Is hormone replacement therapy protective for venous ulcer of the lower limbs?

PURPOSE

Estrogen has been found to increase the risk of deep vein thrombosis (DVT), which is associated with venous ulcers. A matched case-control study was therefore performed to quantify the effect of hormone replacement therapy (HRT) on the occurrence of venous ulcers of the lower limbs.

METHODS

Women presenting to a participating vascular surgery department between January and December 1997 with a first open venous ulcer served as cases. Controls were sampled among women with sub-acute conditions such as skin problems, cold, headache/migraine, sore throat and mild ear infections, and were matched on referral site and age (+/- 5 years). Subjects were eligible for this study if they were postmenopausal, and excluded if they had non-palpable pedal pulse or any chronic active diseases. The study consisted of an interviewer-administered risk factor questionnaire. Conditional multivariate logistic regression analyses were performed adjusting for history of DVT and unbalanced distributions in important covariates.

RESULTS

Forty-four cases and 80 matched controls were recruited. The mean age of participants was 64 years. HRT users were significantly thinner (27% with body mass index (BMI = (kg/height (m2)) > or = 27 vs. 41%, p = 0.04) and less likely to have a history of DVT (12 vs. 33%, p = 0.02) and varicose veins (VV) (52 vs. 69%, p = 0.04) than non-users. A matched univariate logistic regression analysis was performed to quantify the effect of HRT on venous ulcers and generated an odds ratio (OR) of 0.14 with 95% confidence interval of (0.04, 0.49)95%: adjusting for prior DVT resulted in an OR of 0.29 (0.09, 0.93)95%. When adjusting for BMI, history of VV, exercise, education, and smoking, the OR observed was 0.03 (0.01, 0.13)95%: further adjustment for prior DVT gave an OR estimate of 0.06 (0.01, 0.50)95%CI.

CONCLUSIONS

Our study demonstrates that HRT has a protective effect on the occurrence of venous ulcers of the lower limbs. Adjusting for prior DVT moves the estimate closer to the null. DVT is a strong contraindication for HRT and therefore must be considered in order to eliminate confounding by contraindication.

Risk factors for development of lower limb pain in adolescents

OBJECTIVE

Although many clinicians believe high growth leads to inflexibility, which may lead to lower extremity pain, the only prospective data suggest growth is unrelated to flexibility. However, it is still possible that growth and/or flexibility are related to pain even if they are not related to each other. We investigated the incidence of leg pain in adolescents to determine whether high growth spurt and/or poor flexibility are risk factors for the development of lower extremity pain.

METHODS

Repeated measures, prospective cohort study of urban high school students aged 12-18. Subjects were measured at baseline and at 6 and 12 months for flexibility of hamstrings and quadriceps and with the sit-and-reach test. Participants completed a detailed questionnaire on recreational activity, occupational activities, psychosocial variables, and musculoskeletal pain.

RESULTS

Poor hamstring flexibility (odds ratio 0.99, confidence interval 0.97-1.01), poor quadriceps flexibility (OR 1.01, CI 0.99-1.03), poor sit-and-reach flexibility (OR 0.99, CI 0.99-1.01), and growth (OR 0.93, CI 0.50-1.71) were not related to the development of lower extremity pain. There was an association between lower extremity pain and occupational activities (OR 2.08, CI 1.45-2.98) and poor mental health (per 1 SD change, OR 1.41, CI 1.19-1.67).

CONCLUSION

Neither growth nor flexibility is related to the development of lower extremity pain in adolescents. A poor mental health score and occupational activities may be associated with the development of lower extremity pain.

Implementation of a participatory ergonomics program in the rehabilitation of workers suffering from subacute back pain

This paper describes a participatory ergonomics program aimed at early return to regular work of workers suffering from subacute occupational back pain and assesses the perceptions of the participants on the implementation of ergonomic solutions in the workplace. The participatory ergonomics program was used in the rehabilitation of workers suffering from subacute back pain for more than 6 weeks, a program that was associated with an increased rate of return to work. The perceptions of the participatory ergonomics participants were assessed 6 months after completion of the ergonomic intervention through a questionnaire sent to employer representatives, union representatives and injured workers of participating workplaces. About half of the ergonomic solutions were implemented according to the perception of the participants, with a substantial agreement between respondents.

