Osteoporosis Alternative Treatments

The Osteoporosis Reversing Breakthrough

eres just a few things youll learn about how to get back into health. and conquer Osteoporosis. Those not-so innocent yet everyday substances that are currently attacking your body, perpetuating and aggravating your Osteoporosis. What to do and what Not to do to overcome your Osteoporosis effectively and permanently. How to create the energy you need to be able to work full time and feel confident you will be able to take care of your loved ones. How the pharmaceutical and food industry are conspiring to poison you and make you sick (Hint: American medical system is now the leading cause of death in the US). Which food industries use advertising to encourage doctors to tell you that their food is good for you just like those cigarette ads in the 1950s! The single most effective fruits and vegetables in cleaning up excess acidic waste and how to cleanse your inner terrain completely from systemic acidosis. Why, what your Doctor has told you is wrong, and why many medications actually increase the side effects and complications of Osteoporosis (primarily by depleting vital vitamins, minerals and nutrients from your body). Which supplements every patient must take to stop the symptoms and boost your body's ability to reverse Osteoporosis. How to naturally reduce your cravings for toxic foods. Lifestyle and food choices to reverse your Osteoporosis fast, naturally, and for good. Why treating the symptoms of disease is like using an umbrella inside your house instead of fixing the roof. The most powerful creator of health (Hint: its not a food or vitamin!) The best way to simplify the task of making a health-conscious lifestyle adjustment. A miraculous scientific discovery that jump-starts your body to do its natural work, which is to heal itself and restore your Health.

The Osteoporosis Reversing Breakthrough Summary


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Regional Migratory Osteoporosis

Regional migratory osteoporosis (RMO) is also known as idiopathic regional osteoporosis, transient osteoporosis, and migratory algodystrophy. It was first described in 1967 (88) and its etiology remains unknown. It appears to be closely related to the disorder known as transient osteoporosis of the hip.3 RMO occurs in middle-aged men. It begins as gradually increasing joint pain in the lower extremities with no prior history of trauma. Pain generally reaches a maximum level after 2 months. Symptoms subside after 3 to 9 months but may recur at the same or another joint. X rays of the affected joint generally reveal preservation of the articular space with periarticular demineralization. The affected joint will be hot on radionuclide scans. Trevisan and Ortolani (89) reported bone density findings in three Caucasian men who experienced 13 acute episodes of RMO during the study period. The men were 43, 44, and 54 years of age at presentation. Of the episodes, 46 involved the foot. The...

Guidelines from the European Foundation for Osteoporosis and Bone Disease

The European Foundation for Osteoporosis and Bone Disease (EFFO) published in 1996 some of the most practical guidelines yet for the clinical application of bone density measurements (12). Some of the clinical circumstances in which the EFFO believed that bone mass measurements should be considered are shown in Table 7-4. Like AACE, the EFFO was careful to emphasize that bone mass measurements should not be done if the result would not affect the clinical decision-making process. e. Conditions associated with osteoporosis 2. Radiographic evidence of osteopenia and or vertebral deformity a. Hormone replacement treatment in patients with secondary osteoporosis 2. Radiographic evidence of osteopenia and or vertebral deformity a. Hormone replacement treatment in patients with secondary osteoporosis The EFFO guidelines noted that the interval between BMD measurements for the detection of bone loss over time would vary with the anticipated rate of loss from the disease process. In some...

Diagnosing Osteoporosis

Guidelines of the Study Group of the WHO for the Diagnosis OF OSTEOPOROSIS The 1999 WHO and 2000 IOF Recommendations The Clinical Dilemma Diagnosing Osteoporosis in Men Many disease processes can affect skeletal mass. As the use of densitometry has become more widespread, an increasing number of diseases2 have been recognized as causing a decline in bone density. Nevertheless, the use of densitometry to diagnose osteoporosis remains the most common application of densitometry to disease states. In 1991 (1) and again in 1993 (2), Consensus Development Conferences attempted to clarify the clinical definition of osteoporosis. The NOF, the National Institutes of Health (NIH), and the European Foundation for Osteoporosis and Bone Disease sponsored these conferences. The definition of osteoporosis from the 1993 conference reflected only minor modifications from the 1991 conference. At the 1993 Consensus Development Conference (2) it was agreed that osteoporosis was The 1993 definition...

Guidelines of the study group of the who for the diagnosis of osteoporosis

In an extensive report published in 1994 (3), a WHO study group composed of 16 internationally known experts in the field of osteoporosis proposed criteria for the diagnosis of osteoporosis based on a specific level of bone density. The focus of the WHO study group was the study of world populations rather than the diagnosis of osteoporosis in individuals. While endorsing the prior 1991 and 1993 Consensus Development Conferences' definition of osteoporosis, the WHO recognized that their proposed criteria did not include any assessment of microarchitectural deterioration. The WHO attempted to reconcile the prevalence of the disease that would be created depending on the level of bone density chosen with published lifetime fracture risk estimates. The study group noted that a cut-off value of 2.5 SD or more below the average value for healthy young women for bone density at the PA spine or proximal femur or for bone mineral content at the midradius would result in 30 of all...

Changing the Definition of Osteoporosis

There has been considerable debate as to whether T-scores and the WHO Criteria should be retained or whether entirely new approaches to quantitatively defining osteoporosis should be pursued. The 1991 and 1993 Consensus Conferences' (1,2) definition of osteoporosis and even the 2000 Consensus Conference (23) definition2 ultimately define osteoporosis as a state of increased risk for fracture. It would be preferable for the diagnostic threshold for osteoporosis to coincide with the level of bone density that constitutes an unacceptable level of fracture risk, no matter what skeletal site or technique might be used for the measurement. Lu et al. (24) compared the diagnostic agreement for osteoporosis between two normal reference population approaches and a risk-based approach in 7671 women from the Study of Osteoporotic Fractures (SOF). Bone density was measured at eight different regions of interest using a combination of DXA and SPA the PA lumbar spine, total femur, femoral neck,...

Diagnosing osteoporosis in men

The issues surrounding the appropriate criteria for the diagnosis of osteoporosis in men are not substantially different than those for women. The WHO Criteria were 2At this NIH Consensus Conference osteoporosis was defined as a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.

Inulin and Bone Health

For this is probably enhanced passive and active mineral transport across the intestinal epithelium, mediated by increased levels of butyrate and other short-chain fatty acids and decreased pH (ScholzAhrens and Schrezenmeir, 2002). Improvements in calcium and iron absorption may help prevent osteoporosis and anemia, respectively (Ohta et al., 1998 Weaver and Liebman, 2002). Fructooli-gosaccharide ingestion enabled rats, for instance, to recover from experimentally induced anemia and to increase levels of minerals in their bones (Ohta et al., 1998 Oda et al., 1994). Osteoporosis is a condition characterized by a decrease in bone mass and density that causes the bones, especially in postmenopausal women, to become fragile and vulnerable to fracture. It is a growing global problem, which can be alleviated by dietary approaches. Calcium is a key factor in bone strength. By optimizing peak bone mass in early adulthood and by minimizing bone loss during the postmenopausal period, the risk,...

Medical guidelines for the prevention and management of postmenopausal osteoporosis

In women who have X-ray findings that suggest osteoporosis. 5. For establishing skeletal stability and monitoring therapeutic response in women receiving treatment for osteoporosis (baseline measurements should be made before intervention). (From Osteoporosis Task Force. American Association of Clinical Endocrinologists 2001 medical guidelines for clinical practice for the prevention and management of postmenopausal osteoporosis. Endocr Pract 2001 7 293-312.)

The osteoporosis selfassessment tool

Osta Score

Koh and colleagues (11) developed the original Osteoporosis Self-Assessment Tool for Asians (OSTA) based on a study of 860 non-Caucasian, postmenopausal women from eight Asian countries. Risk factors were captured from a self-administered questionnaire and bone density was measured by DXA in the proximal femur. Proximal femur T-scores were based on the manufacturer's reference data for Asian women. Statistical analysis was performed to determine which risk factors were independent predictors of BMD. The risk factors that were captured are listed in Table 8-9. These independent predictors were combined in a multivariable model from which risk factors were dropped one at a time until only statistically significant variables remained in the model. An index was developed from the variables in the final model to identify those women with a high probability of having a femoral neck T-score of -2.5 or less. Adapted with permission of the publisher from Koh LKH, Sedrine WB, Torralba TP, et...

Screening for Osteoporosis

Osteoporosis is a condition of decreased bone mineral density associated with an increased risk of fracture. Half of all postmenopausal women will have an osteoporosis related fracture in their lifetime. These include hip fractures. which are associated with higher risks of loss of independence, institutionalization and death. The risk of osteoporosis is increased with advancing age, tobacco use. low body weight. Caucasian or Asian ancestry, family history of osteoporosis, low calcium intake and sedentary lifestyle. Osteoporosis may also occur in men, although with a lower incidence than it does in women. Along with the risk factors noted above, the prolonged use of corticosteroids, presence of diseases that alter hormone levels (such as chronic kidney or lung disease) and undiagnosed low testosterone levels increase the risk of osteoporosis in men. Screening for osteoporosis is done by measurement of bone density. Measurement of the hip bone density by Dual energy X-ray...

