Gait speed and one-leg standing time each add to the predictive ability of FRAX.

Gait speed or one-leg standing time (OLST) as additional predictors in FRAX. Population 351 elderly women followed 10 years. Both could improve predictions. The area under curve (AUC) for FRAX is 0.59, OLST is 0.69 and gait speed is 0.71. The net reclassification index (NRI) for classification to highest risk quartile or lowest three quartiles was 0.24 for gait speed and non-significant for OLST. INTRODUCTION: The risk of falls and bone strength are two main determinants of hip fracture risk. The fracture risk assessment tool FRAX, however, lacks direct measures of fall risk1. A short OLST and a slow gait speed are both fall-related risk factors for hip fractures. The aim of this study was to investigate whether the addition to FRAX of either gait speed or OLST could improve the predictive ability for hip fractures, compared to FRAX alone. METHODS: A population-based sample of 351 women aged between 69 and 79 years were tested for one-leg standing time with eyes open and mean gait speed over a 15 + 15-m walk. Fracture and mortality data were obtained from health care registers. RESULTS: The AUC for the receiver operating characteristic (ROC) increased from 0.61 to 0.71 when gait speed was added to FRAX. The AUC was 0.69 for OLST added to FRAX. The highest quartile of hip fracture risks according to FRAX had an absolute 10-year risk of ≥15%. The population was divided into one group with a hip fracture risk of ≥15% and one group with a fracture risk of <15%. NRI for addition of gait speed to FRAX was 0.24 (p = 0.023), while NRI was 0.08 (p = 0.544) for addition of OLST to FRAX. CONCLUSION: Gait speed tended to improve the predictive ability of FRAX more than OLST, but they both added value to FRAX.

One-leg standing time and hip-fracture prediction.

UNLABELLED: A hip fracture results in a lower quality of life and a cost of £30,000. In this study, one-leg standing time (OLST) had a negative linear relationship to the risk of a hip fracture. OLST could be a useful tool to assess the need for fracture-preventive interventions. INTRODUCTION: A hip fracture immobilizes, restricts autonomy, shortens life expectancy, and results in a cost of £30,000 in the UK health care system. However, effective preventive treatments can be offered to high-risk individuals. Impaired postural balance is an important risk factor for hip fractures, and the aim of this study was to evaluate whether OLST can predict hip fractures in elderly women. FRAX is the most established fracture risk assessment tool worldwide and a secondary aim was to relate the predictive ability of OLST to that of FRAX in this population. METHODS: Three hundred fifty-one women aged between 69 and 79 years were timed standing on one leg up to 30 s with eyes open and assessed with FRAX. Fracture data was obtained from registers. RESULTS: The main outcome, a hip fracture, occurred in 40 of the 351 participants (11.4%). The age-adjusted risk of a hip fracture was 5% lower with 1 s longer OLST (Hazard ratio 0.95, 95% CI 0.927-0.978). The relation between OLST and hip fracture risk was linear. Harrell's c was 0.60 for FRAX and 0.68 for OLST adjusted for age. CONCLUSION: With 1 s longer OLST, the risk of a hip fracture decreased significantly by 5%. This risk reduction was not explained by differences in the classic fracture risk factors included in FRAX. OLST had a predictive ability similar to FRAX. OLST is an easily performed balance test which may prove to be valuable in the assessment of hip fracture risk.

Mini nutritional assessment and 10-year mortality in free-living elderly women: a prospective cohort study with 10-year follow-up.

BACKGROUND/OBJECTIVES: Mini nutritional assessment (MNA) is the most frequently used screening test for malnutrition in elderly populations in continental Europe and Asia. Most studies on MNA's ability to predict mortality have only included persons admitted to hospital, living in nursing homes or at home with professional help with activities of daily living. The aim of this cohort study was to examine if MNA can predict 10-year mortality in the general elderly female population. SUBJECTS/METHODS: Of the 584 free-living elderly women invited, 351 agreed to participate and were tested with MNA between 1999 and 2000. A 10-year follow-up was conducted in 2010 with dates of death obtained from the Swedish death register. RESULTS: Participants whose MNA score was ≤ 23.5 points at inclusion had a significantly higher age-adjusted 10-year mortality risk than participants with a MNA score of >23.5 points. The hazard ratio was 2.36 (95% confidence interval 1.25-4.46), P <0.01. CONCLUSIONS: Participants with a MNA score, indicating an increased risk for malnutrition, were more than twice as likely to die during the 10-year follow-up as participants whose MNA score indicated normal nutritional status. Hence, MNA can predict mortality in a general, free-living, elderly female population.

