prefracture, increased significantly from three to six months, and increased slightly between six and twelve months after fracture, consistent with expectation. The FRS had predictive validity: prefracture scores were predictive of death, skilled nursing facility transfer, and rehospitalization within one year of fracture. In addition, the FRS had discriminant validity. Mean scores for the following groups were significantly different from each other at three and six months: (a) patients who were alive, living in the community, and did not require rehospitalization; (b) those who were admitted to a skilled nursing facility; and (c) those who were rehospitalized. Comparison of the FRS with a sex- and age-matched non-hip-fracture population indicated that hip fracture resulted in a 20 percent loss of function within the first year. Reliability testing of telephone interviews of patients as a means of obtaining information indicated very high reliability.

CONCLUSION

The Functional Recovery Score is a reliable method of assessing functional outcome for elderly hip fracture patients.

Recovery of severe sciatica

STUDY DESIGN

A prospective study of patients with acute severe sciatica.

OBJECTIVES

To 1) describe the characteristics of patients with acute severe sciatica and the agreement among different diagnostic tests, 2) describe overall recovery during 1 year in terms of perceived disability, and pain, and 3) explore acute-phase predictors of failure to recover at 1 year.

SUMMARY OF BACKGROUND DATA

The development of imaging techniques has been very impressive during recent decades. However, different authors have highlighted the prevalence of abnormal images among asymptomatic subjects. These findings increase the difficulty of interpreting the results from the diagnostic techniques used with each individual patient. Furthermore, other clinical and biopsychosocial variables need to be explored for their associations with recovery or failure to recover. This study aimed to explore those associations.

METHODS

Consecutive patients admitted to the hospital for conservative management of severe acute sciatica were eligible for inclusion in the study. Patients were evaluated at admission, discharge, and 3, 6, and 12 months. All the visits included a standardized clinical examination and the completion of questionnaires that included items on demographics, pain, perceived disability, and quality of life. Imaging and blood samples were collected at the first visit, and an electromyogram was taken for sciatica lasting at least 3 weeks.

RESULTS

The study included 82 consecutive patients (66% men) with a mean age of 43 +/- 10.3 years. The mean intensity of pain, on a visual analog scale of 0 to 100 (VAS) at Visit 1, was 73. The straight leg raising test was positive in 78% of the patients, with a mean value of 59 degrees +/- 18 degrees. The contralateral straight leg raising test was positive in 20% of the patients. Imaging was positive for disc herniation in 74% and electromyogram was positive in 62% of cases. These two diagnostic tests showed a good to excellent total agreement (58-87%) with the straight leg raising tests and the presence of radiating pain below the knee. The recovery of clinical symptoms and signs was observed mainly within the first 3 months. However, clinical recovery and perceived recovery was not complete in most cases.

CONCLUSIONS

In most cases, there was good to excellent agreement among the different diagnostic tests. None of the tests was predictive of recovery. The presence of blood antibodies against 3'LM1 (IgM + IgG) and GD1a (IgM) was significantly associated (P < 0.023) with neurologic symptoms and signs. However, the meaning of these antibodies remains unclear. Only a minority of the patients (29%) had fully recovered after 12 months. Within the 1-year follow-up, one third of the patients had surgery.

Equivalence trials in SLE research: issues to consider

In contrast to the objective of most clinical trials, which is to demonstrate superiority of an experimental treatment over a standard or placebo, the aim of an equivalence trial is to show that two treatments are equivalent in outcome or only marginally different. This would be of interest when an experimental treatment offers advantages such as reduced toxicity, ease of administration, or cost relative to the standard. Demonstrating equivalence may also be a goal when evaluating the safety of certain drugs because similarity in the risks of an adverse event in subjects exposed and unexposed to the drug is an indication of its safety. The classical formulation of the null hypothesis of treatment equality that is used in superiority trials is not applicable to equivalence trials because absolute equivalence between treatment groups cannot be proven. The strategy in equivalence trials is to define a maximum difference between treatment groups that is clinically acceptable and then assess whether there is sufficient evidence from the trial to conclude that the true treatment difference is within this acceptable range. In this paper, we discuss issues surrounding the planning, conduct, and analysis of equivalence trials in the context of SLE, with examples from the SELENA study.