National Osteoporosis Foundation Guidelines

The first guidelines or indications for bone mass measurements from a national organization were released in 1988 by the National Osteoporosis Foundation (NOF). These guidelines or clinical indications were developed in response to a report from the Office of Health Technology Assessment (OHTA) of the Public Health Service that had been submitted to the Health Care Finance Administration (HCFA). The report from OHTA To diagnose spinal osteoporosis in patients with vertebral abnormalities or roentgeno-graphic osteopenia in order to make decisions about further diagnostic evaluation and therapy. The NOF indications also noted the specific skeletal sites and techniques that should be used in these different circumstances. For an assessment of fracture risk in a postmenopausal woman, the NOF suggested that any site by any technique was appropriate. For the confirmation of spinal demineralization or the diagnosis of spinal osteoporosis, measuring the spine with DPA, DXA, or QCT was...

Osteoporosis risk assessment instrument

The Osteoporosis Risk Assessment Instrument (ORAI) questionnaire was developed by Cadarette et al. (7) using information obtained at the baseline visit for women participating in the Canadian Multicentre Osteoporosis Study4 (CaMos). There were 926 par- 4 CaMos is a population-based cohort study in which risk factors for osteoporosis, BMD, and osteoporotic fracture are being evaluated over a 5-year period.

ACOG Recommendations for Bone Density Screening for Osteoporosis

In a press release (13) on February 28, 2002, the American College of Obstetricians and Gynecologists (ACOG) announced long-awaited recommendations for the use of bone densitometry. ACOG, like the NOF and AACE, recommended that all postmenopausal women 65 years of age and older be screened for osteoporosis. Similarly, they ACOG 2001 Recommendations for Bone Density Screening for Osteoporosis. Diseases and Conditions Associated with an Increased Risk for Osteoporosis in Which BMD Testing May Be Useful in Both Pre- and Postmenopausal Women ACOG 2001 Recommendations for Bone Density Screening for Osteoporosis. Diseases and Conditions Associated with an Increased Risk for Osteoporosis in Which BMD Testing May Be Useful in Both Pre- and Postmenopausal Women

Osteoporosis Screening

The prevalence of low bone mineral density in the elderly is high, with osteopenia found in 37 of postmenopausal women. Primary prevention of osteoporosis begins with identification of risk factors (older age, female gender. White or Asian race, low calcium intake, smoking, excessive alcohol use, and chronic glucocorticoid use). Calcium carbonate (500 mg three times daily) and vitamin D (400-800 lU d) reduce the risk of osteoporotic fractures in both men and women. Bone mineral density testing using dual-energy x-ray absorptiometry (DEXA) of patients with multiple risk factors may uncover asymptomatic osteoporosis.


Aging bones tend to lose minerals and density, gradually becoming thinner and more fragile. In osteoporosis, loss of bone mineral has progressed to the point where fractures can occur with minimal or no trauma. Although both men and women can develop osteoporosis, it is much more common in older women. This is because loss of endogenous estrogens during menopause sharply accelerates bone loss. In severe cases, up to 20 of the mineral content of the skeleton can be lost in the 3-5 years of the menopause. Osteoporosis progresses silently, and often the first indication of its presence is a fracture of the hip or spine. Optimum nutrition can substantially reduce risk of osteoporosis.19

Image Analysis Inc Columbia

Analyze Hip Dxa Delphi Qdr

Ered comparable to that of DPA (56-59). DXA spine values and Hologic and Norland DXA proximal femur values are consistently lower than values obtained previously with DPA. There are also differences in the values obtained with DXA equipment from the three major manufacturers.20 Values obtained with either a Hologic or Norland DXA unit are consistently lower than those obtained with a Lunar DXA unit, although all are highly correlated with each other (60-62). Comparison studies using all three manufacturers' central DXA devices have resulted in the development of formulas that make it possible to convert values for the lumbar spine and femoral neck obtained on one manufacturer's device to the expected value on another manufacturer's device (see Appendix II) (63). The margin of error in such conversions is still too great to use such values in following a patient over time, however. Such values should only be viewed as ball park figures. Another set of formulas makes possible the...

Epidemiologic Evidence Supporting Physical Activity

In the United States alone, it has been estimated that roughly 250,000 deaths per year are attributed to lack of regular physical activity3 (roughly one-quarter of all preventable deaths annually). However, others have suggested that these figures may be significantly underestimated.23 Ongoing longitudinal studies have provided consistent evidence of varying strength documenting the protective effects of activity for a number of chronic diseases, including CHD, chronic heart failure (CHF), type 2 diabetes, hypertension, osteoporosis, and site-specific cancers.2,3,6 In contrast, low levels of physical fitness or activity are consistently associated with higher cardiovascular and all-cause mortality rates.2,3,13,14 Midlife increases in physical activity, fitness level, or both, through change in occupation or recreational activities, are associated with a decrease in mortality rates.24,25 Considering the last few years alone (2000-2004), an impressive volume of data has been published...

Late Effects In Survivors

As noted earlier, patients who survive the first five years after HCT are likely to survive long-term with mortality rates eventually approaching that of the general population (5). However, some survivors experience late complications of HCT. Baker et al. (67) studied the long-term risks and benefits of HCT for CML. Two hundred forty-eight recipient of HCT for CML who had survived at least two years post-HCT were compared to 317 normal siblings. Subjects completed a 238-item survey on medical late effects. When compared with sibling controls, survivors had higher risks of ocular, oral health, endocrine, gastrointestinal, musculo-skeletal, neurosensory, and neuromotor impairments. Multivariate analysis of the allograft recipients identified chronic GVHD as a major risk factor for hypothyroid-ism, osteoporosis, cardiopulmonary, neurosensory, and neuromotor impairments. These data show the need for continued monitoring and medical intervention in these patients. The CIBMTR and EBMT...

Estimated Time To Complete

Radiographic Film Analysis

We are pleased to award category 1 credit(s) toward the AMA Physician's Recognition Award. By completing the Review in the CD-ROM Companion in Appendix XIV, you are eligible for up to 30 hours of category 1 credit. After answering all of the questions correctly, complete the review evaluation and enter the required identifying information on the certificate of course completion. This certificate is not valid until signed with authorized signature at the Foundation for Osteoporosis Research. The certificate may be printed one time only. Send the certificate and the required fee to the Foundation for Osteoporosis Research and Education for awarding of continuing education credits. This activity is offered by the Foundation for Osteoporosis Research and Education, a CMA accredited provider. Physicians completing this course may report up to 30 hours of category 1 credits toward the California Medical Association's Certification in Continuing Education and the American Medical...

Heart Transplant Patients

In order to regain a good functional status with good quality of life, physical training is crucial after heart transplantation, and participation in long distance races is possible.14 However, it is controversial whether training modifies the rein-nervation.15 Also resistance exercise is beneficial for counteracting osteoporosis and skeletal muscle myopathy.16 However, due to sympathetic denervation, hypotension during resistance exercise is a problem in about 25 of patients, particularly when lifting above the level of the heart. Therefore exercises improving venous return should be done (cool-down walk 2-5 min, alternate upper body and lower body exercises). In severe osteoporosis, resistance exercises should be done with care.

Use in Prevention and Therapy

Fluoride can stimulate osteo-blastic activity and new bone formation, but its role in osteoporosis remains unclear.614 Although one study found a decrease in vertebral fractures with intermittent fluoride and calcium therapy,12 another found that skeletal fragility and fracture rates were increased by daily supplementation with fluoride and cal-cium.13 Overall, it appears fluoride has little beneficial effect in osteoporosis.14

Shewhart Rules And Cusum Charts

Although much has been written about quality control procedures in densitometry, much of this literature has been concerned with data collection in clinical research rather than patient data collected as part of medical care. Quality control, although absolutely necessary in clinical research, is no less necessary in clinical practice. The original indications for bone mass measurements from the National Osteoporosis Foundation published in 1988 and the guidelines for the clinical applications of bone densitometry from the International Society for Clinical Densitometry published in 1996 called for strict quality control procedures at clinical sites performing densitometry (1,2). The Canadian Panel2 of the International Society for Clinical Densitometry published specific guidelines for quality control procedures in 2002 (3). Such procedures are crucial to the generation of accurate and precise bone density data. When quality control is poor or absent, the bone density data may be...

Replacing a densitometer

Johnston CC, Melton LJ, Lindsay R, Eddy DM. Clinical indications for bone mass measurements a report from the scientific advisory board of the National Osteoporosis Foundation. J Bone Miner Res 1989 4 S1-S28. 7. Pearson J, Dequeker J, Henley M, et al. European semi-anthropomorphic spine phantom for the calibration of bone densitometers assessment of precision, stability and accuracy. The European Quantitation of Osteoporosis Study group. Osteoporos Int 1995 5 174-184. 8. Pearson D. Standardization and pre-trial quality control. In Pearson D, Miller CG, eds. Clinical trials in osteoporosis. London, England Springer, 2002 43-65.