The role of IGF-I and IGFBP-1 status and secondary hyperparathyroidism in relation to osteoporosis in elderly Swedish women.

UNLABELLED: IGFBP-1 showed a strong inverse relation to the BMD values. The IGF-I values had a significant positive relation to the BMD values at all sites with the exception of the lumbar spine. The use of loop diuretics was a more important cause of secondary hyperparathyroidism than vitamin D status. INTRODUCTION: Our aim was to investigate among elderly women the relationship to osteoporosis of calcium-regulating hormones and insulin-like growth factor-I (IGF-I) and insulin-like growth factor binding protein-1 (IGFBP-1). METHODS: A population-based cross-sectional study of 350 elderly women (mean age 73 years). Measurements of bone mineral density (BMD) of the left hip, lumbar spine and heel and risk markers for osteoporosis were studied. RESULTS: The BMD values showed significant inverse relationship with the values of IGFBP-1 at all sites of measurement and significant positive relationship with the values of IGF-I at all sites with the exception of the lumbar spine. There was no significant association between the values of BMD and the values of 25-hydroxy vitamin D (25(OH)D). The use of loop diuretics was strongly and significantly associated with elevated levels of PTH >65 pg/ml (OR 4.4, P < 0.001). CONCLUSIONS: The anabolic growth factor IGF-I and its modulating binding protein IGFBP-1 showed a stronger association with the BMD values than the calcium regulating hormones 25(OH)D and PTH. In this study the use of loop diuretics was a more important cause of secondary hyperparathyroidism than vitamin D status.

Nutritional status, as determined by the Mini-Nutritional Assessment, and osteoporosis: a cross-sectional study of an elderly female population.

OBJECTIVE: To investigate the relationship between osteoporosis and nutritional status as determined by the Mini-Nutritional Assessment (MNA). DESIGN: A cross-sectional study. SETTING: Stockholm, Sweden. SUBJECTS: A total of 351 elderly free-living women (mean age 73+/-2.3 years). METHODS: MNA (range 0-30 points; <17 indicates malnutrition, 17.5-23.5 risk of malnutrition and >or=24 well nourished), measurements of bone mineral density of the left hip and lumbar spine using Hologic QDR 4500, and of the heel using Calscan DEXA-T. RESULTS: The median MNA score was 27 (range 12.5-30). One woman was classified as malnourished and 7.4% were at risk of malnutrition. Osteoporosis of the femoral neck was observed in 22% and a fracture after the age of 50 was reported by 31% of the participants. The following items in the MNA questionnaire exhibited an increased risk of having osteoporosis in the femoral neck and/or total hip: an MNA score of <27 (odds ratio (OR)=2.09; CI=1.14-3.83); a mid-arm circumference of less than 28 cm (OR=2.97; CI=1.29-6.81); and regular use of more than 3 drugs each day (OR=2.12; CI=1.00-4.50). A body weight of more than 70 kg exhibited a decreased risk of having osteoporosis (OR=0.31; CI=0.14-0.70). CONCLUSIONS: In general, the nutritional status was good in this population of free-living elderly women. Nevertheless, half of the women who displayed an MNA score <27 points had a twofold increased risk of having osteoporosis. SPONSORSHIP: Karolinska Institutet, Stockholm County Council.

Bone mineral density measurement in the calcaneus with DXL: comparison with hip and spine measurements in a cross-sectional study of an elderly female population.

