The clinician's guide to prevention and treatment of osteoporosis.

Osteoporosis is the most common metabolic bone disease in the USA and the world. It is a subclinical condition until complicated by fracture(s). These fractures place an enormous medical and personal burden on individuals who suffer from them and take a significant economic toll. Any new fracture in an adult aged 50 years or older signifies imminent elevated risk for subsequent fractures, particularly in the year following the initial fracture. What a patient perceives as an unfortunate accident may be seen as a sentinel event indicative of bone fragility and increased future fracture risk even when the result of considerable trauma. Clinical or subclinical vertebral fractures, the most common type of osteoporotic fractures, are associated with a 5-fold increased risk for additional vertebral fractures and a 2- to 3-fold increased risk for fractures at other sites. Untreated osteoporosis can lead to a vicious cycle of recurrent fracture(s), often resulting in disability and premature death. In appropriate patients, treatment with effective antifracture medication prevents fractures and improves outcomes. Primary care providers and medical specialists are critical gatekeepers who can identify fractures and initiate proven osteoporosis interventions. Osteoporosis detection, diagnosis, and treatment should be routine practice in all adult healthcare settings. The Bone Health and Osteoporosis Foundation (BHOF) - formerly the National Osteoporosis Foundation - first published the Clinician's Guide in 1999 to provide accurate information on osteoporosis prevention and treatment. Since that time, significant improvements have been made in diagnostic technologies and treatments for osteoporosis. Despite these advances, a disturbing gap persists in patient care. At-risk patients are often not screened to establish fracture probability and not educated about fracture prevention. Most concerning, the majority of highest risk women and men who have a fracture(s) are not diagnosed and do not receive effective, FDA-approved therapies. Even those prescribed appropriate therapy are unlikely to take the medication as prescribed. The Clinician's Guide offers concise recommendations regarding prevention, risk assessment, diagnosis, and treatment of osteoporosis in postmenopausal women and men aged 50 years and older. It includes indications for bone densitometry as well as fracture risk thresholds for pharmacologic intervention. Current medications build bone and/or decrease bone breakdown and dramatically reduce incident fractures. All antifracture therapeutics treat but do not cure the disease. Skeletal deterioration resumes sooner or later when a medication is discontinued-sooner for nonbisphosphonates and later for bisphosphonates. Even if normal BMD is achieved, osteoporosis and elevated risk for fracture are still present. The diagnosis of osteoporosis persists even if subsequent DXA T-scores are above - 2.5. Ongoing monitoring and strategic interventions will be necessary if fractures are to be avoided. In addition to pharmacotherapy, adequate intake of calcium and vitamin D, avoidance of smoking and excessive alcohol intake, weight-bearing and resistance-training exercise, and fall prevention are included in the fracture prevention armamentarium. Where possible, recommendations in this guide are based on evidence from RCTs; however, relevant published data and guidance from expert clinical experience provides the basis for recommendations in those areas where RCT evidence is currently deficient or not applicable to the many osteoporosis patients not considered for RCT participation due to age and morbidity.

Post-fracture care programs for prevention of subsequent fragility fractures: a literature assessment of current trends.

Post-fracture care (PFC) programs evaluate and manage patients with a minimal trauma or fragility fracture to prevent subsequent fractures. We conducted a literature review to understand current trends in PFC publications, evaluate key characteristics of PFC programs, and assess their clinical effectiveness, geographic variations, and cost-effectiveness. We performed a search for peer-reviewed articles published between January 2003 and December 2020 listed in PubMed or Google Scholar. We categorized identified articles into 4 non-mutually exclusive PFC subtopics based on keywords and abstract content: PFC Types, PFC Effectiveness/Success, PFC Geography, and PFC Economics. The literature search identified 784 eligible articles. Most articles fit into multiple PFC subtopics (PFC Types, 597; PFC Effectiveness/Success, 579; PFC Geography, 255; and PFC Economics, 98). The number of publications describing how PFC programs can improve osteoporosis treatment rates has markedly increased since 2003; however, publication gaps remain, including low numbers of publications from some countries with reported high rates of osteoporosis and/or hip fractures. Fracture liaison services and geriatric/orthogeriatric services were the most common models of PFC programs, and both were shown to be cost-effective. We identified a need to expand and refine PFC programs and to standardize patient identification and reporting on quality improvement measures. Although there is an increasing awareness of the importance of PFC programs, publication gaps remain in most countries. Improvements in established PFC programs and implementation of new PFC programs are still needed to enhance equitable patient care to prevent occurrence of subsequent fractures.