Oral corticosteroids and fracture risk: relationship to daily and cumulative doses

OBJECTIVE

This study examined the effects of daily and cumulative oral corticosteroid doses on the risk of fractures.

METHODS

Information was obtained from the General Practice Research Database, which contains medical records of general practitioners in England and Wales. The study included 244 235 oral corticosteroid users and 244 235 controls.

RESULTS

Patients taking higher doses (at least 7. 5 mg daily of prednisolone or equivalent) had significantly increased risks of non-vertebral fracture [relative rate (RR)=1.44, 95% confidence interval (CI) 1.34-1.54], hip fracture (RR=2.21, 95% CI 1.85-2.64) and vertebral fracture (RR=2.83, 95% CI 2.35-2.40) relative to patients using oral corticosteroids at lower doses (less than 2.5 mg per day). Fracture risk was also elevated among people with higher cumulative exposure to oral corticosteroids over the study period, but this effect was almost wholly removed by adjustment for daily dose, age, gender and other confounding variables.

CONCLUSIONS

These findings suggest that the adverse skeletal effects of oral corticosteroids manifest rapidly and are related to daily dose. The level of previous exposure to oral corticosteroids was not a strong determinant of the risk of fracture. Preventive measures against corticosteroid-induced osteoporosis should therefore be instituted as soon after the commencement of glucocorticoid therapy as possible.

[The mission of the Director General of the Ministry of Health]

In France, the health and solidarity department of Employment and solidarity Ministry have just been re-organised. The Directory General of the department of Health is experiencing a complete revision of its functions and organisation. This article presents the public health context which has been taken into account for this new organisation and explains its main principles and strategic orientations. The new organisation chart is clarified. It is made up by two departments and seven under-directions. Up to now, control and administrative supervision were predominant among Health General Direction functions. They are now oriented to administrate missions prioritizing the function of health doctrines' elaboration, of programmation, animation and coordination. As the guarantor of sanitary security, the Health General Direction has also to impulse a new partnership which does not only include health professional, social and health organisation and the economic actors: citizen in general and service users in particular have to be included to promote health democracy.

Multiple sclerosis and antecedent infections: a case-control study

OBJECTIVES

To determine whether there is an excess of respiratory tract infections in the 5-week, 3-month, and 12-month periods before MS symptom onset and if there is an association between MS and a history of infectious mononucleosis (IM).

BACKGROUND

The etiology of MS remains unknown, but infection is frequently suggested as a putative etiologic agent. Epidemiologic studies have produced inconsistent evidence for an etiologic role of respiratory tract infections (RTI) and IM in MS.

METHODS

The authors performed a case-control study using the General Practice Research Database from the United Kingdom. There were 225 subjects with definite or probable MS, and 900 controls matched for age, sex, and physician practice. Using computerized patient records, the authors compared the mean rates of RTI per patient in the 5-week, 3-month, and 12-month periods before the date of onset of the first symptoms compatible with MS (index date). They also compared histories of IM.

RESULTS

In all periods, an increased frequency of RTI was associated with a significantly increased risk of MS. A history of IM was associated with greater than five times the risk of MS (OR = 5.5 [95% CI 1.5 to 19.7]).

CONCLUSIONS

These results support an association between a history of IM and subsequent MS. Respiratory tract infections may precipitate disease onset.

