Impact of Medicaid cutbacks on emergency department use: the Oregon experience.

STUDY OBJECTIVE: Federal policy changes and tightened state budgets may reduce Medicaid enrollment in many states. In March 2003, the Oregon Health Plan (Oregon's Medicaid expansion program) made substantial changes in its benefit package that resulted in the disenrollment of more than 50,000 beneficiaries. We sought to study the impact of these Oregon Health Plan policy changes on statewide emergency department (ED) use. METHODS: In this observational study, hospital billing data on 2,680,954 visits to 26 Oregon EDs were obtained, sampled up to 24 months before and 24 months after the cutbacks. These visits represent approximately 62% of all visits to Oregon's 58 EDs. We ascertained counts of ED visits by payer group before and after the Oregon Health Plan cutback date, plus hospital admissions from the ED as a measure of acuity. RESULTS: After the Oregon Health Plan policy changes, ED visits by the uninsured underwent an abrupt and sustained increase, from 6,682 per month in 2002 to 9,058 per month in 2004. Oregon Health Plan-sponsored and commercially insured visits decreased, resulting in a slight decrease in overall ED visits. Multivariable models adjusting for secular trends and seasonality showed a 20% (95% confidence interval 13% to 28%) increase in uninsured ED visits, whereas the adjusted number of Oregon Health Plan-sponsored visits decreased. The proportion of uninsured ED visits resulting in hospital admission increased (odds ratio 1.50; 95% confidence interval 1.39 to 1.62). CONCLUSION: Oregon's Medicaid cutbacks were followed by increases in ED use and hospitalizations by the uninsured. Recent federal legislation facilitating similar Medicaid changes in other states may lead to replication of these events elsewhere.

Prevalent vertebral fractures in black women and white women.

Vertebral fractures are the most common osteoporotic fracture. Hip and clinical fractures are less common in black women, but there is little information on vertebral fractures. We studied 7860 white and 472 black women >or=65 yr of age enrolled in the Study of Osteoporotic Fractures. Prevalent vertebral fractures were identified from lateral spine radiographs using vertebral morphometry and defined if any vertebral height ratio was >3 SD below race-specific means for each vertebral level. Information on risk factors was obtained by questionnaire or examination. Lumbar spine, total hip, and femoral neck BMD and BMC were measured by DXA. The prevalence of vertebral fractures was 10.6% in black and 19.1% in white women. In age-adjusted logistic regression models, a 1 SD decrease in femoral neck BMD was associated with 47% increased odds of fracture in black women (OR = 1.47; 95% CI, 1.12-1.94) and 80% increased odds in white women (OR = 1.80; 95% CI, 1.68-1.94; interaction p = 0.14). The overall lower odds of fracture among black women compared with white women was independent of femoral neck BMD and other risk factors (OR = 0.51; 95% CI, 0.37-0.72). However, the prevalence of vertebral fractures increased with increasing number of risk factors in both groups. The prevalence of vertebral fractures is lower in black compared with white women but increases with age, low BMD, and number of risk factors.

Cervical spine injuries associated with the incorrect use of airbags in motor vehicle collisions.

STUDY DESIGN: Retrospective database review and analysis. OBJECTIVE: The purpose of this study is to determine the rate of cervical spine injuries with correct and incorrect use of front driver and passenger-side airbags. Summary of Background Data. Although there are abundant literature showing reduced injury severity and fatalities from seatbelts and airbags, no recent studies have delineated the affect of incorrect use of airbags in cervical spine injuries. METHODS: The database from the Pennsylvania Trauma Systems Foundation was searched for drivers and front-seat passenger injuries from 1990 to 2002. The resulting records were then grouped into those using both seatbelt and the airbag, airbag-only, seatbelt-only, and no restraints. The data were then analyzed for frequency of cervical spine fractures with or without spinal cord injury and injury severity indexes. RESULTS: The drivers using the airbag-only had significantly higher rate (54.1%) of cervical fractures than those using both airbag and a seatbelt (42.1%). Overall, drivers using the airbag-alone were 1.7 times more likely to suffer a cervical spine fracture than those using both protective devices. Likewise, passengers using the airbag-alone were 6.7 times more likely to suffer from a cervical spine fracture with spinal cord injury than those using both protective devices. In addition, the injury severity indexes (Glasgow coma scale, Injury Severity Score, Intensive Care Unit stays, and Total Hospital days) were significantly worse in patients who used an airbag-only. CONCLUSION: Airbag use without the concomitant use of a seatbelt is associated with a higher incidence of cervical spine fractures with or without spinal cord injuries. Airbag misuse is also associated with higher Injury Severity Score, lower Glasgow coma scale, and longer intensive care unit and total hospital stays, indicating that these patients suffer worse injury than those who use the airbag properly.