Treatment patterns and long-term persistence with osteoporosis therapies in women with Medicare fee-for-service (FFS) coverage.

Osteoporosis, a chronic disease, requires long-term therapy. In Medicare-insured women, denosumab persistence was higher than oral bisphosphonate persistence over up to 3 years of follow-up. Longer-term persistence was higher among women who persisted in the first year of therapy. INTRODUCTION: Osteoporosis, a chronic, progressive disease, requires long-term therapy; this study assessed long-term persistence with anti-resorptive therapies in postmenopausal women. METHODS: This retrospective cohort study used administrative claims for women with data in the 100% Medicare osteoporosis sample who initiated (index date) denosumab, oral/intravenous (IV) bisphosphonate, or raloxifene between 2011 and 2014 and who had ≥ 1 year (zoledronic acid: 14 months) of pre-initiation medical/pharmacy coverage (baseline). Persistence was assessed from index date through end of continuous coverage, post-index evidence of censoring events (e.g., incident cancer), death, or end of study (December 31, 2015). RESULTS: The study included 318,419 oral bisphosphonate users (78% alendronate), 145,056 denosumab users, 48,066 IV bisphosphonate users, and 31,400 raloxifene users; mean age ranged from 75.5 years (raloxifene) to 78.5 years (denosumab). In women with at least 36 months of follow-up (denosumab N = 25,107; oral bisphosphonates N = 79,710), more denosumab than oral bisphosphonate initiators were persistent at 1 year (73% vs. 39%), 2 years (50% vs. 25%), and 3 years (38% vs. 17%). Persistence decreased over time for all treatment groups, with denosumab users having the highest persistence in every follow-up time interval at or after 18 months. Women using denosumab, oral bisphosphonates, or raloxifene who persisted in a given year were more likely to remain persistent through the subsequent year. CONCLUSIONS: Denosumab users persisted longer with therapy than women using other anti-resorptive medications, including oral bisphosphonates. Early persistence may predict long-term persistence. Overall persistence with osteoporosis medications is suboptimal and may impact fracture risk. Efforts to improve first year persistence are needed.

Initial chest radiograph scores inform COVID-19 status, intensive care unit admission and need for mechanical ventilation.

AIM: To evaluate whether portable chest radiography (CXR) scores are associated with coronavirus disease 2019 (COVID-19) status and various clinical outcomes. MATERIALS AND METHODS: This retrospective study included 500 initial CXR from COVID-19-suspected patients. Each CXR was scored based on geographic extent and degree of opacity as indicators of disease severity. COVID-19 status and clinical outcomes including intensive care unit (ICU) admission, mechanical ventilation, mortality, length of hospitalisation, and duration on ventilator were collected. Multivariable logistic regression analysis was performed to evaluate the relationship between CXR scores and COVID-19 status, CXR scores and clinical outcomes, adjusted for code status, age, gender and co-morbidities. RESULTS: The interclass correlation coefficients amongst raters were 0.94 and 0.90 for the extent score and opacity score, respectively. CXR scores were significantly (p < 0.01) associated with COVID-19 positivity (odd ratio [OR] = 1.49; 95% confidence interval [CI]: 1.27 - 1.75 for extent score and OR = 1.75; 95% CI: 1.42 - 2.15 for opacity score), ICU admission (OR = 1.19; 95% CI: 1.09 - 1.31 for extent score and OR = 1.26; 95% CI: 1.10 - 1.44 for opacity score), and invasive mechanical ventilation (OR = 1.22; 95% CI: 1.11 - 1.35 for geographic score and OR = 1.21; 95% CI: 1.05 - 1.38 for opacity score). CXR scores were not significantly different between survivors and non-survivors after adjusting for code status (p>0.05). CXR scores were not associated with length of hospitalisation or duration on ventilation (p>0.05). CONCLUSIONS: Initial CXR scores have prognostic value and are associated with COVID-19 positivity, ICU admission, and mechanical ventilation.

Correction to: Hip fracture trends in the United States, 2002 to 2015.

