Osteoporosis Cure Diet

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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Adverse Effects of T4 and Bone Mineral Density

Thyroid hormone is known to increase osteoclastic activity.83 It is documented that patients with untreated Graves' disease will develop bone loss.84 This is because of persistently high levels of circulating thyroid hormone levels for prolonged periods. There is controversy regarding how patients who have had thyroidectomy for thyroid cancer should be managed. In general, TSH suppression with high-normal T3 and T4 levels is recommended. There are conflicting opinions about the risks and benefits when patients' serum TSH levels are chronically suppressed.85,86 Recently, Quan and associates analyzed the effect of thyroid hormone on bone mineral density in 11 studies that also describe confounding factors relevant to bone loss.87 They concluded that thyroid hormone suppression treatment does not affect bone mineral density in premenopausal women and in men. However, the effect of TSH suppression in postmenopausal women remains controversial.

Geometry effects of osteoporosis on cancellous bone

Osteoporosis is a disorder in which total bone mass is reduced yet the quality of the bone is normal. If a microsection of bone were to be biochemically analyzed, it would demonstrate a normal ratio of osteoid to mineral. Though total bone mass is affected, there is a predisposition to loss of the horizontal trabeculae 4 . This leads to decreased interconnectivity of the internal scaffolding of the vertebral body (Fig. 1b). Without the support of crossing horizontal members, unsupported vertical beams of bone easily succumb to minor, normally subcatastrophic, loads. Clinically, this leads to crush of the cancellous bone within the vertebral body, recognizable as an osteoporotic compression fracture, which may occur with low-energy maneuvers such as picking up a bag of groceries.

Evaluation For Osteoporosis

Once diagnosed with osteoporosis, a complete medical history should be obtained with particular attention to the risk factors for osteoporosis. These include age of 65 years or older, a history of vertebral fracture or any fracture during childhood, a family history of hip fracture, low body weight (BMI 21 or weight 127 lb), cigarette smoking, and use of corticosteroids for more than 3 months.6 The physical examination should be performed particularly at the spine region. Height should be measured and compared with the greatest known height to determine height loss, which is an indicator of the presence of vertebral compression fractures. Balance and walking gait should be observed in each individual. The assessment of functional balance is performed by using the single limb stance test and the 6-minute walking test.

Screening for Osteoporosis with Bone Mineral Density Measurement

A number of risk factors for osteoporosis have been identified by the International Society for Clinical Densitometry (ISCD),7 and should be used to guide the screening process in a cost-effective manner. The current indications for BMD testing include any patient who is one or more of the following

Evaluation for Secondary Osteoporosis

When secondary osteoporosis is suspected on the basis of clinical findings or because the patient is relatively young and presented with fragility fracture, specific tests should be considered to evaluate contributing causes that may require additional medical attention. These include basic laboratory investigation of a complete blood count with differential, erythrocyte sedimentation rate, serum calcium and phosphate level, liver function tests, thyroid-stimulating hormone level, testosterone level in men, and a serum TABLE 12-3 Laboratory Investigations for Secondary Osteoporosis TABLE 12-3 Laboratory Investigations for Secondary Osteoporosis

Combined effects of disc degeneration and osteoporosis

The correlation between degenerative changes to the vertebra and the disc remains an open question. Endplate fracture or vertebral body deformity is not necessarily associated with disc degeneration. While disc thinning may be implied from observed stature changes, disc morphom-etry is altered to accommodate changes to the vertebral body shape by extrusion into the concave endplate, but indicators of degeneration (i.e., MRI signal intensity) are not altered subsequent to throacolumbar spine fractures 26 . Based on MRI imaging and DEXA measurements, a negative correlation between vertebral BMD and intervertebral disc degeneration has been shown 13 . Dai 6 has suggested that, for patients with severe osteoporosis, vertebral bodies adjacent to discs with decreased height or signs of degeneration are less likely to be deformed. In an in vitro study of the influence of disc degeneration on the mechanism of vertebral burst fractures, Shirado et al. 33 demonstrated that disruption of the...

Clinical use in osteoporosis

Bisphosphonates are today the most frequently used drug in metabolic bone disease. About ten are commercially available in the world, the conditions treated most frequently with these compounds being osteoporosis, Paget's disease and metastatic bone disease. This review deals only with osteoporosis. A more extended clinical and clinical information can be found in a book written for the practicing physician 6 . Definition and pathophysiology of osteoporosis Osteoporosis is a disease characterized by a decrease in bone mass and a deterioration in the architecture of the The clinical manifestations of osteoporosis are fractures, occurring often spontaneously or after minimal trauma, and their consequences. Osteoporosis is diagnosed and assessed quantitatively by techniques that measure bone mineral density (BMD), most commonly dual X-ray absorp-tiometry. Chemical analyses cannot be used to diagnose osteoporosis. Markers of bone turnover, however, are useful to determine bone turnover...

D7score Is the number of standard deviations above or below the mean bone mineral density in young adults

Laboratory assessment has little value in diagnosing osteoporosis, but it can be beneficial in identifying or excluding secondary causes of bone loss, such as hyperparathyroidism, low 25-hydroxyvitamin D levels, hyperthyroidism, hypogo-nadism, or cancer.8 Biochemical markers of bone turnover such as pyridinoline, deoxypyridinoline, N-telopeptides, and C-telopeptides of Type I collagen cross-links have been associated with an increased fracture risk in some trials. Variations in the making interpretation of these tests difficult. For these reasons, biochemical markers of bone turnover are not recommended for diagnosis of osteoporosis.

How can a physician determine the cause of osteoporosis

Primary osteoporosis is a diagnosis of exclusion. The physician should perform a complete history and physical examination with attention to specific risk factors for secondary osteoporosis and osteomalacia. Laboratory tests, imaging tests, and transiliac bone biopsy may be indicated based on the history and physical examination. For example

What pharmacologic therapies are currently available for osteoporosis

Food and Drug Administration (FDA)-approved medications for osteoporosis prevention and treatment include Parathyroid hormone Teriparatide or PTH(1-34) is an anabolic agent that increases new bone formation and has demonstrated efficacy in the treatment of osteoporosis. It is administered by injection via a prefilled delivery device

What are the different types of osteoporosis

Osteoporosis has been classified into two major types primary and secondary. Primary osteoporosis is further subdivided into type 1 or postmenopausal osteoporosis and type 2 or senile osteoporosis Type 1 osteoporosis is due to estrogen deficiency and typically occurs in women 5 to 10 years after menopause. It predominantly affects trabecular bone and is associated with vertebral fractures, intertrochanteric hip fractures, and distal radius fractures Figure 65-1. Specimen radiographs of 2-mm slices through the vertebral body of T2. A, The first specimen represents normal bone texture, density, and pattern. B, The second specimen shows a moderate degree of osteopenia, with accentuation of the vertical trabeculae and selective loss of the horizontal trabeculae. C, The third specimen shows severe osteoporosis, with irregular thin trabeculae and partial central collapse of the superior endplate. (From Bullough PG. Orthopaedic Pathology. 5th ed. Philadelphia Mosby 2010.) Figure 65-1....

Diagnosis Of Osteoporosis

Although a good clinical understanding of osteoporosis takes into account the pathophysiology of bone remodeling, mineralization changes, and variable bone quality of the patient, the diagnosis of osteoporosis until recently of Osteoporosis Osteopenia Osteoporosis Severe osteoporosis has relied upon a single criterion the bone mineral density. The current gold standard of measuring BMD is dual-energy x-ray absorptiometry (DXA), which uses an x-ray beam to calculate the patient's BMD. The most preferred skeletal sites for evaluation of BMD are the spine and hip, because these two locations provide the best data for correlating low BMD with the risk of future fracture BMD is reported as the T-score, which is a measurement of how many standard deviations the patient's bone density is below the mean of young, healthy individuals at their peak bone mass. Based on this T-score, the World Health Organization (WHO) developed a classification system to define osteoporosis (Table 12-1)....

Comparing Teriparatide and Alendronate for Treatment of Osteoporosis

Teriparatide and alendronate increase bone mineral density through opposite effects on bone remodeling, namely via anabolic and antiresorptive actions, respectively. In this study8, two randomly assigned groups of postmenopausal osteoporotic women (N 28 teriparatide N 25 alendronate) who had quantitative CT scans of the spine at baseline and postbaseline (6 months and 18 months) were analyzed with BCT for L3 vertebral compressive strength. At 18 months, patients in both treatment groups had increased vertebral strength, the median percentage increase being over fivefold greater for teriparatide (Figure 9-4). Larger increases in the ratio of strength to density were observed for teriparatide, and these were primarily attributed to preferential increases in trabecular strength that occurred only for this treatment. At 6 months, the between-treatment effect was statistically significant for vertebral strength but not for BMD, demonstrating the ability of BCT to differentiate treatment...