Pharmaceutical and industrial uses of marine organisms

The most commonly prescribed antibiotics in US hospitals were derived from aquatic molds. The hormone calcitonin, extracted from salmon, has been found effective in preventing osteoporosis. And protamine sulfate, derived from salmon sperm, provides an antidote to the anticoagulant heparin (Plotkin, 2000).

Clinical Risk Assessment For Periodontal Disease

Information concerning individual risk for developing periodontal disease is obtained through careful evaluation of the patient's demographic data, medical history, dental history, and clinical examination (Table 32-2). The elements that contribute to increased risk that can be identified through the collection of demographic data include the patient's age, gender, and Sl.S. The medical history may reveal elements such as a history of diabetes, smoking, II1V AIDS, or osteoporosis, as well as the perceived level of stress. I he dental history can reveal a

Calcium and Vitamin D

Osteoporosis is increasingly being recognised as a leading extra-intestinal complication of inflammatory bowel disease. Calcium is absorbed in the proximal small intestine by a vitamin D-depend-ent Ca2+-binding protein, and vitamin D is absorbed in the duodenum and jejunum. Therefore, in Crohn's disease patients with extended inflammation or resection of the small intestine, osteoporosis results from impaired absorption of calcium and vitamin D. However, there are also some conflicting data suggesting that many factors, other than calcium or vitamin D deficiency, contribute to the pathogenesis of osteoporosis in Crohn's disease 23, 24 . These factors include cytokines, such as TNF-a, that disproportionately stimulate osteoclast activity, or corticosteroid usage 25, 26 . Overt vitamin D deficiency disease may occur in Crohn's disease patients and patients often present with bone pain and mild myopathy. Other symptoms at presentation include bone pain and mild myopathy.

Alterations in Body Composition

Besides this significant loss of lean tissue, CHF patients also have a lower fat tissue mass (i.e. energy reserves) and decreased bone mineral density (i.e. osteoporosis) 21, 22 (Table 1). Other studies confirmed these findings and found significantly correlated plasma levels of inflammatory cytokines and catabolic hormones 23 , which might represent a mechanism for these changes in body composition. Bone mineral density (g cm2)

Postpartum Depression

Fig. 4.8 Calcium supplementation increases bone density during lactation and weaning. Effects of calcium supplementation and lactation in 389 women on the change in bone mineral density of the lumbar spine during the first 6 months postpartum and postweaning. Significant differences were found between the calcium and placebo groups in the nonlactating women during the first 6 months, and forthe calcium and placebo groups in both the lactating and nonlactating women after weaning. (Adapted from Kalkwarf HJ, et al. N Engl J Med. 1997 337 523) Fig. 4.8 Calcium supplementation increases bone density during lactation and weaning. Effects of calcium supplementation and lactation in 389 women on the change in bone mineral density of the lumbar spine during the first 6 months postpartum and postweaning. Significant differences were found between the calcium and placebo groups in the nonlactating women during the first 6 months, and forthe calcium and placebo groups in both the lactating and...

Effects Of Insufficient Occlusal Force

Insufficient occlusal force may also be injurious to the supporting periodontal tissues. '' Insufficient stimulation causes thinning of the periodontal ligament, atrophy of the fibers, osteoporosis ol the alveolar bone, and reduction in bone height. 1 lypofunction can result from an open-bite relationship, an absence t Junctional antagonists, or unilateral chewing habits tli.it neglect one side of the mouth.

Rational Design Of Mimetic Surfaces

Blood clotting, would healing, inflammation, osteoporosis, and cancer (27,34,35). Integrins interact with cell binding domains on ECM proteins, such as the ubiquitous arginine-glycine-aspartic acid (RGD) tripeptide sequence, through a binding site created by the dimeric, noncovalent interaction between a and b subunits (34,36,37). In contrast to integrin binding, cell surface proteoglycans (e.g., heparan sulfate) bind to ligands via purely electrostatic interactions. This binding is highly dependent on the spacial location of the charges within the ligand. For example, the negatively charged carboxyl and sulfate groups present in heparin interact with the positively charged heparin binding domains present in ECM proteins through consensus amino acid sequences such as X-B-B-X-B-X (X, hydrophobic B, positive basic residue) (6,38,39).

Standardization of Forearm DXA Results

One hundred and one women, aged 20 to 80 years, with 13 to 19 subjects per decade were studied on each of the six devices. Women were excluded if they were pregnant, had a history of distal radial fracture, or had any bone diseases other than osteoporosis. Seventy-four percent of the women were white.

J.bone Miner Res 1994

Lu Y, Fuerst T, Hui S, Genant HK. Standardization of bone mineral density at femoral neck, trochanter and Ward's triangle. Osteoporos Int 2001 12 438-444. 32. Grigorian M, Shepherd JA, Cheng XG, Njech CF, Toschke JO, Genant HK. Does osteoporosis classification using heel BMD agree across manufacturers Osteoporos Int 2002 13 613-617.

Calcium Minerals and Skeleton Health

Ample calcium and mineral intake is particularly important for teenage females. Bone growth is rapid during adolescence, when about half of the total skeleton is formed. The amount of bone mineral that has accumulated in the skeleton during this period is a major determinant of risk of osteoporosis in later life. More calcium deposited into the skeleton during childhood and adolescence means a greater calcium bank to draw from during aging. seven have intakes near 1200 mg day.4 Milk and other dairy products are the primary source of calcium in the teenage diet, yet many adolescents regularly substitute soft drinks, iced tea, or other sweetened beverages for milk. Insufficient dietary calcium during adolescence can have lasting consequences. Poor intakes of calcium (and other minerals, such as zinc19) can compromise bone health and may increase incidence of bony fractures both during adolescence and later in life. Calcium supplements can help children and teenagers reach adequate...

Artifacts in PA or AP Spine Densitometry

Sub Endplate Sclerosis And Osteophytes

The BMD of a fractured vertebra will be increased because of the fracture itself. This increase in density could erroneously lead the physician to conclude that the bone strength is better and the risk for fracture, lower, than is the case. Vertebral fractures in osteoporosis frequently occur in the T7-T9 region and in the T12-L2 region (14,15). Because DXA measurements of the lumbar spine are often employed in patients with osteoporosis, osteoporotic fractures in the lumbar spine, particularly at L1 and L2, are a common problem, rendering the measurement of BMD inaccurate if the fractured vertebrae are included. An increased precision error would also be expected if the fractured vertebrae were included in BMD measurements performed as part of a serial evaluation of BMD. Although a fractured lumbar vertebra can be excluded from consideration in the analysis of the data, this reduces the maximum number of contiguous vertebrae in the lumbar spine available for analysis. For reasons of...

Ankylosing Spondylitis

Low bone density has been frequently observed in ankylosing spondylitis although its etiology remains uncertain. For 2 years Maillefert et al (23) followed 54 patients with ankylosing spondylitis to determine the prevalence of osteopenia and osteoporosis and the relationship of any observed bone loss to therapy, physical impairment, or inflammation. There were 35 men and 19 women in the study with an average age of 37.3 years and average disease duration of 12.4 years. In 23 patients, the disease duration was less than 10 years. Bone density was measured at baseline and 2 years with DXA at the PA lumbar spine and proximal femur (Hologic QDR 2000). The mean PA lumbar spine baseline T-score and z-score for the group was -1.24 and -0.98, respectively. At the proximal femur, the baseline T-score and z-score was -1.07 and 0.46, respectively. Seventeen percent had T-scores at the PA lumbar spine of -2.5 or poorer and 39 had T-scores between -1 and -2.5. At the femoral neck, 11 had T-scores...

Mechanisms of Malnutrition in Chronic Pancreatitis

Chronic Pancreatitis Mechanism

The absorption of fat-soluble vitamins (A, E, and K) is usually preserved 84, 88, 89 in patients with chronic pancreatitis, and, although vitamin D is not significantly reduced, osteopaenia and osteoporosis are much more common than previously thought 90 . Deficiencies of water-soluble vitamin are often seen in chronic alcoholics, and impairment of copper, selenium, and zinc metabolism is particularly pronounced in patients with combined chronic pancreatitis and diabetes melli-tus 91 .

Gluten Sensitive Enteropathy

In a study from Argentina, Gonzalez et al. (46) evaluated 127 consecutive postmenopausal women with osteoporosis, who had a mean age of 68. Osteoporosis was defined as at least one nontraumatic fracture and an L2-L4 and or femoral neck T-score below -2.5. Bone density was measured using a Lunar DPX. The Buenos Aires reference population was used to calculate T- and z-scores for the study populations. This reference database is reported as similar to the reference database for Caucasian women in the United States. The mean T-score for the osteoporotic population was -3.2 and -3.0 for spine and femoral neck, respectively. The prevalence of celiac disease in these osteoporotic women was compared to 747 women, with a mean age of 29, recruited for a population-based study. Screening for celiac disease was done using IgA and IgG antigliadin antibodies (AGA) in all patients. This was followed by antiendomysial antibodies (EmA) and total IgA in the patients testing positive for AGA....

