Effect of discharge opioid on persistent postoperative opioid use: a retrospective cohort study comparing tapentadol with oxycodone

Opioid harm can vary by opioid type. This observational study examined the effect of opioid type (oxycodone vs. tapentadol) on rates of persistent postoperative opioid use ('persistence'). We linked hospital and community pharmacy data for surgical patients who were dispensed discharge opioids between 1 January 2016 and 30 September 2021. Patients were grouped by opioid experience ('opioid-naive' having received no opioids in the 3 months before discharge) and formulation of discharge opioid (immediate release only or modified release ± immediate release). Mixed-effects logistic regression models predicted persistence (continued use of any opioid at 90 days after discharge), controlling for key persistence risk factors. Of the 122,836 patients, 2.31% opioid-naive and 27.24% opioid-experienced patients met the criteria for persistence. For opioid-naive patients receiving immediate release opioids, there was no significant effect of opioid type. Tapentadol modified release was associated with significantly lower odds of persistence compared with oxycodone modified release, OR (95%CI) 0.81 (0.69-0.94) for opioid-naive patients and 0.81 (0.71-0.93) for opioid-experienced patients. Among patients who underwent orthopaedic surgery (n = 19,832), regardless of opioid experience or opioid formulation, the odds of persistence were significantly lower for those who received tapentadol compared with oxycodone. This was one of the largest and most extensive studies of persistent postoperative opioid use, and the first that specifically examined persistence with tapentadol. There appeared to be lower odds of persistence for tapentadol compared with oxycodone among key subgroups, including patients prescribed modified release opioids and those undergoing orthopaedic surgery.

The impact of decreasing U.S. hip fracture rates on future hip fracture estimates

SUMMARY

We examined age- and sex-specific hip fracture hospitalization rates among people aged 65 and older using 1990-2010 National Hospital Discharge Survey data. Trends calculated using Joinpoint regression analysis suggest that future increases in hip fractures due to the aging population will be largely offset by decreasing hip fracture rates among women. However, this trend will be counterbalanced by rising numbers of hip fractures among men.

INTRODUCTION

From 1990 to 2006, age-adjusted U.S. hip fracture rates among people aged 65 years and older declined significantly. We wanted to determine whether decreasing age group-specific hip fracture rates might offset increases in hip fractures among the aging population over the next two decades.

METHODS

This study used data from the National Hospital Discharge Survey, a national probability survey of inpatient discharges from nonfederal U.S. hospitals, to analyze hip fracture hospitalizations, defined as cases with first diagnosis coded ICD-9 CM 820. We analyzed trends in rates by sex and 10-year age groups using Joinpoint analysis software and used the results and projected population estimates to obtain the expected number of hip fractures in 2020 and 2050.

RESULTS

Based on current age- and sex-specific trends in hip fracture hospitalization rates, the number of hip fractures is projected to rise 11.9 %-from 258,000 in 2010 to 289,000 (Projection Interval [PI] = 193,000-419,000) in 2030. The number of hip fractures among men is expected to increase 51.8 % (PI = 15.9-119.4 %) while the number among women is expected to decrease 3.5 % (PI = -44.3-37.3 %). These trends will affect the future distribution of hip fractures among the older population.

CONCLUSIONS

Although the number of older people in the U.S.A. will increase appreciably over the next 20 years, the expected increase in the total number of hip fractures will be largely offset by decreasing hip fracture rates among women. However, this trend will be counterbalanced by rising numbers of hip fractures among men.

The impact of ingested potato type II inhibitors on the production of the major serine proteases in the gut of Helicoverpa armigera

The flowers of the ornamental tobacco produce high levels of a series of 6 kDa serine protease inhibitors (NaPIs) that are effective inhibitors of trypsins and chymotrypsins from lepidopteran species. These inhibitors have a negative impact on the growth and development of lepidopteran larvae and have a potential role in plant protection. Here we investigate the effect of NaPIs on the activity and levels of serine proteases in the gut of Helicoverpa armigera larvae and explore the adaptive mechanisms larvae employ to overcome the negative effects of NaPIs in the diet. Polyclonal antibodies were raised against a Helicoverpa punctigera trypsin that is a target for NaPIs and two H. punctigera chymotrypsins; one that is resistant and one that is susceptible to inhibition by NaPIs. The antibodies were used to optimize procedures for extraction of proteases for immunoblot analysis and to assess the effect of NaPIs on the relative levels of the proteases in the gut and frass. We discovered that consumption of NaPIs did not lead to over-production of trypsins or chymotrypsins but did result in excessive loss of proteases to the frass.

Ultrafast dynamics of nonequilibrium resonance energy transfer and probing globular protein flexibility of myoglobin

Protein structural plasticity is critical to many biological activities and accurate determination of its temporal and spatial fluctuations is challenging and difficult. Here, we report our extensive characterization of global flexibility of a globular heme protein of myoglobin using resonance energy transfer as a molecular ruler. With site-directed mutagenesis, we use a tryptophan scan to examine local structural fluctuations from B to H helices utilizing 10 tryptophan-heme energy transfer pairs with femtosecond resolution. We observed ultrafast resonance energy transfer dynamics by following a nearly single exponential behavior in 10-100 ps, strongly indicating that the globular structure of myoglobin is relatively rigid, with no observable static or slow dynamic conformational heterogeneity. The observation is against our molecular dynamics simulations, which show large local fluctuations and give multiple exponential energy transfer behaviors, suggesting too flexible of the global structure and thus raising a serious issue of the force fields used in simulations. Finally, these ultrafast energy transfer dynamics all occur on the similar time scales of local environmental relaxations (solvation), leading to nonexponential processes caused by energy relaxations, not structural fluctuations. Our analyses of such processes reveal an intrinsic compressed- and/or stretched-exponential behaviors and elucidate the nature of inherent nonequilibrium of ultrafast resonance energy transfer in proteins. This new concept of compressed nonequilibrium transfer dynamics should be applied to all protein studies by time-resolved Förster resonance energy transfer (FRET).

