Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: results from the National Osteoporosis Risk Assessment.

CONTEXT: Large segments of the population at risk for osteoporosis and fracture have not been evaluated, and the usefulness of peripheral measurements for short-term prediction of fracture risk is uncertain. OBJECTIVES: To describe the occurrence of low bone mineral density (BMD) in postmenopausal women, its risk factors, and fracture incidence during short-term follow-up. DESIGN: The National Osteoporosis Risk Assessment, a longitudinal observational study initiated September 1997 to March 1999, with approximately 12 months of subsequent follow-up. SETTING AND PARTICIPANTS: A total of 200 160 ambulatory postmenopausal women aged 50 years or older with no previous osteoporosis diagnosis, derived from 4236 primary care practices in 34 states. MAIN OUTCOME MEASURES: Baseline BMD T scores, obtained from peripheral bone densitometry performed at the heel, finger, or forearm; risk factors for low BMD, derived from questionnaire responses; and clinical fracture rates at 12-month follow-up. RESULTS: Using World Health Organization criteria, 39.6% had osteopenia (T score of -1 to -2.49) and 7.2% had osteoporosis (T score

Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis.

Numerous studies have reported increased risks of hip, spine, and other fractures among people who had previous clinically diagnosed fractures, or who have radiographic evidence of vertebral fractures. However, there is some variability in the magnitudes of associations among studies. We summarized the literature and performed a statistical synthesis of the risk of future fracture, given a history of prior fracture. The strongest associations were observed between prior and subsequent vertebral fractures; women with preexisting vertebral fractures (identified at baseline by vertebral morphometry) had approximately 4 times greater risk of subsequent vertebral fractures than those without prior fractures. This risk increases with the number of prior vertebral fractures. Most studies reported relative risks of approximately 2 for other combinations of prior and future fracture sites (hip, spine, wrist, or any site). The confidence profile method was used to derive a single pooled estimate from the studies that provided sufficient data for other combinations of prior and subsequent fracture sites. Studies of peri- and postmenopausal women with prior fractures had 2.0 (95 % CI = 1.8, 2.1) times the risk of subsequent fracture compared with women without prior fractures. For other studies (including men and women of all ages), the risk was increased by 2.2 (1.9, 2.6) times. We conclude that history of prior fracture at any site is an important risk factor for future fractures. Patients with a history of prior fracture, therefore, should receive further evaluation for osteoporosis and fracture risk.

Efficient patient identification strategies for women with osteoporosis.

The purpose of this analysis was to identify efficient (highest sensitivity at each level of cost) strategies to detect osteoporosis in postmenopausal women. Our study sample consisted of 392 women (age >/=50 yr) who were retirees or active employees of a corporation. The Simple Calculated Osteoporosis Risk Estimation (SCORE) questionnaire was completed, and bone mineral density levels were collected at the forearm using peripheral dual X-ray absorptiometry (pDXA), and at the femoral neck and lumbar spine using central DXA. Osteoporotic women were those with a T-score of -2.5 or less at any one of the three skeletal sites tested. Assumed costs were $5 for SCORE, $35 for pDXA, $120 for DXA at either the hip or spine, and $200 for DXA at both the hip and spine. The analysis indicated that the current "gold standard" is inefficient relative to other strategies investigated. By comparison, a tiered strategy consisting of SCORE, pDXA, and then selective use of DXA at both the hip and spine identified 90% of the women with osteoporosis at a cost of only $106 per woman tested. In choosing among the efficient strategies, decision makers must determine the extent to which they are willing to trade off higher program cost for greater sensitivity.

The labor productivity effects of chronic backache in the United States.

OBJECTIVES: Back pain afflicts approximately 31 million Americans, and is the number one cause of activity limitation in young adults. Little is known about the labor productivity costs associated with this chronic disease. Such information could provide useful input to employers considering alternative health benefits plans for managing their employees' health care needs. The goals of this study were to generate employee-level as well as national estimates of the labor productivity losses associated with chronic back ache. METHODS: Multivariate methods were used to isolate the effects of chronic backache on employment status and disability days. These results were combined with information on earnings to generate labor productivity cost estimates associated with chronic backache. The study used data from the National Medical Care Expenditure Survey (NMES), which provides information on health status, health care utilization and cost, work, disability, and sociodemographic characteristics for a nationally representative sample of the noninstitutionalized civilian population of the United States in 1987. RESULTS: Average annual productivity losses per worker due to chronic backache were $1,230 for male workers, measured in 1996 dollars, and $773 per female worker. These figures translated into aggregate annual productivity losses from chronic backache of approximately $28 billion in the United States. CONCLUSION: The labor productivity losses from chronic backache differed by gender and other sociodemographic characteristics. The aggregate labor productivity losses associated with chronic backache were quite large and comparable to estimates of the direct medical costs associated with treating this chronic illness.

