The document discusses diabetes mellitus and fracture risk. It notes that type 2 diabetes affects over 700,000 people in the Netherlands and is associated with higher bone mineral density but also more rapid bone loss over time. While type 2 diabetes is initially linked to higher bone density due to factors like higher body weight, studies have shown those with type 2 diabetes have a 1.7 times higher risk of hip fractures and 1.2 times higher risk of any fracture after adjusting for characteristics like age, body mass index and bone mineral density. The increased fracture risk in type 2 diabetes may be due to factors beyond bone mineral density, such as changes in bone microarchitecture, turnover and material properties from excess glucose.
Sanni Ali's presentation from Osteoporosis 2016: Antidiabetic medication use and the risk of fracture amongst type 2 diabetic patients: a nested case-control study
Find out more at: https://nos.org.uk/conference
Kate Ward's presentation from Osteoporosis 2016: Relationships between muscle function and bone microarchitecture in the Hertfordshire cohort study.
Find out more at: https://nos.org.uk/conference
Dr Jennifer Walsh's presentation from Osteoporosis 2016: Management of osteoporosis in the young adult.
Find out more at: https://nos.org.uk/conference
Sanni Ali's presentation from Osteoporosis 2016: Antidiabetic medication use and the risk of fracture amongst type 2 diabetic patients: a nested case-control study
Find out more at: https://nos.org.uk/conference
Kate Ward's presentation from Osteoporosis 2016: Relationships between muscle function and bone microarchitecture in the Hertfordshire cohort study.
Find out more at: https://nos.org.uk/conference
Dr Jennifer Walsh's presentation from Osteoporosis 2016: Management of osteoporosis in the young adult.
Find out more at: https://nos.org.uk/conference
Dr Steve Cummings presentation from Osteoporosis 2016: Patients receiving bisphosphonates should not take holidays from treatment.
Find out more at: https://nos.org.uk/conference
Prof. Richard Eastell's presentation from Osteoporosis 2016: Patients receiving bisphosphonates should take holidays from treatment. The case for holidays.
Find out more at: https://nos.org.uk/conference
Prof. Jon Tobias's presentation from Osteoporosis 2016: Day-to-day levels of high impact physical activity are positively related to lower limb bone strength in older women: findings from a population based study using accelerometers to classify impact magnitude.
Find out more at: https://nos.org.uk/conference
Vicki Harber
LA GIOVANE ATLETA
Il ciclo mestruale, punto di riferimento per un sviluppo sano della giovane atleta
Nel processo di sviluppo delle giovani atlete è necessario che siano integrati il monitoraggio continuo del menarca e il controllo del loro stato mestruale. Promuovere lo sviluppo di una giovane atleta e supervisionarne l’allenamento è impegnativo e complesso. Se dispongono di una conoscenza maggiore della funzione mestruale le giovani atlete e le loro famiglie hanno strumenti migliori per rispondere alle esigenze dell’allenamento e delle gare. Lo stato mestruale rappresenta un indicatore globale della salute e del benessere che fornisce informazioni che riguardano l’energia, il rischio di lesioni scheletriche e muscolari, l’apporto alimentare, il profilo metabolico e ormonale, il recupero e altri elementi, importanti per la prestazione. Inoltre, con l’uso crescente dei contraccettivi orali da parte delle giovani atlete che non hanno raggiunto la loro maturità scheletrica, allenatori, allenatrici e genitori debbono essere informati dei risultati recenti che riguardano la salute delle ossa.
Bone health of postpartum women: Unexpected high prevalence of a health probl...Premier Publishers
The aim was to see the effect of pregnancy on Bone Mineral Density (BMD) and bone turnover markers (BTMs) in the immediate postpartum period and 12 months thereafter. Eighty women delivered at KAUH (May 2009-Oct 2010) had BMD, bone profile, 25-OH vitamin D and (BTMs). Inclusion criteria: Singleton pregnancy without medical or pregnancy complications. Exclusion criteria: multiple pregnancies, history of diabetes thyroid or bone disease, and use of any medication that affect calcium metabolism. Biochemical tests were repeated for 27 women after one year. Statistical analysis was done using SPSS 16. Eighty women had BMD before discharge. Sixty four women (80%) had low BMD; sixteen of these (25%) had osteoporosis. Although bone profiles were normal, Vitamin D levels were moderately or severely deficient in 35.37% of women. After adjustment for BMI and age there was no correlation between BMD and other variables. Multiple linear regressions showed that BMI was the predictor for BMD (P=0.0014). There was no significant difference between postpartum bone BTMs and bone profiles, and those after twelve months.
