Randomized trial to improve fracture prevention in nursing home residents.

BACKGROUND: Interventions to improve the fracture prevention in nursing homes are needed. METHODS: Cluster-randomized, single-blind, controlled trial of a multi-modal quality improvement intervention. Nursing homes (n=67) with > or =10 residents with a diagnosis of osteoporosis or recent hip fracture (n=606) were randomized to receive an early or delayed intervention consisting of audit and feedback, educational modules, teleconferences, and academic detailing. Medical record abstraction and the Minimum Data Set were used to measure the prescription of osteoporosis therapies before and after the intervention period. Analysis was at the facility-level and Generalized Estimating Equation modeling was used to account for clustering. RESULTS: No significant improvements were observed in any of the quality indicators. The use of osteoporosis pharmacotherapy or hip protectors improved by 8.0% in the intervention group and 0.6% in the control group, but the difference was not statistically significant (P=.72). Participation in the intervention activities was low, but completion of the educational module (odds ratio [OR] 4.8, 95% confidence interval [CI], 1.9-12.0) and direct physician contact by an academic detailer (OR 4.5, 95% CI, 1.1-18.2) were significantly associated with prescription of osteoporosis pharmacotherapy or hip protectors in multivariable models. CONCLUSIONS: Audit-feedback and education interventions were ineffective in improving fracture prevention in the nursing home setting, although results may have been tempered by low participation in the intervention activities.

Risk of serious bacterial infections among rheumatoid arthritis patients exposed to tumor necrosis factor alpha antagonists.

OBJECTIVE: To evaluate the risk of serious bacterial infections associated with tumor necrosis factor alpha (TNFalpha) antagonists among rheumatoid arthritis (RA) patients. METHODS: A retrospective cohort study of US RA patients enrolled in a large health care organization identified patients who received either TNFalpha antagonists or methotrexate (MTX). Administrative data were used to identify hospitalizations with possible bacterial infections; corresponding medical records were abstracted and reviewed by infectious disease specialists for evidence of definite infections. Proportional hazards models evaluated time-dependent infection risks associated with TNFalpha antagonists. RESULTS: Hospital medical records with claims-identified suspected bacterial infections were abstracted (n=187) among RA patients who received TNFalpha antagonists (n=2,393; observation time 3,894 person-years) or MTX (n=2,933; 4,846 person-years). Over a median followup time of 17 months, the rate of hospitalization with a confirmed bacterial infection was 2.7% among the patients treated with TNFalpha antagonists compared with 2.0% among the patients treated with MTX only. The multivariable-adjusted hazard ratio (HR) of infection among the patients who received TNFalpha antagonists was 1.9 (95% confidence interval [95% CI] 1.3-2.8) compared with patients who received MTX only. The incidence of infections was highest within 6 months after initiating TNFalpha antagonist therapy (2.9 versus 1.4 infections per 100 person-years; multivariable-adjusted HR 4.2, 95% CI 2.0-8.8). CONCLUSION: The multivariable-adjusted risk of hospitalization with a physician-confirmed definite bacterial infection was approximately 2-fold higher overall and 4-fold higher in the first 6 months among patients receiving TNFalpha antagonists versus those receiving MTX alone. RA patients were at increased risk of serious infections, irrespective of the method used to define an infectious outcome. Patients and physicians should vigilantly monitor for signs of infection when using TNFalpha antagonists, particularly shortly after treatment initiation.

Consumer product-related eye injury in the United States, 1998-2002.