Autoimmune-associated congenital heart block: demographics, mortality, morbidity and recurrence rates obtained from a national neonatal lupus registry

OBJECTIVES

The present study describes the demographics, mortality, morbidity and recurrence rates of autoimmune-associated congenital heart block (CHB) using information from the Research Registry for Neonatal Lupus.

BACKGROUND

Isolated CHB detected at or before birth is strongly associated with maternal autoantibodies to 48-kD SSB/La, 52-kD SSA/Ro and 60-kD SSA/Ro ribonucleoproteins and is a permanent manifestation of the neonatal lupus syndromes (NLS). Available data are limited by the rarity of the disease.

RESULTS

The cohort includes 105 mothers whose sera contain anti-SSA/Ro or anti-SSB/La antibodies, or both, and their 113 infants diagnosed with CHB between 1970 and 1997 (56 boys, 57 girls). Of 87 pregnancies in which sufficient medical records were available, bradyarrhythmia confirmed to be CHB was initially detected before 30 weeks of gestation in 71 (82%) (median time 23 weeks). There were no cases in which major congenital cardiac anatomic defects were considered causal for the development of CHB; in 14 there were minor abnormalities. Twenty-two (19%) of the 113 children died, 16 (73%) within 3 months after birth. Cumulative probability of 3-year survival was 79%. Sixty-seven (63%) of 107 live-born children required pacemakers: 35 within 9 days of life, 15 within 1 year, and 17 after 1 year. Forty-nine of the mothers had subsequent pregnancies: 8 (16%) had another infant with CHB and 3 (6%) had a child with an isolated rash consistent with NLS.

CONCLUSIONS

Data from this large series substantiate that autoantibody-associated CHB is not coincident with major structural abnormalities, is most often identified in the late second trimester, carries a substantial mortality in the neonatal period and frequently requires pacing. The recurrence rate of CHB is at least two- to three-fold higher than the rate for a mother with anti-SSA/Ro-SSB/La antibodies who never had an affected child, supporting close echocardiographic monitoring in all subsequent pregnancies, with heightened surveillance between 18 and 24 weeks of gestation.

Predictors of functional recovery after hip fracture in the elderly

Three hundred thirty-eight community dwelling, ambulatory, elderly patients who sustained a hip fracture were observed prospectively to determine which patient and fracture characteristics at hospital admission predicted functional recovery at 3, 6, and 12 months. Multiple logistic regression was performed to estimate the simultaneous contributions of the predictor variables to failure of functional recovery. Before sustaining a fracture, 16% of patients were dependent on basic activities of daily living and 46% were dependent on instrumental activities of daily living. By 1 year after fracture, 73% of the patients had recovered to their basic activities of daily living status before fracture whereas only 48% had recovered to their instrumental activities of daily living status before fracture. Patients who were age 85 years or older, who lived alone before sustaining a fracture, and who had one or more comorbidities were at increased risk of delay or failure in recovering basic activities of daily living. Only instrumental activities of daily living independence before fracture predicted failure to recover instrumental activities of daily living function by 3 and 6 months after fracture. At 1 year, patient age 85 years or older was the only predictor of failure to recover instrumental activities of daily living function that existed before fracture. Based on characteristics at admission, a group of patients at high risk for failure to recover basic activities of daily living function within 1 year of sustaining a hip fracture can be identified.

Patient-health care provider relationship in patients with non-specific low back pain: a review of some problem situations

Problem situations in the patient-health care relationship may relate to the patient or to the health care provider characteristics or to the way they interact; they may also relate to the general social context. Such situations force the clinician dealing with non-specific low back pain patients to look beyond the traditional biomedical model that assumes a linear connection between pathology and symptomatology. The introduction of the biopsychosocial model approximately 10 years ago has improved the understanding of common low back pain. This chapter gives some insight into areas relating to factors that may hamper the patient-therapist relationship and thus complicate treatment and recommendation outcomes. It emphasizes the necessity to involve the patient in the decision-making. Recognizing the patients' psychological, social and cultural background as well as the level of education and employability are important to make successful recommendations. This knowledge is not new but the difficulty is to implement it in today's cost effectiveness driven society. However the benefit at the end may be the decrease of chronicity and/or permanent disability, suffering for the patient and frustration for the clinician. Identifying the underlying cause of non-compliance or of unexpected delayed recovery is an exciting issue. The cause may or may not be biomedical. If a specific cause can be identified, it has to be diagnosed and evaluated. If the clinical examination has ruled out specific or emergency conditions, another perspective may be needed and the course of action could then be determined.