We investigated the relationship between calcaneal and axial bone mineral density in an elderly female population. We also investigated the influence of changing the reference populations on T-score values. Bone mineral density (BMD) was determined in 388 women (mean age 73 years) participating in a cross-sectional study. BMD values were determined at the left hip and the lumbar spine, L1-L4, using Hologic QDR 4500 equipment for dual X-ray absorptiometry (DXA). The calcaneal measurements were made with DEXA-T, a device using a dual X-ray and laser (DXL) technique that combines DXA measurement with measurement of the heel thickness using a laser reflection technique. DEXA-T is an older version of the Calscan DXL device now commercially available. T-score values were calculated for hip measurements with both the original reference population of the Hologic device and the NHANES III reference population. T scores for heel measurements were calculated with the original reference population of the peripheral device and the Calscan database, a new calcaneal reference population. Changing the reference populations had a great influence on both the heel and the hip T scores, especially those of the femoral neck where the percentage of subjects identified as osteoporotic decreased from 53% to 23%. We conclude that, with the NHANES III and the larger Calscan database, using the cut-off point of -2.5 SD, the heel measurements had optimal accuracy for detecting osteoporosis at either the combination of the lumbar spine and the femoral neck or the combination of the lumbar spine, the femoral neck, the total hip and the trochanter. BMD measurements of the calcaneus with DXL correlated fairly well with measurements at axial sites at the group level, while in individual subjects large deviations were observed between all the measured sites. We also conclude that the influence of the reference populations on the T scores is substantial when different DXA methods are being compared; the total number of subjects classified as osteoporotic varied from 7% to 53% between the sites and with different reference populations.

The connection between terms used in medical records and coding system: a study on Swedish primary health care data.

Implementation of problem lists and their relation to standardized coding systems have been approached and analysed in different ways. Most evaluations concern quantitative aspects such as content coverage in a specific domain. In order to reveal the qualitative aspects of diagnostic coding, medical record texts from primary health care encounters were compared with terms from a coding system that was used for describing them statistically. The records were coded by six general practitioners, and in some cases, an applied diagnostic term was found within the text, while other record text-coding system relationships were categorized as synonyms, alternative terms, and interpretations. Thus, the categories roughly corresponded to a measure of semantic distance between the terms in the record text and the rubrics of the coding system, and there was a correlation between semantic distance and inter-rater agreement. The subcategories of this scheme corresponded fairly well to recently published desiderata for clinical terminology servers, including functionality such as word normalization and spelling correction. However, not all problems could have been automatically coded by means of lexical methods, which can be partly explained by the fact that diagnostic coding also relies on clinical knowledge. In addition, proper automation relies on context representation within the records.

The injury panorama in a Swedish professional ballet company.

We performed a combined retro- and prospective study of injuries in a Swedish professional, classical ballet company during 5 consecutive years. There were 390 injuries incurred by 98 dancers over a 5-year period, i.e., 0.6 injuries/1000 dance hours. Most injuries were considered to be due to overuse. The median sick leave was 2.3 weeks per injury. The foot and ankle region is vulnerable in classical ballet dancers, and overuse injuries can result in long periods of sick leave. Of the dancers employed for more than 1 year 95% were suffered injuries during the study period. We found considerable differences in the injury profile between male and female and between younger and older dancers. Male dancers suffered more frequently from acute injuries to the knee joint. Traumatic injuries were seen most frequently in male soloists. Female dancers more often suffered overuse injuries, especially to the foot and ankle region. The younger dancers more often suffered traumatic injuries, for example, ankle sprain, and also stress fractures.

The use of clinical information in diagnosing chronic heart failure: a comparison between general practitioners, cardiologists, and students.

In a clinical judgement analysis study, 27 general practitioners, 22 cardiologists, and 21 medical students assessed 40 case vignettes with regard to the probability of heart failure, in order to study the weights of different kinds of information (cues) measured by the regression coefficients in a multiple regression model. The vignettes were based on actual patients. We found that diagnostic accomplishment and diagnostic strategies were surprisingly similar on the group level, but very different on the individual level. The most important cues for the participants were cardiac enlargement and pulmonary stasis. Strategies in which cardiac enlargement was the predominating cue led to a higher diagnostic accomplishment; a third of the participants used such strategies. The cues given in the vignettes could have been utilized more efficiently; cardiac enlargement seems to be more important and "classical" symptoms less important for predicting heart failure than the participants realize.

Evaluation of changes in public interest concerning lipids and other cardiovascular risk factors between 1990 and 1995.