Agerelated bone loss and osteoporosis

Primary osteoporosis related to aging has been classified as type II, or senile, osteoporosis. The type I disorder is related to the onset of menopause, and is thus termed postmenopausal osteoporosis. Other causes of osteoporosis can be secondary, such as that caused by long-term corticosteroid use or endocrinopathy. Peak bone mass is achieved between the ages of 16 to 25 years in most people. After this age, bone mass slowly, but continuously, decreases. The greater the amount of bone achieved during the peak period, the lower the chance that a person will develop osteoporosis later in life. Normal rates of bone loss are different in men and women. In men, bone mass is lost at a rate of 0.3 per year, while for women this rate is 0.5 . In contrast, bone loss after menopause, in particular the first 5 years after its onset, can be as high as 5-6 per year 17 . Because women live longer than men, it is believed that increased longevity places women at higher risk of senile osteoporosis....

Prevention of osteoporosis and fractures later in life

PA, and especially exercise which poses high strain on the bones, is associated with an elevation in bone mass and bone mineral density during childhood and adolescence 22,23 . It has been estimated that a level of PA achievable by a large proportion of children and adolescents may increase peak bone mass by approximately 7-8 24 . If the activity-related increase of bone mineral density during adolescence is maintained through adulthood, this increase might be sufficient to prevent premature osteoporosis in old age.

Osteoporosis Introduction

The effects of exercise on the skeleton are generally thought to be positive, and numerous studies have indicated that physical activity increases bone mass in humans. Particularly for women, physical activity is recommended for preventing the development of osteoporosis, and regular, vigorous, weight-bearing activity of 1 h or more each week is associated with an increase in bone mineral density (BMD) within a normal population 38 . However, research also indicates that too much physical activity in combination with inadequate energy intake may cause hormonal changes that ultimately increase the risk of bone loss 39 . While osteoporosis, or loss of bone mass, is a well-known effect of menopause and aging in adults, it is also a significant problem among younger individuals. Hypothalamic amenorrhea in young women is associated with reduced bone accretion or premature bone loss during adolescence 40-49 , which places women at high risk for fractures, significant osteopenia (diminished...

Osteoporosis and related fractures

Osteoporosis is characterized by low bone mass and microarchitectural deterioration of bone tissue. These changes lead to enhanced bone fragility and increased risk of fractures. Osteoporosis as such without fracture is usually symptomless and the diagnostic criterion is bone mass. The most commonly used indicator of bone mass is areal bone mineral density (BMD, g m2), which can be measured accurately by dual-energy X-ray absorptiometry (DXA). Bone density accounts for 75-85 of the variance in ultimate bone strength. The diagnostic criterion for osteoporosis is BMD at least 2.5 standard deviations (SD) and for osteopenia (low bone mass) 1-2.5 SD below the mean of young adult women 24 . One SD is usually around 12-14 of a given BMD value. Osteoporosis is most commonly related to aging. The rate of bone loss varies largely between individuals and by site. At the femoral neck BMD is decreased on average by 1 SD at the age of 60 and by 2.5 SD at the age of 90 (Fig. 3.2.3). By the age of...

Describe the typical clinical presentation of a patient with spinal osteoporosis

The clinical presentation can be quite variable. In general, patients with osteoporosis are asymptomatic until a fracture occurs. However, not all patients with spinal fractures are symptomatic, and the initial presentation may be a significant loss of height associated with development of an exaggerated thoracic kyphosis (dowager's hump). Many patients present with acute severe pain after minimal trauma. Paravertebral muscle spasm is common, and tenderness can often be elicited at the fracture site with palpation. Neurologic signs and symptoms are uncommon but may occur (senile burst fracture). Complications associated with osteoporotic vertebral fractures include postural deformity, additional fractures, restrictive lung disease (following thoracic fractures), abdominal dysfunction (following lumbar fractures), chronic pain, disability, and an increased mortality rate.

Laboratory Investigations for Osteoporosis

Generally, laboratory investigations other than BMD measurement are not required for the diagnosis of osteoporosis. Some routine tests, however, should be performed to obtain baseline values as part of the initial workup. These include complete blood count with differential cell count, urinaly-sis, and blood chemistry profiles with serum calcium and phosphate. Some special laboratory tests are available to measure the balance between bone resorption and bone formation from serum and urine samples. These assays are called bone markers. Bone markers can be classified into two groups bone formation and bone resorption markers. Bone specific alkaline phosphatase and serum osteocalcin are both produced when bone is formed and can be used as markers for bone formation. On the other hand, during bone resorption, human collagen is broken down and released into the bloodstream and subsequently secreted into the urine. By assaying the amount of collagen breakdown products, such as the...


Osteoporosis and osteopenia and fractures are potential complications in postmenopausal women and in patients with immobile limbs. Patients at risk for a decline in bone mineral density, especially in the vertebral bodies and the femoral head and neck, should ingest approximately 1500 mg of calcium and 800 IU of vitamin D daily. Postmenopausal women may benefit from hormone replacement therapy, although the effect in mobile older women is modest. Prevention in mobile women appears best using the selective estrogen receptor modulators such as raloxifene and biphosphonates such as alendronate or risedronate.154 Exercise is the best way to maintain mineralization. However, even high intensity resistance training that increases strength may not improve vertebral bone density over 24 weeks of training.

Senile osteoporosis

Aging of men is accompanied by progressive bone loss, which persists and may even accelerate in old age. Osteoporosis in men is increasingly being recognized as a significant problem of public health. The age-specific incidence of both hip and vertebral fracture is about half that in women (Van Der Klift et al. 2002), and A number of recent studies and clinical observations have demonstrated that estrogens are essential for both bone acquisition and maintenance of adult skeletal integrity in men and that both androgenic and estrogenic input intervenes in the regulation of adult bone metabolism in the male (for review Riggs et al. 2002). A preponderant role of estrogen in the regulation of bone metabolism in elderly men has been elegantly demonstrated in a short-term intervention study with selective manipulation of testosterone and estradiol levels (Falahati-Nini etal. 2000). In cross-sectional studies in elderly men, associations of bone mineral status or biochemical markers of bone...

Challenges in Evidence Based Prevention

Preventive Services Task Force (USPSTF) framework for osteoporosis screening. Key questions addressed include the following (1) Does screening using risk factor assessment or bone density testing reduce fractures (2) Does risk factor assessment accurately identify women who may benefit from bone density testing (3) Do bone density measurements accurately identify women who may benefit from treatment (4) What are the harms of screening (5) Does treatment reduce the risk of fractures in women identified by screening (6) What are the harms of treatment Figure 6-1 U.S. Preventive Services Task Force (USPSTF) framework for osteoporosis screening. Key questions addressed include the following (1) Does screening using risk factor assessment or bone density testing reduce fractures (2) Does risk factor assessment accurately identify women who may benefit from bone density testing (3) Do bone density measurements accurately identify women who may benefit from treatment (4) What...

See Your Doctor Within 24 Hours

Possible cause You may have a crush fracture of a vertebra as a result of osteoporosis, in which bones throughout the body become thin and weak. osteoporosis is symptomless unless a fracture occurs. The disorder is most common in women who have passed the menopause. However, a prolonged period of immobility will also lead to the development of osteoporosis. Action Initial treatment for the pain is with painkillers. Your doctor may also request bone densitometry (below). Specific treatment for osteoporosis depends on the underlying cause. However, in all cases, it is important that you try to remain active and take weight-bearing exercise, such as walking.

Burden of Disease

One half of all postmenopausal women will have an osteoporosis-related fracture in their lifetime, including 25 who will develop a vertebral deformity and 15 who will suffer a hip fracture. Osteoporosis is defined as a bone mineral density (BMD) more than 2.5 standard deviations (SD) below the mean for a healthy woman, and osteopenia is a BMD between 1 and 2.5 SD below the mean. Among white women, it is estimated that 41 older than age 50 have osteopenia, and that 15 between ages 50 and 59 and 70 of those older than 80 have osteoporosis. Mexican American women experience similar rates. The rate among black women is approximately one-half the rate of the other groups. Including all races in the United States, an estimated 14 million women older than 50 years have osteopenia, and 5 million have osteoporosis (Nelson and Helfand, 2002).