Increased nitric oxide production accompanied by the up-regulation of inducible nitric oxide synthase in vascular endothelium from patients with systemic lupus erythematosus

OBJECTIVE

To investigate whether systemic lupus erythematosus (SLE) is accompanied by increased serum nitrite levels, whether active compared with inactive disease is associated with greater nitric oxide (NO) production, and whether endothelial cells or keratinocytes serve as cellular sources of NO by virtue of their increased expression of either constitutive nitric oxide synthase (cNOS) or inducible NOS (iNOS).

METHODS

Fifty-one serum samples (46 from patients with SLE) were analyzed for NO production by measuring nitrite levels in a calorimetric assay. Skin biopsy samples from 21 SLE patients and 11 healthy volunteers were evaluated immunohistochemically, using monoclonal antibodies, for endothelial cell and keratinocyte cNOS and iNOS expression.

RESULTS

Serum nitrite levels were significantly elevated in the 46 patients with SLE (mean +/- SEM 37 +/- 6 microM/liter) compared with controls (15 +/- 7 microM/liter; P < 0.01), and were elevated in patients with active SLE compared with those with inactive disease (46 +/- 7 microM/liter versus 30 +/- 7 microM/liter; P < 0.01). Serum nitrite levels correlated with disease activity (r = 0.47, P = 0.04) and with levels of antibodies to double-stranded DNA (r = 0.35, P = 0.02). Endothelial cell expression of iNOS in SLE patients (mean +/- SEM score 1.5 +/- 0.2) was significantly greater compared with controls (0.6 +/- 0.2; P < 0.01), and higher in patients with active disease compared with those with inactive SLE (1.7 +/- 0.2 versus 1.2 +/- 0.2; P < 0.01). Keratinocyte expression of iNOS was also significantly elevated in SLE patients (0.9 +/- 0.1) compared with controls (0.4 +/- 0.1; P < 0.001). With regard to expression of cNOS, there were no differences between patients with active SLE, those with inactive SLE, and normal controls in either the vascular endothelium or the keratinocytes.

CONCLUSION

NO production is increased in patients with SLE, and 2 potential sources of excessive NO are activated endothelial cells and keratinocytes via up-regulated iNOS.

Low back pain assessment training of industry-based physicians

We have developed an educational program to train industry-based physicians in a new low back pain assessment procedure based on the recommendation of The Clinical Practice Guidelines on Acute Low Back Pain Problems in Adults published by the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services. The clinical classification system based on the findings from the Quebec Task Force was used to categorize the subjects. The educational program included group and individual sessions with an extensive period of active follow-up. Protocol compliance was measured through a computer-based surveillance system that monitored evaluation form completion. The results showed significant change (p < 0.001) in physician compliance in completing a standardized examination following an administrative mandate to change. Little change in clinical practice was recorded with an educational training program only. Further research into the factors responsible for the results is suggested.

Does blood transfusion increase the risk of infection after hip fracture?

OBJECTIVE

To determine whether allogeneic red blood cell transfusion is a predictor for developing an in-hospital postoperative urinary tract, respiratory, or wound infection.

STUDY DESIGN

Prospective, consecutive.

METHODS

Six hundred eighty-seven community-dwelling, ambulatory, geriatric hip fracture patients were prospectively followed; all patients had operative fracture treatment and received perioperative antibiotics.

RESULTS

Sixty-eight patients had a culture-positive infection before operative treatment. One hundred thirty-four of the remaining 619 patients (21.6%) developed a postoperative infection, primarily a urinary tract infection. The infection rate was 26.8% in transfused patients compared with 14.9% in nontransfused patients (p = 0.001). When stratifying by the type of infection, only the risk of urinary tract infection was statistically significant (p = 0.001). After controlling for the effect of patient age, sex, number of preinjury medical comorbidities, American Society of Anesthesiologists (ASA) rating of operative risk, fracture type, surgical delay, type of surgery, type of anesthesia, operative time, and blood loss, the relationship between allogeneic red blood cell transfusion and postoperative urinal tract infection remained statistically significant.