Osteoporosis/ osteopenia is a significant health problem in this group of women. Further studies are needed to look into predisposing factors.
Dr Andrea Burden's presentation from Osteoporosis 2016: Intermittent use of high-dose glucocorticoids and risk of fracture in Denmark: A population-based case-control study.
Find out more at: https://nos.org.uk/conference
Presented by Linus Lay, Pharm.D. Candidate from the University of Rhode Island Class of 2022.
This presentation is on behalf of the Hackettstown Medical Center Pharmacy at Hackettstown, New Jersey as part of Continuing Education.
The Osteoporosis Overview goes over a brief introduction to osteoporosis and current/updated treatment guidelines based on global usage, drug effectiveness, and American association of clinical endocrinologists.
View MyCred Portfolio: https://mycred.com/p/2929377185
Diabetes mellitus, enfermedad periodontal y sus implicaciones en la cavidad oral ( enfocado en odontología ) presentación institucional universidad cooperativa de colombia, Area de periodoncia.
Dr Steve Cummings presentation from Osteoporosis 2016: Patients receiving bisphosphonates should not take holidays from treatment.
Find out more at: https://nos.org.uk/conference
Prof. Richard Eastell's presentation from Osteoporosis 2016: Patients receiving bisphosphonates should take holidays from treatment. The case for holidays.
Find out more at: https://nos.org.uk/conference
Prof. Jon Tobias's presentation from Osteoporosis 2016: Day-to-day levels of high impact physical activity are positively related to lower limb bone strength in older women: findings from a population based study using accelerometers to classify impact magnitude.
Find out more at: https://nos.org.uk/conference
Vicki Harber
LA GIOVANE ATLETA
Il ciclo mestruale, punto di riferimento per un sviluppo sano della giovane atleta
Nel processo di sviluppo delle giovani atlete è necessario che siano integrati il monitoraggio continuo del menarca e il controllo del loro stato mestruale. Promuovere lo sviluppo di una giovane atleta e supervisionarne l’allenamento è impegnativo e complesso. Se dispongono di una conoscenza maggiore della funzione mestruale le giovani atlete e le loro famiglie hanno strumenti migliori per rispondere alle esigenze dell’allenamento e delle gare. Lo stato mestruale rappresenta un indicatore globale della salute e del benessere che fornisce informazioni che riguardano l’energia, il rischio di lesioni scheletriche e muscolari, l’apporto alimentare, il profilo metabolico e ormonale, il recupero e altri elementi, importanti per la prestazione. Inoltre, con l’uso crescente dei contraccettivi orali da parte delle giovani atlete che non hanno raggiunto la loro maturità scheletrica, allenatori, allenatrici e genitori debbono essere informati dei risultati recenti che riguardano la salute delle ossa.
Bone health of postpartum women: Unexpected high prevalence of a health probl...Premier Publishers
The aim was to see the effect of pregnancy on Bone Mineral Density (BMD) and bone turnover markers (BTMs) in the immediate postpartum period and 12 months thereafter. Eighty women delivered at KAUH (May 2009-Oct 2010) had BMD, bone profile, 25-OH vitamin D and (BTMs). Inclusion criteria: Singleton pregnancy without medical or pregnancy complications. Exclusion criteria: multiple pregnancies, history of diabetes thyroid or bone disease, and use of any medication that affect calcium metabolism. Biochemical tests were repeated for 27 women after one year. Statistical analysis was done using SPSS 16. Eighty women had BMD before discharge. Sixty four women (80%) had low BMD; sixteen of these (25%) had osteoporosis. Although bone profiles were normal, Vitamin D levels were moderately or severely deficient in 35.37% of women. After adjustment for BMI and age there was no correlation between BMD and other variables. Multiple linear regressions showed that BMI was the predictor for BMD (P=0.0014). There was no significant difference between postpartum bone BTMs and bone profiles, and those after twelve months.
Osteoporosis/ osteopenia is a significant health problem in this group of women. Further studies are needed to look into predisposing factors.
Dr Andrea Burden's presentation from Osteoporosis 2016: Intermittent use of high-dose glucocorticoids and risk of fracture in Denmark: A population-based case-control study.