Mapping solvation dynamics at the function site of flavodoxin in three redox states

Flavoproteins are unique redox coenzymes, and the dynamic solvation at their function sites is critical to the understanding of their electron-transfer properties. Here, we report our complete characterization of the function-site solvation of holoflavodoxin in three redox states and of the binding-site solvation of apoflavodoxin. Using intrinsic flavin cofactor and tryptophan residue as the local optical probes with two site-specific mutations, we observed distinct ultrafast solvation dynamics at the function site in the three states and at the related recognition site of the cofactor, ranging from a few to hundreds of picoseconds. The initial ultrafast motion in 1-2.6 ps reflects the local water-network relaxation around the shallow, solvent-exposed function site. The second relaxation in 20-40 ps results from the coupled local water-protein fluctuation. The third dynamics in hundreds of picoseconds is from the intrinsic fluctuation of the loose loops flanking the cofactor at the function site. These solvation dynamics with different amplitudes well correlate with the redox states from the oxidized form, to the more rigid semiquinone and to the much looser hydroquinone. This observation of the redox control of local protein conformation plasticity and water network flexibility is significant, and such an intimate relationship is essential to the biological function of interprotein electron transfer.

Ultrafast proteinquake dynamics in cytochrome c

We report here our systematic studies of the heme dynamics and induced protein conformational relaxations in two redox states of ferric and ferrous cytochrome c upon femtosecond excitation. With a wide range of probing wavelengths from the visible to the UV and a site-directed mutation we unambiguously determined that the protein dynamics in the two states are drastically different. For the ferrous state the heme transforms from 6-fold to 5-fold coordination with ultrafast ligand dissociation in less than 100 fs, followed by vibrational cooling within several picoseconds, but then recombining back to its original 6-fold coordination in 7 ps. Such impulsive bond breaking and late rebinding generate proteinquakes and strongly perturb the local heme site and shake global protein conformation, which were found to completely recover in 13 and 42 ps, respectively. For the ferric state the heme however maintains its 6-fold coordination. The dynamics mainly occur at the local site, including ultrafast internal conversion in hundreds of femtoseconds, vibrational cooling on the similar picosecond time scale, and complete ground-state recovery in 10 ps, and no global conformation relaxation was observed.

Self-reported falls and fall-related injuries among persons aged>or=65 years--United States, 2006

PROBLEM

In 2005, 15,802 persons aged>or=65 years died from fall injuries. How many older adults seek outpatient treatment for minor or moderate fall injuries is unknown.

METHOD

To estimate the percentage of older adults who fell during the preceding three months, the Centers for Disease Control and Prevention (CDC) analyzed data from two questions about falls included in the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey.

RESULTS

Approximately 5.8 million (15.9%) persons aged>or=65 years reported falling at least once during the preceding three months, and 1.8 million (31.3%) of those who fell sustained an injury that resulted in a doctor visit or restricted activity for at least one day.

DISCUSSION

This report presents the first national estimates of the number and proportion of persons reporting fall-related injuries associated with either doctor visits or restricted activity.

SUMMARY

The prevalence of falls reinforces the need for broader use of scientifically proven fall-prevention interventions.

IMPACT ON INDUSTRY

Falls and fall-related injuries represent an enormous burden to individuals, society, and to our health care system. Because the U.S. population is aging, this problem will increase unless we take preventive action by broadly implementing evidence-based fall prevention programs. Such programs could appreciably decrease the incidence and health care costs of fall injuries, as well as greatly improve the quality of life for older adults.

Fall-related traumatic brain injury deaths and hospitalizations among older adults--United States, 2005

PROBLEM

Among older adults, both unintentional falls and traumatic brain injuries (TBI) result in significant morbidity and mortality; however, only limited national data on fall-related TBI are available.

METHOD

To examine the relationship between older adult falls and TBI deaths and hospitalizations, CDC analyzed 2005 data from the National Center for Health Statistics' National Vital Statistics System and the Agency for Healthcare Research and Quality's Nationwide Inpatient Sample.

RESULTS

In 2005, among adults>or=65 years, there were 7946 fall-related TBI deaths and an estimated 56,423 hospitalizations for nonfatal fall-related TBI in the United States. Fall-related TBI accounted for 50.3% of unintentional fall deaths and 8.0% of nonfatal fall-related hospitalizations.

SUMMARY

These findings underscore the need for greater dissemination and implementation of evidence-based fall prevention interventions.

Visualization of complex automotive data

Making complicated data easier to understand has always been a challenge. Four types of visualization applications (CAD, generalized, specialized, and custom) have successfully been used by automotive manufacturers such as General Motors to help meet this goal. Here are some ways that common processes can be developed for all types of visualization.

The costs of fatal and non-fatal falls among older adults

OBJECTIVE

To estimate the incidence and direct medical costs for fatal and non-fatal fall injuries among US adults aged >or=65 years in 2000, for three treatment settings stratified by age, sex, body region, and type of injury.