OBJECTIVE: To assess changes between 1990 and 1995 in the knowledge of cardiovascular risk factors, attitudes to lifestyle changes and to the role of primary health care in preventive work in an urban population. DESIGN: Postal questionnaire. SETTING: South-western Stockholm. SUBJECTS: 1000 randomly selected men and women aged 40 to 64 years. MAIN OUTCOME MEASURES: Knowledge of and attitudes toward cardiovascular risk factors and contacts with primary health care. RESULTS: Response rate was 67%. In 1995 69% thought it important to know one's own lipid values (75% in 1990; 95% CI for change -11, -2). Forty-two per cent thought hyperlipidaemia was a definite cause of coronary heart disease (CHD) (50% in 1990; 95% CI for change -13, -2). Sixty-one per cent thought that a reduction in hyperlipidaemia would reduce cardiovascular risk (70% in 1990; CI for change -14, -4), and 53% thought that a reduction in hypertension would do so (65% in 1990, CI for change -17, -7). Fewer people believed in the negative consequences of eating habits. A majority expected doctors to know about patients' smoking (88%) or drinking (87%) habits. CONCLUSION: Interest in hyperlipidaemia declined between 1990 and 1995, but people expected doctors to take an interest in patients' lifestyles and in prevention. This knowledge is an important working tool for physicians.

Factors influencing GPs' decisions on the treatment of hypercholesterolaemic patients.

OBJECTIVE: To study factors influencing GPs' decisions to prescribe lipid-lowering drugs and how their judgements agree with the Swedish guidelines on hyperlipidaemia. DESIGN: Postal questionnaire. SETTING: Primary health care. Authentic written case descriptions of patients, all with a cholesterol value of at least 5.5 mmol/l and with variations in seven other variables (cues) in a Clinical Judgement Analysis (CJA) design. SUBJECTS: Sixty randomly selected primary health care doctors in the south-eastern Stockholm area. RESULTS: Thirty-eight doctors answered the questionnaire. Coronary heart disease had the highest influence on judgements, followed by cholesterol. The majority of doctors used two or three of the eight cues. Doctors differed markedly in their strategies. One in four did not use coronary heart disease in their judgements, even though all patients with this risk factor present (12/40) should receive pharmacological treatment, according to the guidelines. Doctors who adhered to the guidelines in this respect were younger than those who did not. The GPs' insights into their own strategies were good. CONCLUSIONS: The results indicate that doctors use very different judgement strategies for drug prescription concerning patients with hypercholesterolaemia. A fairly large subgroup of the doctors did not include coronary heart disease in their judgements, in contrast to the present guidelines.

Evaluation of three Swedish ICD-10 primary care versions: reliability and ease of use in diagnostic coding.

If computer-stored information is to be useful for purposes other than patient care, reliability of the data is of utmost importance. In primary healthcare settings, however, it has been found to be poor. This paper presents a study on the influence of coding tools on reliability and user acceptance. Six general practitioners coded 152 medical problems each by means of three versions of ICD-10, one with a compositional structure. At code level the reliability was poor and was almost identical when the three versions were compared. At aggregated level the reliability was good and somewhat better in the compositional structure. Ideas for improved user acceptance arose, and the study explored the need for several different tools to retrieve diagnostic codes.

Patients' satisfaction with the care given by district nurses at home and at primary health care centres.

The main purpose of this study was to investigate patients' satisfaction with the care given by the district nurses at home and at the primary health care centres in one area of Greater Stockholm. The questionnaire entitled 'Quality of Care from the Patient's Perspective' (QPP) was used. A total of 168 adult, home-care (HC) and 264 outpatient clinic (OC) patients answered this questionnaire. Maximum median scores were reported for most items designed to measure the four following dimensions: 'medical-technical' competence of the district nurses; 'physical-technical' conditions of the care organization; 'identity orientation' in the attitudes and actions of the district nurses and the 'socio-cultural' atmosphere of the care organization; and the perceived accessibility of nursing care. Some areas were identified as being in need of improvement, for example, pain alleviation, safety of the patients' home environment, the possibility of the patients participating in the decision-making process, the feeling that the care is not based on the patients' desires and needs, and the possibility of always meeting the same district nurse. Differences between HC and OC patients and between sub-groups were found regarding demographic characteristics and self-rated, physical health and psychological well-being. HC and OC patients with poor, self-rated, physical health were identified as being likely to be dissatisfied with the care.

Interexaminer reliability in physical examination of the cervical spine.