Use of oral corticosteroids and risk of fractures

Treatment with oral corticosteroids is known to decrease bone density but there are few data on the attendant risk of fracture and on the reversibility of this risk after cessation of therapy. A retrospective cohort study was conducted in a general medical practice setting in the United Kingdom (using data from the General Practice Research Database [GPRD]). For each oral corticosteroid user aged 18 years or older, a control patient was selected randomly, who was matched by age, sex, and medical practice. The study comprised 244,235 oral corticosteroid users and 244,235 controls. The average age was 57.1 years in the oral corticosteroid cohort and 56.9 years in the control cohort. In both cohorts 58.6% were female. The most frequent indication for treatment was respiratory disease (40%). The relative rate of nonvertebral fracture during oral corticosteroid treatment was 1.33 (95% confidence interval [CI], 1.29-1.38), that of hip fracture 1.61 (1.47-1.76), that of forearm fracture 1.09 (1.01-1.17), and that of vertebral fracture 2.60 (2.31-2.92). A dose dependence of fracture risk was observed. With a standardized daily dose of less than 2.5 mg prednisolone, hip fracture risk was 0.99 (0.82-1.20) relative to control, rising to 1.77 (1.55-2.02) at daily doses of 2.5-7.5 mg, and 2.27 (1.94-2.66) at doses of 7.5 mg or greater. For vertebral fracture, the relative rates were 1.55 (1.20-2.01), 2.59 (2.16-3.10), and 5.18 (4.25-6.31), respectively. All fracture risks declined toward baseline rapidly after cessation of oral corticosteroid treatment. These results quantify the increased fracture risk during oral corticosteroid therapy, with greater effects on the hip and spine than forearm. They also suggest a rapid offset of this increased fracture risk on cessation of therapy, which has implications for the use of preventative agents against bone loss in patients at highest risk.

Long-term outcomes after deep vein thrombosis: postphlebitic syndrome and quality of life

In this review, we critically assess the literature on the incidence of postphlebitic syndrome, risk factors for its occurrence, available therapeutic options, and its effects on quality of life. As well, we describe available tools to measure postphlebitic syndrome. Recent prospective studies indicate that postphlebitic syndrome, a chronic, potentially disabling condition characterized by leg swelling, pain, venous ectasia, and skin induration, is established by 1 year after deep vein thrombosis (DVT) in 17% to 50% of patients. The only prospectively identified risk factor for its occurrence is recurrent ipsilateral DVT. In the sole randomized study available, daily use of elastic compression stockings after proximal DVT reduced the incidence of postphlebitic syndrome by 50%. Treatment options for established postphlebitic syndrome are limited, but include compression stockings and intermittent compressive therapy with an extremity pump for severe cases. To date, quality of life after DVT has received little attention in the literature. The recent development of the VEINES-QOL questionnaire, a validated venous-disease-specific measure of quality of life, should encourage researchers to include quality of life as a routine outcome measure after DVT. There is no criterion standard for the diagnosis of postphlebitic syndrome, but a validated clinical scoring system does exist. More research on postphlebitic syndrome is needed to enable us to provide DVT patients with comprehensive, evidence-based information regarding their long-term prognosis, to help quantify the prevalence and health care burden of postphlebitic syndrome, and by identifying predictors of poor outcome, to develop new preventive strategies in patients at risk of developing this condition.

Anorexigens and pulmonary hypertension in the United States: results from the surveillance of North American pulmonary hypertension

BACKGROUND

The use of appetite suppressants in Europe has been associated with the development of primary pulmonary hypertension (PPH). Recently, fenfluramine appetite suppressants became widely used in the United States but were withdrawn in September 1997 because of concerns over adverse effects.

MATERIALS AND METHODS

We conducted a prospective surveillance study on patients diagnosed with pulmonary hypertension at 12 large referral centers in North America. Data collected on patients seen from September 1, 1996, to December 31, 1997, included the cause of the pulmonary hypertension and its severity. Patients with no identifiable cause of pulmonary hypertension were classed as PPH. A history of drug exposure also was taken with special attention on the use of antidepressants, anorexigens, and amphetamines.

RESULTS

Five hundred seventy-nine patients were studied, 205 with PPH and 374 with pulmonary hypertension from other causes (secondary pulmonary hypertension [SPH]). The use of anorexigens was common in both groups. However, of the medications surveyed, only the fenfluramines had a significant preferential association with PPH as compared with SPH (adjusted odds ratio for use > 6 months, 7.5; 95% confidence interval, 1.7 to 32.4). The association was stronger with longer duration of use when compared to shorter duration of use and was more pronounced in recent users than in remote users. An unexpectedly high (11.4%) number of patients with SPH had used anorexigens.

