Factors associated with pharmacologic treatment of osteoporosis in an older home care population

BACKGROUND: A number of studies have shown low rates of osteoporosis treatment. Few, if any, have assessed a comprehensive range of functional and clinical correlates of treatment coverage. Our objective was to examine which sociodemographic, clinical, and functional characteristics are associated with pharmacotherapy for osteoporosis among community-based seniors. METHODS: The study sample included 48,689 home care clients aged >/= 65 years in Ontario, Canada. Treatment coverage (calcium and vitamin D and/or anti-osteoporotic drugs) was assessed in two subgroups, clients with a diagnosis of osteoporosis (without fracture) and those with a prevalent fracture. Sociodemographic, health, and functional measures available from the Resident Assessment Instrument for Home Care (RAI-HC) were assessed as correlates of treatment in multivariable logistic regression analyses. RESULTS: Approximately 59% of clients with a diagnosis of osteoporosis were receiving pharmacotherapy, compared with 27% of those with a prevalent fracture. For both subgroups, treatment coverage was significantly lower among clients with at least three chronic conditions, health instability, fewer than nine medications, functional impairment, and depressive symptoms and among those clients who were widowed. Among clients with a diagnosis of osteoporosis, treatment was positively associated with cognitive impairment and negatively associated with confinement to a wheelchair or bed. Men with a prevalent fracture were significantly less likely to receive treatment, particularly in the absence of an osteoporosis diagnosis. CONCLUSIONS: Many older adults with presumed osteoporosis in our study were not receiving drug therapy for this condition. Indicators of clinical instability and functional decline appear to represent influential factors in treatment decisions. Despite a lower likelihood of treatment among men with a prevalent fracture, this sex difference in treatment largely disappeared in the presence of an osteoporosis diagnosis.     

Validation of Resource Utilization Groups version III for Home Care (RUG-III/HC): evidence from a Canadian home care jurisdiction

BACKGROUND: The case-mix system Resource Utilization Groups version III for Home Care (RUG-III/HC) was derived using a modest data sample from Michigan, but to date no comprehensive large scale validation has been done. OBJECTIVES: This work examines the performance of the RUG-III/HC classification using a large sample from Ontario, Canada. METHODS: Cost episodes over a 13-week period were aggregated from individual level client billing records and matched to assessment information collected using the Resident Assessment Instrument for Home Care, from which classification rules for RUG-III/HC are drawn. The dependent variable, service cost, was constructed using formal services plus informal care valued at approximately one-half that of a replacement worker. RESULTS: An analytic dataset of 29,921 episodes showed a skewed distribution with over 56% of cases falling into the lowest hierarchical level, reduced physical functions. Case-mix index values for formal and informal cost showed very close similarities to those found in the Michigan derivation. Explained variance for a function of combined formal and informal cost was 37.3% (20.5% for formal cost alone), with personal support services as well as informal care showing the strongest fit to the RUG-III/HC classification. CONCLUSIONS: RUG-III/HC validates well compared with the Michigan derivation work. Potential enhancements to the present classification should consider the large numbers of undifferentiated cases in the reduced physical function group, and the low explained variance for professional disciplines.     

Comparing quality of care outcomes between assisted living and nursing homes before and during the COVID-19 pandemic

Background

While assisted living (AL) and nursing home (NHs) residents in share vulnerabilities, AL provides fewer staffing resources and services. Research has largely neglected AL, especially during the COVID-19 pandemic. Our study compared trends of practice-sensitive, risk-adjusted quality indicators between AL and NHs, and changes in these trends after the start of the pandemic.

Methods

This repeated cross-sectional study used population-based resident data in Alberta, Canada. Using Resident Assessment Instrument data (01/2017–12/2021), we created quarterly cohorts, using each resident's latest assessment in each quarter. We applied validated inclusion/exclusion criteria and risk-adjustments to create nine quality indicators and their 95% confidence intervals (CIs): potentially inappropriate antipsychotic use, pain, depressive symptoms, total dependency in late-loss activities of daily living, physical restraint use, pressure ulcers, delirium, weight loss, urinary tract infections. Run charts compared quality indicators between AL and NHs over time and segmented regressions assessed whether these trends changed after the start of the pandemic.

Results

Quarterly samples included 2015–2710 AL residents and 12,881–13,807 NH residents. Antipsychotic use (21%–26%), pain (20%–24%), and depressive symptoms (17%–25%) were most common in AL. In NHs, they were physical dependency (33%–36%), depressive symptoms (26%–32%), and antipsychotic use (17%–22%). Antipsychotic use and pain were consistently higher in AL. Depressive symptoms, physical dependency, physical restraint use, delirium, weight loss were consistently lower in AL. The most notable segmented regression findings were an increase in antipsychotic use during the pandemic in both settings (AL: change in slope = 0.6% [95% CI: 0.1%–1.0%], p = 0.0140; NHs: change in slope = 0.4% [95% CI: 0.3%–0.5%], p < 0.0001), and an increase in physical dependency in AL only (change in slope = 0.5% [95% CI: 0.1%–0.8%], p = 0.0222).