Accuracy of Screening Tests

There are two major components of screening for osteoporosis assessment of risk factors and BMD measurement. Older age, low body mass index (BMI), and not using estrogen replacement are associated with increased risk of osteoporosis and fracture. Other risk factors include white or Asian ancestry, positive family history, tobacco use, and low levels of weight-bearing physical activity (Melton et al., 1989). The WHO FRAX is a common assessment tool.* Other specific instruments, such as the Osteoporosis Risk Assessment Instrument (ORAI) and the Simple Calculated Osteoporosis Risk Estimation (SCORE) tool, use these risk factors to identify women at increased risk for fracture or low BMD. The ORAI has sensitivity of 94 and specificity of 41 , and the SCORE has sensitivity of 91 and specificity of 40 (Nelson and Helfand, 2002). The BMD measured at the femoral neck by dual-energy x-ray absorptiometry (DEXA) is the most validated predictor of hip fractures. Several other methods for...

Effectiveness of Early Detection and Intervention

Treating osteoporosis with bisphosphonates reduces the risk of fracture (Nelson and Helfand, 2002). Estrogen, calcitonin, and selective estrogen receptor modulators have also been used to increase bone density and reduce fractures. The benefits of these treatments are greater for women at high risk for fracture than women at lower risk. Benefits of screening increase substantially with older age, particularly for women older than 65 and for women with important risk factors. In women age 60 to 64 who have risk factors, the benefits of screening are comparable to those of women age 65 to 69. Several potential harms are associated with screening and treatment. An unwarranted diagnosis of osteoporosis may provoke anxiety. Potential harms may also arise from misinterpretation of BMD tests. Patients may have side effects from the medication bisphosphonates often cause gastrointestinal side effects. The cost and inconvenience of undergoing multiple confirmatory tests must be considered.

Note about Some Especially Popular Vitamin Supplements

Vitamin D has a central role in bone health, and very low levels increase the risk of fractures. The relationship between Vitamin D and cancer is extremely complex and not fully understood. A 2010 U.S. National Cancer Institute (NCI) statement indicated that higher intakes of vitamin D are associated with reduced risks of colorectal cancer, but research results overall are not consistent. Further, whether vitamin D may reduce the risk of other

Musculoskeletal system

The skeleton represents only 7-8 of the body weight and the bones are thinner and much more fragile than those of the cat, whose skeleton occupies 12-14 of the body weight. Incorrect or clumsy handling of the animal may cause fractured limbs or spine. In addition, older rabbits, those that are overweight or those not given sufficient exercise may develop osteoporosis or thinning of the cortex.

What It Can Do for You

There are important distinctions between dietary supplements in the form of the vitamin pill that many take each morning, and products aimed at treating illness. A daily vitamin tablet is unnecessary if you eat a healthful, balanced diet, but it will help those whose diets do not provide the necessary nutrients or who have special needs, such as calcium with D to protect against osteoporosis. Megadoses of certain nutrients, especially fat-soluble supplements such as beta carotene taken to prevent illness, can be toxic, and they do not substitute for the nutrient protection obtainable directly from vegetables, fruits, garlic, fish, oat bran, soy products, and other foods associated with lower incidences of disease and longer life spans. Calcium with vitamin D is important for maintaining bone health, especially for those diagnosed with potential bone-weakening problems or osteoporosis. The ever-growing number of encapsulated promises, such as bee products to increase energy, chromium...

Architectural composition cortical versus cancellous bone

Vascularity, the ratio is relatively low. In contrast, cancel-lous bone is much more richly vascularized by osseous vascular complexes that pass between the less densely packed trabeculae. This arrangement produces a much higher surface-to-volume ratio of bone to extracellular fluids. Therefore, cancellous bone responds more quickly to metabolic alterations and, for this reason, the vertebral bodies are more susceptible to processes that increase bone resorption, such as osteoporosis 9 .

Making Clinical Decisions

You recall learning in medical school that HRT reduced the risk of cardiovascular disease and osteoporosis. Because your patient, Mrs. Smith, is clearly at risk for both, you have always refilled her conjugated estrogen (Premarin) since first seeing her 25 years ago. When a bone density scan 4 years ago showed no evidence of osteopenia, you congratulated yourself for all those years of prescribing HRT. However, a colleague recently presented a paper at an educational conference and, based on the results of the Women's Health Initiative (WHI) study, recommended that all women be taken off estrogen replacement therapy. The estrogen was originally started because of concerns about osteoporosis, but now you wonder whether Mrs. Smith should continue it.

Aetiology of fractures

Can be caused by very many disease processes. The most common underlying pathologies for pathological fractures include osteoporosis and malignant infiltration of the bone, either secondaries or rarely primaries. Naturally, the diagnosis of a pathological fracture, and the underlying pathology, have a bearing on appropriate subsequent management.

Management of Follicular Neoplasms

Patients who are at low risk for having thyroid carcinoma rather than adenoma, as well as low risk for a poor outcome if they do have carcinoma, can be managed conservatively. Conservative management consists of TSH suppression with exogenous thyroxine to decrease the growth stimulus for the neoplasm. The value of suppression as a technique for distinguishing between carcinoma and adenoma has been questioned, and the potential downside of oversuppression (osteoporosis in particular) has been recognized. However, it seems reasonable to suppress TSH to a moderately low level (0.3 to 0.6 mU mL) while patients are being observed conservatively. This is done not to decide that lesions that shrink are not cancers, as 2 of 19 follicular cancers shrank with suppression therapy in the University of California series,37 but to remove growth stimulation during the prolonged follow-up. If the lesion does grow during follow-up, the patient should have a thyroid lobectomy and isthmusec-tomy....

Geometry effects on vertebral body strength

Bone mineral density, this anterior concentration of force can lead to catastrophic failure of the underlying bone. This mode of failure is most common in the thoracic spine, which has a physiologic degree of pre-existing kyphosis 11 . Decreases in cortical bone density with aging within the anterior vertebral body may also predispose to such fracture patterns 7 .

Classical reference

This paper was one of the first to show that trained individuals within a variety of different sports events in general had a higher bone mineral density compared to sedentary age-matched individuals. Furthermore, the study showed that within sports events that contained a high workload of the lower extremities the bone mineral density in the distal femur was increased, whereas swimmers, for example, did not show any changes in bone mineral density compared to sedentary individuals. Later studies have confirmed these findings, although the methodologies have been somewhat more advanced, and the design has become more sophisticated. The data from Nielsson & Westlin together with other data have been put together in an overview illustration by Drinkwater (Fig. 1.8.1). (Physical activity, fitness, and osteoporosis. In Bouchard C, Shepperd RJ, Stephen T, eds. Physical activity, Fitness and Health. Toronto Human Kinetics Publishers,

Physiology Of Bone Remodeling And Bone Turnover

Bone remodeling is a complex process that is regulated both locally and systemically. As previously mentioned, RANKL RANK interactions at the local level promote induction of osteoclast activity and subsequent remodeling. Conversely, osteoprotegerin (OPG) is a soluble receptor for RANKL that acts as an antagonist to decrease osteoclastic activation and thereby reduce the rate of bone resorption. Interestingly, there are a number of systemic signaling mechanisms that act through the RANKL RANK OPG pathway to regulate bone homeostasis.4 For example, parathyroid hormone (PTH) and the glucocorticoids both act to increase local expression of RANKL but decrease concomitant expression of OPG, resulting in a net increase in osteoclast activation and bone resorption. Alternatively, estrogens act to increase the local expression of OPG and decrease RANKL, which results in a net decrease in osteoclast activity and bone resorption (Figure 12-1). Derangement of these pathways can alter the...

Vitamin D The Sunshine Vitamin

Vitamin D plays an indispensable role in building and maintaining strong bones and teeth. In fact, vitamin D is responsible for the body's absorption and utilization of the mineral calcium. Insufficient amounts of this key vitamin can lead to serious bone abnormalities, including rickets in children (bones that are soft and malformed) and osteoporosis or osteomalacia (softening of the bones) in adults.

Calcium and Vitamin D Supplementation

Calcium and vitamin D supplementation is the cornerstone of all treatment modalities for osteoporosis. Literature clearly shows that adequate calcium and vitamin D intake reduces the risk of fractures. For optimal treatment, adequate calcium intake of 1000 to 1500 mg day should be maintained in all patients on any type of treatment. To maximize the absorption of calcium across the small bowels, no more than 500 to 600 mg of elemental calcium should be taken at any given time. Among all calcium formulations, calcium citrate is the preferred form. Calcium citrate binds to oxalate, reducing its intestinal absorption, and citrate in urine inhibits crystal formation, thus reducing the incidence of kidney stones. In addition, calcium citrate does not require low pH for salt dissociation therefore the absorption of this calcium formulation is reliable in patients taking H2 blockers or proton pump inhibitors. fractures or with osteoporosis. Nonvertebral fractures osteoporotic fractures...