Physiological Effects Of Glucocortioids

Large doses of cortisol have been shown to antagonize the effect of active vitamin D metabolites on the absorption of Ca2+ from the gut, inhibit mitosis of fibroblasts, and cause degradation of collagen. All of these effects can lead to osteoporosis, which is a reduction in bone mass per unit volume. Glucocorticoids can also delay wound healing because of the reduction of fibroblast proliferation. Connective tissue is reduced in quality and strength. In addition, chronic supra-physiologic doses of glucocorticoids will suppress growth secretion and inhibit somatic growth.

Physiological Functions Of Cas

Sickness and for gastric and duodenal ulcers, neurological disorders, or osteoporosis. The development of more specific agents is required because of the high number of isozymes present in the human body as well as the isolation of many new representatives of CAs from all kingdoms. This is possible only by understanding in detail the catalytic and inhibition mechanisms of these enzymes. These enzymes and their inhibitors are indeed remarkable after many years of intense research in this field, they continue to offer interesting opportunities to develop novel drugs and new diagnostic tools or to understanding in greater depth the fundamental processes of the life sciences.

Qualitative or Categorical Data

If data are classified as belonging to categories, the data are considered qualitative data. Such data are discrete and generally consist of counts or the number of individuals belonging to each category. This type of data is also called categorical data. Categorical data can be ordinal or nominal, depending on whether there is a logical order to the categories. For example, individuals might be placed into height categories of tall, medium or short (remember that the actual measurement of height is a continuous quantitative variable, which is different from the current example). This is clearly qualitative or categorical data. There also is a logical order to these categories, with medium in between tall and short. This is an example of ordinal data. Nominal data has no obvious order. Hair color, for example, cannot be ordered. Qualitative count data of the number of individuals with brown, blond, or black hair can be obtained, but the categories of brown, blond, or black hair have...

Genomics and the Human Genome

Each cell in an organism contains its complete genome but depending on the cell type, only the genes necessary for conducting the work of that cell type are expressed. The human genome sequence consists of an ordered listing of the adenine, cytosine, guanine, and thymine bases found on the 46 human chromosomes. Only about 1 of the genome sequence codes for proteins necessary for human life. Most of the rest of the genome consists of large repetitive noncoding regions whose function is not well understood. It is known, however, that critical clues to diseases such as cancer, diabetes, and osteoporosis lie in areas of the genome that do not code for protein. About one-fourth of the genome contains long,

Osteotropism Of Metastatic Dissemination

The aminobisphosphonate ibandronate has marked osteoclast inhibitory activity and has been investigated as a treatment modality for metastatic bone disease and cancer-induced hypercalcemia. In combination with taxol taxotere, ibandronate appears to be able to inhibit invasion of the bone by the human breast cancer cells MDA-MB231 (Magnetto et al. 1999) and the development of bone lesions in animals injected with myeloma cells (Dallas et al. 1999). Ibandronate markedly affects bone resorption in metastatic bone disease (Coleman et al. 1999). Osteocalcin, PICP, and BA-1p have been found to be reliable dose-dependent markers in a phase II clinical trial with ibandronate treatment of metastatic breast cancer. They were also found to be suitable for monitoring the effects of treatment of osteoporosis (Schlosser and Scigalla, 1997). However, Bombardieri et al. (1997) seem to disagree that any of these markers can replace bone scans.

Pregnancy and Lactation

Controversy exists as to whether a separate entity of pregnancy-induced osteoporosis exists or whether pregnancy is an incidental or precipitating factor in persons who already have osteoporosis. The syndrome is considered rare with about 80 cases documented in the literature. The women who are affected often present with vertebral fractures in the third trimester or shortly after delivery. Densitometry has demonstrated markedly low bone density in both the spine and proximal femur (81). Five cases of postpregnancy osteoporosis have been reported by Yamamoto et al. (82). These women ranged in age from 24 to 37 years. Of the five women, four were diagnosed after their first pregnancy. The fifth was diagnosed after her second pregnancy. All of the women presented with back pain and vertebral compression fractures, most within 1 month of delivery. BMD measurements were made at the 33 radial site with SPA (Norland-Cameron) and at the spine by either QCT or DXA (Hologic QDR-1000)....

Magnetic Resonance Imaging

Renal insufficiency (serum creatinine 2 mg dl) Anemia (hemoglobin 2 episodes in 12 months) For patients with a solitary bone lesion or osteoporosis without fracture as the sole defining criteria, 30 bone marrow plasmacytosis is required for the diagnosis of systemic myeloma. For monoclonal protein, no specific level is required and it is absent in non-secretory myeloma.

Key Outcomes from a Joint Position Statement

In 2004, Osteoporosis Australia were raising concerns in the media about vitamin D deficiency at the same time that new research by Hughes et al. was coming out about possible benefits of sun exposure in reducing non-Hodgkin lymphoma (Huges et al. 2004). Given the significant media attention centred around possible or real benefits of sun exposure, the Cancer Council Victoria considered it was necessary to develop a position statement with the Australasian College of Dermatologists (ACOD), Osteoporosis Australia (OA), Australia and New Zealand Bone and Mineral Society (ANZBMS) and the Cancer Council Australia (CCA) to ensure consistent information was being provided to the general public.

Management Of Skeletal Disease

Bone disease in the form of lytic lesions, pathological fractures, or osteoporosis are present at diagnosis over three-quarters of the time,130 ultimately leading to significant morbidity in many patients with MM. While external beam radiation therapy is remarkably effective palliation for pain relief from existing lesions, it is the localized therapy without the potential to reduce the risk of skeletal complications outside of the radiation port. Bone resorption in MM results occurs due to stimulation of osteoclasts, which in turn results predominantly from receptor activator of NF-kB (RANK) signaling by RANK-ligand.131' 132 Bisphosphonates are synthetic pyrophosphate analogues that inhibit osteo-clast function directly though disruption of intracellu-lar biochemical pathways133, 134 or induction of apopto-sis,135 or indirectly by stimulating production of the inhibitory RANK decoy molecule, osteoprotegerin.136 The two bisphosphonates currently approved for use in treating MM-related...

How Much Sun Exposure Is Enough

Recognising the limitations of existing evidence, a very pragmatic approach was adopted in Australia. Based on evidence relating to bone gracture and vitamin D, it was agreed that one-third of a minimal erythemal dose (MED) to 15 of the body, (e.g. the face, arms and hands) on most days of the week would be sufficient to maintain adequate vitamin D absorption to reduce osteoporosis risk (Newson et al. 2004). In practice this equates in the Australian context to only 10 min sun exposure either side of the peak UV period on most days of the week over summer and 2-3 h per week sun exposure during the winter months. This level was acceptable to the ACOD, as it was considered that the general population were already likely to be exceeding these recommendations as part of their normal day-to-day activity, even if they were always adopting sun protective measures during periods of high ultraviolet (UV) radiation. In addition, all parties agreed that the benefit of some sunlight is far...

Muscle Mass Changes Sarcopenia

Similar to body mass index (BMI), a common definition of sarcopenia accounts for body size by dividing the ASMM by the height squared 44, 50, 51 . In the New Mexico Aging Process Study 45 , sex-specific cut-off points for kg m2 in the ASMM index were set as two standard deviations below the mean for a healthy young-adult population, similar to the definition of osteoporosis. These cut-off points were 7.26 kg m2 in men and 5.45 kg m2 in women. According to this definition, the prevalence of sarcopenia increases from 13-24 among people under 70 to more than 50 among those over 80 (Table 1). Other authors classified their patients as sarcopenic if their ASMM index fell into the sex-specific lowest 20 of the distribution of the index this definition resulted in very similar cut-off values (7.23 kg m2 in men and 5.67 kg m2 in women) 52 . The same authors also measured sarcopenia using the ALM, adjusted for FM and height 52 . The prevalence of sarcopenia according to the first method was...

The Morphologic Diagnosis Of Multiple Myeloma

The growth pattern of myeloma on trephine is also predictive of the type of skeletal defects and correlates strongly with magnetic resonance imaging findings. Nodules of plasma cells are associated with osteolytic lesions, whereas interstitial and sarcomatous types are associated with osteoporosis.7

How can one make lowsodium cheese

Although sodium is an essential component in the human diet, excessive intakes have undesirable physiological effects, the most significant of which are hypertension and increased calcium excretion (which can lead to osteoporosis). The recommended daily requirement of sodium for the adult human is -2.4 g Na+, which is equivalent to -6 g NaCl, per day. Sodium intake in the modern western diet is 2-3-fold higher than recommended. This has given rise to recommendations for reduced dietary intake of Na+ and an increased demand for reduced-sodium foods, including cheese. However, owing to the important role of salt in cheese 39 , reduction in salt level must be such that the quality and safety of the cheese are not compromised. Probably the most effective approaches to date for reducing sodium are

Bone Growth Modeling and Remodeling

Under normal circumstances in the mature skeleton, bone resorption and bone formation are coupled. At any given remodeling site, bone formation predictably follows bone resorption such that resorbed bone is replaced with an equal amount of new bone. This predictable sequence of events in both cortical and trabecular bone remodeling is called ARF, an acronym for activation, resorption, and formation (50). In disease states like osteoporosis, even though the ARF sequence remains, resorption and formation may be uncoupled, leading to an imbalance in resorption and formation and a net bone loss. The rate at which BMUs are activated, initiating bone resorption, is called the activation frequency. In some disease states, the activation frequency may increase or decrease producing changes in bone mass.