Safe zone for anterior cortical perforation of the ulna during tension-band wire fixation: a magnetic resonance imaging analysis.

Placing K-wires obliquely through the anterior ulnar cortex is a common modification of traditional olecranon tension-band wiring. Wire tip protrusion, however, risks injury to adjacent neurovascular structures and may impede forearm rotation. This study examines the proximity of neurovascular structures to the anterior proximal ulnar cortex. The anatomy of 47 adult elbows was examined through magnetic resonance imaging. A radiologist measured the spatial relationship of 6 neurovascular structures to a mid-sagittal reference point 1.5 cm distal to the coronoid on the anterior surface of the ulna. Distance and angular measurements were made in the transverse plane of the reference point. Within a reasonable arc of K-wire placement, the ulnar artery and median nerve were at greatest risk yet were still beyond 10 mm from the anterior ulnar cortex. To avoid iatrogenic neurovascular injury during tension-band wiring of the olecranon, protrusion of wire tips beyond the anterior ulnar cortex should be no more than 1 cm at a distance of 1.5 cm distal to the coronoid.

Anti-Jo-1 antibody levels correlate with disease activity in idiopathic inflammatory myopathy.

OBJECTIVE: Previous case series have examined the relationship between anti-Jo-1 antibody levels and myositis disease activity, demonstrating equivocal results. Using enzyme-linked immunosorbent assays (ELISAs) and novel measures of myositis disease activity, the current study was undertaken to systematically reexamine the association between anti-Jo-1 antibody levels and various disease manifestations of myositis. METHODS: Serum anti-Jo-1 antibody levels were quantified using 2 independent ELISA methods, while disease activity was retrospectively graded using the Myositis Disease Activity Assessment Tool, which measures disease activity in 7 different organ systems via the Myositis Disease Activity Assessment Visual Analog Scale (VAS) and the Myositis Intention-to-Treat Index (MITAX) components. Spearman's rank correlation coefficients and mixed linear regression analysis were used to identify associations between anti-Jo-1 antibody levels and organ-specific disease activity in cross-sectional and longitudinal analyses, respectively. RESULTS: Cross-sectional assessment of 81 patients with anti-Jo-1 antibody revealed a modest correlation between the anti-Jo-1 antibody level and the serum creatine kinase (CK) level, as well as muscle and joint disease activity. Correlation coefficients were similar for CK levels (r(s) = 0.38, P = 0.002), myositis VAS (r(s) = 0.36, P = 0.002), and arthritis VAS (r(s) = 0.40, P = 0.001). In multiple regression analyses of 11 patients with serial samples, anti-Jo-1 antibody levels correlated significantly with CK levels (R(2) = 0.65, P = 0.0002), myositis VAS (R(2) = 0.53, P = 0.0008), arthritis VAS (R(2) = 0.53, P = 0.006), pulmonary VAS (R(2) = 0.69, P = 0.005), global VAS (R(2) = 0.63, P = 0.002), and global MITAX (R(2) = 0.64, P = 0.0003). CONCLUSION: In this large series of patients with idiopathic inflammatory myopathy, anti-Jo-1 antibody levels correlated modestly with muscle and joint disease, an association confirmed by a custom ELISA using recombinant human Jo-1. More striking associations emerged in a smaller longitudinal subset of patients that link anti-Jo-1 antibody levels to muscle, joint, lung, and global disease activity.

Mannose-binding lectin is a disease-modifying factor in North American patients with systemic lupus erythematosus.