Pharmacologic Agents and Spinal Fusion

There are no clinical studies that evaluate pharmacologic agents for osteoporosis in the setting of vertebral fractures or spinal fusion. Bisphosphonates increase fracture callus size during endochondral repair but cause delay in maturation. Some animal studies have demonstrated that bisphosphonates delayed fusion. Therefore until clinical studies are available, we recommend that bisphosphonates should be started a few weeks after spinal fusion or vertebral fracture to reduce the possible adverse effects to the early biological processes of fracture healing. Teriparatide in all animal studies facilitated fracture healing. In both rat and rabbit models of spinal fusion, the administration of teriparatide speeded fusion, and increased the fusion mass. Based on these animal studies, teriparatide offers superior biology for spinal indications, when compared to bisphosphonates and a control group that only took calcium and vitamin D. However, the application of this agent in patients still...

Calcium and phosphorus

Osteoporosis (thinning bones) similar to that which occurs in older people is not common in dogs. Most fractures in dogs are due to trauma and are not age-related. Many people think that, because older people are recommended to take additional calcium to help prevent thinning of the bones, the same must be true for dogs. In fact there is no special need for extra calcium or vitamin D3 in older dogs provided a balanced diet is fed. However, because of possibly decreased kidney function and the high chance of kidney disease, older dogs should be fed a food containing a low level of phosphorus (around 0.5 Table 10.8).

Calcium and Healthy Bones

On the other hand, regularly skimp on this mineral, and you'll wind up calcium-broke Your body fluids still need calcium to regulate normal body functions. What these fluids don't get from food must be borrowed from the calcium-bone bank. Borrowing day after day, year after year, will deplete the savings account and leave you with osteoporosis (brittle bones that break easily).

What happens if I develop bone pain

Biphosphonates are chemicals that interfere with bone breakdown and are typically used for treatment of osteoporosis. Most prostate cancer bone metastases are not lytic metastases (i.e., they do not cause bone breakdown), but some bone breakdown does appear to occur biphosphonates lead to improvement in bone symptoms in men with prostate cancer. Their use in bone pain remains investigational.

Patient demographics

Patients are more susceptible to certain problems at different times of life. Postural syndrome is more likely to be present in the young, whilst young to old adults have derangements and dysfunctions. Osteoporosis is generally only relevant in the elderly, esperially postmenopausal women, although there are exceptions. With increasing age spinal degeneration is more likely to be present, the intervertebral disc becomes dehydrated and fibrosed, and osteophytes and other bony changes can occur around the zygapophyseal and uncovertebral joints and vertebral bodies (Taylor and Twomey 2002). Such changes may predispose to spinal stenosis affecting nerve roots or the spinal cord. MalignanCies are also more common in the older age group. Completely new onset of headache or neck pain in older patients who have never experienced this before is also a possible warning symptom.

Clinical identification of vertebral fractures

Cal symptoms such as pain or height loss. Therefore the evaluation of spinal radiographs for prevalent and incident vertebral fractures is important in both clinical and epidemiological evaluation of patients with established osteoporosis and populations at risk for developing it. Fewer than 1 of back pain episodes are related to vertebral fractures 10 . Therefore vertebral fractures are often not suspected in patients reporting back pain, unless associated with trauma. Trauma-related fractures, however, are not considered as classical osteoporotic fractures. Historical height loss is also difficult to assess clinically. Some height loss is expected with aging due to compression of the intervertebral discs and postural changes. However, height loss could also be due to multiple fractures, which represent significant and irreparable damage. Therefore it has been concluded that height loss is an unreliable indicator of fracture status until it exceeds 4 cm 9 . As a result vertebral...

Radiographic assessment of vertebral fractures

Radiographic diagnosis is considered to be the best way to identify and confirm the presence of osteoporotic vertebral fractures in clinical practice. Traditionally, conventional lateral radiographs of the thoracolumbar spine have been visually evaluated by radiologists or clinicians to identify vertebral fractures. However, there is still no internationally agreed definition for vertebral fracture. One global prospective study (the IMPACT study 6 ) compared the results of local radiographic reports from five continents with that of subsequent central readings in more than 2,000 postmenopausal women with osteoporosis. This study demonstrated that vertebral fractures were frequently underdiagnosed radiologically worldwide, with false-negative rates as high as 30 despite a strict radiographic protocol that provided an unambiguous vertebral fracture definition and minimized the influence of inadequate film quality. It was concluded that the failure was a global problem attributable to...

Bone density in men with disorders of androgen action

A clinical model of androgen effects on bone tissue is represented by the cohort of men undergoing therapeutic orchiectomy for the treatment of prostate cancer or sexual delinquency. In 12 men of the latter group, bone mineral density of the lumbar spine decreased after bilateral orchiectomy (Stepan etal. 1989). Corresponding effects were seen in men treated with surgical or chemical castration for prostate cancer as a consequence, osteoporotic fractures were significantly increased in comparison to controls (14 vs. 1 ) (Daniell 1997 2000). This has been recently confirmed by a study involving 429 men who underwent bilateral orchiectomy for treatment of prostate cancer. Fractures were ascertained from medical records and compared with expected numbers based on local incidence rates this demonstrated a three-fold increase of fractures accounted for by moderate trauma of the hip, spine and distal forearm, locations traditionally linked with osteoporosis (Melton etal. 2003). The...

Standardization of visual approaches to vertebral fracture assessment

In an effort to develop a standardized consensus protocol for the visual assessment of vertebral fractures, the United States National Osteoporosis Foundation's Working Group on Vertebral Fractures suggested the following procedural requirements for a qualitative (semiquantitative) assessment of vertebral fractures in osteoporosis research 25 - Assessments should be performed by a radiologist or trained clinician who has specific expertise in the radiology of osteoporosis.

Alternatives to radiographic assessment of vertebral fractures

The use of fan-beam DXA images for quantitative (morphometric) assessment of spinal fractures has been reported in both research applications and pharmaceutical trials 4, 11, 19, 21, 28, 37, 38, 46 . Clinical studies demonstrated the feasibility of visual evaluation of fan-beam lateral DXA spine images compared to conventional lateral spine radiographs in postmenopausal women, with a strong overall agreement of 96.3 37, 38 . This agreement was approximately as strong as that found among different morphometric techniques 15, 21 . The images permitted visual assessment of about 90 of all vertebrae. The main shortcoming of the MXA scans in comparison with conventional radiographs is the inferior image quality that limits the evaluation of vertebrae in the upper thoracic spine. This is less of a concern if MXA is used as a screening tool for conventional radiography and this approach may help reduce the radiation dose in the diagnosis and monitoring of osteoporosis.

Postmenopausal estrogen replacement therapy

Selective estrogen receptor modulators (SERM) are a class of drugs used for hormone replacement therapy lacking the steroid structure of estrogens but able to bind directly to estrogen receptors 86 . SERMs have estrogen-agonist effects on bone and lipid metabolism but not in the breasts and uterus, and they may therefore prevent cardiovascular risk and osteoporosis without increased risk of breast cancer. To date few studies have investigated the effect of SERMs on stroke risk. The Multiple Outcomes of Raloxifene Evaluation (MORE) trial including 7705 osteoporotic postmenopausal women found no overall effect on cardiovascular events (including stroke) but a decreased risk of stroke (RR 0.4 95 CI 0.2-0.9) and cardiovascular events in a subset of women with increased cardiovascular risk at baseline 87 . In the Raloxifene Use for The Heart (RUTH) trial including 10 101 postmenopausal women with coronary heart disease or multiple risk factors for coronary heart disease no effect of...

The role of 5areduction and aromatization of testosterone in the muscle

Sattler etal. (1998) have reported that serum dihydrotestosterone levels are lower and testosterone to dihydrotestosterone ratios higher in HIV-infected men than in healthy men. These investigators have proposed that a defect in testosterone to dihydrotestosterone conversion may contribute to wasting in a subset of HIV-infected men. If this hypothesis is true, then it would be rational to treat such patients with dihydrotestosterone rather than testosterone. A dihydrotestosterone gel is currently under clinical investigation. However, unlike testosterone, dihydrotestosterone is not aromatized to estradiol. Therefore, there is concern that suppression of endogenous testosterone and estradiol production by exogenous dihydrotestosterone may produce osteoporosis.