Measures Against Rejection

Basic medical therapy to reduce the incidence of acute rejection includes two or three of the following immunosuppressants ciclosporin, azathio-prine, corticosteroids. Ciclosporin, a calcineurin inhibitor,specifically acts on T-cell and B-cell activation and has markedly improved survival in the first 2 years after transplant. However, due to its negative effects on blood pressure, renal function, lipid and glucose metabolism, it had little positive impact on the determinants of long-term survival such as cardiac allograft vasculopathy (CAV). The patient may notice hypertrophic gingivitis, hyper-trichosis, and tremor and headache. It decreases oxidative enzymes and may thus further limit oxidative capacity in HTR.8 Tacrolimus, equally effective against acute rejection, is increasingly substituted for ciclosporin because of a lower incidence of hypertension and hyperlipidemia however, there is a trend for more cases of new-onset diabetes.24 Other side-effects are similar to...

Theoretical And Practical Considerations 821 Choice of Study Population

It is also important to match the cohorts for phenotypic or environmental variables that may otherwise confound any genetic analysis for example, hormone replacement therapy (HRT) has a large impact on bone mineral density (BMD) and it would be necessary to account for this in a search for genetic factors influencing BMD using a cohort of post-menopausal women.

American Association of Clinical Endocrinologists Guidelines

In 1996, the American Association of Clinical Endocrinologists (AACE) developed guidelines for the prevention and treatment of osteoporosis (10). As part of these guidelines, BMD measurements were discussed. The specific clinical circumstances in which AACE believed that bone mass measurements were appropriate were virtually identical to the original guidelines from the NOF published in 1988, although they were clearly Risk assessment in perimenopausal or postmenopausal women who are concerned about osteoporosis and willing to accept available intervention. In women with X-ray findings that suggest the presence of osteoporosis. In women undergoing treatment for osteoporosis, as a tool for monitoring the therapeutic response. These guidelines reflect the increase in available therapeutic options beyond HRT for the prevention or treatment of osteoporosis. With the availability of nasal spray calcitonin and alendronate sodium, a woman's choices for the prevention or treatment of this...

North American Menopause Society Recommendations

The North American Menopause Society (NAMS) published a comprehensive review of postmenopausal osteoporosis in the journal Menopause in 2002 (14). Included in the review were recommendations for bone density testing in the specific context of osteoporosis prevention and management. NAMS noted that measurement of BMD is the preferred method for diagnosing osteoporosis and that DXA is the technological standard for measuring BMD. NAMS stated that the total hip was the preferred region of interest to evaluate, particularly when measuring bone density in women over 60 because of the increased likelihood of degenerative calcification in the spine that would affect spine measurements.3 Nevertheless, spine measurements were described as useful in early postmenopausal women because of the faster rate of bone loss at that site compared to the rate seen at the proximal femur. Citing a report from the International Osteoporosis Foundation (IOF) published in 2000 (15), NAMS stated that they...

World Health Organization Task Force Recommendations for Men and Women

An interim report (25) from the WHO Task Force for Osteoporosis was published in 1999 in which recommendations for bone density testing for both men and women were made. Bone density measurements were recommended if there was the following Radiographic evidence of osteopenia or vertebral deformity. Chronic disorders associated with osteoporosis.

Guide To Further Reading

New England Journal of Medicine 338 736-746. Fraser D R 1995 Vitamin D. Lancet 345 104-107 Greenberg E R, Sporn M B 1996 Antioxidant vitamins, cancer and cardiovascular disease. New England Journal of Medicine 334 1198-1190 Humphrey J H, Rice A L 2000 Vitamin A supplementation in young infants. Lancet 356 422-424 women and men. Lancet 359 1841-1850 Spector T D, Sambrook P N1993 Steroid osteoporosis.

Weight selection criteria

The use of weight alone as a criterion for selecting women for bone mass measurements was proposed in 1996 by Michaelsson et al. (16). In this study reported in Osteoporosis International, only anthropomorphic measures were considered in predicting which individuals were likely to have a low bone density. The measures included height, weight, BMI, waist-to-hip ratio, lean tissue mass, and fat tissue mass. Bone density was measured by DXA at the PA lumbar spine and femoral neck. Lean and fat tissue mass were determined using DXA total body studies. T-scores were calculated using the manufacturer's reference database for US Caucasian women. Osteopenia and osteoporosis were defined using WHO criteria for diagnosis. One hundred seventy-five women were studied, of whom 106 were postmenopausal. Their average weight was 148.6 lb (67.4 kg). The women were divided into tertiles based on weight. The sensitivity, specificity, and positive and negative predictive values for osteopenia and...

Comparing the performance of selfassessment questionnaires

SCORE, ORAI, SOFSURF, and OST were compared by Hochberg et al. (22) in a study of 17,572 Caucasian women ranging in age from 45 to 93 years who were initially screened for participation in FIT (23). Twenty-one percent of these women had osteoporosis at the femoral neck using the WHO criteria of a T-score of -2.5 or poorer and the NHANES III proximal femur database. At approximately 90 sensitivity, both OST and SOFSURF had an acceptable 46 specificity for the prediction of an osteo-porotic T-score at the femoral neck. The cutpoints, sensitivities, specificities, and LRs are shown in Table 8-14. The cutpoints for OST used in this study have been shifted up by one unit compared to those used in the original OSTA index for Asian women. The shift in the cutpoint for SCORE represents the effect of using the NHANES III reference database for the calculation of proximal femur T-scores and the prediction of a lower T-score than called for in the development of the SCORE index.

Predicting fracture risk in men

The number of studies reporting fracture risk in men based on the decline in bone density has increased in recent years. As in so many of the studies on women, the increase in fracture risk is generally reported as the relative risk for fracture per SD decline in bone density. Other studies have reported absolute risk. The findings from these studies have led to two apparently contradictory conclusions women have a greater increase in relative risk for fracture per SD decline in BMD than do men but the absolute risk for fracture at any given level of BMD is the same in women and men (25). In Table 10-11, the age-adjusted relative risk values for fracture in men and women age 35 years and older from a population-based case-control study in Rochester, Minnesota are shown (26). The relative risks differ depending on the reference population used. Note that the relative risk for any type of fracture in men was 1.1 per SD decline in femoral neck BMD when the reference population was 20- to...

Us densitometry center reporting practices

Based on a national survey of densitometry reporting practices, it is clear that the needs of primary care physicians are not being met. In 2002, Fuleihan et al. (3) summarized the reporting practices of 270 densitometry centers in the United States. These were centers that were listed in the National Osteoporosis Foundation (NOF) database of US densitometry centers who responded to a questionnaire on densitometry reporting practices. At 71 of the 270 centers, the PA spine and proximal femur were routinely measured. Thirteen percent of the centers measured only one site routinely, and 11 measured the spine, proximal femur, and forearm routinely. In reporting the results of the studies, 89.6 included T-scores and 55.9 included z-scores as well. At 7.1 of the centers, T-scores were not reported and at 38.9 , z-scores were not reported. Only 64 of the centers mentioned the WHO Criteria for diagnosis and only 70 provided assessments of fracture risk. Of the centers reporting fracture...

Reporting the diagnosis

This patient has osteoporosis according to World Health Organization Criteria based this man has osteoporosis based the T-score of -2.6 at the femoral neck. In utilizing the WHO Criteria, it is important to note that modifiers such as mild, moderate, or severe are not used to describe the diagnostic category of osteopenia or low bone mass. In addition, severe osteoporosis should be used to describe only those individuals with a bone density 2.5 or more SD below the young-adult mean value and who have a presumed fragility fracture. One of the limitations of the WHO Criteria is that the WHO Criteria do not allow for an individual with an osteopenic bone density T-score and presumed fragility fracture to be called osteoporotic. In such a case, it would be reasonable to point out that this individual certainly meets the conceptual definition of osteoporosis as proposed by the Although this patient does not meet the quantitative definition of osteoporosis established by the World Health...