PROBLEM: Eye injury is currently a leading cause of visual impairment and monocular blindness in the United States. Information regarding consumer products associated with eye injuries can have important implications for the prevention of these injuries. METHODS: The National Electronic Injury Surveillance System (NEISS) was used to describe the types of consumer products associated with emergency department treated eye injuries in the United States from 1998 through 2002. RESULTS: The leading product type associated with eye injuries was welding equipment followed by household cleaners, basketball equipment, workshop equipment, and adhesives. Eye injuries attributed to hardware, tools, construction, sports, toys, and lawn equipment were more common among males. In females, eye injuries attributable to chemicals, housewares, storage and organization, and bed and bath items were more common. Differences were also apparent across the age spectrum. CONCLUSION: This study identified specific products and categories of products frequently associated with eye injury and prevention initiatives should focus on these items. IMPACT ON INDUSTRY: This study has identified consumer products associated with eye injuries requiring medical treatment in the United States. Manufacturers of these products could be encouraged to add or strengthen safety messages regarding the potential for eye injury.

Comparison of the Moorfields classification using confocal scanning laser ophthalmoscopy and subjective optic disc classification in detecting glaucoma in blacks and whites.

OBJECTIVE: To compare the diagnostic accuracy of the Moorfields regression classification (MRC) and subjective optic disc evaluation in discriminating early to moderate glaucomatous from nonglaucomatous eyes. DESIGN: Cross-sectional observational study. PARTICIPANTS: Two hundred thirty-three patients with glaucoma and 216 normal subjects were included in the analysis. Racial groups were defined by self-description. METHODS: All subjects underwent confocal scanning laser ophthalmoscopy, stereophotography, and standard perimetry. Glaucoma was defined by visual field defect alone and confirmed with a second visual field test. Stereo photographs were graded as either normal or glaucomatous appearing in a masked fashion by 2 independent graders and adjudicated by a third grader in cases of disagreement. Mean disc area was compared between patients correctly and incorrectly diagnosed with either technique. MAIN OUTCOME MEASURES: Sensitivity and specificity of MRC and subjective evaluation of stereophotographs in the detection of glaucomatous visual field loss. RESULTS: With the MRC, the sensitivity and specificity were higher using the 95% cutoff than using the 99.9% cutoff. Classification based on subjective photo assessment had a greater agreement with the diagnosis of glaucoma than the MRC for blacks (MRC, sensitivity = 62.5%, specificity = 93.2%; Photo, sensitivity = 76.5%, specificity = 91.5%) and whites (MRC, sensitivity = 67.0%, specificity = 92.2%; photo, sensitivity = 78.4%, specificity = 91.9%). Disc area was significantly larger in patients incorrectly diagnosed with the MRC (P = 0.0289). CONCLUSIONS: Subjective optic disc grading by glaucoma specialists outperformed the MRC with the HRT II in both black and white subjects. Both subjective and objective diagnostic methods were associated with similar sensitivity and specificity between racial groups. The MRC was more likely to provide an incorrect diagnosis in subjects with larger optic discs.

Discrimination between glaucomatous and nonglaucomatous eyes using quantitative imaging devices and subjective optic nerve head assessment.

PURPOSE: To compare the diagnostic ability of the confocal scanning laser ophthalmoscope (HRT-II; Heidelberg Engineering, Heidelberg, Germany), scanning laser polarimeter (GDx-VCC; Carl Zeiss Meditec, Inc., Dublin, CA), and optical coherence tomographer (StratusOCT, Carl Zeiss Meditec, Inc.) with subjective assessment of optic nerve head (ONH) stereophotographs in discriminating glaucomatous from nonglaucomatous eyes. METHODS: Data from 79 glaucomatous and 149 normal eyes of 228 subjects were included in the analysis. Three independent graders evaluated ONH stereophotographs. Receiver operating characteristic curves were constructed for each technique and sensitivity was estimated at 80% of specificity. Comparisons of areas under these curves (aROC) and agreement (kappa) were determined between stereophoto grading and best parameter from each technique. RESULTS: Stereophotograph grading had the largest aROC and sensitivity (0.903, 77.22%) in comparison with the best parameter from each technique: HRT-II global cup-to-disc area ratio (0.861, 75.95%); GDx-VCC Nerve Fiber Indicator (NFI; 0.836, 68.35%); and StratusOCT retinal nerve fiber layer (RNFL) thickness (0.844, 69.62%), ONH vertical integrated rim area (VIRA; 0.854, 73.42%), and macular thickness (0.815, 67.09%). The kappa between photograph grading and imaging parameters was 0.71 for StratusOCT-VIRA, 0.57 for HRT-II cup-to-disc area ratio, 0.51 for GDX-VCC NFI, 0.33 for StratusOCT RNFL, and 0.28 for StratusOCT macular thickness. CONCLUSIONS: Similar diagnostic ability was found for all imaging techniques, but none demonstrated superiority to subjective assessment of the ONH. Agreement between disease classification with subjective assessment of ONH and imaging techniques was greater for techniques that evaluate ONH topography than with techniques that evaluate RNFL parameters. A combination of subjective ONH evaluation with RNFL parameters provides additive information, may have clinical impact, and deserves to be considered in the design of future studies comparing objective techniques with subjective evaluation by general eye care providers.

