Biochemical markers in glucocorticoid-induced osteoporosis.

Following the introduction of corticosteroids as therapeutic agents in the 1950s, their use has been expanded so that today glucocorticoids are widely used. There are few studies in the literature directly aimed at describing the changes of bone markers following glucocorticoid administration. The interpretation of some of these investigations may be hampered by a number of confounding factors, whose influence is not always taken into consideration. In general, the effects of glucocorticoid administration are represented by a reduction in bone formation markers (particularly considering serum osteocalcin levels) and a trend to an increase or no change in bone resorption markers. The inconsistency of this last finding may be related to the time at which the observation is carried out and to the marker employed.

Skeletal turnover, bone mineral density, and fractures in male chronic abusers of alcohol.

BACKGROUND: Chronic alcohol abuse is a risk factor for osteoporosis and fractures, whose pathogenesis is still unclear. We investigated the influence of alcoholism and other risk factors on calcium and skeletal metabolism, bone mineral density (BMD), and fractures. MATERIALS AND METHODS: In 51 chronic male alcoholics without liver failure and 31 healthy controls, serum total and ionised calcium, phosphate, creatinine, 25-hydroxy vitamin D (25OHD), PTH, total (ALP) and bone-specific (BALP) alkaline phosphatase, osteocalcin (BGP), carboxy-terminal telopeptide of type I collagen (beta-CTx), osteoprotegerin (OPG) and receptor activator of nuclear factor kappa B ligand (RANKL) were assessed. In patients only, we also measured serum testosterone, 17-beta estradiol, LH, and IGF-I. BMD was measured by dual energy x-ray absorptiometry at lumbar spine (LS-) and femur [neck (FN-) and total hip (TF-)]. Vertebral fractures were identified by a semiquantitative method on thoraco-lumbar spine x-ray, non-vertebral fractures (as life-style factors) by history. RESULTS: Alcoholics were leaner, had significantly higher ALP and BALP, and lower BGP and 25OHD levels than controls. No significant difference in other calcium and bone metabolism parameters was found. OPG/RANKL ratio was significantly higher in alcoholics. Beta-CTx negatively correlated with abuse duration. OPG positively correlated with daily alcohol assumption and with indexes of liver cytolysis. Though LS-, FN- and TF-BMD of alcoholics and controls did not significantly differ, patients had a much higher prevalence of vertebral fractures. The same was found considering both vertebral and non-vertebral fractures. CONCLUSIONS: Ethanol-induced skeletal damage seems mainly dependent on negative effects on bone formation. Lifestyle factors and traumas likely contribute to the high fracture incidence of alcohol abusers, independently of BMD.

Cost reduction and outcome improvement in the intensive care unit.

OBJECTIVE: Decreasing reimbursement provided by third-party payors necessitates reduction of costs for providing critical care services. If academic medical centers are to remain viable, methods must be instituted that allow cost reduction through practice change. METHODS: We used short cycle improvement methodology to rapidly achieve these goals. Short cycle improvement methodology involves identifying the areas for improvement, defining a mechanism to evaluate outcome, initiating an improvement plan on a small number of patients, and repeating the cycle with new adjustments based on outcome. Baseline data on areas for improvement was prospectively collected, and protocols to initiate change were developed and tested by short improvement cycles. Outcomes were evaluated, protocols were modified, and another cycle was performed. This methodology was continued until the desired goals had been achieved. To adjust outcomes for severity of illness, Acute Physiology and Chronic Health Evaluation II methodology was used. Using this methodology, we focused on three areas for improvement. Standing orders for laboratory studies, electrocardiograms, and chest x-ray films were eliminated. Protocols were developed for the appropriate use of sedation, analgesics, and neuromuscular blocking agents. Finally, a protocol for weaning from mechanical ventilation was developed to allow respiratory therapists to proceed through the weaning process, which was ordered by a physician. RESULTS: Laboratory tests were reduced by 65% (from 510 to 180 tests per day) with an annual cost savings of $21,593. Chest x-ray reduction of 56% resulted in an annual savings of $3,941. There was a 75% reduction in cost of neuromuscular blocking agents. The use of neuromuscular blocking agents resulted in a 75% reduction in drug costs. Ventilator hours were reduced by 35% from 140 to 90 hours. The average length of overall intensive care unit stay was reduced by 1.5 days (5.0 to 3.5 days). The cost per patient day decreased with an annualized cost savings of 4% per patient day. Unexpected outcomes included a reduction in intensive care unit days from 54 days at baseline to 7 days at the 6-month interval. The infection rates for blood stream infections, urinary tract infections, and nosocomial pneumonia were reduced. Using national nosocomial infection data, these rates represented a reduction from the fiftieth percentile to the twenty-fifth percentile for all measured indicators. Acute Physiology and Chronic Health Evaluation II scores were 19.54 at baseline and increased to 21.2 (p = 0.001) at the 6-month interval. Mortality rates were 16.7% at baseline and were 17.6% (p = 0.89) at the 6-month interval. CONCLUSION: We concluded that utilization of short cycle improvement methodology provided an ongoing method for reducing costs of critical care services in our patient population with no change in mortality.