CONCLUSIONS

Geriatric hip fracture patients who receive allogeneic red blood cell transfusions are at higher risk for developing a postoperative urinary tract infection than are those patients who are not transfused.

Hip fractures in the elderly: predictors of one year mortality

OBJECTIVE

To determine the one year mortality following hip fracture in an ambulatory, community dwelling, cognitively intact elderly population and to examine the role of specific type, number, and severity of associated medical comorbidities.

DESIGN

Prospective, consecutive.

METHODS

Six hundred twelve elderly who sustained a non-pathologic hip fracture were followed.

RESULTS

Twenty-four patients (4%) died during hospitalization; seventy-eight (12.7%) died within one year of fracture. The factors that were predictive of mortality, based on multivariate analysis, were patient age > 85 years, preinjury dependency in basic activities of daily living, a history of malignancy other than skin cancer, American Society of Anesthesiologists rating of operative risk 3 or 4, and the development of one or more in-hospital postoperative complications; all factors other than the development of an in-hospital complication were independent of treatment.

CONCLUSION

These results indicate that efforts at reducing one year mortality after hip fracture should be directed at the prevention of postoperative complications.

Dependency after hip fracture in geriatric patients: a study of predictive factors

Five hundred and sixteen community-dwelling, ambulatory, geriatric hip fracture patients who were independent prior to fracture were followed prospectively to determine which patients regained their prefracture independent living status at 3-, 6-, and 12-month follow-up. At 3-, 6-, and 12-month follow-up, 78, 77, and 76% of the patients, respectively, had regained their prefracture independent living status. Analysis was performed to determine which pre- and postinjury factors were predictive of a patient regaining prefracture independent living status at 3, 6, and 12 months after fracture. Patients who were younger than age 85, independent in activities of daily living prior to fracture, independent in ambulation at hospital discharge, and who had three or more medical comorbidities were more likely to regain their prefracture independent living status.

Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip

We prospectively studied 367 patients who had a fracture of the hip, to determine the effect of an operative delay on postoperative complications and on the one-year mortality rate. All of the patients were at least sixty-five years old, cognitively intact, living at home, and able to walk before the fracture. An operative delay was defined as an interval of three calendar days or more between the time of admission to the hospital and the operation. The operation was performed within two calendar days after admission in 267 (73 per cent) of the patients. When the factors of the patient's age and sex and the number of pre-existing medical conditions were controlled, it was found that an operative delay beyond this period approximately doubled the risk of the patient dying before the end of the first postoperative year. When the patient's age and sex and the severity of pre-existing medical conditions were controlled, there was also an increase in mortality associated with an operative delay, although this was not significant. With the numbers studied, an operative delay beyond two calendar days did not have a significant effect on the prevalence of complications during hospitalization. We concluded that an operative delay of more than two calendar days after admission is an important predictor of mortality within one year for elderly patients who have a fracture of the hip and who are cognitively intact, able to walk, and living at home before the fracture. Optimally, such patients should have the operation within two calendar days after admission to the hospital.

The estimated frequency of cosmetic breast augmentation among US women, 1963 through 1988

Estimates ranging from 1 to 2 million have been used to describe the number of women in the United States who have had cosmetic breast implants. Original data from a historical cohort study of women with breast augmentation were combined with simulation techniques to compute new estimates grounded on a more objective set of information and assumptions than previous attempts. It was estimated that the number of women who had cosmetic augmentation mammoplasty between 1963 and 1988 was 894,206 (range = 437,602 to 2,035,783). The number of women ever treated with cosmetic augmentation mammoplasty may be substantially smaller than previously reported.

Low back pain in schoolchildren. A study of familial and psychological factors

STUDY DESIGN

The results of a survey organized in the school system of the Swiss canton of Fribourg. An original questionnaire was developed for this study are reported.

