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Background and Purpose. Factors that predict functional recovery in the first few days following hip fracture and that may facilitate discharge to the home directly from the acute care setting have not been identified. This study investigated the attainment of key functional milestones by patients and discharge status from an acute care hospital following hip fracture. Subjects. Subjects were 162 community-based individuals (59 men, 103 women) aged 60 years or older who were admitted to an acute care hospital following unilateral hip fracture. Methods. Data on personal, medical, surgical, hospital course, and acute rehabilitation factors as well as functional status and placement at the time of discharge were collected. Adjusted odds ratios were calculated to determine predictors of independence in seven types of transfers and ambulation activities and discharge directly to the home. Results. Subjects who ambulated independently prior to fracture, stayed longer in the acute care setting, and received physical therapy on average more than once a day had improved odds of regaining independence in bed mobility, transfers, and ambulation. Subjects who regained independence and received physical therapy on average more than once a day had improved odds of discharge directly to the home from the acute care setting. Increasing age and postoperative complications reduced the odds of discharge directly home. Conclusion and Discussion. A substantial proportion of patients with hip fracture achieve independence in bed mobility and transfers and in ambulation with a walker during the early postoperative phase, although few progress to a higher level during a short-term stay in the acute care setting. Frequency of physical therapy, among other factors, appears to improve the odds of regaining functional independence and discharge directly to the home from the acute care setting. [Guccione AA, Fagerson TL, Anderson IJ. Regaining functional independence in the acute care setting following hip fracture. Phys Ther. 1996;76:818-826.], Key Words: Acute care, Functional outcome, Hip fractures, Physical therapy, Rehabilitation. Hip fracture is a health problem of high volume, high cost, and high risk. Medical expenses totaling billions of [...]

PURPOSE: A clinical trial designed to test whether treatment with melphalan, prednisone, and colchicine (MPC) is superior to colchicine (C) alone was performed in patients with primary amyloidosis (AL), a nonmalignant plasma cell dyscrasia. PATIENTS AND METHODS: Patients were randomized to MPC or C with stratification according to sex, time from diagnosis to study entry (ie, less than 3 months or 3 to 12 months), and dominant organ system involvement (ie, cardiac, renal, neurologic, or other). Data were gathered monthly from patients, quarterly from physicians, and annually in the Clinical Research Center. One hundred consecutive patients with AL amyloidosis admitted between 1987 and 1992 who met eligibility requirements were treated and followed for a minimum of 18 months. Fifty patients (group A) received daily oral coichicine and 50 patients (group B) received cycles of oral melphalan and prednisone every 6 weeks for 1 year as well as colchicine. RESULTS: The principal outcome measure was median survival, which was compared in the two treatment groups and in the subgroups. The overall survival of all patients from study entry was 8.4 months. Comparing group A (C) to group B (MPC), the survival was 6.7 months versus 12.2 months (P = 0.087). Both treatment groups had poor survival for patients in the cardiac subgroup, longest survival in the renal group, and significant differences favoring MPC treatment only in patients whose major system manifestations were neurologic (P = 0.037) or other (P = 0.007). Multivariate analysis showed a strongly significant treatment effect (P = 0.003) and improved survival associated with not having cardiac or gastrointestinal involvement. CONCLUSIONS: MPC was advantageous for patients whose major manifestations of amyloid disease were other than cardiac or renal. Better survival regardless of treatment was noted in patients for whom a satisfactory supportive treatment such as transplant or dialysis exists for their organ failure.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) have well-known gastrointestinal and renal toxic reactions. Effects of NSAIDs on blood pressure are less appreciated. A meta-analysis was performed to determine the hypertensive effects of NSAIDs and rank them by magnitude of change in mean arterial pressure (MAP). Methods: A literature search of published English-language studies of NSAIDs and their effects on blood pressure was done. Studies were included if they met the following criteria: (1) the studies were intervention studies; (2) NSAIDs at any dose or aspirin at doses of 1.5 g/d or greater were included; (3) documentation of blood pressure was provided; and (4) the studies were 24 hours in duration. Studies were excluded if 20% or more of their participants dropped out or if the dose of antihypertensive drugs was adjusted while the subjects were taking NSAIDs. The major outcome was change in MAP while patients were receiving NSAIDs. Each NSAID arm was extracted from its trial. Information on possible confounders, including subject age, trial quality, amount of dietary salt intake, and whether study subjects were hypertensive or normotensive, was recorded. We calculated the average change in MAP on each NSAID, adjusting for confounders. Results: Fifty-four studies with 123 NSAID treatment arms met inclusion criteria. The mean age of subjects was 46 years. Of the 1324 participants, 1213 subjects (92%) were hypertensive. The effects of NSAIDs on blood pressure were found solely in hypertensive subjects. Among these, the increase in MAP after adjusting for amount of dietary salt intake was 3.59 mm Hg for indomethacin (57 treatment arms), 3.74 mm Hg for naproxen (four arms), and 0.49 mm Hg for piroxicam (four arms). The MAP decreased by 2.59 mm Hg for placebo (10 arms), 0.83 mm Hg for ibuprofen (six arms), 1.76 mm Hg for aspirin (four arms), and 0.16 mm Hg for sulindac (23 arms). The effects on MAP by using placebo, sulindac, and aspirin were statistically significantly different from indomethacin. Conclusions: In short-term use, NSAIDs vary considerably in their effect on blood pressure. Of the drugs studied, indomethacin and naproxen were associated with the largest increases in blood pressure. The average effects of piroxicam, aspirin, ibuprofen, and sulindac were negligible. (Arch Intern Med. 1993;153:477-484)