Agreement in assessing cup-to-disc ratio measurement among stereoscopic optic nerve head photographs, HRT II, and Stratus OCT.

PURPOSE: To compare the level of agreement between subjective and objective methods in estimating horizontal and vertical cup-to-disc ratios (HCDR and VCDR, respectively) to determine if objective techniques may be used as surrogates for subjective cup-to-disc (CDR) estimation. METHODS: Fifty-one glaucoma patients and 49 control subjects underwent full ophthalmic examination, stereoscopic optic nerve head photographs (ONHPs), confocal scanning laser ophthalmoscopy (Heidelberg Retina Tomography II [HRT II]), and optical coherence tomography (Stratus OCT). The intraclass correlation coefficient (ICC) and Bland Altman plots were used to assess the agreement across the three methods. Repeated measures analysis of variance (ANOVA), Tukey adjustment, and pairwise P values were used to compare the HCDR and VCDR estimates between three clinicians who reviewed photos, Stratus OCT, and HRT II. RESULTS: For the clinicians, the agreement in subjectively assessed HCDR and VCDR was substantial (ICC=0.84 and 0.85, respectively), and for all three methods, overall agreement was good (ICC=0.75 and 0.77 for the HCDR and VCDR, respectively). Stratus OCT provided the largest overall mean+/-SD HCDR (0.68+/-0.14) and VCDR (0.62+/-0.13). The smallest overall mean+/-SD HCDR was provided by ONHP (0.32+/-0.16), and the smallest overall mean+/-SD VCDR was provided by HRT II (0.26+/-0.20). Repeated measures ANOVA test demonstrated significant differences across the three methods for glaucomatous (P=0.0017 and 0.0016, HCDR and VCDR, respectively) and normal (P=0.0001 for both HCDR and VCDR) eyes. Tukey adjustment demonstrated specific statistical differences between pairs of methods. CONCLUSIONS: Although the overall agreement between various methods was good, the mean estimates were statistically different. Additional studies are needed to evaluate the sources of variability, their level of significance, and longitudinal agreement between various methods of the CDR estimation.

Gun-related eye injury in the United States, 1993-2002.

OBJECTIVE: To present the descriptive epidemiology of gun-related eye injury in the United States from 1993 through 2002. METHODS: Data from the National Electronic Injury Surveillance System was used to estimate the number of patients treated in the United States for gun-related eye injury (GEI) (air guns and firearms), air gun-related eye injury (AEI) (BB/pellet guns and rifles) and firearm-related eye injury (FEI) (all powder discharge guns) during the time period 1993 through 2002. Rates were calculated according to age, gender, race, weapon type and circumstances surrounding the injury event (e.g., locale and intent). RESULTS: The rate of gun-related eye injury in the United States declined to 7.5 per 1,000,000 in 2002 from 14.8 per 1,000,000 in 1993, representing a decline of approximately 5.4% per year (p = 0.0002), due primarily to a decline in the rate of FEI (6.7% per year, p = 0.029). The rate of AEI was relatively constant. GEI rates were highest among those aged 10-19 years, males, and Blacks. The overall rate of AEI was higher than the rate of FEI (6.0 per 1,000,000 and 5.1 per 1,000,000, respectively). According to race, the rate of FEI was higher than the rate of AEI in Blacks whereas the rate of AEI was higher than the rate of FEI in Whites and Hispanics. The majority of GEIs occurred at home and were unintentional. CONCLUSION: The rate of gun-related eye injury in the United States declined from 1993 through 2002 primarily due to a reduction in firearm-related eye injury, whereas the rate of air gun-related eye injury remained constant. Persons who were young, Black, and male were at highest risk for gun-related eye injury.