OBJECTIVES

The goal of this study was to evaluate the possible role of familial or psychological factors in schoolchildren reporting nonspecific low back pain.

SUMMARY OF BACKGROUND DATA

Previous surveys have shown a high prevalence of nonspecific low back. pain among schoolchildren, particularly teen-agers. The reported familial incidence raises, among others, the question of a possible role of psychological or behavioral factors.

METHODS

This survey was performed with a validated 43-item self-administered questionnaire eliciting information about back pain history, family characteristics, children's activities, and psychological parameters. All schoolchildren (n = 615), ages 12-17 years, in two secondary schools (Fribourg, Switzerland) were surveyed. The response rate was 98%.

RESULTS

Reported lifetime prevalence of back pain was 74%. Lumbar pain was the most frequent localization of pain (69% of back pain). The measured psychological factors were significantly associated with reported nonspecific low back pain and its consequences as well as with sibling history of low back pain.

CONCLUSIONS

The study suggests that psychological factors play a role in children's reporting of nonspecific low back pain.

Accidental needlesticks: do anesthesiologists practice proper infection control precautions?

Anesthesiologists as well as patients are at risk for acquiring blood-borne infections such as hepatitis and AIDS. We surveyed 2,530 anesthesiologists, a 10% random sample of the members of the American Society of Anesthesiologists, with a response rate of 57.1%, to determine the incidence of accidental needlestick exposure among anesthesia personnel and whether anesthesiologists are adhering to infection control guidelines to protect themselves and their patients from exposure to infectious diseases. Eighty-eight percent of respondents reported at least 1 accidental needlestick in the past 10 years; 21% received a needlestick from a high-risk patient and 4.5% a needlestick from a known HIV-positive patients. Residents reported significantly more accidental needlesticks from known HIV-positive patients (8.5%). Mucous membrane, open cut, eye, or other significant exposure to HIV-contaminated blood or body fluids was sustained by 8.34% of respondents in the past 10 years. Sixty percent of respondents reported they almost never reuse common syringes now compared with a 40.8% non-reuse rate (P < 0.001) in a similar survey on infection control practices conducted in 1990. Sixty-three percent reported they almost never reuse a vasopressor syringe compared with the 1990 non-reuse rate of 52.5% (P < 0.001). In the current survey, 39% of anesthesiologists reported reusing syringes from one patient to another and 36% reported reusing the same vasopressor syringes for different patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Health care utilization for low back pain in Belgium. Influence of sociocultural factors and health beliefs

STUDY DESIGN

A population-based survey was undertaken.

OBJECTIVES

To describe health care utilization for low back pain (LBP) in a culturally diverse society with universal access to health care; to describe how LBP chronicity influences health care utilization; and to describe how sociocultural and demographic factors and health beliefs influence health care utilization.

METHODS

A probability sample of approximately 5,000 Belgian adults stratified by gender, age, social class, and habitat was surveyed by trained interviewers. Information on demographics, health beliefs, frequency of LBP, and health care utilization was elicited. Statistical analysis was conducted by means of univariate and multivariate logistic regression. Analysis was restricted to 2,660 respondents with history of LBP.

RESULTS

Of subjects with LBP, 38% reported daily LBP. Sixty-three percent had seen a health professional for the most recent episode; 11% had been on bed rest. Forty-four percent had at sometime undergone radiography; three and a half percent had ever undergone spinal surgery. Eighty-six percent considered themselves in good health. Controlling for LBP frequency, all forms of health care utilization examined were associated with health beliefs.

CONCLUSIONS

LBP frequency, health beliefs, and sociocultural factors influence health care behaviors and utilization among adults with a history of LBP in a society with universal access to health care. The association of history of spinal surgery with reports of daily LBP suggests that spinal surgery has failed, at least partly, to relieve LBP.