Treatment of rheumatoid arthritis (RA) was boosted in the 1950s by the discovery that injectable gold and antimalarial drugs were effective therapies. The effects of these medications were established by comparing them to placebo (inert) treatment, and they became the standard second-line therapy and were used after nonsteroidal anti-inflammatory drugs such as aspirin, until penicillamine was introduced in the 1970s. Other second-line agents have since become available, including methotrexate, sulfasalazine, and azathioprine. Their effects have been established using placebo controls and also in comparisons with the gold and antimalarial drugs, the ''old standards''. Other changes in the testing of antirheumatic drugs have occurred, including rising costs, which increased support from grant agencies or pharmaceutical companies, publication of standards, and the use of more complex methods in these studies. The changes that have occurred in 105 clinical trials of antirheumatic drugs, from 1945 to 1989, were evaluated. The use of placebos to evaluate drug effects decreased by 75 percent during this time period. The incidence of full funding of drug trials by drug companies increased from zero, in the initial time period, to 61 percent in the most recent decade. The average age of patients was significantly older in the later studies, and patients tended to have less severe disease in these later studies. The use of statistical methods changed somewhat during the study period, but most studies still fail to indicate the statistical power of their study design and type of analysis. This review indicates that the trends in studies of antirheumatic drugs should be considered when comparing results from research performed at different times. (Consumer Summary produced by Reliance Medical Information, Inc.)

Although rheumatoid arthritis (RA) affects women more than men, and women do most household work, studies of the impact of RA have tended to ignore effects on household work and have instead focused on income losses related to employment disability and costs of health care. Household work is a valuable commodity because of its importance for the economic and social well-being of families. Inability to perform household work due to disability can cause personal, family, and economic problems for affected women. To better understand these issues, 142 women with RA and 58 healthy control subjects were questioned about household work in their families. Women with RA were divided into two groups, those with mild disease (84 subjects) and those with more severe disease (58 subjects). The average age of control subjects was 43 years, those with mild RA 49 years, and those with severe RA 53 years. Women with RA reported poorer functional status, more pain, and poorer general health. Those with severe RA reported more depression, lower family income, and a lower employment rate. Although total amount of time spent in household work was similar among subjects' families, the amount done on five of six tasks by women with more severe RA was significantly less than that done by women with mild RA or no disease. However, all women spent a similar amount of time when it came to taking care of others. Women with mild RA spent less time than healthy subjects in shopping and doing errands. Family members of women with more severe RA spent significantly more time on four of the six tasks and on total housework than families of other subjects. Family members of women with mild RA spent more time on general cleaning than families of women with no disease. The use of paid household employees was not related to severity of RA. Decreased functional status was significantly associated with household disability, while increased depression was associated with increased time spent in household work. The presence of children at home was associated with increased time in household work, while outside employment or a college education was associated with less household work done. (Consumer Summary produced by Reliance Medical Information, Inc.)

Rheumatoid arthritis is a joint disease characterized by inflammation of the joints, stiffness, swelling, overgrowth of cartilage tissue, and pain. The effectiveness and toxicity of second-line drugs used to treat rheumatoid arthritis, including methotrexate (MTX), injectable gold, D-penicillamine (DP), sulfasalazine (SSZ), auranofin (AUR), and antimalarial drugs were assessed. Analysis of 66 clinical trials involving 117 treatment groups showed that AUR was less effective than MTX, injectable gold, DP, SSZ, and the antimalarial drugs. There was a lack of uniformity in effectiveness among antimalarial agents. For example, chloroquine was shown to be more effective than hydroxychloroquine. MTX, injectable gold, DP, and SSZ were similar in effectiveness. Analysis of 71 clinical trials involving 129 treatment groups showed that about 30 percent of patients withdrew from the study, and half of these subjects dropped out because of drug toxicity. Injectable gold was the most toxic drug and was associated with the highest dropout rates. Thirty percent of patients treated with gold withdrew from studies compared with a 15 percent dropout rate associated with the other drug treatments. The antimalarial drugs were the least toxic agents. These findings show that AUR is the least effective and injectable gold is the most toxic of the second-line drugs used to treat rheumatoid arthritis. (Consumer Summary produced by Reliance Medical Information, Inc.)

Osteoarthritis is characterized by joint pain and inflammation, cartilage breakdown, and the formation of fibrous tissue and cysts on bones. It is the most common condition affecting the joints. The knee is the joint that is most frequently involved, resulting in reduced ability to walk. People with osteoarthritis visit their doctor twice as often and have more days of restricted mobility than people without this condition. Once osteoarthritis develops there is not much that can be done to alter the course of the disease. Estrogen therapy is used in postmenopausal women to protect against bone loss. Some have proposed that estrogen may increase bone mass and stiffness, and lead to cartilage damage and osteoarthritis. Previous studies have suggested that estrogen may be involved in the development of osteoarthritis in women. Since estrogen therapy is common in postmenopausal women, it is important to determine the relation between estrogen therapy and osteoarthritis. A group of 831 postmenopausal women, with an average age of 73 years, were evaluated for osteoarthritis of the knee. The women were divided into groups based on the amount and length of time of estrogen use. Radiography analysis of the knees showed no relation between estrogen use and osteoarthritis. In some cases a protective effect of estrogen was indicated, but the effect was not statistically significant. These findings demonstrate that estrogen does not increase the risk of developing osteoarthritis. (Consumer Summary produced by Reliance Medical Information, Inc.)