Development and validation of a discriminative quality of life questionnaire for osteoporosis (the OPTQoL).

We report the development and validation of an osteoporosis-targeted quality of life questionnaire to measure the impact of the disease in the general population. From multiple focus groups with women with osteoporosis, healthy women at risk for osteoporosis, spouses and relatives of women with osteoporosis, and health care providers, we identified over 300 potential items related to the disease. A lengthy questionnaire incorporated these items and was administered to a second large study cohort of 222 women with clinical osteoporosis (history of fracture, significant height loss, and/or kyphosis); 101 women with known low bone mineral density levels that would categorize them as osteoporotic but who had not yet shown obvious physical manifestations of the disease; and 142 women with other conditions (such as arthritis, cancer, depression) expected to also have an impact on quality of life. Final items from among the original 300 were chosen for their demonstrated relationship with osteoporosis as measured by clinical manifestations and low bone density and with quality of life measured by a standard generic questionnaire, the SF-36. The final questionnaire contains 26 scored items in three domains-physical activity, adaptations, and fears- and six nonscored questions relating to osteoporotic changes and diagnosis. This instrument is unique among osteoporosis-targeted questionnaires in that it attempts to measure the total impact of the disease on quality of life within a population at a single point in time.

Ascertaining dementia by expert panel in epidemiologic studies of nursing home residents.

A new method for ascertaining dementia in epidemiologic research and the results of a study to evaluate it are described. The method relies on an expert panel of clinicians reviewing clinically relevant information collected by lay evaluators to arrive at a diagnosis based on DSM-III-R criteria. The approach was developed to study dementia in a statewide sample of over 2400 new admissions to 59 nursing homes in Maryland. Expert panel ascertainment of dementia was compared to that obtained by direct clinical evaluation for 100 nursing home residents. Agreement between the panel and direct assessment was 76% (kappa = 0.59) using a three-category classification of dementia, no dementia, and indeterminate. This ascertainment strategy provides an alternative to methods currently in use and is particularly well-suited for populations with a high prevalence, in those dispersed over large geographic areas, and when timely, cost-effective evaluations are required.

The validity of the minimum data set in measuring the cognitive impairment of persons admitted to nursing homes.

OBJECTIVES: This study examined the construct validity of two cognitive scales from the federally mandated Minimum Data Set (MDS) of the nursing home Resident Assessment Instrument. DESIGN: A cross-sectional comparisons of the MDS measures, with scales provided by the resident, a proxy person, and nursing staff. SETTING: Subjects residing in 59 nursing homes (NHs) in Maryland from 1992 to 1995. PARTICIPANTS: Subjects were 1939 new admissions to NHs, aged 65 and older, with complete MDS information at admission. MEASUREMENTS: Two MDS scales, the Cognitive Performance Scale (CPS) and the MDS Cognition Scale (MDS-COGS), were compared with the Mini-Mental State Examination (MMSE) and the staff rating on the Psychogeriatric Dependency Rating Scale (PGDRS) Orientation scale, as well as measures of functioning and functional decline. RESULTS: The CPS and the MDS-COGS were highly correlated (r = 0.92). Both correlated moderately well with the MMSE (r = -0.65 and -0.68) and with staff's rating on the PGDRS Orientation scale (r = 0.63 and r = 0.66). Correlations with the MMSE (r < 0.70) are lower than previously reported (r > or = 0.80). The proportion of cognitively impaired residents in this NH admission cohort was higher using the MDS-COGS than the CPS (65% vs 57%), but both MDS scales produced lower proportions than the MMSE (70%) and higher proportions than the PGDRS (47%). The internal consistency of the CPS was better without the comatose item (alpha = 0.80 vs 0.70). The MDS-COGS had higher internal consistency (alpha = 0.85) and was simpler to compute. CONCLUSIONS: This is the first study to examine the validity of the MDS in a large sample of residents and NHs in situations where the MDS was not completed by research-trained staff. Compared with other instruments, the MDS-COGS and the CPS had moderate and similar validity for assessing cognitive impairment. Differences in the scales could provide different estimates of impairment among persons admitted to nursing homes.

Markers of failure to thrive among older hip fracture patients.

