Santosh K. Verma

Relationship between early opioid prescribing for acute occupational low back pain and disability duration, medical costs, subsequent surgery and late opioid use

Study Design. Retrospective cohort study of workers’ compensation (WC) claims with acute disabling low back pain (LBP). Objective. To examine the association between early opioid use for acute LBP and outcomes: disability duration, medical costs, “late opioid” use (≥5 prescriptions from 30 to 730 days), and surgery in a 2-year period following LBP onset. Summary of Background Data. Opioid analgesics have become more accepted for acute pain management. However, treatment guidelines recommend limited opioid use for acute LBP management. Little is known about the long-term impact on outcomes of opioid use for acute LBP. Methods. The sample consisted of 8443 claimants from a large WC database with new-onset, disabling LBP that occurred between January 1, 2002 and December 31, 2003. Based on morphine equivalent amount (MEA) in milligrams received in the first 15 days (“early opioids”), claimants were divided into 5 groups (0, 1–140, 141–225, 226–450, 450+). The associations between early opioids and outcomes were evaluated using multivariate linear and logistic regression models. Covariates included age, gender, job tenure, and low back injury severity. Injury severity was classified using ICD-9 codes. Results. Twenty-one percent of claimants received at least 1 early opioid prescription. After controlling for the covariates, mean disability duration, mean medical costs, and risk of surgery and late opioid use increased monotonically with increasing MEA. Those who received more than 450 mg MEA were, on average, disabled 69 days longer than those who received no early opioids (95% confidence interval [CI], 49.2–88.9). Compared with the lowest MEA group (0 mg opioid), the risk for surgery was 3 times greater (95% CI, 2.4–4.0) and the risk of receiving late opioids was 6 times greater (95% CI, 4.9–7.7) in the highest MEA group. Low back injury severity was a strong predictor of all the outcomes. Conclusion. Given the negative association between receipt of early opioids for acute LBP and outcomes, it is suggested that the use of opioids for the management of acute LBP may be counterproductive to recovery.

Risk factors for recurrent episodes of care and work disability: case of low back pain.

Recurrences of injuries are common and have significant socioeconomic consequences; it is important to identify associated risk factors as potential opportunities for prevention. This study was conducted to identify risk factors for low back pain (LBP) recurrence and the extent that variation in recurrence definition impacts identified risk factors. Patients with new claims for LBP reported in New Hampshire to a workers’ compensation provider were selected (n = 2023) with a minimum of 3-year follow up. Alternative definitions of recurrence included a new episode of medical care and a new episode of lost work time (work disability). Risk factors better predicted disability-based than treatment-based recurrence. Longer durations of the initial episode of care or work disability were the most powerful predictors of recurrence, implying that shorter episodes of care and early return to work contribute to better outcomes.

Recurrence of Low Back Pain : Definition-Sensitivity Analysis Using Administrative Data

Study Design. Retrospective analysis of administrative claims data in a single workers’ compensation jurisdiction. Objectives. To evaluate the effects of alternative definitions and follow-up parameters on rates of low back pain recurrence based on detailed administrative data. Summary of Background Data. Previous studies reported low back pain recurrence rates ranging from 14% to 45%, without consistency in definitions of recurrence or specifications of follow-up. Methods. Patients with new claims for low back pain reported in New Hampshire to a large workers’ compensation provider in 1996 and 1997 were selected (N = 2944). Definitions of recurrence included: new workers’ compensation claim, new episode of care, and new episode of lost work time (work disability). For the latter two definitions, various minimum between-episode gaps were applied and related to recurrence rates. Two follow-up structures (constant length of follow-up post end of the first episode and fixed-period length of follow-up since the onset of low back pain) were examined for sensitivity of recognizing low back pain recurrence, with a maximum of 3-year follow-up. Results. Recurrence rate using a claims-based definition was 7.9% and 7.1% for the entire cohort and the subset with work disability days, respectively, for the 3 years of follow-up. Care-based recurrence rates ranged between 12% and 49%, whereas disability-based recurrence rates ranged between 6% and 17% over the 3 years, inversely related to the length of the minimum between-episode gap (R = −0.86 for disability and care, P < 0.001). Two-year follow-up was sufficient to identify 85% to 100% of recurrences regardless of the follow-up structure. Conclusions. Recurrence rates are highly sensitive to variations in definitions. Consistency of definitions and application across studies is required to enable valid comparisons.

Extracellular annexins and dynamin are important for sequential steps in myoblast fusion

Annexins A1 and A5 are important for initial lipid mixing, whereas subsequent stages of myoblast fusion depend on dynamin, phosphatidylinositol(4,5)bisphosphate, and cellular metabolism.

Length of disability prognosis in acute occupational low back pain: development and testing of a practical approach.