OBJECTIVE: To investigate whether development of systemic lupus erythematosus (SLE), its clinical manifestations, and autoantibody production are associated with polymorphisms of the mannose-binding lectin (MBL) gene in North American patients with SLE. METHODS: MBL gene polymorphisms in codons 52 (designated variant D, with the wild-type designated A), 54 (variant B), and 57 (variant C) were determined by polymerase chain reaction-sequence specific priming in 130 patients with SLE and 142 healthy controls. Autoantibodies against double-stranded DNA (dsDNA), Smith antigen, phospholipids, Ro/SSA, La/SSB, and RNP were tested at certified clinical pathology laboratories. RESULTS: A statistically significant increased likelihood of anti-Smith antibody production was observed in SLE patients with the heterozygous A/B genotype [odds ratio (OR) 5.1; 95% confidence interval (CI) 1.6-16.6; the A/A genotype as the reference group] or A/C genotype (OR 8.2; 95% CI 2.0-33.9). SLE patients with the homozygous or compound heterozygous variant genotype (O/O; O, a common designation for variant alleles) had an increased likelihood of mounting autoantibody responses against dsDNA, Ro/SSA, and La/SSB, and were more likely to have a history of renal disease (OR 4.8; 95% CI 0.9-25.2). However, differences in the frequencies of MBL variant alleles and genotypes observed between patients with SLE and controls did not reach statistical significance. CONCLUSION: A significantly increased prevalence of anti-Smith antibody was associated with the heterozygous genotypes A/B and A/C. Although MBL structural gene polymorphism was not a risk factor for SLE development in this study population, homozygosity of MBL variant alleles may be a weak disease-modifying factor, particularly for renal involvement, in North American patients with SLE.

Risk factors for the development of perioperative complications in elderly patients undergoing lumbar decompression and arthrodesis for spinal stenosis: an analysis of 166 patients.

STUDY DESIGN: Retrospective review. OBJECTIVE: To quantify and describe perioperative complication rates in a large series of well-matched elderly patients who underwent lumbar decompression and arthrodesis. SUMMARY OF BACKGROUND DATA: Posterior lumbar decompression and fusion is frequently performed to treat lumbar stenosis with instability. An increasing number of elderly patients are undergoing operative treatment for degenerative lumbar disease. The reported morbidity of performing decompression and arthrodesis in this population varies widely in the literature, with recent reports showing a high rate of major complications. METHODS: A total of 166 patients age 65 or older that underwent primary posterior lumbar decompression and fusion with (group 1; n = 75) or without (group 2; n = 91) instrumentation were included. Hospital records were reviewed for the occurrence of any complications (major and minor), the need for transfusion, estimated length of stay, and disposition at discharge. Logistic regression (with the presence/absence of major complications as the dependent variable) was used to identify risk factors for the occurrence of a complication. RESULTS: Five major complications (3%) occurred (group 1, 1; group 2, 4). Minor complications developed in 30.7% of group 1 and 31.9% of group 2. There were no deaths, and only one perioperative complication was attributable to the use of instrumentation. Decompression/fusion of 4 or more segments was significantly associated with the occurrence of a major complication. Advanced age, the presence of medical comorbidities, or the use of instrumentation did not increase the rate of major or minor complications. The occurrence of either a major or minor complication prolonged hospital stay. CONCLUSIONS: Posterior lumbar decompression and fusion can be safely performed in elderly patients, with a low rate of major complications. The addition of instrumentation does not increase the complication rate. These results differ from those previously reported in the literature, which describe a significantly higher rate of complications in this age group, with a prolonged rate of hospitalization.

Measurement of lumbar lordosis: inter-rater reliability, minimum detectable change and longitudinal variation.

STUDY DESIGN: Repeated measures design to examine reliability and longitudinal variation of lumbar lordosis measurement. OBJECTIVES: To determine the interrater reliability, minimum detectable change (MDC) and longitudinal variation of the Cobb method for measuring lumbar lordosis using standardized rules. SUMMARY OF BACKGROUND DATA: The reliability of the 4-line Cobb method for measuring lumbar lordosis was not examined when standardized rules were instituted for drawing the lines. METHODS: A random sample of participants was selected from the Pittsburgh clinic of the multicenter Study of Osteoporotic Fractures for radiographic measurement of lumbar lordosis reliability (n=48) and stability (n=109). A standardized version of the 4-line Cobb method was used for all measurements of lordosis. The Intraclass Correlation Coefficient (ICC) was used to calculate interrater reliability for lordosis and to measure the stability of this measure over an approximate 2-year-time period. The standard error of measurement and MDC were calculated for lordosis measurement based on the ICC value. RESULTS: The interrater reliability coefficient for lumbar lordosis was in the excellent range (ICC=0.98; 95% CI: 0.95, 0.99). The MDC based on measurements between raters was 3.90 degrees. The ICC value for the stability, or reliability from time 1 to time 2, of lordosis measurement over time was 0.81 (95% CI: 0.74, 0.87). CONCLUSION: This study demonstrates that the 4-line Cobb method can be a highly reliable and precise method for measuring lumbar lordosis if standardized procedures are used. The Cobb method has an MDC that is appropriate for clinical use. Also, there is minimal longitudinal variation in lordosis measurements over a 2-year period.

