Carmen S. Kirkness

Clinical Risk Factors for Fracture in Postmenopausal Osteoporotic Women: A Review of the Recent Literature

Objective: To review recent literature regarding relationships among age, weight or body mass index (BMI), bone mineral density (BMD), maternal history of fracture, or personal prior history of fracture and fragility fractures in women with postmenopausal osteoporosis (PMO). Data Sources: A MEDLINE database search (1995–June 30, 2007) was conducted to identify literature related to risk factors of interest for PMO-related fractures. Study Selection and Data Extraction: Cohort studies, case—control studies, and meta-analyses that reported fracture outcomes were included if they provided an estimate of relative risk for at least 1 of the 5 selected clinical risk factors (CRFs) and studied women with PMO or stratified risk estimates by age and sex. Of 313 identified studies that evaluated fractures as an endpoint, 245 did not report risk estimates for a CRF of interest and/or did not report data for a PMO population. Data Synthesis: In the 68 included articles, the risks associated with the evaluated CRFs were high and significant. Prior fracture was a strong predictor of fracture and increased risk up to 18 times. Each standard deviation below the referent mean for BMD was associated with an increased fracture risk of up to 4.0 times; maternal fracture history increased risk 1.3–2.9 times. Age (per 5 year increment) increased risk by 1.2–5.0 times; low weight or BMI inconsistently showed a 0.5–3.0 times greater risk. Conclusions: Low BMD is widely used as a diagnostic indicator for osteoporosis; however, other CRFs play an important role in determining fracture risk among women with PMO.

The Societal Costs of Low Back Pain

The paper reviews low back pain (LBP) studies with economic implications in order to determine whether the societal cost attributed to lower back pain (LBP) have changed since 2001, a time during which LBP treatment guidelines were updated. A Medline search of publications 2001 and 2007 using broadly defined keywords produced 338 abstracts that were screened, of which 68 potentially relevant articles were retrieved and reviewed. Cost estimates for the management of LBP were high, consistent with the results of review of LBP economic studies published prior to 2001. Pharmacotherapy plays an important role in LBP treatment, although drug cost data in LBP is limited. Newer, more costly agents such cyclooxengenase-2 selective nonsterioidal antiinflammatory agents will increase drug costs as a portion of total costs, particularly if not used in accordance with treatment guidelines.

Diabetes and Associated Risk Factors in Patients Referred for Physical Therapy in a National Primary Care Electronic Medical Record Database

Objective: The prevalence of diabetes (type 2) in the general population has increased dramatically over the last decade, yet patients with diabetes are rarely referred for physical therapy management of their condition. The majority of patients referred for outpatient physical therapy have musculoskeletal-related conditions. Secondary conditions, such as diabetes, may be prevalent in this population, and physical therapists need to be aware of this to adjust interventions and treatment. The purpose of this article is to describe the prevalence of diabetes and the associated risk factors in adults referred for physical therapy in a primary care outpatient setting. Subjects and Methods: Patients aged 18 years or older referred for physical therapy were identified from the Centricity Electronic Medical Records database during the period of December 13, 1995, to June 30, 2007. Patients were evaluated on the basis of clinical (height, weight, blood pressure, laboratory values), treatment (prescriptions), and diagnostic (ICD-9 codes) criteria to identify the presence of diabetes or associated risk factors (eg, hypertension, elevated triglycerides, low high-density lipoprotein, body mass index, and prediabetes). Results: There were 52,667 patients referred for physical therapy, the majority of whom were referred for a musculoskeletal-related condition. Approximately 80% of the total study population had diabetes, prediabetes, or risk factors associated with diabetes. The prevalence of diabetes in the study population was 13.2%. Of the diabetes-associated risk factors evaluated, hypertension was the most prevalent (70.4%), and less than half (39.1%) of the study population had an elevated body mass index. Only 20% of the study population had values within normal limits for all clinical, treatment, and diagnostic criteria. Clinical and treatment measurements available to physical therapists identified the majority of associated risk factors. Conclusions: Although not the primary indications for referral, diabetes and associated risk factors were identified in a high proportion of the study population. The evaluation of associated conditions in the outpatient orthopedic setting needs to be considered for treatment planning adjustments and to optimize care.

Cost–benefit evaluation of liposomal bupivacaine in the management of patients undergoing total knee arthroplasty

PURPOSE Results of a cost-benefit analysis of intraoperative use of liposomal bupivacaine for postsurgical pain management in patients undergoing total knee arthroplasty (TKA) are presented. METHODS In a retrospective single-site study, clinical and cost outcomes were compared in a group of 134 consecutive patients who received liposomal bupivacaine (by local infiltration) during TKA and a propensity score-matched historical cohort of 134 patients undergoing TKA who received usual care (continuous femoral nerve blockade with conventional bupivacaine delivered via elastomeric pump). RESULTS Postsurgical pain scores and opioid use were similar in the two study groups; the mean total amount of nonsteroidal antiinflammatory drugs administered was lower in the liposomal bupivacaine group. Patients who received liposomal bupivacaine typically ambulated earlier than those who received usual care (22% and 3%, respectively, walked on the day of surgery; p < 0.05) and were more likely to be discharged within two days (50% versus 19%, p < 0.001); on average, liposomal bupivacaine- treated patients walked farther on the day of surgery (6.0 m versus 3.1 m, p < 0.001) and the day after surgery (63.7 m versus 25.5 m, p < 0.001) and had a shorter length of stay (LOS) (3.1 days versus 3.6 days, p < 0.03). The mean adjusted total direct hospital cost per patient was significantly lower with liposomal bupivacaine use versus usual care (

Trends and predictors in methadone maintenance treatment dropout in Shanghai, China: 2005-2011.