METHODS

Incidence data came from the 2000 National Vital Statistics System, 2001 National Electronic Injury Surveillance System-All Injury Program, 2000 Health Care Utilization Program National Inpatient Sample, and 1999 Medical Expenditure Panel Survey. Costs for fatal falls came from Incidence and economic burden of injuries in the United States; costs for non-fatal falls were based on claims from the 1998 and 1999 Medicare fee-for-service 5% Standard Analytical Files. A case crossover approach was used to compare the monthly costs before and after the fall.

RESULTS

In 2000, there were almost 10 300 fatal and 2.6 million medically treated non-fatal fall related injuries. Direct medical costs totaled 0.2 billion dollars for fatal and 19 billion dollars for non-fatal injuries. Of the non-fatal injury costs, 63% (12 billion dollars ) were for hospitalizations, 21% (4 billion dollars) were for emergency department visits, and 16% (3 billion dollars) were for treatment in outpatient settings. Medical expenditures for women, who comprised 58% of the older adult population, were 2-3 times higher than for men for all medical treatment settings. Fractures accounted for just 35% of non-fatal injuries but 61% of costs.

CONCLUSIONS

Fall related injuries among older adults, especially among older women, are associated with substantial economic costs. Implementing effective intervention strategies could appreciably decrease the incidence and healthcare costs of these injuries.

Motor imagery of gait: a quantitative approach

Motor imagery (MI) is widely used to study cognitive aspects of the neural control of action. Prior studies were mostly centred on hand and arm movements. Recently a few studies have used imagery tasks to explore the neurophysiology of human gait, but it remains unclear how to ascertain whether subjects actually perform imagery of gait as requested. Here we describe a new experimental protocol to quantify imagery of gait, by behaviourally distinguishing it from visual imagery (VI) processes and by showing its temporal correspondence with actual gait. Fourteen young healthy subjects performed two imagery tasks and an actual walking (AW) task. During both imagery tasks subjects were sitting on a chair and faced a computer screen that presented photographs of walking trajectories. During one task (MI), subjects had to imagine walking along the walking trajectory. During the other task (VI), subjects had to imagine seeing a disc moving along the walking trajectory. During the AW task, subjects had to physically walk along the same walking trajectory as presented on the photographs during the imagery tasks. We manipulated movement distance by changing the length of the walking trajectory, and movement difficulty by changing the width of the walking trajectory. Subjects reported onset and offset of both actual and imagined movements with a button press. The time between the two button presses was taken as the imagined or actual movement time (MT). MT increased with increasing path length and decreasing path width in all three tasks. Crucially, the effect of path width on MT was significantly stronger during MI and AW than during VI. The results demonstrate a high temporal correspondence between imagined and AW, suggesting that MI taps into similar cerebral resources as those used during actual gait. These results open the possibility of using this protocol for exploring neurophysiological correlates of gait control in humans.

Gender differences for non-fatal unintentional fall related injuries among older adults

OBJECTIVES

To quantify gender differences for non-fatal unintentional fall related injuries among US adults age 65 years and older treated in hospital emergency departments (EDs).

METHODS

The authors analyzed data from a nationally representative sample of ED visits for January 2001 through December 2001, available through the National Electronic Injury Surveillance System All Injury Program (NEISS-AIP). For each initial ED visit, coders record one principal diagnosis (usually the most severe) and one primary part of the body affected.

RESULTS

Based on 22,560 cases, an estimated 1.64 million older adults were treated in EDs for unintentional fall injuries. Of these, approximately 1.16 million, or 70.5%, were women. Fractures, contusions/abrasions, and lacerations accounted for more than three quarters of all injuries. Rates for injury diagnoses were generally higher among women, most notably for fractures which were 2.2 times higher than for men. For all parts of the body, women's injury rates exceeded those of men. Rate ratios were greatest for injuries of the leg/foot (2.3), arm/hand (2.0), and lower trunk (2.0). The hospitalization rate for women was 1.8 times that for men.

CONCLUSIONS

Among older adults, non-fatal fall related injuries disproportionately affected women. Much is known about effective fall prevention strategies. We need to refine, promote, and implement these interventions. Additional research is needed to tailor interventions for different populations and to determine gender differences in the underlying causes and/or circumstances of falls. This information is vital for developing and implementing targeted fall prevention strategies.

Interference effects demonstrate distinct roles for visual and motor imagery during the mental representation of human action

Four experiments were completed to characterize the utilization of visual imagery and motor imagery during the mental representation of human action. In Experiment 1, movement time functions for a motor imagery human locomotion task conformed to a speed-accuracy trade-off similar to Fitts' Law, whereas those for a visual imagery object motion task did not. However, modality-specific interference effects in Experiment 2 demonstrate visual and motor imagery as cooperative processes when the action represented is tied to visual coordinates in space. Biomechanic-specific motor interference effects found in Experiment 3 suggest one basis for separation of processing channels within motor imagery. Finally, in Experiment 4 representations of motor actions were found to be generated using only visual imagery under certain circumstances: namely, when the imaginer represented the motor action of another individual while placed at an opposing viewpoint. These results suggest that the modality of representation recruited to generate images of human action is dependent on the dynamic relationship between the individual, movement, and environment.

Recreational injuries among older Americans, 2001

OBJECTIVE

To describe the epidemiology of non-fatal recreational injuries among older adults treated in United States emergency departments including national estimates of the number of injuries, types of recreational activities, and diagnoses.

METHODS

Injury data were provided by the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), a nationally representative subsample of 66 out of 100 NEISS hospitals. Potential cases were identified using the NEISS-AIP definition of a sport and recreation injury. The authors then reviewed the two line narrative to identify injuries related to participation in a sport or recreational activity among men and women more than 64 years old.