Conclusions

QIs differed significantly between AL and NHs before and during the pandemic. Any changes implemented to address deficiencies in either setting need to account for these differences and require monitoring to assess their impact.     

Braided bronchus: A previously undescribed airway anomaly

Infants with congenital heart disease frequently experience recurrent atelectasis, in many cases associated with anomalous branching of the bronchial tree. The bridging bronchus has been well described and has been associated with both left-sided obstructive lesions and a sling-like left pulmonary artery. We describe a similar, though distinct airway anomaly, the “braided bronchus,” associated with a bridging bronchus in a child with coarctation of the aorta and recurrent atelectasis. Methods used to delineate the “braided bronchus” are described. Pediatr Pulmonol. 1998; 25:348–351. © 1998 Wiley-Liss, Inc.     

Results of revision total knee arthroplasty performed for aseptic loosening

One hundred thirty-seven revision total knee arthroplasties (TKA) performed in 117 patients with failed aseptic metal-to-plastic knees over ten years (1974-1984) were studied to determine the long-term clinical and roentgenographic results and were compared to primary TKA. The mean age was 65 years (range, 32-90 years). Fifty-three percent had rheumatoid arthritis, and 47% had osteoarthritis. The mean interval from initial to revision TKA (129 knees) was four years (range, three months to 11 years) and from the first to second revision (seven knees) was 2.4 years (range, seven months to 5.5 years). The most common reasons for failure were loosening (73%), patellar complications (13%), and instability (10%). The mean follow-up time was 5.2 years (range, two to 12 years). Function, instability, motion, and pain all improved after revision TKA, but these improvements were significantly less than those seen after primary TKA. One-third of the patients still ambulated with crutches, a walker, or not at all. While mean postoperative flexion was 100 degrees, 24% could not flex to 90 degrees. Most patients (90%) were malaligned at the time of failure and remained so after revision (78%). The increased incidence of radiolucent lines (tibial, 61%; femoral, 24%) was not related to increased failure. Complications were not increased over primary TKA. The failure rate was 5.8% at 5.2 years, or approximately 1% per year. A successful clinical result was defined as a knee with mild or no pain, mild or no instability, and flexion to at least 90 degrees.(ABSTRACT TRUNCATED AT 250 WORDS)     

A new combined in-vitro test model for the identification of substances affecting essential sperm functions [published erratum appears in Hum Reprod 1997 Nov;12(11):2580]

Binding of mammalian spermatozoa to the zona pellucida and the induction of the acrosome reaction are prerequisites for successful oocyte fertilization. It has been postulated that xenobiotics that are released in the environment as well as exposure to pharmaceutical medications may be associated with reproductive problems in men and wildlife. Examining physiological and non-physiological effects of particular compounds on sperm functions requires high quality in-vitro test systems. We established a reliable combined in-vitro test system with bovine gametes and evaluated if aliquots of pooled post-thaw spermatozoa are suitable for examining essential sperm functions. Using cryopreserved semen, the PSA-FITC/Hoechst 33258 staining procedure was applicable to evaluate the acrosomal status and cell viability. In the bovine hemizona assay, hemizona indices revealed no differences between cryopreserved and fresh semen. Treatment of post-thaw bovine spermatozoa with progesterone (1 microM or bovine follicular fluid (20%) induced the acrosome reaction from 12% (untreated spermatozoa) to 25% (P < 0.001) and to 22% [corrected] (P < 0.01), respectively. Incubation of both compounds (1 microM progesterone and 20% follicular fluid) raised the percentage of acrosome-reacted spermatozoa to 30% (P < 0001). Our results demonstrate that cryopreserved semen can be integrated into an in-vitro screening model for reproductive toxicology testing. Pooled, cryopreserved bovine spermatozoa will thus permit reproducible experiments for clinical and basic science purposes and may also be applicable for the human system.      

Expediting return of bowel function after colorectal surgery

BackgroundPostoperative ileus is the main determinant of the length of hospital stay after colorectal surgery. Our objective was to analyze modifiable factors, including polyethylene glycol administration, associated with the return of bowel function.MethodsA retrospective review of all patients who underwent elective open partial colectomy from 2004 to 2006 at a single institution.ResultsThe time to the first bowel movement with and without oral intake within 48 hours postoperatively was 76 hours versus 134 hours (P < .001); with and without polyethylene glycol administration it was 73 hours versus 94 hours (P = .001); and with and without frequent ambulation it was 78 hours versus 95 hours (P = .012). With postoperative nasogastric tube drainage, the time to the first bowel movement was 22 hours longer (P = .002).ConclusionsThese data confirm previous findings supporting no nasogastric tube drainage, early feeding, and frequent ambulation after colorectal surgery. Additionally, our data suggest a strong association (P = .001) between the use of polyethylene glycol and the early return of bowel function.