Find out more at: https://nos.org.uk/conference
Presented by Linus Lay, Pharm.D. Candidate from the University of Rhode Island Class of 2022.
This presentation is on behalf of the Hackettstown Medical Center Pharmacy at Hackettstown, New Jersey as part of Continuing Education.
The Osteoporosis Overview goes over a brief introduction to osteoporosis and current/updated treatment guidelines based on global usage, drug effectiveness, and American association of clinical endocrinologists.
View MyCred Portfolio: https://mycred.com/p/2929377185
Diabetes mellitus, enfermedad periodontal y sus implicaciones en la cavidad oral ( enfocado en odontología ) presentación institucional universidad cooperativa de colombia, Area de periodoncia.
Diabetes has already reached global epidemic proportions. Pills aren't the long-term solution and diet alone doesn't work. The missing piece is exercise. But what if you hurt when you walk? Read this presentation to find the answer.
Update on the 18th International Conference on Co-morbidities and Adverse Drug Reactions in HIV
Daniel Lee, M.D.
January 20th, 2017
UCSD HIV & Global Health Rounds
A talk by Pratik Pandharipande at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All of the conference content can be found here: https://scanfoam.org/ssai2017/
Developed in collaboration between scanFOAM, SSAI and SFAI.
IWO Meeting 1 November 2023 - Stopping with Denosumab and Romosozumab, basic mechanisms and clinical aspects door Prof. dr. S. Ferrari, Geneva, Switzerland. (Engelstalige lezing)
IWO Meeting 16 November 2022 - ASBMR young talent: Silvia Storoni (Amsterdam): Prevalence and Hospital Admissions in Patients With Osteogenesis Imperfecta in The Netherlands: A Nationwide Registry Study
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
2. Prevalence
of
Diabetes
in
the
Netherlands
• 800.000
pa8ents
– 700.000
DM
type
2
– 100.000
DM
type
1
• Yearly
incidence:
81.000
(>1.500
/
week)
0
2
4
6
8
10
12
14
16
18
20
0 10 20 30 40 50 60 70 80 90
mannen vrouwen
incidentie (per 1.000)
leeftijd (jaren)
Copyright
Dr. J.P.W. van
den
Bergh
3. DM
type
1
• Modest
reduc8on
in
BMD
– LS
Z-‐score:
-‐0.22
– TH
Z-‐score:
-‐0.37
• Hip
fracture
RR:
6.9
(3.2-‐14.9)
• Lack
of
data
for
other
fracture
sites
Vestergaard
2007
Copyright
Dr. J.P.W. van
den
Bergh
4. DM
type
2
• Average
higher
BMD
– LS
Z-‐score:
+0.41
– TH
Z-‐score
+0.27
• Overweight
• Expected
lower
fracture
risk
Vestergaard
2007
Copyright
Dr. J.P.W. van
den
Bergh
5. Associa8on
between
bone
mineral
density
and
type
2
diabetes
mellitus
Ma
et
al.
Eur
J
Epidemiol
(2012)
27:319–332
Copyright
Dr. J.P.W. van
den
Bergh
6. Meta-‐regression
• Posi8ve
associa8on
with
higher
BMD
levels
in
diabe8cs
– younger
age
– male
gender
– higher
body
mass
index
– higher
HbA1C
Copyright
Dr. J.P.W. van
den
Bergh
7. Longitudinal
BMD
changes:
more
rapid
bone
loss
in
DM
type
2
Fracture
Interven8on
Trial
(total
hip)
Copyright
Dr. J.P.W. van
den
Bergh
8. More
rapid
bone
loss
in
DM
type
2
• At
the
hip:
– FIT
Keegan
at
al.
2004
– Health
ABC
Schwartz
et
al.
2005
– MrOS
Strotmeyer
et
al.
2008
– SOF
Schwartz
et
al.
2013
• No
differences
at
the
radius
– Krakauer
et
al.
1995
– Schwartz
et
al.