OBJECTIVES: To determine whether there is a group of recent hip fracture patients who exhibit the signs of failure to thrive and to identify potential precursors to their decline in physical functioning. DESIGN: Prospective (nonintervention) study of hip fracture recovery; patients were assessed in the hospital and at 2, 6, 12, 18, and 24 months post-fracture. SETTING: Hip fracture patients admitted to one of eight Baltimore area hospitals from the community with a new fracture of the proximal femur between January 1, 1990, and June 15, 1991. PARTICIPANTS: Patients were 65 years of age and older and lived in the community before the fracture. A total of 804 patients were eligible for the study; the present study analyses were restricted to the 252 patients who survived 1 year and had a self-report assessment at 6 and 12 months post-fracture. MEASUREMENTS: A questionnaire administered during hospitalization assessed pre-fracture functional and health status and current affective and cognitive status. In-home interviews post-fracture ascertained dependence and difficulty with physical and instrumental activities of daily living. Abstraction of the medical records provided information about comorbidities, surgical procedure, and hospital length of stay. RESULTS: Patients who declined in ability to walk from 6 to 12 months post-fracture had greater use of health resources (more hospitalizations) and poorer physical functioning up to 2 years post-fracture. Impaired function in physical activities of daily living at 6 months, high glucose, calcium, and CO2 at admission, and low BUN and creatinine at admission were more prevalent among decliners than among non-decliners. CONCLUSIONS: Findings indicate that certain older hip fracture patients begin to exhibit signs and symptoms of failure to thrive. About 10% of patients who survived at least 1 year after fracture could not retain their recovery level of functioning after 6 months and began to decline further. High glucose and CO2 and low BUN and creatinine on hospital admission were associated with later functional decline among hip fracture patients, but their clinical significance is uncertain.

The economic cost of hip fractures in community-dwelling older adults: a prospective study.

OBJECTIVES: To evaluate the incremental cost in the year after hip fracture. DESIGN: Prospective cohort study. SETTING: Baltimore, Maryland. PARTICIPANTS: 759 community dwelling older patients who sustained a hip fracture and participated in the Baltimore Hip Fracture Study. MEASUREMENTS: Resource use for direct medical care, formal nonmedical care, and informal care in the 6 months before and the year after fracture was estimated from interviews with patients or proxy respondents. Costs in 1993 dollars were estimated by multiplying resources times national unit cost estimates. RESULTS: The annualized costs in the year before the fracture ranged between $18,523 and $20,928. The costs in the year after the fracture equaled $37,250. The incremental costs in the year after the fracture, compared with the costs in the year before the fracture, ranged between $16,322 and $18,727. The largest cost differences were attributable to hospitalizations, nursing home stays, and rehabilitation services. CONCLUSIONS: Because we compared the costs after a fracture with costs before, our estimates of the incremental cost of a hip fracture are lower than others in the literature. These results, obtained from interviews with patients enrolled in a cohort study, or their proxies, provide the best data available to date on the economic cost of hip fractures among community-dwelling older persons.

Accuracy of medical records in hip fracture.

OBJECTIVE: To determine the accuracy of diagnoses and procedure codes in medical records for hip fracture patients. DESIGN: A validation sample of hip fracture medical records was used to compare the facesheet data with progress notes, operative reports, and discharge summaries for patients in a prospective study of functional recovery. SETTING: Eight Baltimore hospitals with the highest volume of older hip fracture patients. PATIENTS: Study subjects were 343 community-dwelling patients, 65 years of age and older, admitted to one of eight Baltimore hospitals between January 1990 and June 1991 with a diagnosis of hip fracture. MAIN OUTCOME MEASURES: Facesheet diagnosis codes were compared with admitting notes, discharge summary, and/or progress notes. The abstracted surgical procedure was compared with postoperative radiographs. RESULTS: Excess coding of diagnoses on the hospital facesheet was evident in 12% of charts. In 17% of charts, a complication identified in the chart was not coded on the facesheet. More complications with low severity were omitted. Agreement between the abstractor's procedure review and radiograph readings for arthroplasty was 84%. In 15% of patients, the abstractor coded total arthroplasty when hemiarthroplasty was done. CONCLUSIONS: Discrepancy between the hospital facesheet and the medical record and between the abstracted surgical procedure and radiographs was found for hip fracture patients. This may make findings from health outcomes research relying on administrative databases uncertain and reimbursement inaccurate.

Mobility after hip fracture predicts health outcomes.