Jrg A Gasser 1 Introduction

Quantitative computed tomography (QCT) is an established technique for the determination of bone mineral density (BMD) in the axial and appendicular skeleton (1). QCT is unique amongst methods of bone mineral measurement in providing separate estimates of trabecular and cortical bone mineral density as a true volumetric mineral density value (g cm3) (2). In addition, QCT can measure geometric properties of cortical bone with great accuracy (3) and predict some mechanical properties with remarkable precision (4-6). Peripheral quantitative computed tomography (pQCT) is a special type of computed tomography in which scans of the appendicular skeleton are performed at a low radiation dosage. Bone and muscle development can be assessed noninvasively by pQCT at peripheral sites in studies of bone development, experimental models of bone loss, and in monitoring the effectiveness of therapeutic interventions. In addition, pQCT can be used to assess excised bones ex vivo from virtually any...

Recommending evaluations for secondary causes of bone loss

More detailed and aggressive recommendations can be made based on published findings from studies of patients with osteoporosis such as those from Johnson et al. (9) and Tannenbaum et al. (10). In 1989, Johnson et al. (9) evaluated 180 individuals (173 women, 7 men) with osteoporosis. In this study, osteoporosis was defined as two atraumatic spinal compression fractures or as a PA lumbar spine bone density 10 or more below the age-matched predicted value. After a thorough medical evaluation, 83 of the 180 individuals were found to have additional diagnoses that could potentially contribute to the development of osteoporosis. These diagnoses are shown in Table 12-1. A total of 128 diagnoses were identified in the 83 patients. In 11 of the 180 patients, the diagnosis was previously unknown. In the study from Tannenbaum et al. (10), 173 postmenopausal women with osteoporosis at the PA lumbar spine, proximal femur, and or forearm based on WHO Criteria were evaluated for secondary causes...

Jade W M Chow 1 Introduction

Estrogen is known to be one of the major hormonal influences in bone remodeling and bone mass. Estrogen deficiency after the menopause is one of the leading causes of osteoporosis, and currently estrogen replacement is the first line management for postmenopausal osteoporosis. The bone loss associated with estrogen deficiency is due to increased bone resorption and a relative deficiency in bone formation. Although estrogen is thought to prevent bone loss mainly by suppressing bone resorption (1,2), there is also recent evidence to suggest that estrogen may exert an anabolic effect in bone in humans (3,4). Estrogen receptors (ER) are present in osteoblasts (5), and oestradiol has been shown to increase type I collagen and alkaline phosphatase production by osteoblasts in vitro (6). Animal models have proved invaluable in the study of the role of estrogen in bone metabolism. There is a large body of evidence that the cancellous bone of the secondary spongiosa of adult female rats has...

American college of obstetricians and gynecologists guidelines for bone density measurements

Pre- or postmenopausal women with diseases or conditions associated with an increased risk of osteoporosis. (From ACOG releases recommendations for bone density screening for osteoporosis. Washington, DC American College of Obstetricians and Gynecologists, 2002. Accessed March 26, 2002, at

Experimental Control Of Oxidative Stress Pathways

Several groups have been developing animal models with mitochondria deficiencies 91-93 . These models include the adenine nucleotide translocator (ANT-1), mitochondria superoxide dismutase- (SOD2-) deficient mice, Tfam-deficient mice, and the PolgA. ANT-1- deficient mice are a model for chronic ATP deficiency. These mice have increased production of ROS and hydrogen peroxide and a parallel increase in mtDNA mutations consistent with levels seen in much older mice 94 . SOD2-deficient mice die in the neonatal period from dilated cardiomyopathy or neonatal degeneration in the brain stem 92, 93 . The Tfam-deficient mice exhibit cytochrome c oxidase deficiency and die at around 3 weeks of age 95 . PolgA is a more recent mouse model, independently developed by two groups 29, 96 , that expresses a deficient version of the nucleus-encoded catalytic subunit of mtDNA polymerase. These mice develop a mtDNA mutator phenotype with a three- to fivefold increase in levels of mtDNA point mutations,...

Vertebral Morphometry and Fractures

Genant Vertebral Fractures

A number of studies have demonstrated that the presence of a spine fracture is predictive of future fractures, independent of bone density (33-39). The strongest association is between existing spine fractures and future spine fractures with estimates of the increase in risk from only one prevalent spine fracture of 3- to 11.1-fold. One of the first such studies was from Ross et al. (33). This study was performed in the same group of women from the Kuakini Osteoporosis Study who were described earlier in the discussion of the definition of a spine fracture threshold. In this study, the presence of one vertebral fracture at baseline resulted in a fivefold increase in the risk for new vertebral fractures. If two vertebral fractures were present at baseline, the risk for new vertebral fractures increased 12-fold. In a second study, Ross et al. (35) evaluated 380 postmenopausal women with an average age of 65 who were participants in a multicenter trial of etidronate therapy for...

Treatment recommendations

There are two aspects to treatment recommendations whom to treat and how to treat them. The NOF Guidelines (11) for the treatment of postmenopausal osteoporosis are extremely useful as well as clear. In 1998, the NOF recommended that prescription medications be considered for women with a bone density T-score of less than -1.5 in the presence of other risk factors and in women with a bone density T-score less than -2, regardless of other risk factors. It is relatively straightforward then, to make a statement such as The patient meets (or does not meet) National Osteoporosis Foundation guidelines for prescription intervention to prevent or treat osteoporosis. To recommend specific treatments is a more difficult undertaking. The Canadian Panel (4) did not recommend the inclusion of such recommendations in a densitometry report. It is clear, however, that primary care physicians want suggestions in this regard (2). Given the diverse specialties of physicians involved in densitometry,...

Guidelines of the International Society for Clinical Densitometry

The guidelines from the International Society for Clinical Densitometry (ISCD) (5) were initially developed in 1994 during a meeting of an international panel of experts in bone densitometry and published in 1996. On the panel were 22 members from eight countries. The guidelines addressed both the use and interpretation of bone mass measurements in the prevention, detection, and management of all diseases characterized by low bone mass with an emphasis on osteoporosis. The guidelines provided a broad overview of how bone mass measurements should be used regardless of specific clinical circumstances in which they were employed. Although they did not specifically deal with patient selection, a review of the ISCD guidelines is included here because of their importance and their influence on the patient selection guidelines that followed. There were six major points on which the panel reached a consensus. Those points are summarized in Table 7-3. Diseases Associated with an Increased Risk...

Remaining Lifetime Fracture Probability

The fracture incidence and bone loss rate data on which the RLFP model was originally based were derived from the Kuakini Osteoporosis Study. The original implementation of RLFP was based on measurements of bone mass at the calcaneus. Bone density measurements performed at other sites had to be converted to an equivalent calcaneal measurement. Using nomograms, the physician could find the calcaneal BMC on one scale and the patient's age on a second scale (19). By connecting the two values, the physician could find the RLFP on a third scale. RLFP predictions have now been recalculated for DXA measurements of the axial and appendicular skeleton and are available on the internet at www.medsurf.com. After entering the patient's age, menopausal age, skeletal site measured, type of equipment used, and BMD, the RLFP calculation is presented as shown in Fig. 10-4. In this RLFP analysis, the RLFP was

The Fracture Threshold

Ross et al. (22) proposed that the fracture threshold be defined as the BMC or BMD at which the risk of fracture doubled in comparison to premenopausal women. This recommendation was based on a prospective study of 1098 women who participated in the Kuakini Osteoporosis Study beginning in 1981. These women underwent BMC and BMD measurements at the proximal and distal radius and os calcis yearly with SPA and, beginning in 1984, lumbar spine BMD measurements with DPA. Four hundred eight women had spine films at baseline and were used to calculate spine fracture incidence during 4 years of follow-up. Spine fracture prevalence was calculated based on data from subjects who had fractures prior to the first bone density measurement. The authors looked at a variety of ways to define the fracture threshold and the BMC or BMD levels at the various sites that resulted. These considerations are shown in Table 10-10. They observed that the levels of BMC and BMD that corresponded to the 10th...

Drugs used in hypertension and angina

Vasoconstrictors, principally noradrenaline. While this hyposensitivity may be a consequence of the sodium depletion, thiazides are generally more effective antihypertensive agents than loop diuretics, despite causing less salt loss, and evidence suggests an independent action of thiazides on an unidentified ion-channel on vascular smooth muscle cell membranes. Maximum effect on blood pressure is delayed for several weeks and other drugs are best added after this time. Adverse metabolic effects of thiazides on serum potassium, blood lipids, glucose tolerance, and uric acid metabolism led to suggestions that they should be replaced by newer agents not having these effects. It is, however, now recognised that unnecessarily high doses of thiazides have been used in the past and that with low doses, e.g. bendro-fluazide (bendroflumethiazide) 1.25-2.5 mg d or less (or hydrochlorothiazide 12.5-25 mg), thiazides are both effective and well-tolerated. Moreover, they are not only by far the...