Specific Patient Populations and Situations

Osteoporosis Bone quality is a major determinant of success in all fusion procedures, especially those involving instrumentation. A mild spondylolisthesis can progress and become more symptomatic as osteoporosis worsens, as commonly occurs in postmenopausal females. As the vertebrae weaken, the asymmetric load can cause increasing deformity and de novo scoliosis, which can increase the patient's symptoms.

Anticoagulant Therapy During Pregnancy And The Peripartum Period

Heparins are the anticoagulant of choice during pregnancy for situations in which their efficacy is established. Neither UFH, LMWH nor heparinoids cross the placenta54. Heparins are not associated with any known teratogenic risk, and the fetus is not anticoagulated as a result of maternal heparin use. LMWHs have potential advantages over UFH during pregnancy because they have a longer plasma half-life and a more predictable dose-response than UFH, with the potential for once-daily administration. In addition, LMWHs are associated with a lower risk of HIT and osteoporosis than UFH.

Antiphospholipid Antibodyinduced Pregnancy Loss

Over the last two decades, APS has emerged as a leading cause of pregnancy loss and pregnancy-related morbidity. It is now recognized that recurrent miscarriage occurs in 1 of couples (39-39), that up to 20 of women with recurrent miscarriage have aPL antibodies, and that in approximately 15 of otherwise apparently normal women aPL is the sole explanation for recurrent fetal loss (31, 40). The primary treatment for these patients, anticoagulation throughout pregnancy, is inconvenient, sometimes painful, expensive, and fraught with potential complications, including hemorrhage and osteoporosis. Moreover, it is often ineffective. Thus, the identification of a novel mechanism for pregnancy loss in women with aPL antibodies holds the promise of new, safer and better treatments.

Workingout And Gym Training

No equipment is better than the skills of the instructor. Working-out with weights is technically difficult and there are lots of pitfalls that need to be considered in close collaboration with a licensed instructor and access to appropriate training equipment. Training should start with an objective function test, so a reasonable measure of progress can be made. Beginners usually start with an individual training programme based on six to ten exercises. After working-out a few times at low resistance and learning the specific movements, the training is documented, including what kind of equipment is used, how many repetitions and sets and how much resistance. Warming up, on a bike or treadmill, is essential before strength training. Depending on any underlying problems, such as osteoporosis or injury, such as a temporary fragile cruciate ligament graft, the programme must be modified over time.

Materials and methods

We searched Medline, Embase and Current Contents from 1980 to 2002 for randomized controlled trials with drug treatment intervention in Caucasian women with postmenopausal osteoporosis (defined as T-score below -2SD at inclusion and or prevalent anamnestic fracture) and reporting vertebral fracture data (either as a primary or secondary endpoint or as an adverse event). Duplicates, abstracts, and posters were eliminated by manual selection. Studies of less than 36 months' duration were eliminated. The minimum required duration for a phase III trial for development of anti-osteoporotic drugs is usually specified at 3 years in Europe and in the US, the European CPMP regulations being the most stringent, requiring demonstrated anti-fracture efficacy prior to registration of an osteoporosis drug 14 . For steroid-induced osteoporosis and osteoporosis in men, an overview is given based on selected publications.

Selective outcome reporting 8131 Rationale for concern about bias

Selective choice of data for an outcome For a specific outcome there may be different time points at which the outcome has been measured, or there may have been different instruments used to measure the outcome at the same time point (e.g. different scales, or different assessors). For example, in a report of a trial in osteoporosis, there were 12 different data sets to choose from for estimating bone mineral content. The standardized mean difference for these 12 possibilities varied between -0.02 and 1.42 (G0tzsche 2007). If study authors make choices in relation to such results, then the meta-analytic estimate will be biased.

Comorbidity Influence On Rehabilitation

Osteoporosis must be considered when therapeutic exercises are instituted. Physical therapy should be tailored to individual fitness level and anticipated propensity to fracture or current fractures. Precautions include avoiding spine flexion exercises, which may predispose to vertebral compression fracture.

Preclinical characteristics

Bisphosphonates can also prevent an experimentally induced increase in bone resorption. Thus they impair resorption induced by many bone resorbing agents such as parathyroid hormone, 1,25(OH)2D and retinoids, the latter effect having been used to develop a powerful and rapid screening assay for new compounds. They also inhibit bone loss induced by different procedures to induce experimental osteoporosis such as immobilization, the first model used 15 , ovariectomy, corticosteroids, or lactation combined with a low calcium diet. When not given in excess, bisphosphonates have also a positive effect on mechanical characteristics both in normal animals and in various experimental osteoporosis models 25 . This effect seems to be due to alterations in bone mass, architecture and quality.

Lifetime increase in physical activity

In adults, a sedentary lifestyle has been linked to a higher morbidity and mortality from cardiovascular disease, a higher risk for certain types of cancer, compromised mental health, and a higher incidence of non-insulin-dependent diabetes mellitus, obesity and osteoporosis 26 . One key question when assessing the benefits from PA during childhood is therefore whether the level of PA during childhood might affect the level of PA during adulthood. Unfortunately, there are only relatively few studies that have addressed this question. Data from the Amsterdam growth study show no significant tracking of total weekly PA from the teens (age 13-16 years) to age 27 years in females and males 27 . However, a long-term follow-up of the Trois-Rivieres experiment demonstrates that an intense involvement in physical education during primary school may enhance PA in females in their thirties, but not in males 28 .

Conservative Followup in Clinically Detected Primary Hyperparathyroidism

1 patient had advancing osteoporosis, 1 showed a modest increase in serum calcium, and another experienced a rise in serum creatinine. When deceased and noncompliant patients were excluded, the final compilation of data (including patients undergoing parathyroid surgery) revealed increased serum calcium in 10 of die patients (including one patient with probable hypercalcemic crisis, but a subtle rise in others), decreased renal function in 8 , active renal stone disease in 6 , bone disease in 5 , and psychological problems to the extent that parathyroid surgery was indicated in 5 (Table 41-2). The authors concluded that, for the comparatively few patients in whom adequate data could be collected for the whole study period, marked disease progression was noted only in a minority. Although the authors recommended surgical exploration by an experienced surgeon for the patients with asymptomatic HPT, they also concluded that patients who declined surgery or who had contraindications to...

Epidemiology and etiology

Osteoporosis is the most common skeletal disorder, affecting over 10 million Americans. Additionally, over 30 million Americans have low bone mass. The prevalence of vertebral fracture in postmenopausal women is greater than 20 . Only one in three patients with osteoporosis has been diagnosed, and only one in seven will receive Osteoporosis can be classified as either primary (no known cause) or secondary (caused by drugs or other diseases). Primary osteoporosis is most often found in postmenopausal women and aging men, but it can occur in other age groups as well. The prevalence of osteoporosis varies by age, gender, and race ethnicity. The risk of fracture increases exponentially with each decade in age over 50.8 Residents of nursing homes may be at an even higher risk of fracture. Both men and women lose bone as they age. However, women have accelerated bone loss surrounding menopause due to loss of estrogen. Men have some protection from osteoporosis due to their large bone mass...

Patient Care and Monitoring

Assess patient risk factors for osteoporosis, with special attention to age, menopausal status, previous history of osteoporotic fracture, smoking status, low body weight, family history of osteoporotic fracture in first-degree relatives, and presence of secondary causes of osteoporosis. Bone mineral density National Osteoporosis Foundation

Nonsteroidal Anti Inflammatory Drugs

Low-dose glucocorticoid treatment (equivalent to prednisone 10 mg day or less) effectively reduces inflammation through inhibition of cytokines and inflammatory mediators and prevents disease progression.19,21 The goal of glucocorticoid use is to minimize adverse drug events by keeping doses low and using the drugs as infrequently as possible. Patients may receive glucocorticoids for a brief time as bridge therapy following DMARD initiation or via intra-articular injections to relieve symptoms of active disease. Patients taking more than 10 mg day prednisone or equivalent are at an increased risk for clinically significant adverse reactions, especially bone loss leading to osteoporosis. Other glucocorticoid-related adverse reactions include Cushing's syndrome, peptic ulcer disease, hypertension, weight gain, infection, mood changes, cataracts, dyslipidemia, and hyperglycemia.

Classification and symptoms of hypogonadism

Voice mutation will not occur. The frontal hairline will remain straight without lateral recession, beard growth is absent or scanty, the pubic hairline remains straight. Hemoglobin and erythrocytes will be in the lower normal to subnormal range. Early development of fine perioral and periorbital wrinkles are characteristic. Muscles remain underdeveloped. The skin is dry due to lack of sebum production and free of acne. The penis remains small, the prostate is underdeveloped. Spermatogenesis will not be initiated and the testes remain small. If an ejaculate can be produced it will have a very small volume. Libido and potency will not develop. A lack of testosterone occurring in adulthood cannot change body proportions, but will result in decreased bone mass and osteoporosis. Early-on lower backache and, at an advanced stage, vertebral fractures may occur. Once mutation has occurred the voice will not change again. Lateral hair recession and baldness...