BACKGROUND: Most of the studies of physical examinations of the cervical spine have shown poor reliability. PURPOSE: To assess the interexaminer reliability in physical examinations of the cervical spine. SUBJECTS: Forty-eight subjects, age range 18 to 63 years. METHODS: Two physiotherapists independently evaluated a number of clinical tests of passive general and intersegmental movement. RESULTS: Acceptable kappa/kappa (w) values were obtained in several of the clinical tests of passive general motion range but in few of the clinical tests of passive intersegmental movement. More clinical tests had acceptable reliability and less bias in symptomatic subjects than asymptomatic subjects. CONCLUSION: Many of the clinical tests of passive general motion range were shown to be reliable. The increased number of acceptable kappa (w) values obtained in the symptomatic subjects indicates that further studies of the reliability of the clinical tests of passive intersegmental movement should be performed on patients.

The opinions of district nurses regarding the knowledge, management and documentation of patients with chronic pain.

This is the first of two studies investigating district nurses' opinions regarding the knowledge, management and nursing documentation of patients with chronic pain conditions, before and after the introduction of 'pain advisers' in one health care region in Stockholm. Seventy (97%) district nurses at 12 selected primary health care centres (PHCCs) answered a questionnaire. The study showed that 85% of the district nurses met patients with chronic pain conditions at least once a week. None of the 12 PHCCs had any written information/policies on pain control. Many district nurses did not perform any individual analysis of the patients' pain and very few used any tool, such as VAS, to assess or evaluate the patients' pain. The district nurses reported insufficient pain documentation. A number of district nurses were dissatisfied with the present management of patients with chronic pain at their PHCCs, their own knowledge of pain control, their own preparedness to meet these patients, their own follow-ups and their own documentation. The study also showed that the district nurses' attitudes to pain and pain control varied, depending on how satisfied they were with their own management of patients with chronic pain conditions.

Hyperlipidaemia: differences in management practices and attitudes in two regions in Europe--Sicily and the Stockholm area.

In order to compare attitudes and management concerning hyperlipidaemia and risk factors for coronary heart disease among doctors in northern and in southern Europe, a questionnaire study was undertaken among doctors in primary health care and departments of internal medicine in Sicily and Stockholm. The regions differed in culture and health-care structure. Guidelines were similar, but screening of healthy individuals was recommended in Sicily, and not in Sweden. One hundred and fifty-three general practitioners in Sicily and 120 in Stockholm, 211 internists in Sicily and 83 in Stockholm participated. Main outcome measures were management policies for investigation and treatment and also attitudes. Routine lipid checks at first visits were done by few doctors in Stockholm but by a majority in Sicily (p < 0.001); in the presence of general cardiovascular risk factors (other than heredity, diabetes, cardiovascular disease and hypertension), routine checks were carried out more often by both general practitioners (p < 0.001) and internists (p < 0.005) in Stockholm. Drug treatment was initiated at lower cholesterol levels for secondary and primary intervention, cardiovascular disease, cardiovascular risk factors and hereditary hyperlipidaemia by both groups in Sicily (p < 0.001), as was dietary treatment. Secondary prevention was considered important by all groups, but primary prevention only by Sicilian doctors. We concluded that there were differences in views and management practice between doctors in Sicily and in Stockholm on the investigation and treatment of patients with hyperlipidaemia. Doctors tested lipids at first visits in Sicily but not in Stockholm. Treatment was initiated at lower levels of cholesterol in Sicily.

How do GPs use clinical information in their judgements of heart failure? A clinical judgement analysis study.

OBJECTIVE: To study general practitioners' (GP) clinical diagnoses of heart failure. DESIGN: A Clinical Judgement Analysis study. SETTING: Primary health care. SUBJECTS: Twenty-seven GPs from nine health centres in Stockholm County. INTERVENTION: Forty-five case vignettes, based on actual patients from two health centres in Stockholm, were presented to each GP. For each case vignette, the GPs judged the probability of heart failure. MAIN OUTCOME MEASURES: The GPs' assessments of the probability of heart failure in the case vignettes. The GPs' utilization of clinical information in their judgement strategies, as measured by the regression coefficients in a multiple regression equation, with the probability assessments as dependent and the clinical criteria as independent variables. RESULTS: The variation between the GPs' assessments of the probability of heart failure was considerable. The judgemental strategies differed between the doctors, the most important variables for most of them being lung and heart X-rays and a history of myocardial infarction. CONCLUSIONS: With new treatment recommendations, it has become increasingly important to identify patients with heart failure. This study demonstrates large differences in GPs' diagnoses of heart failure. An important source of this variation is the differences in how they make use of clinical information.