3-hydroxy-3-methylglutaryl coenzyme a reductase inhibitors and the presence of age-related macular degeneration in the Cardiovascular Health Study.

OBJECTIVE: To evaluate both the use of cholesterol-lowering medications as a group and the use of statins specifically with regard to the risk of age-related macular degeneration (AMD). METHODS: A case-control study was conducted using data from the Cardiovascular Health Study, a population-based prospective study of adults enrolled from 4 communities in the United States in 1989 and 1990. Individuals with AMD (cases) and those without AMD (controls) were compared with regard to their use of cholesterol-lowering medications and statins. RESULTS: Nearly equal proportions of cases and controls used cholesterol-lowering medications, both before adjustment (odds ratio, 0.92; 95% confidence interval, 0.70-1.21) and after adjustment for selected confounding variables (age, sex, and race) (odds ratio, 1.35; 95% confidence interval, 0.98-1.87). Statin use was also found to be similar among cases and controls (odds ratio, 0.98; 95% confidence interval, 0.73-1.30). After controlling for the aforementioned 3 confounders (odds ratio, 1.40; 95% confidence interval, 0.99-1.98), we noted a modest trend for statin users to have an increased risk of AMD. CONCLUSION: The results suggest that no association exists between having used cholesterol-lowering medications and AMD. However, there was a suggestion that statin use might increase the risk of AMD.

Health-related quality of life and psychosocial characteristics of patients with benign essential blepharospasm.

OBJECTIVE: To examine vision-targeted health-related quality of life and psychosocial characteristics in patients with benign essential blepharospasm (BEB) compared with patients with hemifacial spasm (HFS). METHODS: Persons with BEB (n = 159) or HFS (n = 91) were identified based on International Classification of Diseases, Ninth Revision, Clinical Modifications codes with subsequent verification by record abstraction. Information regarding demographics, health characteristics, disease characteristics, and vision-targeted health-related quality of life was obtained through a telephone interview. RESULTS: For patients with BEB and HFS, the composite scores and subscale scores on the 25-item National Eye Institute Visual Function Questionnaire (NEI-VFQ-25) were low. Compared with patients with HFS, patients with BEB reported more depressive symptoms (P = .03), met the criteria for generalized anxiety disorder (P = .007), had lower NEI-VFQ-25 composite scores (P<.001), and had lower NEI-VFQ-25 subscale scores regarding general vision (P = .03), ocular pain (P<.001), distance activities (P = .001), driving (P<.001), and all of the vision-specific subscales addressing psychosocial issues. CONCLUSIONS: Compared with patients with HFS, those with BEB experience a greater reduction in vision-targeted health-related quality of life and are more prone to symptoms of depression and anxiety. This underscores the inadequacy of current treatment options for BEB in light of the fact that these patients had been undergoing standard-of-care treatments for some time.

Trends in eye injury in the United States, 1992-2001.