The name of the first author, E.M. Lewiecki, was rendered incorrectly in the original publication. The publisher regrets any inconvenience and is pleased to correct the error here.

Hip fracture trends in the United States, 2002 to 2015.

An analysis of United States (US) Medicare claims data from 2002 to 2015 for women aged ≥ 65 years found that age-adjusted hip fracture rates for 2013, 2014, and 2015 were higher than projected, resulting in an estimated increase of more than 11,000 hip fractures. INTRODUCTION: Hip fractures are a major public health concern due to high morbidity, mortality, and healthcare expenses. Previous studies have reported a decrease in the annual incidence of hip fractures in the US beginning in 1995, coincident with the introduction of modern diagnostic tools and therapeutic agents for osteoporosis. In recent years, there has been less bone density testing and fewer prescriptions for osteoporosis treatments. The large osteoporosis treatment gap raises concern of possible adverse effects on hip fracture rates. METHODS: We assessed hip fracture incidence in the US to determine if the previous decline in hip fracture incidence continued. Using 2002 to 2015 Medicare Part A and Part B claims for women ≥ 65 years old, we calculated age-adjusted hip fracture rates, weighting to the 2014 population. RESULTS: We found that hip fracture rates declined each year from 2002 to 2012 and then plateaued at levels higher than projected for years 2013, 2014, and 2015. CONCLUSIONS: The plateau in age-adjusted hip fracture incidence rate resulted in more than 11,000 additional estimated hip fractures over the time periods 2013, 2014, and 2015. We recommend further study to assess all factors contributing to this remarkable change in hip fracture rate and to develop strategies to reduce the osteoporosis treatment gap.

The effects of Platelet-rich Plasma on healing of partial thickness burns in a porcine model.

Platelet-rich plasma (PRP) derived from autologous peripheral blood is rich in platelets that release growth factors and cytokines. We determined the effects of topically applied autologous PRP in a partial thickness porcine burn model. Partial thickness burns were created on the backs and flanks of six domestic pigs (24 burns each) using an aluminium bar preheated to 80° C for 20 seconds. After removing the necrotic epidermis, the burns were randomly treated with a topical antibiotic ointment or a single (day 2), double (days 2 and 7), or triple (days 2, 7, and 14) topical application of PRP that was prepared freshly before application. Periodic imaging and full thickness biopsies were conducted to monitor healing over 28 days. The percentage wound reepithelialization at days 11, 14, 18 and 21 did not differ significantly among the groups. By day 28 all wounds were completely (>95%) reepithelialized, and there were no differences among the groups. Time to complete healing (presented as mean, [SD]) did not differ among the groups (antibiotics, 17.1 [3.5]; single PRP, 17.6 [4.0]; double PRP, 18.4 [3.9]; and triple PRP, 17.7 [3.3] days; ANOVA P=0.43). Scar depth (presented as mean, [SD]) in mm at day 28 by treatment group was: antibiotic 5.0 [1.0], single PRP 5.5 [1.1], double PRP 5.4 [1.1], and triple PRP 5.5 [0.6], ANOVA P=0.026. We conclude that PRP results in similar rates of reepithelialization and scar depth to standard topical antibiotics in a partial thickness porcine burn model.

Le plasma riche en plaquettes (PRP), dérivé du sang autologue, permet le relargage de facteurs de croissance et de cytokines. Nous avons étudié l'effet de PRP appliqué localement sur un modèle de brûlure intermédiaire chez le porc. Cette brûlure du dos et des flancs était réalisée au moyen de l'application pendant 20 s d'aluminium chauffé à 80°C sur 4 groupes de 6 porcs. Après ablation de l'escarre, les animaux étaient tirés au sort pour être traités par topique antibiotique, 1 (J2), 2 (J2 et J7) ou 3 (J2, J7, J4) application locale de PRP préparé juste avant utilisation. Des photos et des biopsies ont été réalisées régulièrement pendant 28 j afin de surveiller la cicatrisation. Les pourcentages de surface cicatrisée à J11, J14, J18 et J21 étaient similaires dans tous les groupes. La cicatrisation était quasi complète (> 95%) à J28, dans tous les groupes. Le délai jusqu'à cicatrisation complète n'était pas différent dans les groupes (ANOVA, p=0,43) : Contrôle 17,1 +/- 3,5 ; PRP J2 17,6 +/- 4 ; PRP J2 et J7 18,4 +/- 3,9 ; PRP J4, J7 et J14 17,7 +/- 3,3 jours. La profondeur de la cicatrice, bien que statistiquement significative (ANOVA p = 0,026 ) : 5 +/- 1 (contrôle) ; 5,5 +/- 1,1 (1 PRP) ; 5,4 +/- 1,1 (2 PRP) ; 5,5 +/- 0,6 (3 PRP) mm n'est pas considérée comme cliniquement significative. PRP donne des résultats équivalents aux topiques antibiotiques sur une brûlure intermédiaire du porc.

Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores.

STUDY OBJECTIVES: Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. METHODS: We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART≤3, TIMI≤0, GRACE≤50, and EDACS≤15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics. RESULTS: The patients' median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92-0.97). CONCLUSIONS: Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE≤48, TIMI=0, EDACS≤11, HEART≤2) missed no case of AMI, but classified less patients as low-risk.

Bromelain-based enzymatic debridement and minimal invasive modality (mim) care of deeply burned hands.

The objective was to critically review the data and assess the implications of NexoBrid [NexoBrid-NXB formerly Debrase Gel Dressing-DGD]a in the special field of deep hand burns. Detailed analysis of endpoints in the treatment of hand burn patients was conducted as part of a multi-center, open label, randomized, controlled two-arm study to evaluate the safety and efficacy of NXB enzymatic debridement, comparing it to the current standard of care (SOC). These results were compared to a large cohort of patients treated with NXB in a previous, single arm study. Thirty-one burned hands were treated with NXB and 41 hand burns were in the SOC group. In the NXB group, 4 out of 31 hand burns (12.9%) required some excisional debridement compared to 29 out of the 41 (70.7%) in the SOC group (p<0.0001). Mean percentage of burn wound area excised in the NXB group was 4.4 ± 13.1% compared to 52.0 ± 41.4% in the SOC group (p<0.0001). None of the NXB-treated hands required escharotomy compared to 4 out of the 41 (9.7%) in the SOC group. NXB enzymatic debridement demonstrated a statistically significant reduction in burn wound excision and auto-grafting compared to SOC, and seems to prevent the need for emergency escharotomy. a DGD is produced by MediWound and distributed under the name NexoBrid®.

Le but était de réaliser une révision attentive des données et d'évaluer la place de Nexobrid (Nexobrid-NXB, précédemment Debrase Gel Dressing-DGD) dans l'indication particulière des brûlures profondes de la main. Une analyse détaillée des objectifs dans le traitement des brûlures de la main a été conduite en partie par une étude multicentrique, ouverte, randomisée, contrôlée avec 2 groupes pour évaluer la sécurité et l'efficacité de ce débridement enzymatique par rapport aux soins habituels (Standard of Care ou SOC). Ces résultats ont été comparés à une vaste cohorte de patients traités par NXB dans une étude précédente sur un seul groupe. 31 mains brûlées furent traitées par NXB et 41 dans le groupe SOC. Dans le groupe NXB, 4 sur 31 mains brûlées soit 12,9 % nécessitèrent une excision partielle, alors que 29 sur 41 dans le groupe SOC (70,7 %) (p < 0,0001). La moyenne des zones brûlées excisées dans le groupe NXB était de 4,4 (+ ou - 13,1 %) comparée aux 52,0 (+ ou - 41,4 % du groupe SOC) (p <0,0001). Aucune des mains traitées par NXB ont nécessité une excision totale, comparée à 4 sur 41 du groupe SOC (9,7 % du groupe). Le débridement enzymatique NXB montre une réduction statistiquement significative de l'indication d'excision avec autogreffe par rapport au groupe traité classiquement et semble prévenir la nécessité d'une escarrotomie en urgence.

Immediate tangential excision accelerates wound closure but does not reduce scarring of mid-dermal porcine burns.