Ambulatory ability after hip fracture. A prospective study in geriatric patients

Three hundred thirty-six community-dwelling, previously ambulatory, geriatric patients with hip fracture were observed prospectively to determine ambulatory ability at a minimum followup of 1 year. One hundred thirty-seven (41%) patients maintained their prefracture ambulatory ability at a minimum followup of 1 year; 134 (40%) patients remained ambulatory but became more dependent on assistive devices; 39 (12%) previous community ambulators became household ambulators, and 26 (8%) patients became nonfunctional ambulators. Analysis was performed to determine which pre- and postinjury factors were predictive of failure to recover ambulatory capacity 1 year after fracture. Potential predictor variables analyzed included age, gender, number of comorbid conditions, prefracture ambulatory ability, prefracture living situation, fracture type, American Society of Anesthesiologists rating of operative risk, type of surgery, and number of postoperative complications. Multiple logistic regression analysis identified significant contributions of age, prefracture ambulatory ability, American Society of Anesthesiologists rating of operative risk, and fracture type to ambulatory recovery.

Non-specific low-back pain among schoolchildren: a field survey with analysis of some associated factors

A study population composed of 1,755 children 8-16 years of age were surveyed using a 15-item, self-administered questionnaire. The response rate was 97.7%. The purpose of the survey was to evaluate the possible association between low-back pain and certain social factors and predicaments. Descriptive statistics and logistic regression analysis showed that parental history of treated low-back pain (adjusted odds ratio 2.10; p < 0.001), competitive sports activity (adjusted odds ratio 1.73; p = 0.003), and time spent watching television (adjusted odds ratio 1.23; p = 0.05) significantly increased the risk for low-back pain among children, controlling for the child's age and gender.

Sociocultural factors and back pain. A population-based study in Belgian adults

A population-based survey of approximately 4000 adults in Belgium, a bi-cultural country with a uniform health care system, explored the relationships of socio-cultural and employment factors to the reported experience of low back pain (LBP). Predictors of 1) history of LBP, 2) first LBP, and 3) daily LBP were examined by multiple logistic regression analysis. Thirty-three percent of the population had current LBP, including 5% experiencing their first episode; 26% had past but not current LBP, and 41% had never had LBP. Increasing age (OR > 2.0, P = .000) and female gender (OR 2.16, P = .000) were associated with history of LBP; only gender (OR 1.40, P = .02) was associated with first episode; neither was associated with daily LBP. Language was associated with history (OR 1.80, P = .000) and first occurrence (OR 1.77, P = .000) but not daily LBP. Among those employed, work dissatisfaction was associated with history of LBP (OR > 2.4, P = .02) and daily LBP (OR 3.85, P = .02), but not with first episode. The results suggest that sociocultural factors influence the expression of LBP, but not the risk of chronicity once LBP is reported, and that work satisfaction may not be causally related to LBP, but may intervene along with type of occupation in the possibility of continuing employment once LBP is present. Prospective studies are needed to confirm these results and elucidate causal relationships.

Epidemiology of low back pain

At present, although there have been many epidemiological studies of risk factors for low back pain, there are few risk factors established in prospective studies; and our understanding of them remains relatively crude. Individuals in jobs requiring manual materials handling, particularly repeated heavy lifting and lifting while twisting, are at increased risk of back pain leading to work absence. In addition, exposure to whole-body vibration and job requirements for static postures are associated with back pain. Individual trunk strength has not been consistently demonstrated as associated with back pain; although there is some suggestion that when work requirements for heavy lifting exceed individual capacities, back pain is more likely to occur. The pattern of peak age at onset in the 20's is consistent with back pain development early in working life. Among other individual characteristics, only cigarette smoking has consistently been associated with back pain; and the biological mechanism for this finding is not understood. Evidence with respect to spinal flexibility, aerobic capacity, educational attainment and other variables is suggestive but not consistent. There is some evidence that the individual's relation to work, expressed as job satisfaction or supervisor rating, is also related to work absence due to back pain. While it is possible to describe, however crudely, the characteristics placing people at risk for back pain leading to work absence and/or medical attention, the problem of predicting chronicity and thus identifying patients for more intensive clinical intervention remains unresolved. At this time, only age of the patient and certain clinical features of the back pain such as the presence of sciatic symptoms, duration of the current episode, and history of prior episodes are consistently demonstrated predictors. In chronic patients, there is suggestive evidence that spinal flexibility, trunk strength, and certain psychological characteristics such as coping skills, fear and avoidance of pain or movement, job satisfaction, attribution of fault and hysterical or hypochondriacal features are associated with treatment failure. In addition, there is suggestive evidence that the availability of alternative work placement may allow for earlier return to work than otherwise. While the availability of disability compensation in excess of usual wages may serve as a disincentive to return to work. The latter-cited remain to be verified, while findings in chronic patients remain to be tested in acute. Further, the role of physical demands of work in duration of back pain episodes has not been well studied.