PURPOSE: To report the trends of eye injury in the United States from 1992 through 2001. METHODS: The National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, and the National Hospital Discharge Survey were used to collect information on eye injuries from 1992 to 2001. Rates of eye injury per 1000 population were calculated according to age, gender, and race. RESULTS: From 1992 through 2001, the overall estimated rate of eye injury ranged from 8.2 to 13.0 per 1000 population. During this period the incidence of eye injury significantly declined overall, in persons aged 39 years and younger, in both genders, and in the black and white populations (all P <0.05). CONCLUSIONS: From 1992 through 2002, the incidence of eye injury in the United States declined overall, in persons aged 39 and younger, in both genders, and in both racial groups. Certain segments of the population, however, continued to be at high risk (i.e., males and persons aged 39 and younger) of eye injury and represent those groups toward whom prevention resources should be directed.

Benign essential blepharospasm: risk factors with reference to hemifacial spasm.

BACKGROUND: To identify risk factors associated with benign essential blepharospasm (BEB) with reference to hemifacial spasm (HFS). Persons with BEB and HFS experience similar physical symptoms, yet the two disorders have different etiologies. METHODS: Patients with BEB (n = 159) or HFS (n = 91) were identified from two large neuro-ophthalmology clinics. Demographic, medical, behavioral, and psychological characteristics were obtained from chart review and a telephonic survey questionnaire. RESULTS: The average age of BEB and HFS was 66 years. Most patients in both groups were retired, white, and female. BEB patients were more than two times as likely to meet the diagnostic criteria for generalized anxiety disorder than HFS patients (odds ratio, 2.13; 95% confidence interval, 1.22-3.72). There was no difference between the two groups regarding demographics, smoking, a family history of dystonia, Parkinson disease, Bell palsy, Tourette disorder, obsessive compulsive symptoms, history of head trauma, alcohol use, or caffeine consumption. CONCLUSIONS: As compared to HFS, BEB was significantly more often associated with generalized anxiety disorder. Given the similarity of other clinical features of these two disorders, it is reasonable to conclude that anxiety is a cause not a consequence of BEB. Contrary to previous studies, BEB was not associated with obsessive-compulsive symptoms, head trauma, Parkinson disease, Bell palsy, Tourette disorder, or lack of smoking.

Visual field defects and the risk of motor vehicle collisions among patients with glaucoma.

PURPOSE: To evaluate the association between visual field defects in the central 24 degrees field and the risk of motor vehicle collisions (MVCs) among patients with glaucoma. METHODS: A nested case-control study was conducted in patients with glaucoma aged 55 or more. Cases were patients who were involved in a police-reported motor vehicle collision (MVC) between January 1994 and June 2000; controls were those who had not experienced an MVC at the time of their selection. For each patient, an Advanced Glaucoma Intervention Study (AGIS) score was calculated on automated visual fields collected with the 24-2 or 3-2 programs. RESULTS: With respect to the better-eye AGIS score, compared with patients with no visual field defect, those with severe defects (scores 12-20) had an increased risk of an MVC (odds ratio [OR] 3.2, 95% CI 0.9-10.4), although the association was not statistically significant. Moderate (6-11) or minor field defects (1-5) in the better eye were not associated with the risk of involvement in a crash. In the worse eye, patients with moderate or severe field defects were at significantly increased risk of an MVC (OR 3.6, 95% CI 1.4-9.4 and OR 4.4, 95% CI 1.6-12.4, respectively) compared with those with no defects. Minor field defects in the worse eye did not increase risk of MVC (OR 1.3, 95% CI 0.5-3.4). CONCLUSIONS: Patients with glaucoma who have moderate or severe visual field impairment in the central 24 degrees radius field in the worse-functioning eye are at increased risk of involvement in a vehicle crash.

Rate of eye injury in the United States.