2013
Copyright
Dr. J.P.W. van
den
Bergh
9. DM
type
2:
hip
fracture
risk
• Age
adjusted
RR
=
1.4
(1.2
–
1.5)
• Mul8variable
adjusted
(age,
BMI,
BMD)
RR
=
1.7
(1.3
–
2.2)
Vestergaard
2007
Janghorbani
2007
Copyright
Dr. J.P.W. van
den
Bergh
10. DM
type
2:
any
fracture
risk
• Age
adjusted
RR
=
1.0
(0.6
–
1.6)
• Mul8variable
adjusted
(age,
BMI,
BMD)
RR
=
1.2
(1.01
–
1.5)
Vestergaard
2007
Janghorbani
2007
Copyright
Dr. J.P.W. van
den
Bergh
11. Fracture
predic8on
in
DM
type
2
Schwartz
et
al.
JAMA
2011:
2184-‐2192
Copyright
Dr. J.P.W. van
den
Bergh
12. Schwartz
et
al.
JAMA
2011:
2184-‐2192
Copyright
Dr. J.P.W. van
den
Bergh
13. Schwartz
et
al.
JAMA
2011:
2184-‐2192
Copyright
Dr. J.P.W. van
den
Bergh
14. The
FRAX
score
tends
to
underes8mate
risk
in
pa8ents
with
DM
type
2
Schwartz
et
al.
JAMA
2011:
2184-‐2192
Copyright
Dr. J.P.W. van
den
Bergh
15. Leslie
et
al.
JBMR
2012:
2231-‐2237
Copyright
Dr. J.P.W. van
den
Bergh
16. DM
type
2
more
likely
to
fracture
at
given
BMD
• Cause?
– More
frequent
falls
– Diabe8c
bone
fragility
– Aspects
of
bone
strength
not
captured
by
BMD/DXA
Copyright
Dr. J.P.W. van
den
Bergh
18. Falls:
not
the
whole
story
• DM2
is
s8ll
associated
with
higher
fracture
risk
ajer
adjustment
for
fall
frequency
– WHI
Bonds
et
al.
2006
– Rolerdam
study
de
Liefde
et
al.
2005
– Health,
Ageing
Study
Strotmeyer
et
al.
2005
– SOF
Schwartz
et
al.
2001
Copyright
Dr. J.P.W. van
den
Bergh
19. Diabe8c
bone
fragility
possible
contribu8ng
factors
• Bone
turnover
• Microarchitecture
• Geometry
• Material
proper8es
• Rela8onship
with
glycemic
control
(HbA1C)
Copyright
Dr. J.P.W. van
den
Bergh
21. Bone
turnover
• Reduced
bone
forma8on
– Bone
biopsy:
lower
bone
forma8on
rate
– Compared
with
controls:
postmenopausal
women
(n=
5
vs
4)
Manavalan
et
al.
JCEM
2012:
3240
Copyright
Dr. J.P.W. van
den
Bergh
23. DMFx
had
4.7-‐fold
greater
porosity
than
DM
Patsch
et
al.
JBMR
2013:
313
Copyright
Dr. J.P.W. van
den
Bergh
24. Geometry:
(p)QCT
in
DM
type
2
• Higher
volumetric
BMD,
especially
trabecular
BMD
• Modest
reduc8on
in
cross
sec8onal
area
• Load
to
strength
ra8o
– Similar
for
hip,
spine
– Reduced
in
radius
and
8bia
– In
spite
of
higher
BMD
Melton
et
al.
2008
and
Patsch
et
al.
JBMR
2013:
313
Copyright
Dr. J.P.W. van
den
Bergh
25. Material
proper8es:
AGEs
• Advanced
Glyca8on
End
products
(AGEs)
– Formed
by
nonenzyma8c
reac8on
between
glucose
and
protein
– Accumulate
in
collagen
(and
other
structures)
– Form
cross-‐links
that
increase
s8ffness
of
collagen
and
reduce
osteoblast
func8on
Wang
et
al.
2002
and
Willet
et
al.
2013
Copyright
Dr. J.P.W. van
den
Bergh
26. Advanced
Glyca8on
End
products
(AGEs)
AGEs
form
on
different
molecules
as
collagen,
laminin
and
elas8n.
This
alters
the
physiological
proper8es
of
the
matrix
and
increases
its
s8ffness
Hegab
et
al.
World
J
Cardiol
2012;
90–102
Copyright
Dr. J.P.W. van
den
Bergh
27. Glycemic
control
and
fractures
Schneider
et
al.
Diabetes
Care
2013:1153
Copyright
Dr. J.P.W. van
den
Bergh
28. Glycemic
control
and
fractures
Schneider
et
al.