OBJECTIVES: Balance and gait are essential to physical functioning and the performance of activities of daily living. The objective of this study was to determine the predictive value of a balance and gait test on subsequent mortality, morbidity, and healthcare utilization among older hip fracture patients. DESIGN: A prospective study of hip fracture recovery. SETTING: Patients with a new hip fracture admitted from the community to one of eight Baltimore hospitals and followed in their homes for 2 years postfracture. PARTICIPANTS: A total of 306 patients with hip fracture, 65 years of age and older, who completed a gait and balance assessment at 2 months postfracture. MEASUREMENTS: The relationship between gait and balance test performance at 2 months postfracture and mortality, physician visits, rehospitalizations, nursing home placement, and falls up to 24 months postfracture was assessed by Cox proportional hazards and least squares regression. RESULTS: After adjusting for age, sex, race, and comorbidity, the balance score and the summary mobility score predicted mortality. A 17% increase in the risk of mortality was demonstrated for each unit decrease in the balance score (range 0-17), and a 10% increase was demonstrated for each decrease in the summary score (range 0-26). Unsteady balance during immediate standing, turning, sitting down, and rising from a chair were associated significantly with increased mortality. Poor balance, but not poor gait, was associated with an increase in hospitalizations up to 24 months postfracture. Both poor balance and poor gait were associated with nursing home placement, with 20% and 17% increased odds, respectively. Mobility did not predict future physician visits or falls. CONCLUSIONS: These findings demonstrate that balance and gait are predictive of future health outcomes for older hip fracture patients.

Serum and urine markers of bone metabolism during the year after hip fracture.

OBJECTIVE: As part of a larger study to describe indices of recovery during the year after hip fracture, the current prospective study investigated longitudinal changes in serum and urine markers of bone metabolism for the year after hip fracture and related them to bone mineral density (BMD). DESIGN: A representative subset of participants provided serum and urine samples and had bone density measured at 3, 10, 60, 180, and 365 days postfracture. SETTING: Two Baltimore hospitals. PARTICIPANTS: The subjects were 205 community-dwelling, white women age 65 and older with fresh proximal femur fractures. MEASUREMENTS: Samples were assayed for specific bone-related proteins and bone turnover markers, including serum osteocalcin (OC), procollagen type 1 carboxy-terminal extension peptide (PICP), bone-specific alkaline phosphatase (BAP), and urinary deoxypyridinoline (DPD) cross-links. Selected hormonal regulators of bone metabolism, including parathyroid hormone (PTH), calcitonin (CT), 1,25-dihydroxy vitamin D(3) (1,25 (OH)(2)D), and estrone (E(1)) were measured from serum samples. Repeated measures analyses were used to evaluate postfracture changes in each of the markers. RESULTS: BAP, OC, and PICP were most active during the early postfracture period (3-60 days). BAP and OC remained elevated at 365 days compared with 3 days. DPD rose 48% from 3 days to 60 days, but this difference was not statistically significant. PTH and 1,25 (OH)(2)D increased steadily and significantly from 3 to 365 days. E(1) was highest at baseline and decreased at each time point, whereas CT showed no significant changes. When subjects were stratified into high-, medium-, and low-BMD groups based on their measurement at 3 days, both osteoclastic and osteoblastic markers in the low-BMD group displayed exaggerated and different patterns over time compared with the other groups. CONCLUSION: Currently, the standard treatment of care for hip fractures still results in high morbidity and mortality and failure to regain prefracture quality of life. Gaining an understanding of bone cell activity in these patients after hip fracture, derived by measuring markers longitudinally during recovery, provides a baseline by which to measure the effectiveness of new interventions to improve recovery from hip fracture.

Delirium on hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes.

BACKGROUND: Hip fracture patients are at increased risk of confusion or delirium due to the trauma associated with the injury and the rapid progression to hospitalization and surgery, in addition to the pain and loss of function experienced. Hip fracture patients who develop delirium may require longer hospital stays, are more often discharged to long-term care, and have a generally poor prognosis for returning home or regaining function in activities of daily living (ADL). METHODS: The present study examines the impact of delirium present on hospital admission in a sample of 682 non-demented, aged hip fracture patients residing in the community at the time of their fracture. In-hospital assessments designed to assess both prefracture and postfracture functioning, as well as follow-up interviews at 2, 6, 12, 18, and 24 months postfracture, were obtained from participants. RESULTS: Analyses indicate that baseline or admission delirium is an important prognostic predictor of poor long-term outcomes in persons without known cognitive impairment, after controlling for age, gender, race, comorbidity, and functional status. Delirium at admission (i.e., prior to surgery) was associated with poorer functioning in physical, cognitive, and affective domains at 6 months postfracture and slower rates of recovery. Impairment and delays in recovery may be further exacerbated by increased depressive symptoms in confused patients over time. Delirium on hospital admission was not a significant predictor of mortality after adjustment for confounding factors. CONCLUSIONS: The present findings further emphasize the significance of immediate detection and treatment of delirium in hip fracture patients to ameliorate the short and long-term effects of acute confusion on functional outcomes.