Technique with polymethylmethacrylate

A topic of interest is the occurrence of new vertebral body fractures after PVP in patients with osteoporosis 2, 9, 62 . This was noted in a follow-up of 25 patients who underwent PVP. The average follow-up was 48 months. The authors found a significantly increased risk of vertebral fractures adjacent to a cemented vertebra, with the odds ratio of 2.27, whereas the odds ratio for sustaining a vertebral fracture next to an uncemented fracture was 1.44

Nutrition And Dysphagia

During rehabilitation, optimal nutrition can offset the effects of a catabolic state. For patients whose mobility is impaired, nutritional interventions may also lessen the risk of developing skin sores, osteoporosis, and obesity. A consensus group of the American Heart Association offers reasonable dietary guidelines with rationales for recommendations that deserve review by patients.42

Impact of Inflammatory Bowel Disease on the Patient

Inflammatory bowel disease may lead to long absences from school or work, disruption of family life, malabsorption, malnutrition, and multiple hospitalizations. A patient can have 10 to 30 watery or bloody bowel movements each day. As a consequence, patients with inflammatory bowel disease can have many psychologic problems, particularly when they are young adults. Because of malabsorption, the prevalence of osteopenia in patients with inflammatory bowel disease ranges from 40 to 50 osteoporosis is present in 5 to 30 of all patients. Fractures of the hip, spine, and distal radius occur. One study revealed that the incidence of fractures among persons with inflammatory bowel disease is 40 greater than in the general population.

Prevention of eating disorders in athletes

It is likely that talking to athletes and coaches about eating disorders and related issues such as reproduction, bone health, nutrition, body composition and performance may help to prevent eating disorders in that population 120 . Therefore, coaches, trainers, administrators and parents should receive information about eating disorders and related issues. In addition, coaches should realize that they can strongly influence their athletes. Coaches or others involved with young athletes should not comment on an individual's body size, or require weight loss in young and still growing athletes. Without further guidance, dieting may result in unhealthy eating behavior or eating disorders in highly motivated and uninformed athletes 135 . Because of the importance that athletes ascribe to their coaches, the success of a prevention program tends to be related to the commitment and support of the coaches and others involved.

Weakness Associated Shoulder Pain

Pain in the upper extremity often limits therapy and function and interferes with sleep, so it requires immediate attention. Indiscriminate traction on a paretic arm and shoulder during bed mobilization and transfers can start the pain. In the shoulder, some level of pain has been noted in up to 75 of patients by approximately 2 months after a hemispheric stroke. Subluxation of 1 or more cm, found in 50 -85 of hemiplegic patients, may contribute, though studies have not always shown this relationship. Glenohumeral subluxation is lessened by a variety of slings, but these do not necessarily prevent shoulder pain.121 Sources of pain include biceps tendonitis, capsulitis, rotator cuff impingement or tear, myofascial pain, brachial plexopathy, suprascapsular neuropathy, heterotopic osssification, osteoporosis and fractures, contractures, flaccidity or spasticity, overuse, degenerative joint disease, and RSD. Most patients have inflammation of the rotator cuff tendons and subacromial...

Clinical Manifestations of Secondary Hyperparathyroidism

Histologic skeletal abnormalities develop early in patients with chronic renal disease. Bone resorption, the most common abnormality, occurs in several locations (subperiosteal, subchondral, trabecular, endosteal, and subligamen-tous), whereas brown tumors and periosteal reaction are less common. Osteosclerosis primarily affects the axial skeleton, and associated osteoporosis and osteomalacia cause generalized osteopenia. Bone biopsies reveal increased PTH activity on bone in half of the patients whose glomerular filtration rate has fallen to 50 of normal or less. In the early stages, mild hyperparathyroid bone disease is seen. When the glomerular filtration rate falls to between 20 and 40 mL min, bone biopsies show a mineralization defect.59 Youth, female gender, tubulointerstitial types of nephropathy, and a long duration of uremia appear to be independent risk factors for the development of bone disease.61 Increased bone resorption may persist114 and osteopenia may be present for...

Vertebral fractures which come to clinical attention

Gehlbach et al. 5 studied the resource implications of hospitalization for osteoporosis-related vertebral fractures. They used data from national samples of patients with hospitalized fractures, mainly from discharge databases. Patients with metastatic cancer or severe trauma were excluded. The total charges averaged USD 8000-10000 per hospi-talization and were higher in men. The length of stay was just under 6 days, and more than 50 of discharged patients required some form of continuing care, indicating that the overall cost is much higher than just the hospital-ization. These costs were gathered from a US database where vertebral fracture accounted for over 400 000 total hospital days and generated charges in excess of USD 500 million. In total, vertebral fractures were responsible for almost 70 000 annual hospitalizations, about one-fourth of the number due to hip fractures, and it was found that the average total charge for vertebral fracture hospitalization was about half of...

Possible MCI Therapies

Despite promising basic science research, estrogen has not consistently shown benefits in treating or preventing cognitive disorders. The data currently do not support the use of this agent for the treatment of AD. In one meta-analysis (LeBlanc et al., 2001) examining nine randomized controlled trials and eight cohort studies with respect to the role of estrogen and cognition, women with menopausal symptoms showed improvement in verbal memory, vigilance, reasoning, and motor speed but no benefit in other cognitive domains. Asymptomatic women did not improve. Likewise, clinical trials have failed to demonstrate benefits for coronary artery disease, cerebrovascular disease, osteoporosis, and cognition. Further, its long-term use may be contraindicated in women with intact uteruses due to the potential risk of endometrial hyperplasia, endometrial cancer, gallstones, and breast cancer.

General Considerations

In the United States at least 10 of the population experiences a bone fracture, dislocation, or sprain annually. Each year more than 1.2 million fractures are sustained by women older than 50 years. There are more than 200,000 hip fractures annually, and these are associated with prolonged disability. Osteoporosis* is the most common musculoskeletal disorder in the world and is second only to arthritis as a leading cause of morbidity in the geriatric population. Postmenopausal osteoporosis and age-related osteoporosis increase the risk of fractures in the older population. There are more than 40 million women in the United States older than 50 years, and more than 50 of them have evidence of spinal osteoporosis. Almost 90 of women older than 75 years have significant radiographic evidence of osteoporosis.

Management of Clinically Inapparent Adrenal Masses Surgery Versus FollowUp

A relatively high percentage of patients with a clinically inapparent adrenal mass display pathologic features such as impaired glucose tolerance, insulin resistance, increased blood pressure, high triglyceride levels, low HDL, central fat deposition and reduced trabecular bone mineral density. 2. There are associated pathologic features such as hypertension, impaired glucose tolerance (or diabetes), pathologic triglyceride profile, central fat deposition, and reduced bone mineral density.

Effects on morbidity and mortality

Titrated to maintain a serum testosterone concentration of 20 nM (Howell et al. 2001). Testosterone treatment did not alter bone turnover markers, hip, spine or forearm bone mineral density (quantitative computed tomography and DEXA), lean mass or fat mass (DEXA), mood (hospital anxiety and depression scale) or sexual function. However, two out of five components of the multi-dimensional fatigue inventory were improved (activity was increased and physical fatigue was reduced). These inconsistent and minor effects were supported by a case control study showing minimal differences based on lower serum testosterone concentrations in similar men (Howell et al. 2000) suggesting that androgen replacement therapy offers little objective benefit for men with compensated Leydig cell failure post-cytotoxic therapy.

Genomics and Diet The Future

Diet-related diseases that will benefit from nutritional genomics research and applications are chronic diseases such as cardiovascular diseases, cancers, diabetes, neurologic disorders, obesity, osteoporosis, and inflammatory disorders (Debusk et al., 2005). These conditions result when homeostasis is disrupted by bioactive dietary components affecting the genotype and environmental factors influencing cellular changes, leading to altered protein and metabolite expression and, eventually, altered physiologic function.

Additional clinical variables

To placebo in elderly men, the largest treatment effect being observed in men with the lowest initial serum testosterone in the latter study there was no treatment effect for any other sub-score of the SF-36 questionnaire. In studies with androgen administration to elderly men with low or (low) normal serum testosterone, there were no significant effects over placebo for mood and or overall quality of life (Gruenewald and Matsumoto 2003 Kunelius etal. 2002 Ly etal. 2001 Steidle etal. 2003) improvement of quality of life as measured with a questionnaire intended for patients with osteoporosis and vertebral fracture was reported for testosterone administration in glucocorticoid-treated men (Crawford etal. 2003).