Gastric ulcers in finishing pigs: their prevalence and failure to influence growth rate.

In an abattoir survey the stomachs of 1242 pigs from 15 farms were examined. Ulceration of the pars oesophagea was present in 22.95 per cent with a range from 4.7 to 57.4 per cent. The ulcers were graded mild in 9.5 per cent and severe in 13.4 per cent of the stomachs. Bile staining and hyperkeratinisation of the pars were significantly more common in stomachs with ulcers than in those without (P < 0.001), although the difference between the hyperkeratinisation in cases with severe ulcers and cases without ulcers was not significant. The daily liveweight gains of 208 males and 150 females from two units with a high prevalence of ulcers were calculated from their weaning weights at about five weeks of age and their slaughter weights at around 90 kg. At the abattoir their stomachs were examined for the presence of ulcers of the pars. The daily liveweight gain of the males was significantly greater than that of the females (P < 0.001), but the presence of mild or severe ulcers had no influence on the rate of gain of the pigs from either unit. The prevalence of ulcers in the males and females was 57.2 and 49.3 per cent, respectively, but the difference was not significant.

Labour productivity effects of prescribed medicines for chronically ill workers.

Previous work on the labour productivity effects of chronic illness has not separated the effects of chronic illnesses from the effects of prescription medications taken to alleviate these conditions. Using nationally representative observational data, this study estimates the pure effect of chronic illness, and the marginal effect of prescription medicines, on labour productivity. As Americans continue to scrutinize health care expenditures, such estimates will play an increasing role in determining the allocation of resources for medical treatments. Estimates are presented of the costs and benefits to employers of covering prescription medications for workers aged 18-64 years afflicted with specific chronic illnesses. The effects of prescription medicines on hourly wages and days lost from work are examined for four major chronic illnesses: hypertension, heart disease, non-insulin dependent (type II) diabetes and depression. The net benefits to employers from having workers take prescription medicines for their chronic illnesses are substantial. Assuming average compliance rates are achieved, net benefits to employers in 1987 amounted to $286 per hypertensive employee, $633 per employee with heart disease; $822 per depressed employee, and $1475 per type II diabetic employee under medication from a physician. These estimated benefits accrue because prescription medications substantially lower absenteeism among chronically ill workers.

Osteoporosis: the need for comprehensive treatment guidelines.

Osteoporosis is a debilitating disease that results in nearly 1.3 million fractures per year in the United States. The cost of treating these fractures has been estimated to be as high as $10 billion per year. These costs are expected to more than double during the next 50 years unless comprehensive programs of prevention and treatment are initiated. Both pharmacologic and nonpharmacologic interventions (eg, diet and exercise) have been shown to have a significant impact on the incidence of osteoporosis, depending on the time of their application. Unfortunately, osteoporosis is often not diagnosed until after fractures have occurred, when it may be too late for treatment to have a major impact. To be most effective, therapy should be started early, before serious bone loss has occurred. Because of its efficacy and relatively low acquisition cost, long-term hormone replacement therapy (HRT) is considered first-line pharmacologic therapy for the prevention of osteoporosis. However, for various reasons, less than 25% of US women who might benefit from HRT are receiving it. Aside from HRT, the only other products approved by the US Food and Drug Administration for the treatment of osteoporosis are salmon calcitonin and alendronate. Several other agents are under development, including sustained-release fluoride and other products in the bisphosphonate class. The development and adoption of early detection programs and treatment guidelines are crucial to help ease the economic burden of osteoporosis. These guidelines should incorporate preventive measures such as diet and exercise, risk assessment through proper screening programs, and the appropriate use of pharmaceutical products. The purpose of this paper is to discuss relevant economic issues associated with osteoporosis and discuss the need for a management algorithm that could be used to more efficiently prevent and treat this disease. We conclude that further modeling is needed to determine which programs and treatments are most cost-effective within each at-risk subgroup. As clinicians better understand the need for preventive care and the advantages of the various pharmacologic therapies, patients with osteoporosis will receive higher-quality and more efficient medical care.