Living with artificial grass: a knowledge update. Part 2: Epidemiology

Part 2 of our study evaluated the effect of artificial grass on the athletes that play on it. In this section we have reviewed the epidemiological studies that have evaluated the influence that artificial grass has on the frequency and site of injury to American football players. From this review we have concluded that play and practice on an artificial surface is probably responsible for an increase in the relative risk of injury to the lower extremity of the participants. However, it is evident that more well controlled studies are necessary to completely clarify this issue.

Living with artificial grass: a knowledge update. Part 1: Basic science

Part I of this two part study reviews the development and characteristics of artificial grass, and the influence of this surface on the American football player. Artificial grass was initially developed to provide city children with increased play space and thus enable them to maintain a fitness level equal to their peers in more rural locales. Today, artificial grass fields allow for increased use when field availability is limited, or for a grass substitute where grass will not grow. However, epidemiologic studies suggest that there is an increased risk of lower extremity injury to the football athlete playing on an artificial grass field. By reviewing available studies, a knowledge base can be formed that can serve to direct future investigations concerning the influence of artificial grass surfaces and injury and, ultimately, how that influence can be affected.

Delayed childbearing and the outcome of pregnancy

Whether women who delay childbearing are at increased risk for adverse outcomes of pregnancy is of concern because of the growing proportion of first births to older women. We assessed the effect of advancing maternal age on the outcome of pregnancy in first births in a hospital-based cohort study of 3917 private patients who were 20 years of age or older with a singleton gestation. There was a slight elevation in the risk of having a low-birth-weight infant among women who were 35 years of age or older (adjusted odds ratio, 1.3; 95 percent confidence interval, 0.9 to 1.9) as compared with the risk among women 20 to 29 years of age. However, there was no evidence that women between 30 and 34 or those 35 and older had an increased risk of having a preterm delivery or of having an infant who was small for gestational age, had a low Apgar score, or died in the perinatal period. In contrast, even after controlling for sociodemographic and medical risk factors, we found that women who were 35 or older were significantly more likely to have specific antepartum and intrapartum complications and those who were 30 or older were significantly more likely to have both cesarean sections and infants who were admitted to the newborn intensive care unit. This study suggests that although older primiparous women have higher rates of complications of pregnancy and delivery, their risk of a poor neonatal outcome is not appreciably increased.

Environmentally induced disorders of the musculoskeletal system

The human suffering and economic cost attributable to musculoskeletal disorders cannot be overemphasized. Biomechanical principles have been introduced to explain the microtrauma and macrotrauma as mechanisms of injury. Stress-induced remodeling is a useful paradigm in the study of environmentally induced disorders. The concept of environment should include psychosocial and organizational factors with respect to musculoskeletal complaints and chronic pain. Low back pain, osteoarthritis, osteoporosis and its associated fractures, and cumulative trauma disorders are the most critical and common musculoskeletal disorders. The risk factors for low back pain have been identified, and preventive measures for reducing the chronicity of low back pain have been discussed. Preventive approaches to control or limit the fractures associated with osteoporosis and loss of bone mass are preferred to simple management of the fracture of osteoporotic patients. It can be concluded that too little or too much stress can disturb the homeostatic or the equilibrium state of health and that much remains to be researched to quantify the optimal stress levels.