RESULTS

In 2001, an estimated 62 164 (95% confidence interval 35 570 to 88 758) persons >/=65 years old were treated in emergency departments for injuries sustained while participating in sport or recreational activities. The overall injury rate was 177.3/100 000 population with higher rates for men (242.5/100 000) than for women (151.3/100 000). Exercising caused 30% of injuries among women and bicycling caused 17% of injuries among men. Twenty seven percent of all treated injuries were fractures and women (34%) were more likely than men (21%) to suffer fractures.

CONCLUSIONS

Recreational activities were a frequent cause of injuries among older adults. Fractures were common. Many of these injuries are potentially preventable. As more persons engage in recreational activities, applying known injury prevention strategies will help to reduce the incidence of these injuries.

The formation of cluster elliptical galaxies as revealed by extensive star formation

The most massive galaxies in the present-day Universe are found to lie in the centres of rich clusters. They have old, coeval stellar populations suggesting that the bulk of their stars must have formed at early epochs in spectacular starbursts, which should be luminous phenomena when observed at submillimetre wavelengths. The most popular model of galaxy formation predicts that these galaxies form in proto-clusters at high-density peaks in the early Universe. Such peaks are indicated by massive high-redshift radio galaxies. Here we report deep submillimetre mapping of seven high-redshift radio galaxies and their environments. These data confirm not only the presence of spatially extended regions of massive star-formation activity in the radio galaxies themselves, but also in companion objects previously undetected at any wavelength. The prevalence, orientation, and inferred masses of these submillimetre companion galaxies suggest that we are witnessing the synchronous formation of the most luminous elliptical galaxies found today at the centres of rich clusters of galaxies.

Motor vehicle and fall related deaths among older Americans 1990-98: sex, race, and ethnic disparities

OBJECTIVES

To examine differences in motor vehicle and fall related death rates among older adults by sex, race, and ethnicity.

METHODS

Annual mortality tapes for 1990-98 provided demographic data including race and ethnicity, date, and cause of death. Trend analyses were conducted using Poisson regression.

RESULTS

From 1990-98, overall motor vehicle related death rates remained stable while death rates from unintentional falls increased. Motor vehicle and fall related death rates were higher among men. Motor vehicle related death rates were higher among people of color while fall related death rates were higher among whites. Among whites, fall death rates increased significantly during the study period, with an annual relative increase of 3.6% for men and 3.2% for women.

CONCLUSIONS

The risk of death from motor vehicle and fall related injuries among older adults differed by sex, race and ethnicity, results obscured by simple age and sex specific death rates. This study found important patterns and disparities in these death rates by race and ethnicity useful for identifying high risk groups and guiding prevention strategies.

The public health perspective in health promotion and disability prevention for older adults: the role of the Centers for Disease Control and Prevention

As the United States federal public health agency, the role of the Centers for Disease Control and Prevention (CDC) in health promotion and disability prevention with older adults encompasses research, surveillance and program activities in aging. This article characterizes the objectives and context of prevention in later life and summarizes CDCs functions, collaborative partnerships with public health agencies and other organizations, and range of activities in older adult health. As a major focus of these efforts, chronic disease risk reduction is examined through CDC's efforts in the area of physical activity; a longitudinal investigation of osteoarthritis in an older biracial rural population; and chronic illness self-management programs as a prototype for secondary prevention. Other CDC activities highlighted include addressing the burden of vaccine-preventable diseases through CDC-funded programs to improve immunization coverage in older adults, and falls prevention interventions and resources. Future directions in aging at CDC are also outlined.

Submillimeter evidence for the coeval growth of massive black holes and galaxy bulges

The correlation, found in nearby galaxies, between black hole mass and stellar bulge mass implies that the formation of these two components must be related. Here we report submillimeter photometry of eight x-ray-absorbed active galactic nuclei that have luminosities and redshifts characteristic of the sources that produce the bulk of the accretion luminosity in the universe. The four sources with the highest redshifts are detected at 850 micrometers, with flux densities between 5.9 and 10.1 millijanskies, and hence are ultraluminous infrared galaxies. If the emission is from dust heated by starbursts, then the majority of stars in spheroids were formed at the same time as their central black holes built up most of their mass by accretion. This would account for the observed demography of massive black holes in the local universe. The skewed rate of submillimeter detection with redshift is consistent with a high redshift epoch of star formation in radio-quiet active galactic nuclei, similar to that seen in radio galaxies.

Reducing falls and resulting hip fractures among older women

SCOPE OF THE PROBLEM

Fall-related injuries are the leading cause of injury deaths and disabilities among older adults (i.e., persons aged > or = 65 years). The most serious fall injury is hip fracture; one half of all older adults hospitalized for hip fracture never regain their former level of function. In 1996, a total of 340,000 hospitalizations for hip fracture occurred among persons aged > or = 65 years, and 80% of these admissions occurred among women. From 1988 to 1996, hip fracture hospitalization rates for women aged > or = 65 years increased 23%.

ETIOLOGIC OR RISK FACTORS

Risk factors for falls include increasing age, muscle weakness, functional limitations, environmental hazards, use of psychoactive medications, and a history of falls. Age is also a risk factor for hip fracture. Women aged > or = 85 years are nearly eight times more likely than women aged 65-74 years to be hospitalized for hip fracture. White women aged > or = 65 years are at higher risk for hip fracture than black women. Other riskfactors for hip fracture include lack of physical activity, osteoporosis, low body mass index, and a previous hip fracture.