Change in muscle mass and muscle strength after a hip fracture: relationship to mobility recovery.

BACKGROUND: Hip fracture in elderly persons has a serious impact on long-term physical function. This study determines the change in muscle strength and muscle mass after a hip fracture, and the associations between these changes and mobility recovery. METHODS: Ninety community-dwelling women aged 65 years and older who had recently experienced a fracture of the proximal femur were included in the study. At 2 to 10 days after hospital admission, the women's grip strength, ankle dorsiflexion strength, and regional muscle mass (by dual-energy x-ray absorptiometry) were measured, and the prefracture level of independence for five mobility function items was assessed. All measurements were repeated at 12 months. RESULTS: At follow-up, only 17.8% of the women had returned to their prefracture level of mobility function for all five items. Mobility function recovery was not related to change in skeletal muscle mass of the nonfractured leg or the arms. However, women who lost grip strength (mean loss of -28.7%, SD = 16.9%), or who lost ankle strength of the nonfractured leg (mean loss of -21.5%, SD = 14.7%), had a worse mobility recovery compared with those who gained strength (p = .04 and p = .09, respectively). In addition, chronic disease (p = .03), days hospitalized (p = .04), and self-reported hip pain (p = .07) were independent predictors of decline in mobility function. CONCLUSIONS: The results suggest that loss of muscle strength, but not loss of muscle mass, is an independent predictor of poorer mobility recovery 12 months after a hip fracture. When confirmed by other studies, these findings may have implications for rehabilitation strategies after a hip fracture.

Recovery from hip fracture in eight areas of function.

BACKGROUND: This report describes changes in eight areas of functioning after a hip fracture, identifies the point at which maximal levels of recovery are reached in each area, and evaluates the sequence of recuperation across multiple functional domains. METHODS. Community-residing hip fracture patients (n = 674) admitted to eight hospitals in Baltimore, Maryland, 1990-1991 were followed prospectively for 2 years from the time of hospitalization. Eight areas of function (i.e., upper and lower extremity physical and instrumental activities of daily living; gait and balance; social, cognitive, and affective function) were measured by personal interview and direct observation during hospitalization at 2, 6, 12, 18, and 24 months. Levels of recovery are described in each area, and time to reach maximal recovery was estimated using Generalized Estimating Equations and longitudinal data. RESULTS: Most areas of functioning showed progressive lessening of dependence over the first postfracture year, with different levels of recovery and time to maximum levels observed for each area. New dependency in physical and instrumental tasks for those not requiring equipment or human assistance prefracture ranged from as low as 20.3% for putting on pants to as high as 89.9% for climbing five stairs. Recuperation times were specific to area of function, ranging from approximately 4 months for depressive symptoms (3.9 months), upper extremity function (4.3 months), and cognition (4.4 months) to almost a year for lower extremity function (11.2 months). CONCLUSIONS: Functional disability following hip fracture is significant, patterns of recovery differ by area of function, and there appears to be an orderly sequence by which areas of function reach their maximal levels.

Serum concentrations of steroids, parathyroid hormone, and calcitonin in postmenopausal women during the year following hip fracture: effect of location of fracture and age.

