PubMed · 8078534
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S R Cummings, M C Nevitt. 1994-09-29. Falls.. https://doi.org/10.1056/nejm199409293311310
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OBJECTIVE: To recommend clinical practice guidelines for the assessment of people at risk for osteoporosis, and for effective diagnosis and management of the condition. OPTIONS: Screening and diagnostic methods: risk-factor assessment, clinical evaluation, measurement of bone mineral density, laboratory investigations. Prophylactic and corrective therapies: calcium and vitamin D nutritional supplementation, physical activity and fall-avoidance techniques, ovarian hormone therapy, bisphosphonate drugs, other drug therapies. Pain-management medications and techniques. OUTCOMES: Prevention of loss of bone mineral density and fracture; increased bone mass; and improved quality of life. EVIDENCE: Epidemiologic and clinical studies and reports were examined, with emphasis on recent randomized controlled trials. Clinical practice in Canada and elsewhere was surveyed. Availability of treatment products and diagnostic equipment in Canada was considered. VALUES: Cost-effective methods and products that can be adopted across Canada were considered. A high value was given to accurate assessment of fracture risk and osteoporosis, and to increasing bone mineral density, reducing fractures and fracture risk and minimizing side effects of diagnosis and treatment. BENEFITS, HARMS AND COSTS: Proper diagnosis and management of osteoporosis minimize injury and disability, improve quality of life for patients and reduce costs to society. Rationally targeted methods of screening and diagnosis are safe and cost effective. Harmful side effects and costs of recommended therapies are minimal compared with the harms and costs of untreated osteoporosis. Alternative therapies provide a range of choices for physicians and patients. RECOMMENDATIONS: Population sets at high risk should be identified and then the diagnosis confirmed through bone densitometry. Dual-energy x-ray absorptiometry is the preferred measurement technique. Radiography can be adjunct when indicated. Calcium and vitamin D nutritional supplementation should be at currently recommended levels. Patients should be counselled in fall-avoidance techniques and exercises. Immobilization should be avoided. Guidelines for management of acute pain are listed. Ovarian hormone therapy is the therapy of choice for osteoporosis prevention and treatment in postmenopausal women. Bisphosphonates are an alternative therapy for women with established osteoporosis who cannot or prefer not to take ovarian hormone therapy.
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BACKGROUND: Efficient and safe transport infrastructure is vital for economic growth in developing countries. The city of Cape Town, South Africa, has an extensive rail network with high levels of injury and violence. We investigated the reporting and frequency of railway injuries and examined their reduction through a range of interventions. METHODS: We analysed railway injury and death reporting by Cape Town's rail utility, state mortuaries, and a regional trauma survey. The data were obtained over 2.5 years, and the use of more than one data source was necessary to increase the size of the data pool and to determine under-reporting. FINDINGS: There were 379 railway-related deaths and 505 serious injuries during the study period. Most death (190) were train-pedestrian collisions, and the fatality rate on the metropolitan lines was about 60 per 100 million passenger journeys. There was substantial under-reporting by the rail utility of both fatal (20% under-reported) and non-fatal injuries (at least 24%). Many injuries occurred during peak commuting times and alcohol played an important part, especially in pedestrian fatalities. INTERPRETATION: Our results demonstrate the importance of a comprehensive, sustainable railway injury surveillance system to promote safety engineering and law enforcement in a metropolitan rail system.