Prospective clinical outcomes of revision fusion surgery in patients with pseudarthrosis after posterior lumbar interbody fusions using stand-alone metallic cages.

BACKGROUND CONTEXT: Posterior lumbar interbody fusion (PLIF) is a popular method of arthrodesis for surgical treatment of instabilities and degenerative conditions of the spine. With the introduction of threaded titanium cage devices, surgeons began performing PLIF procedures using these cages as stand-alone devices. Complications have been reported, however, including pseudarthrosis with persistent pain. Outcomes after revision surgical treatment for these patients with failed PLIF are not known. PURPOSE: To prospectively evaluate clinical outcomes of revision fusion surgery in patients who previously underwent posterior lumbar interbody fusion with stand-alone metallic cages resulting in pseudarthrosis. STUDY DESIGN/SETTING: Prospective case series. METHODS: Nineteen patients referred to the senior author were evaluated and diagnosed with pseudoarthrosis having previously undergone a PLIF procedure with stand-alone metallic cages. History, physical exam, and imaging studies were performed preoperatively and postoperatively. All underwent revision posterolateral fusion with iliac crest graft and pedicle screw instrumentation. Patient demographics, SF-36, and Oswestry Disability Index (ODI) data were collected prior to surgery and two years postoperatively. RESULTS: Patients undergoing revision fusion surgery were found to have had extensive facetectomies and pseudarthrosis intraoperatively. Outcomes data was collected on eighteen of nineteen patients (95%). Mean clinical follow up was 3.2 years (range 2.5-3.5 years). Seventeen patients (94%) achieved a solid fusion. Improvement was noted in seven of eight SF-36 sub-categories, but was significant only in two (Physical Function and Role Emotional). There was no significant difference in ODI scores. CONCLUSIONS: Pseudarthrosis should be considered in the differential diagnosis if severe symptoms persist in patients who undergo PLIF with stand-alone metallic cages. Successful revision fusion did not always correlate with improved clinical outcomes in these challenging patients undergoing further surgery. Performing PLIF using stand-alone metallic cages, especially after total resection of the facet joints, is not advocated unless supplemental instrumentation is utilized.

Prevalence of symptoms of cervical and lumbar stenosis among participants in the Osteoporotic Fractures in Men Study.

STUDY DESIGN: Cross-sectional. OBJECTIVES: To determine the prevalence of symptoms typical of cervical and lumbar stenosis, evaluate the relationship between lumbar and cervical symptoms, and assess the impact of these symptoms on health status. SUMMARY OF BACKGROUND DATA: Degenerative changes of the spine frequently associated with aging, may result in stenosis, a narrowing of the spinal canal. Little is known about the prevalence or health impact of symptoms associated with stenosis in older individuals. METHODS: Between March 2000 and April 2002, 5995 men aged > or = 65 years participating in the Osteoporotic Fractures in Men Study completed a self-administered questionnaire and clinical examination. Information was collected on demographics, spinal/joint health, and general health status. RESULTS: Overall, 14.4% of men had had clinically relevant neck pain during the previous year, and almost half this group (6.5%) had numbness/tingling/weakness (NTW) extending into the arm; 26.2% reported clinically relevant lower back pain, which in 12.2%, was accompanied by NTW extending into the leg. Men with spinal pain (neck or lower back) accompanied by NTW radiating into a limb had poorer health status than those with milder pain. CONCLUSIONS: Symptoms suggestive of cervical and lumbar stenosis are relatively common among this cohort of older men, and generalized spinal stenosis may occur in as many as 4%.

Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures?