Aspects of the spectrum, prevalence and disease susceptibility determinants of Reiter's syndrome and related disorders associated with HIV infection

Arthrocutaneous disorders including Reiter's syndrome, psoriasiform rashes, and other forms of chronic arthritis and enthesopathy, such as psoriatic arthritis, occur with an increased prevalence in the setting of HIV infection. Herein we describe the spectrum and prevalence of musculoskeletal and allied skin disorders as they occur in the setting of HIV infection. The role of genetic susceptibility in the development of these disorders is addressed. Based on the frequency of infectious agents capable of triggering reactive arthritis and the presence of HLA-B27 in 71% of these individuals, it is suggested that the disorder strongly resembles Reiter's syndrome as it occurs in the not HIV-infected group. Preliminary evidence indicates an enhanced penetrance for susceptibility among HLA-B27 individuals. In contrast, among HIV-infected patients with psoriasiform lesions there was no statistically significant association (P less than 0.05) between the presence of psoriasiform rash and the HLA alleles Cw6, B7, B17, Bw16, or Bw57 when compared with HIV-infected controls. These findings suggest that among HIV-infected individuals the development of Reiter's syndrome involves an immune recognition event primarily dependent upon HLA-B27 molecules in which an unknown antigen in the context of HLA-B27 is presented to CD8 lineage suppressor/cytotoxic cells. In contrast, the pathogenesis of psoriasiform lesions in HIV patients, despite their similarity to certain lesions in Reiter's syndrome, proceeds by distinct pathways that do not involve events influenced by specific polymorphic class I molecules.

Implications from the occurrence of Reiter's syndrome and related disorders in association with advanced HIV infection

Information bearing on the prevalence and character of Reiter's syndrome and allied disorders as they occur in a setting of HIV infection was reviewed. Based on the frequency of infections by organisms capable of inducing reactive arthritis and the presence of HLA-B27 in 71% of the individuals, it was concluded that the disorder strongly resembled Reiter's syndrome occurring in the non-HIV infected group. Preliminary evidence suggested an enhanced penetrance of susceptibility among HLA-B27 individuals. In view of the preservation of CD8 lineage T cells and functional loss of CD4 lineage T cells in HIV-infected patients, it was suggested that a specific immune recognition event is at the center of the pathogenesis of this syndrome which involves preservation of an unknown antigen in the context of HLA-B27 to CD8 lineage suppressor/cytotoxic T cells.

The usefulness of peripheral venous blood in estimating acid-base status in acutely ill patients

The usefulness of peripheral venous sampling in determining acid-base status in acutely ill patients was studied. A total of 171 nonarrest patients and 12 patients in cardiac arrest had paired samples of arterial and venous blood compared for correlation of blood gas results. Linear equations relating arterial and venous values of pH, PCO2, and bicarbonate were developed in both groups of patients; however, the accuracy of predicting arterial values from venous values was limited. Severe acid-base disturbances were essentially ruled out by normal or nearly normal venous blood gases. Extremely abnormal venous levels reliably reflected comparable arterial abnormalities. The results suggest that immediate intravenous bicarbonate therapy should be considered for patients with pH less than or equal to 7.05 and PCO2 less than or equal to 40 torr despite the possibility of inadvertent venous sampling. A larger series is needed to verify these results in the setting of cardiac arrest.

Cardiopulmonary resuscitation in a hospitalized population: prospective study of factors associated with outcome

A prospective study of advanced cardiopulmonary resuscitation (CPR) was carried out on 226 patients in order to examine factors predicting successful resuscitation and 6 month survival. The mean age of all patients was 70 years and median age was 74. Cardiopulmonary resuscitation was successful in 40.5% (137) of all arrests and in 48.7% (110) of the first arrests. Thirty of 207 patients with one or more cardiac arrests were discharged alive (14%). Twenty-one of our patients were alive at 6 months (10.3%). Patients in ventricular fibrillation and/or ventricular tachycardia at the time of arrest were more likely to have successful outcomes. When the patient required Isuprel or bicarbonate, cardiopulmonary resuscitation was significantly less successful. We found no correlation of immediate outcome with the following variables: location of arrest; time of day; pre-existence of shock; coma; stroke; malignancy. Uremia and/or chronic obstructive pulmonary disease was not significantly associated with failed resuscitation. Most notable in our results of specific treatments was the evidence for the need to improve the initial pH, particularly when it was less than 7.2. Failure to do so by the time the second blood gas was drawn was associated with failure of cardiopulmonary resuscitation. Our results also suggest that the adequate treatment of metabolic acidosis, and improved ventilatory management with improved PO2 and optimization of PCO2, play a role in the better outcome of cardiopulmonary resuscitation.