OBJECTIVE: To provide a comprehensive estimate of the rate of eye injury in the United States. METHODS: Data from the National Ambulatory Medical Care Survey, the National Hospital Ambulatory Medical Care Survey, and the National Hospital Discharge Survey for 2001 were combined and used to provide estimates of eye injuries treated in emergency departments, inpatient and outpatient facilities, and private physicians' offices, as well as their causes and characteristics [corrected] RESULTS: In the United States in 2001, an estimated 1 990 872 (6.98 per 1000 population) individuals experienced an eye injury requiring treatment in an emergency department, inpatient or outpatient facility, or private physician's office. Most eye injuries are treated in emergency departments (50.7%), followed by private physicians' offices (38.7%), and outpatient (8.1%) and inpatient (2.5%) facilities. Eye injury rates were highest among individuals in their 20s, males, and whites. Injury rates were highest for superficial injuries, foreign bodies, contusions, and open wounds. CONCLUSIONS: This study provides a comprehensive estimate of the rate of eye injury in the United States. Private physicians represent an important source of care for eye injury in the United States.

The use of cholesterol-lowering medications and age-related macular degeneration.

PURPOSE: To evaluate the association between cholesterol-lowering medications and age-related macular degeneration (AMD). DESIGN: Case-control study. PARTICIPANTS: The Atherosclerosis Risk in Communities study is a prospective, population-based, cohort study conducted in 4 communities across the United States. A total of 15792 individuals aged 45 to 65 years were enrolled between 1987 and 1989; fundus photographs were added to the study protocol at the 6-year follow-up (1993-1995). Cases were subjects who were identified as having AMD after applying a standard definition to their fundus photographs; controls did not have AMD. METHODS: The use of cholesterol-lowering medications at any time during the study was determined and compared between cases and controls, adjusting for the potentially confounding effect of demographic, behavioral, and medical characteristics. MAIN OUTCOME MEASURES: Presence of AMD and the use of cholesterol-lowering medications. RESULTS: A total of 871 AMD cases and 11,717 controls were identified. Of the AMD cases, 11% made use of cholesterol-lowering medications, as compared with 12.3% of controls (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.71-1.11). Adjusting for the confounding influence of age, gender, and race revealed a statistically significant relationship between AMD and use of cholesterol-lowering medications (OR, 0.79; 95% CI, 0.63-0.99). CONCLUSIONS: The results of this study add to the growing body of evidence that cholesterol-lowering medications may reduce the risk of developing AMD. Additional research is needed to document the mechanism responsible for this association. A clinical trial of the impact of statins on AMD deserves consideration.

Differences in optic disc topography between black and white normal subjects.

PURPOSE: To determine if differences in optic disc topography exist between blacks and whites independent of racial differences in the area of the scleral canal. DESIGN: Cross-sectional observational study. PARTICIPANTS: A cohort of 146 eyes from black subjects and 97 eyes from white subjects without detectable ocular disease. METHODS: Reliable bilateral images were obtained using a retinal topographer. Mean values for all topographic parameters were compared both unadjusted and adjusted for differences in optic disc area and/or reference plane height. Comparisons of group differences for parameters and linear discriminant functions were adjusted for interocular dependence and multiple comparisons. RESULTS: Blacks had a significantly greater optic disc area (mean disc area in right eye: black subjects, 2.14 mm(2); white subjects, 1.96 mm(2) [P = 0.02]; mean disc area in left eye: black subjects, 2.18 mm(2); white subjects, 2.02 mm(2) [P = 0.04]). Most racial differences in optic disc parameters were not significant after adjustment for differences in optic disc area and reference plane height. However, eyes of black subjects demonstrated a deeper maximum cup depth than those of whites (P = 0.004), independent of differences in disc area and reference plane height. The values of linear discriminant functions did not differ significantly between racial groups, and the Moorfield classification correctly identified a similar proportion of subjects as normal in each racial group. CONCLUSIONS: Most of the normal variation in optic disc topography between blacks and whites seen with a retinal topographer is due to either differences in disc area or differences in reference plane height. However, small residual differences remain in cup depth independent of these parameters. These racial differences in optic disc structure should be considered in the statistical judgment of disease status based on these parameters. The Moorfield classification, which takes disc area into account, performed with similar specificity in each racial group.