Who should be considered for treatment

As to the first question, in theory androgen administration to elderly men may be either substitutive to alleviate symptoms and prevent complications of a partial or more complete androgen deficiency, or rather pharmacological administration to elderly men who are not necessarily androgen deficient, but with specific treatment goals such as prevention or treatment of osteoporosis, frailty, or treatment of erectile dysfunction. Clearly, although there have been a few small-scaled studies providing indications of potential treatment benefits (Gruenewald and Matsumoto 2003), for no single indication does the present evidence even approach justifying pharmacological androgen treatment in elderly men. Thus we are left with only substitutive treatment to be considered at this time. As to the objective signs of relative androgen deficiency, although a decrease of muscle mass and strength and a concomitant increase in central body fat and osteoporosis can most easily be objectified, they are...

Do androgens have physiologic relevance in women

A speculative line of reasoning that androgens are physiologically important hormones in women is that there might be parallels between female and male androgen deficiency. Testosterone deficiency in men, from either surgical or natural hypogonadism, is a well defined state, and the sequelae are outlined extensively in chapter 13. These men are obese, insulin resistant, at risk for heart disease, have decreased muscle mass and strength, are certainly at risk for osteoporosis, and clearly have diminished sexual function. The question is automatically raised is there a similar clinical syndrome in women, albeit subtler We believe what little data does exist in this regard supports this contention.

Medical overview and Epidemiology

Taneous remissions and exacerbations. More than 30 of young patients experience neurological symptoms including dysarthria, dysphagia, and a variety of movement disorders that include dystonia, rigidity, tremor, ataxia, and ballism. Patients may also present with premature osteoporosis and arthritis, cardiomyopathy, pancreatitis, nephrolithiasis, hypoparathyroidism, and infertility. Laboratory studies have noted a low ceruloplasmin in up to 95 of the cases, although the level can be low in asymptomatic cases, and a high 24-hour urine copper level. In half of patients with liver disease and in nearly all patients with neurological or psychiatric symptoms, patients will have Kayser-Fleischer rings on slit-lamp examination. A liver biopsy is another option when the diagnosis is uncertain or when measuring copper concentration. Neuroimaging is recommended in cases with neurological and psychiatric symptoms and frequently demonstrates an increased T2-weighted signal in the caudate,...

Describe the role of the various imaging studies in the diagnosis of pyogenic vertebral infection

Radiographs Positive radiographic findings are not evident for at least 4 weeks after the onset of symptoms. The earliest detectable radiographic finding is disc space narrowing, followed by localized osteopenia and finally destruction of the vertebral endplates. Radiographs remain valuable to rule out other noninfectious etiologies responsible for back pain symptoms MRI This is the imaging modality of choice for diagnosis of vertebral infection. It provides detailed assessment of the vertebral body, disc space, spinal canal, and surrounding soft tissue not provided with any other single test. The typical findings associated with pyogenic vertebral infection are decreased signal in the vertebral body and adjacent discs on T1 -weighted sequences and increased signal intensity noted in these structures on T2-weighted images. Paravertebral abscess, if present, also demonstrates increased uptake on T2-weighted images. Gadolinium contrast is a useful adjunct in diagnosing infection because...

Nonpharmacologic Therapy

This year, roughly 1.6 million people will be diagnosed with cancer in the United States and Canada. With improvements in detection and treatment, approximately two-thirds of those diagnosed with the disease can expect to be alive in 5 years. With improving longevity, the cumulative adverse effects of both the disease and treatment are becoming an increasingly important issue. Late-effects data show that both adult and pediatric cancer survivors are at greater risk for developing second malignancies, cardiovascular disease, diabetes, and osteoporosis than those in the general population. With respect to the growing population of pediatric cancer survivors, data confirm that they are eight times more likely than their siblings to have a severe or life-threatening chronic health condition. For example, the survivors of pediatric ALL have an increased onset of obesity, osteopenia, and associated comorbidities. Thus, it is important to provide supportive care and intervention and...

The ideal tissueselective androgen

In comparison to hypogondism, the definition for an ideal dissociation is different in male contraception or PCa. For male contraception a reduction in gonadotrophins is necessary, for PCa protection it is desired. For PCa, an ideal dissociated androgen should have antagonistic action on the prostate, but maintaining agonistic effects on brain, muscle and bone, to avoid side effects, like hot flushes, loss of libido, mood disturbance, muscle wasting and osteopenia.

Micro and Nanotechnology and the Aging Spine

The aging process presents a cascade of events that affect the health of the musculoskeletal system, in particular, the human spine. The maximum bone mineral density of an individual is reached between the ages of 18 to 20 years of age. As aging progresses, muscle size and strength begin to decrease, by as early as age 25. Accompanying these changes are reductions in hormone levels for both men and women, contributing to a decline in bone density and muscular strength. As we age, the musculoskeletal system experiences degenerative changes resulting in fibrosis, stiffening, and shrinkage of the soft tissue bone loss joint changes and tissue desiccation due to a reduction in proteoglycans and a change in collagen type (i.e., intervertebral disc).10 With respect to the aging spine, this fibrosis and stiffening reduces the osmotic properties of the disc and the ability of the disc to obtain and or maintain vital nutrients while eliminating noxious wastes. Disc desiccation initiates a...

Spinal Deformity Scoliosis Kyphosis

Which the deformity starts at age 40 or greater, resulting from osteoporosis and or age-related degenerative disc changes. These deformities are characterized by the location of their curvatures (i.e., thoracic, lumbar, or tho-racolumbar) and can be biplanar in nature. Treatment for such pathology often results in a fusion with rigid instrumentation for curvature correction. Currently, trapezoidal mesh cages with bone morphogenic protein (BMP) are used to provide the anterior column support and improved curve correction with BMP to ensure fusion incorporation. However, this is a surgically-invasive approach requiring significant rigid stabilization implants, and is subject to early failure if the surrounding bone integrity is suboptimal or compromised, as that of the older spine.

Step 1 Identify the concepts in your focused clinical question P E O and M

We have extensively discussed the components of a focused clinical question in previous chapters. P refers to the population of interest, E to the exposure being evaluated and O to the outcomes expected. If a clinical question is focused and well stated, it can often be clearly categorized into a quest for articles on therapy, diagnosis, harm or prognosis. The advantage of this association is that we can now link the focused question with specific study designs, using so-called methodological filters (M). For example, not only can we search for articles on treatment of osteoporosis (P) using bisphosphonates (E) to prevent fractures (O), but we can also narrow our search so that we only get randomized controlled trials (M) A powerful feature of electronic databases is the ability to make the computer carry out some of the critical appraisal. Table 7.1 lists method filters you may want to use for various types of articles.

Symptoms of Menopause

Eighty percent of women will experience hot flashes when they become menopausal. Other symptoms include night sweats, difficulty sleeping, memory loss, irritability, and mood changes. Later, most women will experience vaginal dryness. Sometimes urinary symptoms such as leakage, frequency, and urgency occur because of the loss of estrogen action on the urogenital tissues, which include the urethra and the supporting tissues around the bladder. Without estrogen these tissues may atrophy somewhat over time. The lack of ovarian hormones may also contribute to the development of osteoporosis, a gradual thinning of the bone that increases the risk of fractures. As estrogen decreases, blood lipids, especially cholesterol and LDL, increase. At one time it was thought that these changes contributed to the development of cardiovascular disease and that supplementation with estrogens in menopause would protect against heart disease. Recent data from large studies (WHI, HERS, which are discussed...

Drug Delivery Therapies719

Over the last few decades, considerable advances have been made toward drug delivery technologies. However, considerable challenges still exist. The continuous release of therapeutic agents over extended time periods following a preprogrammed temporal profile, local delivery of the drug at a constant rate to the diseased microenvironment to overcome systemic toxicity, improved ease of administration, increased patient compliance, minimized risk of side effects, reduced hospital stay, and independent application all pose significant challenges to the effectiveness of the delivered pharmaceutical. Injected or ingested drugs follow first-order kinetics with high blood levels of the drug immediately after initial dosing, followed by an exponential decay in blood concentration. The rapid rise in the drug can lead to toxicity, and the efficacy of the drug is diminished as the drug levels fall exponentially. A continuous drug release profile in a controlled manner for maintaining blood...