CONCLUSION

The magnitude of the association with PPH, the increase of association with increasing duration of use, and the specificity for fenfluramines are consistent with previous studies indicating that fenfluramines are causally related to PPH. The high prevalence of anorexigen use in patients with SPH also raises the possibility that these drugs precipitate pulmonary hypertension in patients with underlying conditions associated with SPH.

Use of oral corticosteroids in the United Kingdom

Administration of oral corticosteroids is associated with the development of osteoporosis and an increased risk of fractures. However, the size of the treated sub-population who would benefit from preventive therapy remains uncertain. The objective of this study was to investigate the usage pattern of oral corticosteroids in a large sample representative of the general population in England and Wales. Information was obtained from the General Practice Research Database (GPRD) which contains medical records of general practitioners. Oral corticosteroid users were patients aged 18 years or older who received one or more prescriptions for oral corticosteroids. Over 1.6 million oral corticosteroid prescriptions were issued to the cohort of 244 235 oral corticosteroid users. At any point in time, oral corticosteroids were being used by 0.9% of the total adult GPRD population. The highest use (2.5%) was by people between 70 and 79 years of age. Respiratory disease was the most frequently recorded indication for oral corticosteroid treatment (40%). Patients with arthropathies were most likely to use long-term, continuous treatment, and patients with chronic obstructive pulmonary disease least likely (19.3% and 6.1%, respectively, used oral corticosteroids for more than 2 years). The overall use of bone-active medication (oestrogens, bisphosphonates, vitamin D, and calcitonin) during oral corticosteroid treatment was low (between 4.0% and 5.5%). The current population in the UK at risk of developing corticosteroid-induced fractures might be as large as 350 000. Identification of these patients will be important for implementing preventive strategies in a cost-effective manner.

Coordination of primary health care for back pain. A randomized controlled trial

STUDY DESIGN

A randomized controlled trial comparing usual care with a program for the coordination of primary health care (CORE) for the treatment of subacute low-back pain patients.

OBJECTIVES

To measure the effectiveness of the CORE program as a mean for implementing clinical practice guidelines for low-back pain in an urban community.

SUMMARY OF BACKGROUND DATA

Clinical practice guidelines have been developed for primary care physicians and patients on the clinical management of low-back pain. The implementation of the guidelines in a large community is difficult with the multiplicity of medical and nonmedical back care providers and products. The CORE program was designed to make the guidelines fit in this complex environment.

METHODS

One hundred ten workers compensated for low-back pain for 4 to 8 weeks in metropolitan Montreal were randomized in two groups: usual care (N = 56) and the CORE program (N = 54). Coordination of primary health care was performed by two primary care physicians and a nurse in liaison with the treating physicians, and included a complete examination, recommendations for the clinical management, and support to carry out the recommendations. All workers were followed for 6 months. Back pain and functional status were assessed at baseline, 3 months, and 6 months.

RESULTS

In the 6-month follow-up, the CORE group returned to work 6.6 days (standard error = 8.9) quicker than the control group, a difference that was not statistically significant. However, the CORE group showed a sustained improvement in pain and functional status with two-fold differences at the end of the 6 months of follow-up. This represented nine points on the Oswestry scale (P = 0.02) and 12 points on the Quebec Back Pain Disability Scale (P = 0.01). The CORE group also used three times less specialized imaging tests of the spine at 3 months (P < 0.01) and exercised twice as much at 6 months (P < 0.05) than the controls.

CONCLUSIONS

The therapeutic results for workers with low-back pain could be improved by implementing the clinical practice guidelines with primary care physicians in a large community, without delaying the return to work. The CORE intervention for back pain patients is highly relevant to primary care practice. It is simple in its application, flexible to accommodate physicians' and- patients' preferences in health care, and it is effective on patients' clinical outcome.

Smoking. A risk factor for development of low back pain in adolescents

STUDY DESIGN

A prospective, repeated-measures cohort design with high school students from Montreal, Canada.