RECOMMENDATIONS FOR PREVENTION

Because approximately 95% of hip fractures result from falls, minimizing fall risk is a practical approach to reducing these serious injuries. Research demonstrates that effective fall prevention strategies require a multifaceted approach with both behavioral and environmental components. Important elements include education and skill building to increase knowledge about fall risk factors, exercise to improve strength and balance, home modifications to reduce fall hazards, and medication assessment to minimize side effects (e.g., dizziness and grogginess).

PROGRAM AND RESEARCH NEEDS

Coordination needs to be improved among the diverse Federal, state, and local organizations that conduct fall prevention activities. The effectiveness of existing fall prevention programs among specific groups of women (e.g., those aged > or = 85 years or living with functional limitations) needs careful evaluation. New primary fall prevention approaches are needed (e.g., characterizing footwear that promotes stability), as well as secondary prevention strategies (e.g., protective hip pads) that can prevent injuries when falls occur. Finally, efforts are needed to increase collaboration among national experts from various disciplines, to reach consensus regarding priority research areas and program issues, and to work toward long-term strategies for reducing falls and fall-related injuries among older adults.

CONCLUSION

Persons aged > or = 65 years constitute the fastest-growing segment of the U.S. population. Without effective intervention strategies, the number of hip fractures will increase as the U.S. population ages. Fall prevention programs have reduced falls and fall-related injuries among high-risk populations using multifaceted approaches that include education, exercise, environmental modifications, and medication review. These programs need to be evaluated among older adults aged > or = 65 years who are living independently in the community. In addition, secondary prevention strategies are needed to prevent hip fractures when falls occur. Effective public health strategies need to be implemented to promote behavioral changes, improve current interventions, and develop new fall prevention strategies to reduce future morbidity and mortality associated with hip fractures among older adults.

New aspects of motion perception: selective neural encoding of apparent human movements

Perception of apparent motion operates somewhat differently for objects and human figures. Depending on the interstimulus interval, the latter d may give rise to either perception of a direct path (i.e. biologically impossible) or indirect path (i.e. biologically possible). Here, PET was used to investigate whether a change in brain activity accompanies this perceptual shift. We found neural encoding of apparent motion to be a function of the intrinsic properties of the stimulus presented (object vs human) as well as the kind of human movement path perceived (biomechanically possible vs impossible). Motor and parietal cortex were only involved for possible motion which suggests that these regions are selectively activated to process actions which conform to the capabilities of the observer.

Surveillance for injuries and violence among older adults

PROBLEM/CONDITION

Injuries and violence are major causes of disability and death among adults aged > or =65 years in the United States. Injuries impair older adults' quality of life and result in billions of dollars in health-care expenditures each year.

REPORTING PERIOD

This report reviews 1987-1996 data regarding fall-related deaths, 1988-1996 data on hospitalizations for hip fracture, 1990-1997 data regarding motor vehicle-related injuries, 1990-1996 data on suicides, and 1987-1996 data on homicides.

DESCRIPTION OF SYSTEMS

Data on fall-related deaths, suicides, and homicides are from the National Center for Health Statistics annual mortality data tapes for 1987-1996. Homicide data are supplemented with information from the Federal Bureau of Investigation's Supplemental Homicide Reports for 1987-1996. Data on hospitalizations for hip fracture are from the 1988-1996 National Hospital Discharge Surveys. Information regarding motor vehicle-related injuries for 1990-1997 is from the National Highway Traffic Safety Administration's Fatality Analysis Reporting System and General Estimates System.

RESULTS

Rates of fall-related deaths for older adults increased sharply with advancing age and were consistently higher among men in all age categories. Men were 22% more likely than women to sustain fatal falls. A trend of increasing rates of fall-related deaths was observed from 1987 through 1996 in the United States, although rates were consistently lower for women throughout this period. Rates of hospitalizations for hip fracture differed by age and were higher for white women than for other groups. Rates increased with advancing age for both sexes but were consistently higher for women in all age categories. U.S. hospitalization rates for hip fracture increased for women from 1988 through 1996 while the rates for men remained stable. Rates of motor vehicle-related injuries increased slightly from 1990 through 1997, and marked variations in state-specific death rates were observed; in most states, older men had death rates approximately twice those for older women. Although suicide rates remain higher among older adults than among any other age group, rates of suicide among adults aged > or =65 years decreased 16% during the study period. Suicide rates among older adults varied by sex and age group. Homicide rates declined 36% among older adults. Homicide rates were highest for black men, followed by black women and white men; the homicide risk for blacks relative to whites decreased from 4.8 to 3.9 per 100,000 persons, indicating that the gap between rates for blacks and whites is closing. Half of the older homicide victims were killed by someone they knew.

INTERPRETATION

The increase in rates of fall-related deaths and hip fracture hospitalizations from 1988 through 1996 might reflect a change in the proportion of adults aged > or =85 years compared with those aged 65-84 years - a change that results, in part, from reduced mortality from cardiovascular and other chronic diseases. Fall-related death rates might be higher among older men because they often have a higher prevalence of comorbid conditions than women of similar age. Racial differences in hospitalization rates might have some underlying biologic basis; the prevalence of osteoporosis, a condition that contributes to reduced bone mass and increased bone fragility, is greatest among older white women. Compared with whites aged > or =65 years, blacks of comparable ages have greater bone mass and are less likely to sustain fall-related hip fractures. Additional studies are needed to determine why rates of motor vehicle-related injury have increased slightly among older adults and why these rates vary by state. Declining rates of suicide among older adults might be related to changes in the effect or type of risk factors traditionally observed in this age group. Research is needed to identify reasons for variations in suicide rates among older persons. Homicides among olde

Client perceptions of a rural-based cardiac rehabilitation program: a grounded theory approach

A grounded theory approach was used in an attempt to generate theory about client perceptions and experiences of a cardiac rehabilitation program conducted in a rural community. A series of interviews was conducted with a selection of people who had experienced a life-threatening cardiac event. The cohort was divided into two groups: those who attended a cardiac rehabilitation program and those who did not. The findings, though not generalisable, allowed the generation of a number of theories (which may come to be the genesis of future research) regarding the differences in the physiological, psychological, sociological and vocational well-being between the groups. The findings also suggested that location of the program, the times it was conducted, and the communication skills of significant healthcare workers who recruited participants were important factors affecting attendance.