BACKGROUND: Hip fracture in the aged is a major health problem, especially considering the increasing proportion of the elderly in the population. This study examines changes in circulating levels of hormones, which are purported to affect bone metabolism, in response to hip fracture in postmenopausal women. METHODS: Patients consisted of women ages 65 and older who had surgery within 2 days of fracture. Serum samples were obtained at 3, 10, 60, 180, and 360 days postfracture. Healthy women without hip fractures from the same age range served as a control group (n = 17). Hormones were determined by radioimmunoassay. Subjects with fractures in the neck region of the femur (n = 78) were compared to subjects with fractures in the trochanteric region (n = 88). RESULTS: Estrone concentration (47.6 +/- 5.7 pg/mL; mean +/- SEM) at 3 days postfracture was elevated (p < .001) compared to control levels of 20.7 +/- 4.6 pg/mL. By 2 months, levels had declined to control levels. Androstenedione and the adrenal hormones, DHEAS and cortisol, displayed similar responses. Parathyroid hormone (PTH) levels were not significantly different from the control concentration at 3 days following fracture, but increased (p < .001) during the year following fracture. Calcitonin concentrations were much higher (p < .001) 3 days postfracture (42.1 +/- 3.7 pg/mL) compared to controls without fracture (9.8 +/- 3 pg/mL). Except for testosterone, no differences could be attributed to fracture location. Only PTH, with concentrations higher in the older age groups (p < .001), showed an age-related response. CONCLUSIONS: Following hip fracture, there are some dramatic responses in hormones that purportedly are mechanistically important in bone metabolism. These changes include transient increases in steroid hormones, chronic elevations in calcitonin, and rising levels of PTH during the year after fracture.

Extending gerontological research through linking investigators' studies to public-use datasets.

PURPOSE: Public-use datasets can extend data collected by individual investigators in various ways: making external comparisons, providing additional data on individual respondents, and creating internal comparison groups. The authors describe the advantages and limitations of these methods and practical and conceptual issues in combining investigator-initiated and public-use datasets. DESIGN AND METHODS: These issues are illustrated with a study of functional decline among 674 patients following hospitalization for hip fracture that was augmented with data from a public-use dataset, the Established Populations for Epidemiologic Studies of the Elderly (EPESE). RESULTS: By creating an internal comparison group of EPESE respondents, frequency matched to hip fracture patients on age, sex, and baseline functional limitations, the authors formed a single dataset and performed multivariable analyses of factors associated with functional decline. IMPLICATIONS: Gerontological research may benefit by applying these methods to program evaluations and longitudinal analyses of health outcomes with numerous public-use datasets.

The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group.

This study estimated the prevalence of dementia in 2,285 new admissions age 65+ to a statewide sample of 59 nursing homes in Maryland, 1992-1995. Dementia was ascertained according to DSM-III-R criteria by an expert panel of geriatric psychiatrists, neurologists, and a geriatrician using detailed information collected by trained lay evaluators from residents, family, staff, and medical records. Admissions to Maryland nursing homes are similar to admissions to nursing homes elsewhere in the United States. The prevalence of dementia was 48.2% (CI: 43.6-52.8) with an upper bound estimated at 54.5% (CI: 49.9-59.1). Prevalence is highest in facilities with <50 beds versus 200+ beds (65.5% vs 39.6%) and those in urban versus rural areas (50.0% vs 39.1%). Those who are non-White, married, and with fewer years of education are more likely to be demented. Prevalence is highest among those with 4+ physical impairments versus 0-1 (60.3% vs 27.7%) and lowest in those with 4+ comorbidities versus 0-1 (44.8% vs 52.0%). There was considerable overlap in the comorbid status of demented and nondemented admissions, and both groups contained members with only a few functional limitations. Results suggest that the level of medical supervision provided in nursing homes may not be required for some residents with dementia.

Resident contact with family and friends following nursing home admission.

PURPOSE: This study explored factors that are related to the level of contact (number of visits and calls) between newly admitted nursing home residents and their family and friends. In addition to reexamining factors studied previously, several new factors were explored: contact level prior to nursing home placement, dementia status, and resident race. DESIGN AND METHODS: Interviews were conducted with the significant others of 1,441 residents from a representative sample of nursing homes in Maryland. RESULTS: Contact decreased by approximately half following admission, compared to reported preadmission contact. Rates of contact are positively related to nonuse of Medicaid, kinship closeness, support network proximity, nondemented status, and White race. After controlling for preadmission contact, postadmission contact is positively associated with kinship closeness, support network proximity, nondemented status, and White race. IMPLICATIONS: The study identifies factors that are useful to consider when designing interventions to increase family involvement with nursing home residents.

The University of Maryland experience in integrating preventive medicine into the clinical medicine curriculum.