OBJECTIVES

To determine whether smoking was a risk factor for the development of low back pain or other musculoskeletal pain in a cohort of adolescents.

SUMMARY OF BACKGROUND DATA

Smoking has been associated with low back pain in adults. Many adolescents smoke, and the prevalence of low back pain in this age group is 30%. A history of low back pain is predictive of future problems.

METHODS

A total of 502 students from grades 7 to 9 were assessed from 3 schools. Data were collected at 3 times: at the beginning of the study, at 6 months, and at the end of a 12-month period. Students responded to a questionnaire addressing musculoskeletal health and life-style factors, which included smoking. Measurements of height, weight, trunk and leg flexibility, and trunk strength were obtained. Low back pain occurring at a frequency of at least once a week in the past 6 months was defined as the outcome. Multivariate methods were used to model the repeated-measures dichotomous outcome as a function of smoking and other covariates.

RESULTS

Smokers experienced low back pain more than nonsmokers (odds ratio, 2.4; 95% confidence interval, 1.3-6.0). There was also a dose-response relationship between amount smoked and development of low back pain. Smokers tended to experience more upper limb or lower limb pain than nonsmokers, although this result was not significant.

CONCLUSIONS

Smoking was found to increase the risk for low back pain in this cohort of adolescents.

Colorectal cancer prevention by non-steroidal anti-inflammatory drugs: effects of dosage and timing

Epidemiological studies show that non-steroidal anti-inflammatory drugs (NSAIDs) reduce colorectal cancer incidence. We measured the rate ratio for colorectal adenocarcinoma according to dosage and the timing of exposure by means of a case-control study, nested in a non-concurrent cohort linkage study, using the population of beneficiaries of the Saskatchewan Prescription Drug Plan from 1981 to 1995 with no history of cancer since 1970 as the source population. Four controls per case, matched on age and gender and alive when the case was diagnosed, were randomly selected. Dispensing rates, calculated over successive time periods, characterized NSAID exposure. We accrued 3844 cases of colon cancer and 1971 cases of rectal cancer. For colon cancer a significant trend towards a decreasing rate ratio was associated with increasing exposure during the 6 months preceding diagnosis (P-trend = 0.002). For both cancers, significant trends were associated with exposure 11-15 years before diagnosis (colon: P-trend = 0.01; rectum: P-trend = 0.0001). At the highest exposure levels the rate ratio for colon cancer was 0.57 (95% confidence interval (CI) 0.36-0.89); for rectal cancer it was 0.26 (95% CI 0.11-0.61). No protection was associated with exposure during other periods. The timing of NSAID use must be considered in planning intervention trials to prevent colorectal cancer. There may be a 10-year delay before any preventive effect will appear.

Chronic venous disorders of the leg: epidemiology, outcomes, diagnosis and management. Summary of an evidence-based report of the VEINES task force. Venous Insufficiency Epidemiologic and Economic Studies

BACKGROUND

To critically review the classification, epidemiology, outcomes, diagnosis and treatment of chronic venous disorders of the leg (CVDL), to issue evidence-based recommendations, and to identify areas requiring further research.

METHODS

Articles identified by an extensive literature search were scored by members of an international task force. Only those articles with a moderate or strong rating for internal validity were retained.

RESULTS

A scoring system weighing CVDL severity according to the probability of ulcer occurrence is proposed. Epidemiological data on the frequency of CVDL and its risk factors are reviewed. The following items are evaluated: costs associated with treatment; clinical outcomes related to CVDL and its treatment; available generic and disease-specific measures of quality of life; diagnostic procedures used to detect venous reflux; and efficacy of available treatments.

CONCLUSIONS

CVDL is an important public health problem, based on its prevalence, cost and impact on quality of life. High-priority areas for research on CVDL are identified.