Test Methodology 1111 Total Magnesium By Metallochromic Indicator Method

The referral laboratory received the samples in acceptable condition and analyzed 25-hydroxy vitamin D, parathyroid hormone, calcitriol, and osteocalcin. The results were as follows osteocalcin, 18.7 ng mL (reference range, 0.4 to 8.2 ng mL) 25-hydroxy vitamin D, 67 ng mL (10 to 55 ng mL) pTh, 69 pg mL (10 to 65 pg mL) and calcitriol, 32 pg mL (15 to 60 pg mL). Thus osteocalcin, vitamin D, and PTH were all elevated and the calcitriol was normal. The patient's complaint was of chronic muscle pain, fatigue, and twitching, and she has a previous diagnosis of osteoporosis. She had repeated elevated levels of serum calcium, ranging from 11.3 to 12.1 mg dL (compared to the reference range of 8.6 to 10.2 mg dL) other laboratory results were phosphate, 2.2 mg dL (2.5 to 4.5 mg dL) alkaline phosphatase, 60 IU L (42 to 98 IU L) 24-hour urinary calcium, 167 mg (100 to 250 mg) and magnesium, 1.7 mg dL (1.6 to 2.6 mg dL). After parathyroidectomy, the PTH level dropped significantly (68 ) to 10 pg...

Implication of Biomechanical Processes in Osteoarthritis

Integrity of the overlying articular cartilage depends on the mechanical properties of its bony bed. The sclerosis of subchondral bone in OA may result from an increased stiffness of the tissue and not from an increase in bone mineral density 134 . Indeed, there is no direct relationship between BMD and accumulation of microdamage in bone tissue, whereas the accumulation of microdamage to bone is directly related to OA 65 . Moreover, although subchondral bone sclerosis in OA has been explained as a response to overloading, the morphologic changes observed in underloading are similar and overloading cannot therefore be the cause of subchondral bone sclerosis 112 . The association between osteophytes and femoral bone mineral density also indicates that aspects of bone formation may underlie the pathophysiology of OA 96 . Nonetheless, bone mass of OA patients is better preserved 36,165,205 than that of normal individuals 72 primary OA and osteoporosis rarely coexist 52,196,233 .

Role of Bone Tissue in Osteoarthritis Progression or Initiation

The concept of a role for bone tissue in OA is based on the observation that this tissue is sclerotic and that OA patients show increased bone mineral density (BMD) upon dual x-ray measures. Even though OA patients are said to have higher BMD and increased osteoid matrix, mineralization of the subchondral bone tissue is reduced 144 . This could result from an alteration in bone tissue remodeling or a change in bone turnover 8,17,68,90,145,197 and would also increase bone stiffness 32 . To increase the density of subchondral bone means bone formation exceeds bone resorption, 49,153, 217 . On the other hand, studies of changes in structure and metabolism of subchondral bone in the early phases of OA have, in general, indicated that bone resorption has increased more than bone formation 19,20,38,49,106,224,226 . A report by Bettica et al 13 has clearly shown that bone resorption is increased in patients with progressive knee OA. These changes are associated with an increase in the number...

Osteocalcin In Bone Metabolism And Osteotropism Of Cancer

Bone turnover in osteoporosis (Delmas et al. 1983 Eastell et al. 1993). Mutations of the gla protein, a member of the osteocalcin family of proteins, have been suggested as a causal factor in the autosomal recessive Keutel syndrome, which is characterised by abnormal calcification of the cartilage (Munroe et al. 1999).

Dimension of the Nutritional Problem in the World

Severely Undernourished People

Induced blindness affects around 2.8 million children under 5 years of age. More than 200 million people are considered vitamin A deficient. Calcium deficiency in pregnant and lactating women can affect the development of their children, and appears as osteoporosis later in life. Severe vitamin C deficiency (scurvy) is mostly a problem in the extremely deprived, such as refugees populations. Micronutrients - minerals and vitamins - are needed for proper growth, development, and body function. Deficiencies are particularly common among women of reproductive age, children, and the immunocomprised, such as people with AIDS. Some micronutrient deficiencies affect people whose energy intake is low, but those consuming too much energy can also suffer from it.

Bone Tissue Changes in Osteoarthritis

Using quantitative microfocal radiography, they demonstrated that thickening of the subchondral cortical plate is the earliest anatomic change in OA joints. It precedes changes in articular cartilage thickness, evaluated radiographically as joint space narrowing. Using labeled bisphosphonate in a scintigraphic study, Dieppe et al 56 demonstrated elevated bone cell activity in patients who had progressed to severe OA. The same investigators also showed that an increased bone scintigraphic signal at the affected knee was predictive of OA progression in the 5 years to follow. Similar results were reported for OA of the hand 201 . More recently, the same group of investigators has shown that in the OA knee, the scintigraphic abnormalities correlated with osteocalcin concentration in the synovial fluid, osteocalcin being a marker of bone formation 215 . Because increased subchondral bone turnover appears to parallel progression of OA, the level of urinary N-terminal...

Sports Preparticipation Examination

It is important to screen for eating disorders, as well as for a desire to change body weight, either for body image or for athletic purposes (e.g., weight cutting for wrestlers). Eating disorders are more common in female than male athletes. Females should be questioned about menstrual irregularities, as amenorrhea could signal anorexia and amenorrheic female athletes could be at risk for osteoporosis.

Qualitative Risk Assessments

Qualitative fracture risk assessments are descriptions of risk as being low, moderate, or high or as not increased, increased, or markedly increased. At its most basic, a qualitative assessment of fracture risk may be a statement of not at risk versus at risk. This is an assessment of current fracture risk. In 2002, the Canadian Panel of the ISCD recommended that bone density reports contain a qualitative assessment of fracture risk (24). Thresholds for moderate and high fracture risk or increased and markedly increased fracture risk are generally the same as the WHO diagnostic categories of osteopenia and osteoporosis. These types of qualitative assessments of risk are commonly seen on computer-generated printouts of bone density data. Caution must be used however as such assessments are inappropriate in individuals under age 50. In deciding whether a quantitative or qualitative assessment of risk is necessary or sufficient, the physician must decide what difference such an...

Clinical Pearls Immunizations 2017

Noncontraceptive benefits of combination oral contraceptives include decreased incidence of benign breast disease, relief from menstrual disorders (dysmenorrhea and menorrhagia), reduced risk of uterine leiomyomata, protection against ovarian cysts, reduction of acne, improvement of bone mineral density, and a reduced risk of colorectal cancer.

The Difference between the Diet of Our Distant Ancestors and Our Diet Today

In the industrialized countries diets have changed remarkably over the past 100 years. This dietary shift, combined with an increasingly sedentary lifestyle, is a major cause of many common diseases-heart disease, osteoporosis, tooth decay, high blood pressure, and diabetes. These disorders, so prevalent now, were rare before the 20th century. For thousands of years, humans adapted to and thrived on a diet radically different from today's diet.19,20 Looking at the diet of our ancestors provides an insight into what foods and nutrients humans were genetically designed to consume for good health.

Calculation of Derived Indices

Activation frequency (Ac.F) Activation frequency is a key determinant of bone mass in the adult skeleton and increased Ac.F is an important mechanism of bone loss in osteoporosis (18). Ac.F is the frequency with which a given site on the bone surface will undergo new remodeling. At present there are no in situ markers of activation and so it has to be calculated indirectly, as the frequency with which a given site on the bone surface undergoes new remodeling, as follows

US Preventive Services Task Force Recommendations

In September 2002, the US Preventive Services Task Force (USPSTF) issued recommendations for bone density testing when screening for postmenopausal osteoporosis (16). Like the recent guidelines from the NOF, AACE, NAMS, and ACOG that preceded the release of these recommendations, the USPSTF recommended that women age 65 and older be routinely screened for osteoporosis. Unlike previous guidelines that also recommended testing for postmenopausal women younger than age 65 who had risk factors for osteoporosis, the USPSTF limited their recommended for screening in younger postmenopausal women to those women ages 60 to 64 who were at high risk for osteoporosis. They made no comment on screening for postmenopausal women younger than age 60. The USPSTF also noted that there was no data to determine an upper age limit for screening. The recommendations to screen women age 65 and older and women 60 to 64 at high risk for osteoporosis were classified by the USPSTF as grade B recommendations. A...

The challenge in reporting densitometry results

Images Bone Density Cancer

The knowledge that a densitometrist must bring to bear on the quantitative assessment of bone density to interpret the findings and place them in the appropriate clinical context is considerable. But the conclusions must be carefully crafted in the most succinct fashion possible. Long reports are simply not read. Vague statements will not be understood or appreciated. At present, it is not sufficient to simply say that the patient does or does not have osteoporosis or is or is not at increased risk for fracture. For the densitometry report to be useful it must be accurate, clear, and complete but also concise. Even though some have said that densitometrists should restrict their statements to a simple review of the numbers, referring physicians want and require more from the experienced densitometrist to better serve their patients' needs. read. Addressing these issues at present is primarily a matter of trial and error and personal opinion. To meet the needs and requests of the...