OBJECTIVE: To evaluate whether an open technique used to obtain reduction during intramedullary nailing of closed tibial shaft fractures increases the risk of infection, compared to closed reduction and nailing. SETTING: University level 1 trauma center. DESIGN: Retrospective database analysis. PATIENTS/PARTICIPANTS: One hundred seventeen patients with 119 fractures from our trauma database who had sufficient follow-up and met study criteria. The patients were grouped by open versus closed reduction. Only OTA fracture types 42 A to C were included in this study. INTERVENTION: Locked reamed intramedullary nailing for closed tibial shaft fractures accomplished through either open or closed reduction. MAIN OUTCOME MEASUREMENT: The presence or absence of infection as determined by the clinical presentation (erythema, warmth, purulent drainage, fevers, chills, increased pain at the fracture site), indicative laboratory work (complete blood count, erythrocyte sedimentation rate, C-reactive protein), and/or positive culture. RESULTS: There were 85 males and 32 females. The average age was 35.7 years; the average follow-up was 14.3 months. Of the 119 fractures, 79 had closed reduction whereas 40 had open reduction. The open reductions consisted of 13 with a formal incision (>1 cm in length), 22 with percutaneous incisions, and 5 with fasciotomies. There were no infections in the closed reduction group and 2 infections (5%) in the open reduction group. This difference was not statistically significant (P=0.1). The average time to union was 7.0 months in closed reductions and 7.3 months in open reductions. By latest follow-up, 107 fractures had reached union (89.9%), 1 had not (0.8%), and 11 were lost to final follow-up (9.2%). CONCLUSIONS: Limited open techniques can greatly facilitate the reduction of closed tibial shaft fractures but raise concern for infection through exposure of the fracture site. This study found that the rate of infection for open versus closed reductions was higher but not statistically different. Judicious use of open reduction techniques during intramedullary nailing of closed tibia fractures seems to have a minimal risk of infection.

Baseline compartment pressure measurements in isolated lower extremity fractures without clinical compartment syndrome.

BACKGROUND: The diagnosis of compartment syndrome is most commonly made by clinical examination. Direct compartmental measurements generally serve an adjunctive role in establishing the diagnosis, except when patients have an alteration in mental status. There is little known on what are the expected baseline elevations in compartments after the simple occurrence of a fracture when clinical compartment syndrome does not exist. Knowledge of such measurements might influence the utility of pressure measurements in diagnosing compartment syndrome. METHODS: A prospective analysis of compartment measurements was performed in 19 isolated lower extremity fractures with the opposite leg as the control. The patients had no clinical evidence of compartment syndrome, had no alteration in mental status, and underwent planned surgical treatment within 48 hours of injury. RESULTS: Average compartment measurements were 35.5 +/- 13.6 mm Hg (range 10 to 62 mm Hg) in the injured leg versus 16.6 +/- 7.5 mm Hg (range 3 to 40 mm Hg) in the control leg (p = 0.0001). Eighteen patients (95%) had at least one compartment measurement that exceeded a single threshold of 30 mm Hg and 12 patients (63%) exceeded a threshold of 45 mm Hg. Eleven patients (58%) had at least one compartment reading within 20 mm Hg of their diastolic pressure and 16 patients (84%) had one within 30 mm Hg of their diastolic pressure. Ten patients (53%) had a reading within 40 mm Hg of their mean arterial pressure (delta P) and eight patients (42%) had a reading within 30 mm Hg of the mean arterial pressure. No patient developed sequelae or required surgery related to an unrecognized compartment syndrome during a minimum 1-year follow-up. CONCLUSIONS: Based on our data, use of direct compartment measurements with existing thresholds and formulations to determine the diagnosis of compartment syndrome may not accurately reflect a true existence of the syndrome. A search for other quantitative measures to more accurately reflect the presence of compartment syndrome is warranted.

Reduction of verbal pain scores after anterior cruciate ligament reconstruction with 2-day continuous femoral nerve block: a randomized clinical trial.

BACKGROUND: Single-injection femoral nerve block analgesia and spinal anesthesia have been associated with fewer postoperative nursing interventions and successful same-day discharge after anterior cruciate ligament reconstruction. In the current study, the authors prospectively determined the effect of continuous femoral nerve block on a numeric rating scale (NRS) of pain intensity with movement for 7 postoperative days. METHODS: Patients undergoing this surgery with no history of previous invasive surgery on the same knee were recruited for this study. After standardized spinal anesthesia, intravenous sedation, and perioperative multimodal analgesia, patients received a femoral nerve catheter with (1) saline bolus (30 ml) plus saline infusion (270 ml at 5 ml/h, placebo group); (2) levobupivacaine (0.25%) bolus with saline infusion (group I), or (3) levobupivacaine (0.25%) bolus and infusion (group II). Patients were surveyed preoperatively and on postoperative days 1-4 and 7 to determine NRS scores (scale 0-10). RESULTS: Data from 233 participants were analyzed. On days 1-2, 50% of placebo patients had NRS scores of 5 or above, whereas among group II patients, only 25% had scores of 5 or above (P < 0.001). In regression models for NRS scores during days 1-4, group II was the only factor predicting lower pain scores (odds ratios, 0.3-0.5; P = 0.001-0.03). Overall, patients with preoperative NRS scores greater than 2 were likely to report higher NRS scores during days 1-7 (odds ratios, 3.3-5.2; P < 0.001). CONCLUSIONS: Femoral nerve block catheters reliably keep NRS scores below the moderate-to-severe pain threshold for the first 4 days after anterior cruciate ligament reconstruction.