Clinical prediction of deep vein thrombosis in patients with leg symptoms

Symptoms and clinical signs individually are inaccurate for the diagnosis of DVT. However, when assessing patients with leg symptoms, clinicians have access to additional information, such as whether or not DVT risk factors are present that could improve the accuracy of clinical judgment. The purpose of this study was to identify which clinical variables best predict DVT, and to use these variables to create a clinical prediction index for DVT. We studied 271 university hospital patients with a first episode of symptomatic, clinically suspected DVT. The prevalence of DVT was 27%, of which 71% were proximal. At baseline, information was collected on demographic features, comorbidity, and symptoms and signs. A Bayesian model selection strategy was used to estimate the logistic regression model that best predicted DVT. Male sex [OR = 2.8 (1.5, 5.1)], orthopedic surgery [OR = 5.4 (2.2, 13.6)], warmth [OR = 2.1 (1.2, 3.9)] and superficial venous dilation on exam [OR = 2.9 (1.4, 5.7)] were independent predictors of DVT. Using the model, a clinical prediction index that categorized patients into different levels of DVT risk was created, and was useful in a theoretical strategy aimed to limit the need for contrast venography in patients with suspected DVT, such that 96% of study patients could have avoided contrast venography. This index should be evaluated prospectively in other patient populations.

Adolescent growth is not associated with changes in flexibility

OBJECTIVE

To determine whether adolescent growth is associated with a decrease in flexibility.

DESIGN

Longitudinal cohort study of urban high school students.

MAIN OUTCOME MEASURES

Flexibility of hamstring muscles (popliteal angle), quadriceps muscles (quadriceps angle), lumbar extensor muscles (Schober test), and combined lower extremity-trunk muscles (Sit and Reach test).

RESULTS

There was no relation between growth and changes in flexibility for the lumbar flexor muscles, hamstring muscles, or muscles involved in the Sit and Reach test. Although there was a slight decrease in flexibility of the quadriceps muscle with increases in growth, the very low r2adj value (0.01-0.06) strongly suggests that growth plays only a small role in determining the flexibility of individuals.

CONCLUSION

These results strongly suggest that growth is not a cause of decreased flexibility during the peripubescent period.

Postmarketing surveillance of the safety of cyclic etidronate

To evaluate the safety of cyclic etidronate in routine clinical practice, we obtained information from 550 general practices in the United Kingdom that provide the medical records to the General Practice Research Database. A group of 7977 patients taking cyclic etidronate and two age-, gender-, and practice-matched control groups, one with osteoporosis and one without, were analyzed. For the group taking cyclic etidronate, the average age was 71.6 years and follow-up was 10,328 person-years. Conditions that do not induce osteoporosis generally occurred in these patients at a rate comparable to that in the control groups. The incidence of osteomalacia was low and comparable between patients taking cyclic etidronate and controls with osteoporosis. No medically significant increases in frequency were observed among patients taking cyclic etidronate for a broad group of diseases that may potentially be induced by exposure to the drug. These data support the favorable risk:benefit ratio of cyclic etidronate.

Is work status of low back pain patients best described by an automated device or by a questionnaire?

STUDY DESIGN

A prospective cohort study of patients with subacute occupational back pain.

OBJECTIVES

To study the relation between a marketed opto-electric device measuring trunk kinematics, a widely used specific functional capacity questionnaire, and work status in back pain patients, and to assess the responsiveness to change in work status of the opto-electric device and the questionnaire.

SUMMARY OF BACKGROUND DATA

Several instruments have been developed to evaluate the functional capacities of patients with back pain, but the relation between these instruments and work status has rarely been studied.

METHODS

The relation between the opto-electric device, the questionnaire, and work status in patients with back pain was evaluated. The study population was a prospective cohort of patients with subacute back pain who were absent from regular work for more than 4 weeks. All data were compiled blindly on the same day, at study entry (4 weeks after work accident), and at 12, 24, and 52 weeks after the work accident. The validity of the questionnaire and opto-electric device scores was assessed with partial correlation analyses, standardized response mean, logistic regression analyses, and receiver operating characteristics curves.

RESULTS

The correlation between the questionnaire and opto-electric device scores was low. The questionnaire scores were significantly related to work status, but the opto-electric device scores were not. The questionnaire was responsive to change in work status, whereas the opto-electric device was not.