An evaluation of the accuracy and efficiency of a school screening model that uses a questionnaire

The role of the school nurse is changing to meet the increasing needs for health promotion and health education. However, the evolution is being hampered by the inefficient work practices involved in undertaking some of the more traditional tasks such as school screening. A survey questionnaire model of screening was developed and trialed with a sample of students and parents and then compared with the results of the more traditional one to one screening programme. The questionnaire survey model was evaluated for accuracy and efficiency against the traditional screening model. The questionnaire method exhibited a relatively low error rate and required one third of the time to complete when compared with the traditional screening programme. The implications of these findings as well as the advantages and limitations of each model are examined in the discussion.

Chronic medical conditions and risk of fall injury events at home in older adults

OBJECTIVE

To evaluate the association between selected chronic medical conditions (CMCs) and fall injury events at home among community-dwelling older persons.

DESIGN

Population-based case-control study.

SETTING

The general community.

PARTICIPANTS

Persons aged 65 and older living at home, excluding those using a wheelchair; 467 cases and 691 control subjects were studied.

MEASUREMENTS

The main independent variables were self-reported histories of 10 CMCs: diabetes, high blood pressure, anemia, heart attack, Parkinson's disease, stroke, emphysema, cancer (other than skin), cataracts, and glaucoma.

RESULTS

The final multivariate model included variables for age, sex, body mass, dependency in activities of daily living, current exercise (three or more times per week), mental status scores, and three CMCs. Persons with a history of stroke or anemia had an increased risk of a fall injury event: for stroke the adjusted odds ratio (aOR) equalled 1.7 (95% confidence interval (CI), 1.0-3.0); for anemia the aOR equalled 1.5 (95% CI, 1.0-2.2). Those with a history of high blood pressure had decreased risk (aOR = .7, 95% CI 0.5-0.9).

CONCLUSIONS

Persons 65 and older with a self-reported history of anemia or stroke are at increased risk of a fall injury event in the home, whereas those with a self-reported history of high blood pressure are at decreased risk.

The short-term natural history of irritable bowel syndrome: a time-series analysis

Although researchers have studied irritable bowel syndrome (IBS), including its physiological and psychological characteristics and treatments' effectiveness, basic descriptive information about IBS has been limited to lists of symptoms and explanations of what IBS is not. The purpose of the present study is to describe how core IBS symptoms vary over time. Twenty-five subjects (17 females, 8 males), who were not receiving treatment for IBS, rated the severity of their IBS symptoms daily for 8 weeks. Four symptoms' (abdominal pain, abdominal tenderness, constipation and diarrhea) ratings were slimmed to create a primary IBS symptom score. The data were detrended, then a time-series analysis was performed. Many subjects' IBS severity was predictable over more than one day, and symptoms tended to occur in clusters rather than randomly. Anxiety and depression were slightly to moderately correlated with IBS variables, but virtually all of these correlations were nonsignificant.

Physical activity, functional limitations, and the risk of fall-related fractures in community-dwelling elderly

This case-control study examines the association of vigorous and mild physical activity with fall-related fractures in a community-dwelling population age 65 and older in South Florida. Vigorous physical activity was defined as exercising, doing heavy housecleaning, or other hard labor three or more times per week in the month prior to the index date; mild physical activity was defined as the number of hours per day subjects reported spending on their feet. A case was any subject who sustained a fall-related fracture (ICD-9CM-800 through ICD-9CM-829) over a 21-month period (n = 471). Controls were at 10% random sample selected from the Health Care Financing Administration Medicare files (n = 712). The presence of any limitation in activities of daily living (ADL) significantly modified the effect of vigorous physical activity. Physically active subjects with no limitations (ADL = 0) were less likely to sustain a fall-related fracture than were inactive subjects with an adjusted odds ratio (aOR) of 0.6, (0.5-0.8 95% CI), and active subjects with any limitation (ADL > or = 1) had an aOR of 3.2 (1.1-9.8 95% CI). Limiting this analysis to 159 hip fracture cases produced similar results. Mild physical activity was not associated with fracture. These results suggest that vigorous physical activity is associated with a lower fracture risk among elderly persons who have no limitation in ADL and with a higher risk among those with any limitations.

Risk factors for injuries from in-line skating and the effectiveness of safety gear

BACKGROUND

Of the estimated 22.5 million people participating in in-line skating in the United States in 1995, about 100,000 were sufficiently injured so as to require emergency department care. We investigated the effectiveness of wrist guards, elbow pads, knee pads, and helmets in preventing skating injuries.

METHODS

We used data from the 91 hospital emergency departments participating in the National Electronic Injury Surveillance System, a national probability sample of randomly selected hospitals with 24-hour emergency departments. Injured in-line skaters who sought medical attention between December 1992 and July 1993 were interviewed by telephone. We conducted a case-control study of skaters who injured their wrists, elbows, knees, or heads as compared with skaters with injuries to other parts of their bodies.