Study Design. Retrospective cohort study. Objectives. Practical evaluation of a rapid prognostic screening method to predict length of disability after acute occupational low back pain (OLBP). Summary of Background Data. Few studies have evaluated the prognostic value of administrative data and selected clinical variables in typical practice settings. Methods. Nurse case manager (NCM) input for 16 variables and 7 administrative data variables were collected for 494 OLBP cases with at least 30 days of disability. Length of disability (LOD) was ascertained by individual indemnity payment analysis. Cases were censored after accumulating 365 days of temporary total disability or if they received a lump sum settlement. Prognostic variables were evaluated by Cox proportional hazards modeling. Results. In a multivariate model, prolonged LOD was associated with older age, shorter job tenure, female gender, presence of language barriers, comorbidity, prior work absence, delayed referral, attorney involvement nonsupportive of return to work (RTW), and low RTW motivation. Although only 12% of overall variance in LOD was explained by the model, high-risk and low-risk terciles were readily distinguished. Conclusions. In a typical setting, data collection and risk prediction by nurses or case managers are feasible and provide specific information that can be used to identify who should receive intervention, as well as some guidance on factors that should be addressed.

Falls and Fall-Related Injuries among Community-Dwelling Adults in the United States.

Introduction Falls are the leading cause of unintentional injuries in the U.S.; however, national estimates for all community-dwelling adults are lacking. This study estimated the national incidence of falls and fall-related injuries among community-dwelling U.S. adults by age and gender and the trends in fall-related injuries across the adult life span. Methods Nationally representative data from the National Health Interview Survey (NHIS) 2008 Balance and Dizziness supplement was used to develop national estimates of falls, and pooled data from the NHIS was used to calculate estimates of fall-related injuries in the U.S. and related trends from 2004–2013. Costs of unintentional fall-related injuries were extracted from the CDC’s Web-based Injury Statistics Query and Reporting System. Results Twelve percent of community-dwelling U.S. adults reported falling in the previous year for a total estimate of 80 million falls at a rate of 37.2 falls per 100 person-years. On average, 9.9 million fall-related injuries occurred each year with a rate of 4.38 fall-related injuries per 100 person-years. In the previous three months, 2.0% of older adults (65+), 1.1% of middle-aged adults (45–64) and 0.7% of young adults (18–44) reported a fall-related injury. Of all fall-related injuries among community-dwelling adults, 32.3% occurred among older adults, 35.3% among middle-aged adults and 32.3% among younger adults. The age-adjusted rate of fall-related injuries increased 4% per year among older women (95% CI 1%–7%) from 2004 to 2013. Among U.S. adults, the total lifetime cost of annual unintentional fall-related injuries that resulted in a fatality, hospitalization or treatment in an emergency department was 111 billion U.S. dollars in 2010. Conclusions Falls and fall-related injuries represent a significant health and safety problem for adults of all ages. The findings suggest that adult fall prevention efforts should consider the entire adult lifespan to ensure a greater public health benefit.

Geographic variation in opioid prescribing for acute, work-related, low back pain and associated factors: A multilevel analysis

BACKGROUND Given reports about variation in opioid prescribing, concerns about increasing opioid use and its associated negative consequences make understanding the sources of variability important. The aims of the study were to assess the extent of and factors associated with geographic variation in early opioid prescribing for acute, work-related, low back pain (LBP). METHODS Cases were selected from workers compensation administrative data filed between January 1, 2002 and December 31, 2003 and included claims from states with more than 40 cases. Early opioid prescribing (one or more prescriptions within first 15 days) was the outcome. Weighted coefficient of variation (wCOV) estimated geographic variation, and multilevel models measured variability controlling for individual and contextual factors. RESULTS Of the 8,262 claimants, 21.3% received at least one early opioid prescription. Significant between-state variation was found (wCOV = 53%), from 5.7% (Massachusetts) to 52.9% (South Carolina). Seventy-nine percent of the between-state variation was explained by three contextual factors: state household income inequality (prevalence ratio [PR] 1.06, 95% confidence interval [CI] = 1.01, 1.12), number of physicians per capita (PR 0.99, 95% CI = 0.98, 0.99), and workers compensation cost containment effort score (PR 1.12, 95% CI = 1.02, 1.24). Individual-level factors, including severity, explained only a small portion of the geographic variability. CONCLUSION Geographic variation of early opioid prescribing for acute LBP is important and almost fully explained by state-level contextual factors. The study suggests that clinician and patient interaction and the subsequent decision to use opioids are substantially framed by social conditions and control systems. Am. J. Ind. Med. 52:162-171, 2009. (c) 2008 Wiley-Liss, Inc.

A prospective study of floor surface, shoes, floor cleaning and slipping in US limited-service restaurant workers