Abattoir observations of the weights of stomachs and their contents in pigs slaughtered at known times after their last feed.

From 15 farms, 1242 pigs (range per farm 12-169) were sent for slaughter at known times after their last feed. The time of feeding, quantity and type of last feed, time of loading, time in transit, distance travelled, time in lairage and time of slaughter, were recorded. The mean +/- SD stomach weight and wet stomach contents weight were 0.68 +/- 0.12 and 0.55 +/- 0.45 kg, respectively. There were 148 stomachs (11.9%) with wet contents weights > 1 kg, nine > 2 kg but < 3 kg, and one weighed 3.04 kg. The means and ranges for times from last feed to loading interval, time in transport, and time in lairage were 13.6 (0-40), 3.1 (0.75-6.0) and 4.1 (2.1-12.5) h, respectively. The mean and range for distance travelled was 193.1 (43-320) km. Ten stomachs were collected at random from a further load of pigs from one farm. They had been fed 0.64 kg dry pellets and were slaughtered 18.5 h later. The mean and range for wet stomach contents weight was 0.87 kg (0.24-1.33). Samples were dehydrated and the mean calculated stomach dry matter content for the 10 pigs was 127.4 +/- 69.1 g.

Price regulation in the pharmaceutical industry: prescription or placebo?

President Clinton and several Legislators have proposed restrictions on price increases in the pharmaceutical industry similar to those on some public utilities. Studies, however, suggest that under conditions of rapidly changing demand (as found in pharmaceuticals), price-caps could be manipulated. Using simulations, we show that in reaction to regulation, pharmaceutical firms would optimally set launch prices 50 percent higher than in an unregulated market. Although initially hurt, after seven years consumers benefit as the unregulated price rises above the price-cap. Thus, before enacting legislation, Congress should assess America's willingness to pay more now for lower prices in the future.

Pig welfare and carcase quality: a comparison of the influence of slaughter handling systems at two abattoirs.

Pigs from four farms (two producing 'easy' and two 'difficult to handle' pigs) were slaughtered at two abattoirs, each with two slaughter handling systems, so that 25 pigs of each behavioural type were slaughtered by all four handling systems on each day; there were 16 replicates (3200 pigs) in total. The pigs at abattoir X were electrically stunned, either in a floor pen holding five pigs or in a race-restrainer. At abattoir Y the pigs were stunned either in a floor pen holding five pigs or in a dip-lift carbon dioxide stunner. The following measurements were made: hot carcase weight and backfat thickness at P2, degree of rigor mortis 35 minutes post mortem, skin blemish, pH and muscle reflectance in the m longissimus dorsi at 60 minutes and 18 hours post mortem, and pH and muscle reflectance in the m adductor at 18 hours post mortem. At abattoir X, the pigs slaughtered in the race-restrainer had heavier carcases (74.0 kg vs 73.0 kg, P < 0.05), developed rigor mortis more rapidly (8.1 mm vs 7.3 mm, P < 0.01), had more skin blemish (2.8 vs 2.7, P < 0.01), paler m longissimus dorsi muscles after one hour (15.7 vs 13.9, P < 0.01) and 18 hours (27.8 vs 26.6, P < 0.05), and paler m adductor muscles (24.5 vs 22.7, P < 0.001) after 18 hours. At abattoir Y, the pigs handled through the floor pen system had more skin blemish (2.7 vs 2.6, P < 0.05) and a tendency to develop rigor mortis more quickly (6.11 vs 5.32, P = 0.089).(ABSTRACT TRUNCATED AT 250 WORDS)

Coccidia of the llama, Lama glama, in Colorado and Wyoming.

Fecal samples were collected from 144 llamas, Lama glama, on four premises in northern Colorado and southern Wyoming. Feces were examined for the presence of coccidial oocysts; Eimeria alpacae was found in 55.6%, Eimeria lamae in 67.3% and Eimeria macusaniensis in 1.4% of the samples. An adult female llama was found to be infected with Eimeria macusaniensis at necropsy. This is the first report of these species of coccidia in the llama.