RESULTS

Of 206 eligible injured subjects, 161 (78 percent) were interviewed. Wrist injuries were the most common (32 percent); 25 percent of all injuries were wrist fractures. Seven percent of injured skaters wore all the types of safety gear; 46 percent wore none. Forty-five percent wore knee pads, 33 percent wrist guards, 28 percent elbow pads, and 20 percent helmets. The odds ratio for wrist injury, adjusted for age and sex, for those who did not wear wrist guards, as compared with those who did, was 10.4 (95 percent confidence interval, 2.9 to 36.9). The odds ratio for elbow injury, adjusted for the number of lessons skaters had had and whether or not they performed trick skating, was 9.5 (95 percent confidence interval, 2.6 to 34.4) for those who did not wear elbow pads. Non-use of knee pads was associated with a nonsignificant increase in the risk of knee injury (crude odds ratio, 2.2; 95 percent confidence interval, 0.7 to 7.2). The effectiveness of helmets could not be assessed.

CONCLUSIONS

Wrist guards and elbow pads are effective in protecting in-line skaters against injuries.

Cross-resistance phenotypes of fluconazole-resistant Candida species: results with 655 clinical isolates with different methods

Candida species test results with two broth macrodilution antifungal susceptibility methods were compared using 655 clinical isolates, and the frequency of fluconazole resistance and phenotypes of azole cross resistance are detailed. A method with an 80% inhibition endpoint (as compared to clear tube endpoint) suggested greater fluconazole susceptibility to C. albicans but had a less pronounced effect on C. glabrata, and seemed to have a negligible influence on results with C. parapsilosis and C. tropicalis. The latter were grouped as susceptible and resistant (based on achievable blood levels), respectively, by both methods. Cross resistance was method dependent and more pronounced with itraconazole than ketoconazole. In vivo correlations are needed to validate the groupings proposed by any in vitro method.

A standardized instrument to assess hazards for falls in the home of older persons

Hazards in the home are implicated in up to half of all falls among older persons. Yet, the instruments used to identify these hazards usually have been unstandardized, have lacked specific definitions of hazards, and have not been evaluated. Therefore, in 1988, as part of the Study to Assess Falls among the Elderly, in Miami Beach, Florida, the authors evaluated the reliability of a standardized instrument used for assessing the training of evaluators and assessing home environments. Based on up to 176 observations for each potential hazard, the interviewers' assessment of hazards such as throw rugs, tripping hazards, light switch hazards, and hazardous bath surfaces had good overall reliability (kappa = 0.65-0.92). Their assessment of grab-bars and hazardous furniture was unreliable (kappa = 0.18-0.35). Variations in the reliability reflect the difficulty in creating definitions that are simple to be understood and used, yet detailed enough to produce sensitive and specific survey items. Investigators studying falls among older persons should use standardized definitions to train evaluators and assess environmental hazards.

Alcohol as a risk factor for fall injury events among elderly persons living in the community

OBJECTIVE

To determine if alcohol use is a risk factor for fall injury events among community-dwelling older persons.

DESIGN

Case-control study.

SETTING

South Miami Beach, Florida.

PARTICIPANTS

320 persons 65 or older who sought treatment at six area hospitals for injuries resulting from falls; 609 controls, matched for sex and age, selected randomly from Health Care Financing Administration (Medicare) files.

MAIN INDEPENDENT VARIABLES

Self-reported current alcohol use.

RESULTS

No association was found between fall injury events and average weekly alcohol use.

CONCLUSIONS

Further efforts at reducing injuries to older persons from falls should concentrate on other modifiable risk factors, including adequate treatment of underlying medical conditions, reducing inappropriate psychotropic medication use, and installing safety devices in the home.

Histologic types of benign breast disease and the risk for breast cancer. The Cancer and Steroid Hormone Study Group

Specific histologic types of benign breast disease (BBD) may increase breast cancer risk. The authors analyzed data from a population-based, case-control study of women aged 20 to 54 with newly diagnosed breast cancer and control subjects randomly selected from the general population. A panel of pathologists classified the histologic findings of biopsy slides for 433 women with breast cancer and 261 control subjects, all of whom had a history of biopsy for BBD, as to the presence of epithelial hyperplasia, atypia, and other histologic features. When compared with women who had never had a breast biopsy, women with BBD without hyperplasia had an odds ratio of 1.5 (95% confidence limits [CL] 1.3 to 1.9), women with hyperplasia without atypia had an odds ratio of 1.8 (CL = 1.3, 2.4), and women with hyperplasia and atypia had an odds ratio of 2.6 (CL = 1.6, 4.1). Fibroadenoma was an independent risk factor for breast cancer (odds ratio = 1.7; CL = 1.1, 2.5). These findings suggest that women with BBD with epithelial hyperplasia either with or without atypia and women with fibroadenoma should be monitored carefully because of their elevated risk for breast cancer.

Working with the elderly: do student nurses care for it?

This study investigates neophyte student nurses' attitudes to working with the elderly through placing them in relation to attitudes to other nursing career options and by exploring student nurses' reasons for such attitudes. The results are based on a questionnaire answered by 610 students from five NSW teaching institutions. The results indicate that nurses rate working with the elderly very poorly, and that this negativity is based on unfavourable stereotypes of aged persons and their care. These findings are placed in the context of projected demographic changes and the pressures these will place on the health care system and its need for nurses qualified in this area of work.

Race and weight change in US women: the roles of socioeconomic and marital status

BACKGROUND

The prevalence of overweight among Black women in the US is higher than among White women, but the causes are unknown.