Objectives Slips and falls are a leading cause of injury at work. Few studies, however, have systematically examined risk factors of slipping outside the laboratory environment. This study examined the association between floor surface characteristics, slip-resistant shoes, floor cleaning frequency and the risk of slipping in limited-service restaurant workers. Methods 475 workers from 36 limited-service restaurants from three major chains in six states in the USA were recruited to participate in a prospective cohort study of workplace slipping. Kitchen floor surface roughness and coefficient of friction (COF) were measured in eight working areas and then averaged within each restaurant. The use of slip-resistant shoes was determined by examining the participants shoes and noting the presence of a ‘slip-resistant’ marking on the sole. Restaurant managers reported the frequency of daily kitchen floor cleaning. Participants reported their slip experience and work hours weekly for up to 12 weeks. The survey materials were made available in three languages: English, Spanish and Portuguese. The associations between rate of slipping and risk factors were assessed using a multivariable negative binomial generalised estimating equation model. Results The mean of individual slipping rate varied among the restaurants from 0.02 to 2.49 slips per 40 work hours. After adjusting for age, gender, BMI, education, primary language, job tenure and restaurant chain, the use of slip-resistant shoes was associated with a 54% reduction in the reported rate of slipping (95% CI 37% to 64%), and the rate of slipping decreased by 21% (95% CI 5% to 34%) for each 0.1 increase in the mean kitchen COF. Increasing floor cleaning frequency was significantly associated with a decreasing rate of slipping when considered in isolation but not after statistical adjustment for other factors. Conclusion These results provide support for the use of slip-resistant shoes and measures to increase COF as preventive interventions to reduce slips, falls and injuries.

Direct and rapid determination of sulphate in environmental samples with diffuse reflectance Fourier transform infrared spectroscopy using KBr substrate

The feasibility of employing diffuse reflectance Fourier transform infrared spectroscopy (DRS-FTIR) as a sensitive tool in the submicrogram level determination of sulphate (SO(4)(2-)) was checked in this work. This paper presents the development of a new, rapid and precise analytical method for ppb levels of sulphate (SO(4)(2-)) in environmental samples like coarse and fine aerosol particles, dry deposits and soil. The determination of submicrogram levels of sulphate is based on the selection of a quantitative analytical peak at 617cm(-1) among the three observed vibrational peaks and preparing calibration curve using different known concentrations of sulphate by diffuse reflectance-Fourier transform infra red spectrometric (DRS-FTIR) technique. Pre-weighed and ground IR grade KBr was used as substrate over which remarkably wide range of known concentration of sulphate was sprayed and dried. The dried sample was analysed by DRS-FTIR. Three calibration curves for three different concentration ranges of sulphate were prepared for samples containing low and relatively higher sulphate contents. The relative standard deviation (n=8) for the sulphate concentration ranges, 2.5-35.5, 25.5-165, 55-1000mug/0.5g KBr, as used to prepare calibration curves, were 2.4%, 2.1% and 1.5%, respectively. The relative standard deviation for the sulphate concentration in real samples were found to be in the range, 3.11-5.76% (n=16), 4.05-7.75% (n=16) and 1.48-3.52% (n=10) for aerosol, dry deposits and soil, respectively. The LOD of the method is 0.20mug/g SO(4)(2-). The F- and t-tests were performed to check the analytical quality assurance test. The noteworthy feature of the reported method is the non-interference of any of the associated anions and cations. The results were compared with that of ion-chromatographic method with high degree of acceptability. The method can be applied in wide concentration ranges. A method for sulphate determination was introduced that did not require pretreatment of samples. This method employed the direct determination of the sulphate. The method is reagent less, nondestructive, very fast, repeatable, and accurate and has high sample throughput value.

Single-drop micro-extraction and diffuse reflectance Fourier transform infrared spectroscopic determination of chromium in biological fluids

The present paper deals with a new micro-extraction procedure for selective separation of Cr(VI) in the form of a metaloxy anionic species namely dichromate (Cr(2)O(7)(2-)) with N(1)-hydroxy-N(1),N(2)-diphenylbenzamidine (HOA) in to dichloromethane and its subsequent and rapid diffuse reflectance Fourier transform infrared spectroscopic (DRS-FTIR) determination employing potassium bromide matrix. The diffuse reflectance Fourier transform infrared spectroscopy gives both qualitative and quantitative information about the dichromate. The determination of chromium is based on the analytical peak selection, among the various vibrational peaks, at 902 cm(-1). The micro-extraction was based on the liquid-liquid solvent extraction (LLSE) principle. The dichromate binds with the nitrogen and oxygen atoms of N(1)-hydroxy-N(1),N(2)-diphenylbenzamidine (HOA) and forms 1:2, Cr(VI):HOA complex in 0.1 mol L(-1) HCl medium. The formation of above complex, in the acidic medium, is confirmed by the appearance of chocolate-brown color in the micro-extract. The speciation studies of Cr(III) and Cr(VI) is done by conversion of Cr(III) into Cr(VI) utilizing H(2)O(2) as an oxidizing agent. The chemistry of pure dichromate and that of its HOA complex is discussed. The limit of detection (LoD) and the limit of quantification (LoQ) of the method are found to be 0.01 microg g(-1) Cr(2)O(7)(2-) and 0.05 microg g(-1) Cr(2)O(7)(2-), respectively. The standard deviation value and the relative standard value at a level of 10 microg Cr(2)O(7)(2-)/0.1g KBr for n=10 is found to be 0.26 microg Cr(2)O(7)(2-) and 2.6%, respectively. The relative standard deviation (n=8 and 6) for the determination of dichromate (Cr(2)O(7)(2-)) in real human biological fluid samples is observed to be in the range 3.1-7.8%.