Current evidence supports the use of excision to remove eschar from deep dermal and full-thickness burns. However, the role of excision of mid-dermal burns remains unclear. This study aimed to develop a porcine model that could produce reproducible middermal thermal burns that undergo tangential excision; and investigate the effects of immediate tangential excision (30 minutes postburn) on healing and scarring. An aluminum bar preheated in hot water (70°C) was applied for 20 or 30 s to produce a total of sixteen mid-dermal burns per pig on each of six pigs. Thirty minutes after burn creation, half of the burns were tangentially excised. Four partial- thickness wounds per pig were created as controls. Depth of burn injury (1 and 24 h), reepithelialization (7 and 10 d) and scar depth (28 d) were assessed microscopically. Total scar surface area was grossly evaluated on day 28. Exposure of porcine skin to a preheated aluminum bar at 70 °C for 20 or 30 sec resulted in reproducible mid-dermal burns, where immediate excision enhanced complete wound closure as judged by complete re-epithelialization, but did not reduce initial depth of injury, scar contraction and scar depth. Immediate surgical intervention is sufficient to enhance wound closure, but not to mitigate mid-dermal burn scar formation. This work provides a suitable animal model to evaluate novel therapies that may be used to inhibit burn progression, accelerate wound closure and decrease scarring, especially those therapies unable to penetrate burn eschar.

Les données actuelles des connaissances sont en faveur de l'excision des brûlures des 2ème degré profond et 3ème degré. L'intérêt de l'excision des brûlures intermédiaires reste mal précisé. Cette étude se penche sur un modèle porcin destiné à la réalisation de brûlures intermédiaires reproductibles et à l'évaluation de l'effet l'excision ultra précoce (30 mn après la brûlure) sur l'épidermisation et la cicatrisation de ces brûlures. Six porcs ont subi chacun un total de 16 brûlures intermédiaires infligées au moyen d'une barre d'aluminium chauffée à 70°C et appliquée pendant 20 à 30 s. La moitié des zones brûlées étaient excisées à la trentième minute. Quatre brûlures superficielles servaient de contrôle. La profondeur de la brûlure (à h1 et h24), la réépithélialisation (à J7 et J10) et l'épaisseur de la cicatrice (à J28), étaient étudiées microscopiquement. La surface cicatricielle totale était évaluée à J28. L'exposition pendant 20 à 30s de la peau d'un porc à de l'aluminium préalablement chauffé à 70°C entraîne une brûlure intermédiaire reproductible. L'excision immédiate en favorise la guérison lorsqu'elle est jugée sur la réépithélialisation mais n'en réduit ni la profondeur, ni la rétraction cicatricielle, pas plus que l'épaisseur de la cicatrice. L'excision immédiate favorise la fermeture de la plaie mais pas son évolution vers des séquelles. Ce travail permet de décrire un modèle animal fiable dans le but d'évaluer de nouvelles thérapeutiques destinées à limiter le progression des lésions, accélérer la fermeture et diminuer la survenues de séquelles, en particulier celles incapables de pénétrer dans une lésion constituée.

Minimally invasive burn care: a review of seven clinical studies of rapid and selective debridement using a bromelain-based debriding enzyme (Nexobrid®).

Current surgical and non-surgical eschar removal-debridement techniques are invasive or ineffective. A bromelainbased rapid and selective enzymatic debriding agent was developed to overcome these disadvantages and compared with the standard of care (SOC). The safety and efficacy of a novel Debriding Gel Dressing (DGD) was determined in patients with deep partial and full thickness burns covering up to 67% total body surface area (TBSA). This review summarizes data from seven studies, four of which were randomized clinical trials that included a SOC or control vehicle. DGD eschar debridement efficacy was >90% in all studies, comparable to the SOC and significantly greater than the control vehicle. The total area excised was less in patients treated with DGD compared with the control vehicle (22.9% vs. 73.2%, P<0.001) or the surgical/non-surgical SOC (50.5%, P=0.006). The incidence of surgical debridement in patients treated with DGD was lower than the SOC (40/163 [24.5%] vs. 119/170 [70.0%], P0.001). Less autografting was used in all studies. Long-term scar quality and function were similar in DGD- and SOCtreated. DGD is a safe and effective method of burn debridement that offers an alternative to surgical and non-surgical SOC.