Limitations of Histomorphometry

Tural units, and resorption cavities. In addition, the criteria for corticomedullary differentiation, staining methods used and the magnification at which measurements are made all contribute to variation. Many of these sources of variance can be minimized by the standardization of staining methods, corticomedullary delineation, and magnification. In addition, standardization of the criteria used to identify histological features should be employed where possible 3 m is used as the lower limit for the recognition of an osteoid seam width (15) and resorption cavities are identified under polarized light by the presence of cut off collagen fibers at the edge of the cavity (16). Measurement of the tetracycline-labeled perimeter is also subject to substantial variation between observers, especially if old labels are present as a result of tetracycline administration in the past. Current histomorphometric techniques are limited by the lack of reliable markers for activation and resorption....

Sensitivity and Specificity

Sensitivity and specificity are easily illustrated by considering a population of 1000 women in whom the spine bone density has been measured. A cut point can be chosen, most simply by picking a T-score such as -2.5 to determine the exact percentages of women with spine T-scores of -2.5 or poorer and spine T-scores better than -2.5. The women with T-scores of -2.5 or poorer are considered diseased. Based on World Health Organization (WHO) criteria,2 they have osteoporosis. The women with T-scores better than -2.5 are considered nondiseased in this example. They do not have osteoporosis, although many of them may be osteopenic. By using the T-score to pick a cut point that defines the categories of diseased and nondiseased, quantitative continuous bone density data has been converted into two qualitative nominal data categories. 2 See Chapter 9 for a discussion of the WHO criteria for the diagnosis of osteoporosis.

The 1999 who and 2000 iof recommendations

The 1994 WHO Criteria did not direct physicians to measure bone density at a specific site for the diagnosis of osteoporosis. An interim report (5) from the WHO Task-Force for Osteoporosis was published in 1999 in which it was stated that DXA of the proximal femur was preferred for diagnostic bone density measurements, particularly in elderly individuals. Physicians were not directed in this report, however, to limit the application of the WHO Criteria for diagnosis to BMD measurements made at the proximal femur. In 2000, the IOF (6) recommended that only bone density measured at the total femur be used for the diagnosis of osteoporosis based on the WHO Criteria. In 2002 however, the ISCD (7) stated that the WHO Criteria could be utilized with bone density measurements at the PA spine, total femur, femoral neck, or trochanter. They also stated that the WHO Criteria should not be applied to measurements of bone density made at any peripheral site (8). These positions strongly suggest...

Role Of Cas In The Skin

Models that receive particular attention in providing further evidence and helping explain the evolving concepts of CAs physiology are those that report the clinical effects and systemic adverse events from the use of CAIs. Such interesting pharmacological agents, sulfonamide CAIs, have a firm place in medicine and are mainly useful as diuretics or to treat and prevent a variety of diseases such as glaucoma, epilepsy, congestive heart failure, mountain sickness, gastric and duodenal ulcers, neurological disorders and osteoporosis (Supuran and Scozzafava 2000a Supuran et al. 2003). Cases of olygohydrosis, a potentially serious adverse event characterized by deficient production and secretion of sweat, were reported in six children treated with zonisamide, an antiepileptic drug chemically classified as a sulfonamide and first marketed in Japan in 1989 (Knudsen et al. 2003). The apparent increased risk of oligohydrosis in the pediatric age group might be related to the dose and resulting...

Answers To Case 2 Health Maintenance Age 66 Years

Next step Each of the following should be performed Stool for occult blood, colonoscopy or barium enema flexible sigmoidoscopy, pneumococcal vaccine, influenza vaccine, tetanus vaccine (if not within 10 yr), cholesterol screening, fasting blood sugar level, thyroid function tests, bone mineral density screening, and urinalysis.

Clinical Features

The disease presents a few weeks after birth with feeding difficulties, lethargy, hypotonia, hypothermia, and seizures. Psychomotor development is markedly delayed, and death usually occurs within 1 to 2 years of onset. Somatic, vascular, and bony changes are characteristic. The infant's hair is short, stringy, wiry, often white, and, under the microscope, appears twisted. The skin is pale and thick or pasty. The blood vessels, as revealed by angiogram or at autopsy, are elongated, tortuous, and display focal luminal narrowing and dilations resulting from disruption and fragmentation of the elastic layer. The bone shows osteoporosis and an irregular lucent trabecular pattern on radiographs.

The Role of Sex Hormones

The relationship between steroid hormones and cancer production introduces serious concerns regarding hormone replacement therapy, particularly for women, to minimize bone loss in the elderly. Hormone replacement therapy can alleviate some of the symptoms of osteoporosis in men and women, but it may do so at the risk of developing cancer. Similar concerns exist in the sporting world, where steroids are used to enhance performance. While such treatments seem to be effective, the athlete who uses hormone supplements will likely pay a heavy price for it in later life by developing prostate, breast, or uterine cancer.

Precautions During Chronic Adrenal Steroid Therapy

The most important precaution during replacement and pharmacotherapy is to see the patient regularly with an awareness of the possibilities of adverse effects including fluid retention (weight gain), hypertension, glycosuria, hypokalemia (potassium supplement may be necessary) and back pain (osteoporosis) and of the serious hazard of patient noncompliance.

Skeletal Complications

The skeletal complications of MM are the most distressing of all the end-organ complications encountered in this disease. Osteopenia and lytic bone lesions are a cause of disabling pain and pathologic fractures. Spinal cord compression may result as well. Thirty percent of patients will present with nonvertebral fractures and more than 50 will present with back pain or vertebral fractures.44,45 Approximately 80 of patients will have radiographic evidence of osteoporosis, lytic lesions, or fractures at the time of diagnosis.2 Osteoporosis, focal lysis, and hypercalcemia all result from increased osteoclastic activity. The molecular mechanism causing this enhanced activity is incompletely understood, but continues to be an area of intense investigation. The current paradigm proposes that an imbalance in osteoprotegerin (OPG) and osteoprotegerin ligand (OPGL) are central to bone resorption.46 OPGL is known to activate osteoclastic cells via the receptor activator of NF-kB (RANK).46 Ex...

Reporting fracture risk

The previous discussion highlights the clinical dilemma of the densitometrist in explaining what these numbers mean, because the level of bone density that constitutes a diagnosis of osteoporosis is not necessarily the same level of bone density that constitutes an unacceptable level of risk for fracture. The prediction of fracture risk is therefore a separate statement. 1 See Chapter 9 for a discussion of the 1991 and 1993 Consensus Conferences' definition of osteoporosis.

Toward a Biological Definition of Aging

Disease Trajectory Definition

The role of chronic inflammation in aging is well established, and according to some investigators, aging is a chronic and progressive inflammation (10). Interleukin 6 (IL6) has been the most studied of inflammatory markers. Circulating levels of IL6 are elevated in the presence of several geriatric syndromes, including dementia, osteoporosis, failure to thrive, unexplained anemia, sarcopenia, and functional disability (13,14). Other inflammatory cytokines were found elevated in the circulation of individuals affected by different forms of cognitive disorders (15). In home-dwelling individuals aged 70 and over, increased circulating levels of IL6 and of D-dimer heralded the increased risk of death and of functional

Biochemical Parameters of Nutrition in the Elderly

And metabolism should be studied more closely. Vitamins that act as antioxidants appear to have a role in preventing coronary artery disease and cancer 53 . Current work is focusing on the actions of vitamins as related to immune function, the formation of cataracts, and the development of osteoporosis, all associated with ageing 53 . The Food and Nutrition Board, the Institute of Medicine, and the National Academy of Science and Health of Canada have recently developed a standard set of nutrient recommendations, known as dietary reference intakes (DRIs), which has added, with regard to vitamin intakes, the groups for ages 51-70 years and for 70 years and older 54 . These recommendations are listed in Table 3 54 .

A Mammography screening

Another decision analysis study attempted an approach of this type 21. The authors used bone density as a surrogate marker of estrogen levels and risk of breast cancer. They concluded that continuing mammography up to age 79 in women with the top 3 quartiles of bone mineral density would prevent 9.4 deaths 10,000, and add on average 2.1 days to life expectancy, at a marginal cost of 66,773. If mammography were used in all patients, it would prevent only 1.4 deaths 10,000, and add only 7.2 hours at a marginal cost-effectiveness of 117,689.

Guidelines for Bone Density Testing in

Determining when testing is appropriate in men has become increasingly important with the advent of prescription pharmacologic therapy for the treatment of osteoporosis in men. The prevalence of osteoporosis in men, although not as great as that in women, is high. In one study (19), the prevalence of osteoporosis in a population-based sample of 348 men was 19 when osteoporosis was defined as 2.5 SD or more below the average peak BMD for men. The major risk factors for osteoporosis in men are not dissimilar from those seen in women cigarette smoking, advancing age, risk of falls, and the presence of diseases or the use of medications known to affect bone metabolism (20-22). Heavy alcohol consumption is considered a major risk factor in men, more so than in women. Other risk factors include a sedentary lifestyle, lifelong low calcium intake, and low body weight. Men with radiographic evidence of osteopenia. A Comparison of Major Guidelines for Bone Density Testing for the Detection of...

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