Interexaminer reliability in physical examination of the neck.

BACKGROUND: There are numerous clinical tests used in the evaluation of patients with symptoms arising from the cervical spine. It is necessary to use clinical tests with high validity and reliability. Previous studies of reliability of clinical tests used in the evaluation of the cervical spine have come to various conclusions, most of which suggest low reliability. This might be explained by differences between examiners in performance and where the limit of normality is placed. OBJECTIVE: To evaluate the interexaminer reliability of clinical tests used in everyday clinical work, where the examiners base their evaluations on a comparison between left and right sides. STUDY DESIGN: A total of 50 volunteers were examined by two physiotherapists. The interexaminer reliability of clinical tests included in the physical examination of patients with symptoms from the cervical spine was evaluated. METHODS: Two physiotherapists independently examined volunteers. RESULTS: An acceptable reliability was found for two of 10 clinical tests. CONCLUSION: When it is possible to compare left and right sides, it is possible to show acceptable reliability for some clinical tests. Reliability studies most often find low reliability, perhaps because of bias; clinical tests are not standardized. In future studies, greater efforts should be taken to reduce bias.

Interexaminer reliability in physical examination of patients with low back pain.

STUDY DESIGN: Seventy-one patients with low back pain were examined by two physiotherapists (50 patients) and two physicians (21 patients). The two physiotherapists had worked together for many years, but the two physicians had not. The interexaminer reliability of the clinical tests included in the physical examination was evaluated. OBJECTIVES: To evaluate the interexaminer reliability of clinical tests used in the physical examination of patients with low back pain under ideal circumstances, which was the case for the physiotherapists. SUMMARY OF BACKGROUND DATA: Numerous clinical tests are used in the evaluation of patients with low back pain. To reach the correct diagnosis, only tests with an acceptable validity and reliability should be used. Previous studies have mainly shown low reliability. It is important that clinical tests not be rejected because of low reliability caused by differences between examiners in performance of the examination and in their definition of normal results. METHODS: Two examiners, either two physiotherapists or two physicians, independently examined patients with low back pain. RESULTS: In approximately half of the clinical tests studied, an acceptable reliability was demonstrated. CONCLUSION: On the basis of the physiotherapists series, the reliability was acceptable for a number of clinical tests that are used in the evaluation of patients with low back pain. The results suggest that clinical tests should be standardized to a much higher degree than they are today.

The opinions of nursing documentation held by district nurses and by nurses at primary health care centres.

Before a general, nursing documentation model was implemented in one health care region of the Stockholm County Council the opinions which district nurses and nurses at the primary health care centers (PHCCs) had of nursing documentation were investigated. 164 nurses (94%) at all the 22 PHCCs within the region answered a questionnaire in October, 1995. The study showed that the nurses in general were dissatisfied with their own, as well as with their colleagues, nursing documentation. The lack of a common, patient-record model for nursing documentation was considered the greatest obstacle, followed by lack of time and lack of knowledge. Most of the nurses believed that patient records which clearly included all parts of the nursing process would promote patient care. However, according to the nurses themselves, less than one-fifth of them recorded nursing history and nursing outcomes for all or most of their patients. One-third of the nurses reported that documented planned nursing interventions, about one-fourth nursing status and about half of them implemented nursing interventions for all or most of their patients. The nurses said that nursing diagnoses, goals and epicrises were rarely documented. There was no significant correlation between the nurses' ages and their opinions of nursing documentation. Nurses who had completed their education after 1985 were more positive to further education in nursing documentation and to computerised patient records, and confirmed more than others that patient records which included the entire nursing process model would promote patient care. Nurses who worked only at PHCCs were more satisfied with their own documentation as well as with that at their centres and were more positive to computer support than district nurses. Nurses at PHCCs were less in favour of education in nursing documentation, compared with nurses working in home health care and child care. The nurses who were not satisfied with their own nursing documentation were not satisfied with their colleagues' documentation either, but they were positive to further nursing education. More than others, they were of the opinion that better patient care follows from patient records which include the entire nursing process model. The study shows the need for education and continuous support aimed at nurses within the primary health care system regarding nursing documentation.