Spica cast application in the emergency room for select pediatric femur fractures.

OBJECTIVES: This study was designed to evaluate the efficacy and safety of immediate spica casting in the emergency room (ER) and evaluate the effect of discharge from the emergency room on short- term complications. DESIGN: Retrospective review of patients treated with immediate spica casting in the ER between June 1, 1993 and July 30, 2001. SETTING: Major, pediatric, orthopaedic trauma and referral center. PATIENTS: A total of 145 pediatric femur fractures in children, younger than age 7 years, treated with immediate spica casting in the ER were reviewed to determine radiographic outcome and short-term complication rates. INTERVENTION: All patients underwent immediate spica cast placement in the ER under conscious sedation. Patients meeting specific criteria were discharged immediately from the ER. MAIN OUTCOME MEASUREMENTS: Radiographic acceptability of alignment at fracture union (angulation, shortening), loss of reduction, number of return visits to the emergency room, and clinical outcome at final follow-up. RESULTS: Average follow-up was 20 +/- 16 weeks (range, 1-9 months). Forty-eight patients (33%) were discharged from the ER. No clinical complications were noted at last follow-up. All children younger than age 2 years, and 86.5% of children ages 2 to 5 years, met acceptable malalignment parameters on final radiographs. There were 16 ER visits (11%) for cast problems. Re-reduction in the operating room was needed in 11 patients (8.9%); 6.9% of patients had a cast problem noted during follow-up visits. Only 9% of patients developed a major complication. Initial shortening was the only independent risk factor found to be associated with loss of reduction. Admission status had no significant effect on the number of ER visits or development of a complication. CONCLUSIONS: If there are no associated factors requiring admission (ie, child abuse or polytrauma), spica casting in the ER for pediatric femur fractures followed by immediate discharge can be safely performed with a low complication rate in children younger than age 6 years, nearly eliminating the need for general anesthesia.

Quality of arthritis information on the Internet.

PURPOSE: The quality and reliability of Internet-based arthritis information were studied. METHODS: The search terms "arthritis," "osteoarthritis," and 'rheumatoid arthritis" were entered into the AOL, MSN, Yahoo, Google, and Lycos search engines. The Web sites for the first 40 matches generated by each search engine were grouped by URL suffix and evaluated on the basis of four categories of criteria: disease and medication information content, Web-site navigability, required literacy level, and currentness of information. Ratings were assigned by using an assessment tool derived from published literature (maximum score of 15 points). RESULTS: Of the 600 arthritis Web sites identified, only 69 were unique and included in the analysis. Fifty-seven percent were .com sites, 20% .org sites, 7% .gov sites, 6% .edu sites, and 10% other sites. Total scores for individual sites reviewed ranged from 3 to 14. Eighty percent of .gov sites, 75% of .edu sites, 29% of other sites, 36% of .com sites, and 21% of .org sites were within the top tertile of scores. No Web site met the criterion for being understandable to people with no more than a sixth-grade reading ability. .Gov sites scored significantly higher overall than .com sites, .org sites, and other sites. .Edu sites also scored relatively well. CONCLUSION: The quality of arthritis information on the Internet varied widely. Sites with URLs having suffixes of .gov and .edu were ranked higher than other types of sites.

Influence of workers' compensation eligibility upon functional recovery 10 to 28 years after polytrauma.