Step 2 Prioritize the concepts from most to least important

Which one is the most important Ask yourself this if you were allowed only one term to search, which concept would you search for Consider the earlier example among patients with osteoporosis (P) how effective are bisphosphonates (E) in preventing fractures (O) Let's say you're interested in finding systematic reviews (M). In this situation, which concept would you search first - P, E, O or M If you search for articles on 'fractures' (O), you would be in trouble. There would be too many The same would be true if you search for 'systematic reviews' (M). If you search for articles on 'osteoporosis' (P), you would pick up fewer articles but a lot would be on the use of other drugs such as calcium and vitamin D. However, if you search for articles on 'bisphosphonates' (E), they are likely to also be on osteoporosis and fracture prevention. Thus, the term bisphosphonates would be a reasonable start for this search, because it would yield the most useful set of articles. If you search for...

Elderly Patients with Obesity

The majority of obese patients are 40 to 59 years of age. However, the prevalence of obesity in older adults is increasing therefore, it should not be surprising that more cardiovascular risk factors are present in this group of individuals. Additionally, obesity is a major predictor of functional limitation and mobility problems in older persons. Age alone should not prejudice the clinician from treating geriatric patients, whereas the benefits of cardiovascular health and functionality should be considered. Treatments should be initiated that minimize adverse effects on bone health and nutritional status and should include dietary and activity modifications.6

Pharmacological options

The objective clinical success of the bisphosphonate depends significantly on the reduction and delay of skeletal complications (SREs pathological fracture, spinal cord compression, need for irradiation or surgery for stabilization) 19, 22 . It can be anticipated today that the bisphosphonates have an immediate antitumoral effect. Bisphos-phonate treatment has the goal of diminishing the incidence of bony complications, vertebral body fractures, pain, and osteoporosis. The outcome should be determined by the survival time - once a spinal metastasis is detected -in an ambulatory, independent status, where pain is controlled, and the patient is not hospitalized. The mean survival time is 14- 18 months depending obviously on the patient's condition before entering treatment for the spinal problem. Wise et al. 56 report a mean survival time of 15.9 months after surgery for spinal metastasis, whereas Weigel 55 reports a 13.1 months mean survival time with 11.1 months mean time at home...

Progressive Diseases of Infancy and Childhood

Osteoporosis is a common late complication, and half of the patients will show some evidence of it by 20 years of age. It is more severe and appears earlier in pyridoxine-nonresponsive patients. Biconcave vertebrae are seen. Ihe maturation of the skeleton is abnormal and leads to lengthening of the long bones (dolichostenomelia), which accounts for the marfanoid appearance of patients.

Neurological Applications in Diagnosis and Treatment

Structural and Developmental Abnormalities. Several acquired abnormalities can be demonstrated by plain films. Fibrous dysplasia classically features sclerosis, lucency, and thinning and bulging of the inner table. This entity can be confused with Paget's disease but is encountered in a younger age group and often ceases to grow at about the third decade of life. The classic calvarial presentation of eosinophilic granuloma is that of a sharply circumscribed lucency involving the diploe and inner and outer tables, similar in appearance to that of a destructive lesion. Indeed, the differential considerations are metastatic neoplasm, infection, and recent surgical repair. Hemangiomas of the calvarium usually have a diagnostic appearance on plain film. They are typically discrete, predominantly lucent areas with a reticular or spoke wheel trabecular configuration, and a prominent diploic vascular channel is frequently identified entering the lesion. The initial or lytic phase of Paget's...

Treatment of IBD in Special Populations Table 196

Treatment of elderly patients with IBD is similar to that for younger patients, but special consideration should be given to some of the medications used. Corticosteroids may worsen diabetes, hypertension, heart failure, or osteoporosis. The TNF-a inhibitors should be used cautiously in patients with heart failure and should be avoided in New York Heart Association Class III or IV disease. Lastly, elderly patients requiring major surgical interventions may be at higher risk for surgical complications or

Ankylosing Spondylitis

Patients with the cauda equina syndrome of AS 9 have a gradual and relatively symmetrical loss of function in the L5, S1, and S2 roots. Both motor and sensory fibers are affected. Foot drop, weakness of plantar flexion, and perianal sensory loss are typical. Nearly all patients develop bladder and bowel incontinence. The cervical spine disorder most often associated with AS is instability at the craniocervical junction because of ligamentous laxity at the level of the odontoid process. y Some patients have stepwise subluxation of the cervical spine, resembling that seen in seropositive rheumatoid arthritis. In either case, myelopathy may develop, often with significant sensory loss in the hands, as well as quadriparesis. As in rheumatoid arthritic disease, there may be marked instability of the cervical spine or craniocervical junction with much local pain, sudden changes in neurological symptoms with postural change, and eventual requirement for surgical fusion. Patients with AS may...

Treatment of Special Populations

The NOF recommends measuring bone mineral density in premenopausal women with specific risk factors for osteoporosis, such as medical condition or medication, in whom treatment would be considered.1 Premenopausal women at risk for osteoporosis should follow all nonpharmacologic recommendations for exercise and adequate calcium and vitamin D intake. Currently, no good data are available regarding pharmacologic therapy on fracture reduction in this population. Bisphosphonates should be Compared to postmenopausal osteoporosis, few clinical trials have been conducted evaluating therapies in men. Although alendronate and calcitonin have both been studied, only alendronate reduces fracture rates in men. Teriparatide has also been studied, but no data are yet available on fracture rates. At this time, alendronate and teriparatide are FDA-approved for the treatment of osteoporosis in men. Dae to proven benefit in reducing fractures and relative safety, alendronate should be considered...

Rationale for Parathyroidectomy

Hyperparathyroidism And Stool Frequency

There is good evidence that in about 80 of patients the clinical manifestations improve after successful parathyroidectomy.8'9,10'46'47 Thus, fatigue, exhaustion and weakness, polydipsia, polyuria and nocturia, bone and joint pain, constipation, nausea, and depression improve in some patients.8 I0'46'47 This is also true for associated conditions. In these patients, new kidney stones usually stop forming, osteoporosis stabilizes or improves, peptic ulcer disease often resolves, and pancreatitis becomes less likely.4647 Thus, both neuropsychiatry and somatic problems improve in most, but not all, patients (Figs. 40-1 to 40-4).10-48 Increased fracture risk and weakness also improve after successful parathyroidectomy in most, but certainly not all, patients.1948 Objective increase in muscular strength has also been documented after successful parathyroidectomy.49 Patients can also resume a regular diet with or without calcium supplementation and hypercalcemia is not a concern when...

Mecanism Of Centripetal Lipid Accumulation Supraclavicular Fat And Face

Seborrhea and hirsutism may be present. In men the most common clinical manifestation of hyperprolactinemia is the progressive loss of libido and impo-tency. Oligospermia and other physical signs of hypogonadism (i.e., muscular hypotrophy, increased abdominal fat) are commonly reported. Galactorrhea or gynecomastia is present in 15 to 30 of male patients.2 Prolactinomas among men and postmenopausal women are often macroadenomas ( 1 cm), because changes in libido are not detected early. Hyperpro-lactinemia in both sexes can also be associated with anxiety, depression, fatigue, emotional instability, and hostility.10,11 Hyperthyroidism, or thyrotoxicosis, is most commonly caused by thyroid gland pathology (Graves' disease, toxic multinodular goiter, and toxic adenoma), which is associated with low or undetectable TSH levels. TSH-secreting (thy-rotroph) adenomas are rare and account for less than 1 of all pituitary adenomas. They are associated with...

Clinical Features of Hypercalcemic Crisis

Mild to moderate hypercalcemia may be manifested only by anorexia, malaise, weakness, osteoporosis, and kidney stones. When these manifestations develop slowly, as they do in many mildly hyperparathyroid patients, their presence may be recognized only retrospectively, after parathyroidectomy.7'26 Hypercalcemia causes anorexia, polyuria, nausea, and vomiting, and the resultant dehydration may be profound.9 Isolated components of the syndrome are often nonspecific and observed in many other diseases,10 but the simultaneous presence of several of these components strongly suggests hypercalcemia.

What is Pagets disease

Mitch Paget

Osteoporosis is a metabolic bone disease characterized by a decreased amount of normally mineralized bone per unit volume. 3. Osteopenia is a descriptive and nonspecific term for decreased radiographic bone density. Osteoporosis and bone physiology Clinician's guide to prevention and treatment of osteoporosis (2010) 2. Dawson-Hughes B, Lindsay R, Khosla S, et al. Clinician's guide to prevention and treatment of osteoporosis. Washington, DC National Osteoporosis Foundation 2010. 3. Dell RM, Greene D, Anderson D, et al. Osteoporosis disease management What every orthopaedic surgeon should know. J Bone Joint Surg 2009 91 S79-S86.