METHODS

We examined the weight change for 514 Black and 2,770 White women who entered the first Health and Nutrtion Examination Survey (1971-75) at ages 25-44 years and were weighed again a decade later. We used multivariate analyses to estimate the weight-change effectgs associated with race, family income, education, and marital change.

RESULTS

After multiple adjustments, Black race, education below college level, and becoming married during the follow-up interval were each independently associated with an increased mean weight change. Using multivariate logistic analyses, Black race was not independently associated with an increased risk of major weight gain (change greater than or equal to +13 kg), but it was associated with a reduced likelihood of major weight loss (change less than or equal to -7 kg) (odds ratio - 0.64 [95% CI -0.41, 0.97])]. Very low family income was independently associated with the likelihood of both major weight gain (OR - 1.71 [95% CI - 1.15, 2.55]) and major weight loss (OR - 1.86 [95% CI - 1.18, 2.95]).

CONCLUSIONS

Amont US women, Black race is independently associated with a reduced likelihood of major weight loss, but not with major weight gain. Women at greatest risk of weight gain are those with education below college level, those entering marriage, and those with very low family income.

The incidence of fall injury events among the elderly in a defined population

Falls are a leading cause of death from injury among older persons in the United States, and about one in three older persons falls each year. Yet, reliable estimates of the incidence of fall injury events in a population-based setting are not readily available. Therefore, the authors analyzed population-based surveillance data, between July 1985 and June 1987, from the Study to Assess Falls Among the Elderly, Miami Beach, Florida. The rate of fall injury events coming to acute medical attention increased exponentially with age for both elderly men and women (predominantly white), reaching a high for those aged 85 years or more of 138.5 per 1,000 for males and 158.8 per 1,000 for females. Compared with males, females had a higher incidence of fractures other than skull. Males were nearly twice as likely to die, however, following a fall injury event than were females. Of those fall injury events identified through the surveillance system, about 42% resulted in hospital admission. The mean length of hospital stay was 11.6 days overall and was 15.5 days for hip fracture, 9.8 days for skull fracture/intracranial injury, 11.2 days for all other fractures, and 9.1 days for all other injuries. About 50% of fall injury events that occurred at home and required hospital admission resulted in a person being discharged to a nursing home.

Viral hepatitis as a major cause of maternal mortality in Addis Ababa, Ethiopia

Causes of maternal mortality were investigated in Addis Ababa, Ethiopia, from September 1981 to September 1983. Viral hepatitis ranked third among the leading causes of maternal mortality behind septic abortion and puerperal sepsis. There were 26 deaths from viral hepatitis during the 2-year study period for a hospital maternal mortality rate of 91.0 per 100,000 live births. Although 30% of women who died of all maternal causes received antenatal care in Addis Ababa, only 13% of women who died from viral hepatitis in our hospital study received antenatal care. Low socio-economic status (SES) has been shown to be associated with low antenatal care utilization and with an increased risk of protein malnutrition. Malnutrition is considered a predisposing factor for liver damage. Suggestions for reducing hepatitis transmission and maternal mortality through education, better hygiene, and improved sanitation are discussed.

Alcohol treatment outcome evaluation methodology: state of the art 1980-1984

The methodology of alcohol treatment outcome studies published during two sequential intervals from 1976 through mid-1984 is critically reviewed. Although considerable methodological improvements have occurred over time, major methodological deficiencies continue to characterize much of the literature, with inadequate reporting of subjects' pretreatment characteristics (e.g., severity of dependence) being the most striking problem. Pervasive differences across studies regarding the types of data gathered and the ways in which findings are reported seriously impede attempts to compare studies and weaken the types of conclusions that can be drawn about treatment efficacy in general. It is suggested that journal editors establish standards of reporting for follow-up studies.

Cancer incidence rates among blacks in urban and rural Georgia, 1978-82

The records of the Atlanta Cancer Surveillance Center were reviewed for all incident cases of cancer diagnosed among Black residents of the catchment areas during calendar years 1978 through 1982. The resultant age-adjusted overall cancer incidence rates for urban Blacks were greater than those for rural Blacks. The largest urban excess was found for cancers of the buccal cavity and pharynx. Urban residence also was associated with lung and prostate cancers among males, and pancreatic cancers among females.

Effect of antacid on bioavailability of theophylline from rapid and timed-release drug products

Magnesium aluminum hydroxide suspension (an antacid) was given concurrently with either theophylline anhydrous tablets or theophylline anhydrous timed-release capsules to 13 volunteers using a four-way crossover design. Serum theophylline was measured by reversed-phase high-pressure liquid chromatography. The serum level-time curves were individually fitted to an oral absorption one-compartment open model. The pharmacokinetic parameters (mean +/- SD) KA, K, AUC, and F/V for theophylline from the rapid release theophylline anhydrous tablets were 2.1 +/- 1.3 hr-1, 0.15 +/- 0.06 hr-1, 89.2 +/0 39 microgram hr/ml, and 0.0023 +/- 0.002 kg/ml, respectively; from the anhydrous timed-release capsules, they were 0.27 +/- 0.08 hr-1, 0.20 +/- 0.07 hr-1, 79.0 +/- 27 microgram hr/ml, and 0.0030 +/- 0.007 kg/ml, respectively. The concurrent administration of 15 ml of antacid (magnesium aluminum hydroxide suspension) with the theophylline products did not significantly affect any of these pharmacokinetic parameters. The extent of theophylline bioavailability from all drug products was consistent and similar as shown by the F/V and AUC values.