Diabetes
Care
2013:1153
Copyright
Dr. J.P.W. van
den
Bergh
29. Oei
et
al.
Diabetes
Care
2013:1619
Copyright
Dr. J.P.W. van
den
Bergh
30. Oei
et
al.
Diabetes
Care
2013:1619
Schneider
et
al.
Diabetes
Care
2013:1153
Copyright
Dr. J.P.W. van
den
Bergh
31. HSA
=
hip
structural
analysis
(on
DXA)
Oei
et
al.
Diabetes
Care
2013:1619
Copyright
Dr. J.P.W. van
den
Bergh
32. Oei
et
al.
Diabetes
Care
2013:1619
Copyright
Dr. J.P.W. van
den
Bergh
33. Possible
contributors
to
bone
fragility
in
DM
type
2
• Deficits
in:
– Geometry
– Cor8cal
microarchitecture
(porosity)
– Material
proper8es
Copyright
Dr. J.P.W. van
den
Bergh
34. Effect
of
treatment
on
hip
fracture
HbA1C
Odds
ra8o
Copyright
Dr. J.P.W. van
den
Bergh
37. Diabetes
Medica8on:
Effect
on
bone
• Meqormin
One
RCT
(meq
&
SU)
• Sulfonylureas
• Insulin
Observa8onal
• TZD
RCT
(fracture
as
AE)
• Incre8n
based
RCT
(fracture
as
SAE)
– DPP-‐4
inhibitors
– GLP-‐1
agonists
• SGLT2
inhibitors
Lack
of
data
Copyright
Dr. J.P.W. van
den
Bergh
38. ADOPT
trial:
Increased
risk
in
women
(not
men)
treated
with
rosiglitazone
Kahn
et
al.
Diabetes
Care
2008:845–851
Copyright
Dr. J.P.W. van
den
Bergh
39. TZDs
and
fractures
Meta-‐analysis
of
5
RCTs
• Women
OR
2.2
(1.6-‐3.0)
• Men
OR
1.0
(0.7-‐1.4)
• Dura8on
1-‐4
years
Loke
et
al.
2009
Copyright
Dr. J.P.W. van
den
Bergh
42. Effect
of
diabetes
treatments
on
bone
• Poten8al
(indirect)
effect
of
insulin
• TZDs
should
be
avoided
in
women
at
higher
risk
of
fracture
• Poten8al
posi8ve
effect
of
DPP4-‐inhibitors?
Copyright
Dr. J.P.W. van
den
Bergh
47. Observa8onal
studies
• Diabetes
does
not
seem
to
affect
the
fracture-‐preven8ve
poten8al
of
bisphosphonates
and
raloxifene.
• The
low-‐turnover
state
of
diabetes
thus
does
not
seem
to
be
a
hindrance
to
the
effect
of
bisphosphonates
and
raloxifene.
• Pa8ents
with
diabetes
should
receive
an8-‐osteoporo8c
treatment
in
the
same
way
as
non-‐diabe8c
pa8ents
Vestergaard
et
al.
Calcif
Tissue
Int
2011:209
Copyright
Dr. J.P.W. van
den
Bergh
48. Summary
• DM
type
1
and
2
associated
with
higher
risk
of
fracture
• At
the
same
BMD,
DM2
are
at
higher
risk
• DXA
T-‐score
and
FRAX
predict
fracture
in
DM
type
2,
but
underes8mate
the
risk
• More
frequent
falls
(hypoglycemia?)
and
poorer
bone
quality
probably
contribute
to
higher
fracture
risk
• Bone
proper8es
are
altered
in
DM
type
2
– decreased
diameter
– increased
cor8cal
thickness
and
porosity
– lower
bone
forma8on
– Effect
on
cross-‐links
of
higher
AGEs
Copyright
Dr. J.P.W. van
den
Bergh
49. Summary
• Fracture
risk
is
higher
with
increased
HbA1C
• Intensive
control
does
not
increase
fractures
– (except
one
study)
• Diabetes
medica8on
can
affect
bone
– TZD:
increased
fracture
risk
in
women
– Insulin?
• Limited
data
on
efficacy
and
safety
of
an8-‐osteoporosis
therapy
in
DM
type
2
– Alendronate:
1
BMD
study
– Raloxifene:
decrease
of
VF
incidence
Copyright
Dr. J.P.W. van
den
Bergh