Les protocoles actuels de détersion d'une brûlure, chirurgicaux et non chirurgicaux, sont soit invasifs soit inefficaces. Un enzyme détersif rapide et spécifique, dérivé de la bromélaïne, a été développé dans le but de palier à ces 2 inconvénients. Il a été comparé aux techniques usuelles (TU). L'efficacité et l'innocuité d'un Gel Topique Détersif (GTD) ont été évaluées chez des patients souffrant de brûlures intermédiaires et profondes atteignant jusqu'à 67% de la Surface Corporelle Totale (SCT). Cette revue compile les données de 7 études cliniques, dont 4, randomisées, faisaient appel aux TU ou à un groupe contrôle. La détersion obtenue avec GTD était toujours > 90%, comparable aux TU et meilleure que dans le groupe contrôle. La surface relative excisée totale était moindre après GTD que chez les contrôles (22.9% VS 73.2%, p<0,001) ou les patients sous TU (50.5%, p=0,006). Le nombre de patients ayant eu besoin de chirurgie a été inférieur dans le groupe GTD que dans le groupe TU (40/163 [24.5%] VS 119/170 [70%], p<0,001). Le recours aux greffes était moins fréquent dans toutes les études. Les qualités cicatricielle et fonctionnelle à distance étaient comparables après TU et GTD. GTD est une technique de détersion efficace et sûre qui offre une alternative au TU, chirurgical ou non.

Health economic aspects of vertebral augmentation procedures.

We reviewed all peer-reviewed papers analysing the cost-effectiveness of vertebroplasty and balloon kyphoplasty for osteoporotic vertebral compression fractures. In general, the procedures appear to be cost effective but are very dependent upon model input details. Better data, rather than new models, are needed to answer outstanding questions. Vertebral augmentation procedures (VAPs), including vertebroplasty (VP) and balloon kyphoplasty (BKP), seek to stabilise fractured vertebral bodies and reduce pain. The aim of this paper is to review current literature on the cost-effectiveness of VAPs as well as to discuss the challenges for economic evaluation in this research area. A systematic literature search was conducted to identify existing published studies on the cost-effectiveness of VAPs in patients with osteoporosis. Only peer-reviewed published articles that fulfilled the criteria of being regarded as full economic evaluations including both morbidity and mortality in the outcome measure in the form of quality-adjusted life years (QALYs) were included. The search identified 949 studies, of which four (0.4 %) were identified as relevant with one study added later. The reviewed studies differed widely in terms of study design, modelling framework and data used, yielding different results and conclusions regarding the cost-effectiveness of VAPs. Three out of five studies indicated in the base case results that VAPs were cost effective compared to non-surgical management (NSM). The five main factors that drove the variations in the cost-effectiveness between the studies were time horizon, quality of life effect of treatment, offset time of the treatment effect, reduced number of bed days associated with VAPs and mortality benefit with treatment. The cost-effectiveness of VAPs is uncertain. In answering the remaining questions, new cost-effectiveness analysis will yield limited benefit. Rather, studies that can reduce the uncertainty in the underlying data, especially regarding the long-term clinical outcomes of VAPs, should be conducted.

Impact of helical computed tomography in clinically evident appendicitis.

OBJECTIVES: To determine the utility of multidetector computed tomography (MDCT) in patients with clinically evident acute appendicitis and to compare the test characteristics of overall clinical impression, Alvarado scores, and MDCT in suspected appendicitis. METHODS: A prospective observational cohort study was conducted in two urban emergency departments (ED). Consecutive patients with suspected acute appendicitis were clinically evaluated by an emergency physician who was asked to determine whether appendicitis was clinically evident or not. Elements of the Alvarado scores were collected and all patients then underwent MDCT and a decision to operate, observe, or discharge the patients was made by a surgeon. The final diagnosis was based on surgical pathology or clinical follow-up. The test characteristics of clinical impression, Alvarado scores and MDCT were then calculated and the rates at which acute appendicitis was falsely diagnosed based on clinical impression and MDCT were compared using McNemar's test. RESULTS: Of 157 study patients, 71 were considered to have clinically evident appendicitis before MDCT and 91 had findings of acute appendicitis on MDCT. 19 of the 71 patients with clinically evident appendicitis did not have appendicitis. 14 of 52 patients with an Alvarado score > or = 8 also did not have appendicitis. Three of 91 patients with acute appendicitis based on MDCT did not have appendicitis. The specificities of clinical impression and Alvarado score > or = 8 were 71.6% and 79.1%, respectively, and these were significantly lower than that of MDCT (95.5%, p<0.05). CONCLUSION: The performance of abdominal MDCT in patients with a high degree of clinical suspicion for acute appendicitis reduces the number of false positives and has the potential to reduce negative appendectomies.