Lifestyle risk factors play a major role in the etiology of premature mortality, morbidity, and disability in the United States. Numerous professional groups as well as the Surgeon General of the Public Health Service have recommended that increased attention be devoted to training medical students and physicians to improve their knowledge and skills in health promotion and disease prevention. Such training is critical for attaining many of the "Healthy People 2000" objectives. For a variety of reasons, however, most medical schools have had difficulty in successfully integrating preventive medicine into their clinical curriculums. This article describes the critical elements that allowed the faculty at the University of Maryland School of Medicine to accomplish this goal through its fourth year clinical preventive medicine course. The strategies employed in this course may serve as a model for other institutions to achieve the integration of preventive medicine into their clinical curriculums.

Outcome expectations for exercise scale: utility and psychometrics.

OBJECTIVES: The purpose of this study was to develop a measure of outcome expectations for exercise specifically for the older adult (The Outcome Expectations for Exercise [OEE] Scale), and to test the reliability and validity of this measure in a sample of older individuals. This scale was developed based on Bandura's theory of self-efficacy and the work of prior researchers in the development of measures of outcome expectations. METHODS: The OEE scale, which was completed during a face-to-face interview, was tested in a sample of 175 residents in a continuing care retirement community. RESULTS: There was support for the internal consistency of the OEE scale (alpha coefficient of .89), and some support for reliability based on a structural equation modeling approach that used R2 estimates, although less than half of these were greater than 0.5. There was evidence of validity of the measure based on: (a) a confirmatory factor analysis in which the model fit the data (normed fit index [NFI] = .99, root mean square error of approximation [RMSEA] - .07, chi2/df = 2.8); (b) support for the hypothesis that those who exercised regularly had higher OEE scores than those who did not (F = 31.3, p < .05, eta squared = .15); and (c) a statistically significant relationship between outcome expectations and self-efficacy expectations (r = .66). DISCUSSION: This study provides some initial support for the reliability and validity of the OEE scale. Outcome expectations for exercise were related to exercise behavior in the older adult, and the OEE scale can help identify older adults with low outcome expectations for exercise. Interventions can then be implemented to help these individuals strengthen their outcome expectations, which may subsequently improve exercise behavior.

Racial differences in the prevalence of dementia among patients admitted to nursing homes.

OBJECTIVE: The purpose of this study was to determine the prevalence of dementia among black and white residents on admission to nursing homes and to determine whether demographic and health characteristics known to be associated with dementia were correlated with dementia in this population. METHODS: Data from medical records and structured interviews with family members, nursing staff, and nursing home residents were gathered for 2,285 persons newly admitted to nursing homes in Maryland from 1992 to 1995. A stratified sample of 59 nursing homes was used. An expert panel of five physicians classified each resident as demented, nondemented, or indeterminate. Associations between dementia status, race, and selected characteristics were examined. RESULTS: Black residents (77 percent) were significantly more likely than white residents (57 percent) to be classified as demented. Older age was associated with dementia in both races. Less education, male gender, and a history of a cerebrovascular accident were associated with an increased prevalence of dementia among white residents only. After demographic and health characteristics associated with dementia were controlled for, black race remained independently associated with a diagnosis of dementia. CONCLUSIONS: The rate of dementia on admission to nursing homes was higher among black residents than among white residents, a finding that has implications for the delivery of care. The higher rate may be due to psychosocial factors operating differently in blacks and whites that influence the timing of admission to a nursing home.

Spinal anesthesia versus general anesthesia for hip fracture repair: a longitudinal observation of 741 elderly patients during 2-year follow-up.

The Baltimore Hip Studies, a multicenter, noninterventional, observational trial, provided an opportunity to investigate the effects of anesthetic technique on the long-term outcome of elderly patients after hip fracture repair. Detailed interviews assessing functional status and pain were conducted during the hospital stay. Out-of-hospital evaluations were repeated after the procedure at 2, 6, 12, 18, and 24 months with a portable gait and balance laboratory. Multivariate analysis was done to determine the effects of anesthetic technique on functional and other outcomes, after controlling for multiple baseline variables. Of 741 enrolled patients who completed the study, 430 and 311 patients received spinal anesthesia or general anesthesia, respectively. Subgroup analysis of three spinal anesthetics, tetracaine, lidocaine, and epinephrine, was also done. In the present large observational study, general anesthesia was at least as efficacious as spinal anesthesia, and possibly better, in affording good long-term outcome.

Neuropathy in the workplace.

Cumulative trauma disorders are frequently responsible for the development of occupational neuropathy. Predisposing factors in the workplace are identified, and ergonomic principles to minimize these risks are presented.