8758 versus

Local infiltration for postsurgical analgesia following total hip arthroplasty: a comparison of liposomal bupivacaine to traditional bupivacaine

9213, p = 0.033). CONCLUSION In patients undergoing TKA, intraoperative administration of liposomal bupivacaine for management of postsurgical pain was found to offer advantages over usual care, including decreased time to ambulation and reduced hospital LOS.

Explaining the link between access-to-care factors and health care resource utilization among individuals with COPD

Abstract Background: The methadone maintenance treatment (MMT) program has been implemented in Shanghai since 2005. This study aims to portray the trend of MMT dropout and identify predictive factors that may influence dropout in Shanghai MMT clinics, which could assist in the intervention strategy development. Methods: A retrospective evaluation was used in the Shanghai component of the National MMT data management system between January 1, 2005 and December 31, 2011. The Cox model for recurrence events was employed to estimate hazard ratio (HR) predicting dropout during the follow-up period. Results: Of all 6169 participants, 63% dropped out of the program at least once (ranging from 0 to 10 times), and 74% of them did not return by the end of this study. The average monthly incidence rate of dropout was 4.4% with a range from 0 to 9.3%. Adjusted analyses demonstrated that the individuals with methadone tapering didn’t have a greater probability of dropping out compared to those with stable dosage (HR = 1.07, 95% CI: 0.90–1.27). However, there was a higher dropout rate among younger individuals (<30 years vs. ≥50 years old; HR = 1.41, 95% CI: 1.16–1.71), among those who were less educated (HR = 1.48, 95% CI: 1.17–1.87), among those who shared needles with others (HR = 1.29, 95% CI: 1.06–1.58), among those whose urine tested positive for opiates (HR = 1.69, 95% CI: 1.51–1.89), and among those who had a low average methadone dose at the initial stable stage of treatment (≤35 mg/day vs. >65 mg/day; HR = 1.39, 95% CI: 1.19–1.63). Conclusions: Shanghai has been facing the challenge of keeping a high MMT retention rate. Increasing the use of methadone tapering after a stable treatment stage with sufficient dosage could be attempted in the MMT program, as well as considering comprehensive interventions among specific populations, such as young, poorly educated, opiate-positive and needle sharing individuals.

Assessment of liposome bupivacaine infiltration versus continuous femoral nerve block for postsurgical analgesia following total knee arthroplasty: a retrospective cohort study

Abstract Objective: To assess postsurgical clinical and economic outcomes of patients who received local infiltration containing liposomal bupivacaine versus traditional bupivacaine for pain management following total hip arthroplasty (THA). Methods: This retrospective study included two groups of consecutive patients undergoing THA. The experimental group received local infiltration with a combination of liposomal bupivacaine, bupivacaine HCl 0.25% with epinephrine 1:200,000, and ketorolac for postsurgical analgesia. The historical control group received the previous standard of care: local infiltration with a combination of bupivacaine HCl 0.25% with epinephrine 1:200,000 and ketorolac. Key outcomes included distance walked, length of stay (LOS), opioid medication use, numeric pain scores, hospital charges, hospital costs, all-cause 30 day readmission rate, and adverse events (AEs). Both unadjusted and adjusted (i.e. age, sex, insurance type, living situation, body mass index, procedure side, and comorbidity) outcomes were compared between the two groups. Results: The experimental group (n = 64) demonstrated statistically significant improvement versus the historical control group (n = 66) in mean distance walked on discharge day (249.2 vs. 180.0 feet; unadjusted p = .025, adjusted p = .070), mean LOS (2.0 vs. 2.7 days; p < .001, p = .002), proportion of patients who used opioid rescue medication on postoperative day (POD) 1 (29.7% vs. 56.1%; p = .002, p = .003) and POD 2 (7.8% vs. 30.3%; p = .001, p = .003), mean cumulative area under the curve for pain score on POD 0 (127.6 vs. 292.5; p < .001, both), POD 1 (92.9 vs. 185.0; p < .001, both), and POD 2 (93.8 vs. 213.8; p = .006, both). Among a subgroup of patients with available financial information, mean hospital charges were lower in the experimental group (

Characterization of Patients Undergoing Total Hip Arthroplasty in a Real-World Setting and Pain-Related Medication Prescriptions for Management of Postoperative Pain

43,794 [n = 24] vs.

Race Differences: Use of Walking Speed to Identify Community-Dwelling Women at Risk for Poor Health Outcomes—Osteoarthritis Initiative Study

48,010 [n = 66]; p < .001, both). Rates of all-cause 30 day readmission and AEs were not significantly different between groups. No falls occurred. Conclusions: Infiltration at the surgical site with liposomal bupivacaine was associated with improved postsurgical outcomes when compared with traditional bupivacaine in patients undergoing THA.