Percutaneous regional compared with local anaesthesia for facial lacerations: a randomised controlled trial.

OBJECTIVE: Facial lacerations are usually repaired after local infiltration of an anaesthetic agent. Regional nerve blocks of the face offer several theoretical advantages over local infiltration. This study compared the pain of injection and anaesthetic efficacy of percutaneous regional and local anaesthesia for facial lacerations. STUDY DESIGN: Randomised clinical trial. PARTICIPANTS: Convenience sample of emergency department patients with facial lacerations requiring suturing in anatomical areas innervated by a regional nerve (supraorbital, infraorbital, or mental). INTERVENTIONS: Facial lacerations treated using standard wound care. Lacerations were randomised to local or regional infiltration of lidocaine (lignocaine) 1% with adrenaline (epinephrine) 1:100 000 using a number 27 needle. OUTCOMES: Pain of injection on 100 mm visual analogue scale (VAS) and need for rescue anaesthetic infiltration before suturing. DATA ANALYSIS: Group comparisons were with Student's t test and chi(2) test. This study had 80% power to detect a 20 mm difference in pain of injection (two tailed, alpha = 0.05). RESULTS: 36 patients were randomised to local (18) and regional (18) anaesthesia. Mean (SD) age was 20 (14); 19% were female. Groups were similar in baseline characteristics. Patients in the regional anaesthesia group experienced more pain during infiltration than patients in the local anaesthesia group (42.4 mm v 24.8 mm, mean difference 17.6 mm (95% CI 0.3 to 35.6 mm) and were more likely to require additional infiltration of a local anaesthetic (28% v 0%, (95% CI 6% to 50%)) than patients in the local anaesthetic group. CONCLUSIONS: Local infiltration of anaesthetics for facial lacerations is less painful and results in more effective anaesthesia than percutaneous regional infiltration.

Bone marrow fat and bone mineral density on proton MR spectroscopy and dual-energy X-ray absorptiometry: their ratio as a new indicator of bone weakening.

OBJECTIVE: Bone weakening can be affected by agents other than bone mineral density (BMD). Increased bone marrow fat may have a direct link to bone loss. This pilot study analyzes the relationship between bone marrow fat and BMD in subjects with normal and structurally weakened vertebrae. SUBJECTS AND METHODS: Twenty-six subjects underwent both dual-energy X-ray absorptiometry and proton MR spectroscopy of 71 lumbar vertebrae. Fifteen subjects had normal-appearing vertebrae on MRI, and 11 had signs of bone weakening. RESULTS: We found that high bone marrow fat did not consistently equate with low BMD. Bone marrow fat can indicate bone weakening nearly as well as BMD, but neither parameter alone is suitable to be used independently as an indicator. The bone marrow fat/BMD ratio showed significant diagnostic power to detect bone weakening, even in this relatively small subject sample. CONCLUSION: An inverse relationship between bone marrow fat and BMD could not be confirmed. Bone marrow fat can be used to diagnose reduced bone strength nearly as well as BMD. The bone marrow fat/BMD ratio is a significant diagnostic indicator of bone weakening.

National analgesia prescribing patterns in emergency department patients with burns.

Previous studies suggest that many patients with burns receive inadequate analgesia. A secondary analysis of the 1992 to 1999 National Hospital Ambulatory Medical Care Survey (a national, weighted sample of emergency department [ED] encounters) was performed to estimate national analgesia prescribing patterns in ED patients with burns. In 1999, there were 21,103 patient encounters sampled from 376 EDs, resulting in an estimated 102.8 million ED visits in 1999. One hundred thirty-eight patients in the sample (0.7%) had burns for an estimated 827,000 annual burns. Patient mean age was 28 years. Forty-three percent were female, 25% were children under 18 years of age, and 81% were white. Pain assessments were performed in about half of the patients, and only half of the patients received analgesics. Analgesia administration did not differ by year, sex, age, race, ethnicity, geographic location, or insurance payment type, yet it was more likely with increased pain. We conclude that many patients with burns do not have documentation of pain assessment or analgesia administration while in the ED.