BACKGROUND: Previous studies have shown that work-related injuries are often associated with inferior outcomes. The aim of the current study was to compare the long-term functional outcome after polytrauma between work-related and non-work-related injuries at a minimum follow-up of 10 years. METHODS: Six hundred thirty-seven polytrauma patients were evaluated using a patient questionnaire and a physical examination. The average follow-up was 17.5 years (range 10-28 years); the average Injury Severity Score (ISS) was 20.7 (range 4 to 54). RESULTS: A multivariate analysis, with adjustments for age, sex, injury severity, and injury pattern, demonstrated that work-related injuries resulted in significantly inferior outcomes measured by the Hannove Score for Polytrauma Outcome (HASPOC), 12-Item Short-Form Health Survey (SF-12), requirement for medical aids and devices, length of rehabilitation, and retirement status (P < .05). CONCLUSIONS: Polytrauma patients receiving workers' compensation achieve significantly inferior long-term outcomes than other patients. The obtained results demonstrate that psychosocial variables such as insurance status have a significant impact on the functional recovery following polytrauma.

Gene transfer to human joints: progress toward a gene therapy of arthritis.

This article describes the clinical application of gene therapy to a nonlethal disease, rheumatoid arthritis (RA). Intraarticular transfer of IL-1 receptor antagonist (IL-1Ra) cDNA reduces disease in animal models of RA. Whether this procedure is safe and feasible in humans was addressed in a phase I clinical study involving nine postmenopausal women with advanced RA who required unilateral sialastic implant arthroplasty of the 2nd-5th metacarpophalangeal (MCP) joints. Cultures of autologous synovial fibroblasts were established and divided into two. One was transduced with a retrovirus carrying IL-1Ra cDNA; the other provided untransduced, control cells. In a dose escalation, double-blinded fashion, two MCP joints were injected with transduced cells, and two MCP joints received control cells. One week later, injected joints were resected and examined for evidence of successful gene transfer and expression by using RT-PCR, ex vivo production of IL-1Ra, in situ hybridization, and immunohistochemistry. All subjects tolerated the protocol well, without adverse events. Unlike control joints, those receiving transduced cells gave positive RT-PCR signals. Synovia that were recovered from the MCP joints of intermediate and high dose subjects produced elevated amounts of IL-1Ra (P = 0.01). Clusters of cells expressing high levels of IL-1Ra were present on synovia of transduced joints. No adverse events occurred. Thus, it is possible to transfer a potentially therapeutic gene safely to human rheumatoid joints and to obtain intraarticular, transgene expression. This conclusion justifies additional efficacy studies and encourages further development of genetic approaches to the treatment of arthritis and related disorders.

Analgesic usage for low back pain: impact on health care costs and service use.

STUDY DESIGN: Cross-sectional analysis of analgesic use by patients with low back pain (LBP). OBJECTIVES: To describe patterns of analgesic use and their cost implications for the use of other care services among individuals with LBP enrolled in a health insurance plan during 2001. It was hypothesized that the use of analgesics would be most frequent among patients with LBP with neurologic findings. SUMMARY OF BACKGROUND DATA: National guidelines have recommended analgesics as the primary pharmacologic treatment of LBP. The choice of specific analgesics has major cost and service use implications. METHODS: The University of Pittsburgh Health System includes 18 affiliated hospitals, more than 5000 physicians, and a commercial health plan with 255,958 members in 2001. This study uses the System Health Plan's insurance claims database to identify members who had services provided for one of 66 International Classification of Diseases, Version 9, Clinical Modification codes that identify mechanical LBP (n = 17,148). RESULTS: In 2001, 7631 (43.5%) members with claims for LBP services had no analgesic pharmacy claims. The other 9517 (55.5%) had analgesics claims costing a total of $1.4 million; 68% of claimants were prescribed an opioid and 58% nonselective nonsteroidal antiinflammatory drugs (NSAID). The costs of opioids, NSAID, and cyclooxygenase-2 selective NSAID for patients with LBP represented 48%, 24%, and 28%, respectively, of total health plan expenditures for all uses of these drugs, including cancer. Opioid use was associated with the high volume usage of LBP care services. Patients with LBP with and without neurologic involvement and those with acquired lumbar spine structural disorders had similar patterns of analgesic use: those with congenital structural disorders were less likely to use analgesics; and those with psychogenic pain and LBP related to orthopedic devices were more likely to use opioids. CONCLUSIONS: With this health plan, a high proportion of patients with LBP had claims for opioids during 2001. The use of opioids by patients with LBP represents a major cost for the health plan, and is associated with specific patient characteristics and their use of other LBP services.