CONCLUSIONS

The opto-electric device scores were not related to either functional capacity scores (questionnaire) or work status in patients with low back pain, and the opto-electric device was not responsive to change in work status. Conversely, the questionnaire was related to work status and was responsive to change in work status.

Reliability study of the Leg-O-Meter, an improved tape measure device, in patients with chronic venous insufficiency of the leg. VEINES Group.(Venous Insufficiency Epidemiologic and Economic Study)

The objective of this study was to evaluate the inter-rater reliability of the Leg-O-Meter, an instrument designed to measure the ankle or calf circumference. The Leg-O-Meter consists of a tape measure fixed to a stand attached to a small board on which the patient is in standing position. For this study the tape measure of the Leg-O-Meter was fixed at 10 cm from the board in order to standardize all measurements. Informed consent to participate in the study was obtained from 39 patients consulting the phlebology clinic of Hôpital St-Michel, Paris, France. Participants were asked to enter a closed room where four independent and blinded observers consecutively took measurements of both legs with the Leg-O-Meter. The order of the observers was randomized between patients. Under the assumption of a two-way random effects model an intraclass correlation coefficient (ICC) was used to determine the reliability or reproducibility of a measure with the Leg-O-Meter. The overall reliability coefficient calculated by the ICC for the right and left leg were estimated at 97.09% [95.52%;100%]95% and 97.08% [95.86%;100%]95%, respectively. The authors conclude that the Leg-O-Meter gives a standardized and reliable measure of the circumference of the ankle. Furthermore, it is not invasive or costly.

Use of cyclical etidronate and prevention of non-vertebral fractures

This study examined the effects of cyclical etidronate, when used in routine clinical practice, on the prevention of fracture. Information was obtained from 550 general practices in the UK that provide their medical records to the General Practice Research Database. A total of 7977 patients taking cyclical etidronate treatment and 7977 age-, sex- and practice-matched control patients with a diagnosis of osteoporosis were analysed. People taking cyclical etidronate had a significantly reduced risk of non-vertebral fracture (by 20%) and of hip fracture (by 34%) relative to the osteoporosis control patients. The relative risk of non-vertebral fracture was 0.80 (95% confidence interval 0.70-0.92), that of hip fracture 0.66 (0.51-0.85) and that of wrist fracture 0.81 (0.58-1.14). When fracture incidence rates were compared between the two groups, the rate of non-vertebral, hip and wrist fracture decreased significantly (P < 0.05) with increasing etidronate exposure. The results of this study complement and extend clinical observations supporting the anti-fracture efficacy of cyclical etidronate therapy.

A population-based, randomized clinical trial on back pain management

STUDY DESIGN

Population-based randomized clinical trial.

OBJECTIVES

To develop and test a model of management of subacute back pain, to prevent prolonged disability.

SUMMARY OF BACKGROUND DATA

The present management of back pain seems inadequate, and development of innovative models has been urged.

METHODS

A model for the treatment of subacute work-related back pain has been developed and evaluated in a population-based randomized clinical trial. Workers (n = 130) from eligible workplaces in the Sherbrooke area (N = 31), who had been absent from work for more than 4 weeks for back pain, were randomized, based on their workplace, in one of four treatment groups: usual care, clinical intervention, occupational intervention, and full intervention (a combination of the last two). The duration of absence from regular work and from any work was evaluated using survival analysis. Functional status and pain were compared at study entry and after 1 year of follow-up.

RESULTS

The full intervention group returned to regular work 2.41 times faster than the usual care intervention group (95% confidence interval 1.19-4.89; P < 0.01). The specific effect of the occupational intervention accounted for the most important part of this result, with a rate ratio of return to regular work of 1.91 (95% confidence interval = 1.18-3.10; P < 0.01). Pain and disability scales demonstrated either a statistically significant reduction or a trend toward reduction in the three intervention groups, compared with the trend in the usual care intervention group.

CONCLUSIONS

Close association of occupational intervention with clinical care is of primary importance in impeding progression toward chronicity of low back pain.