This document summarizes guidelines for evaluating and managing patients with fragility fractures. It defines fragility fractures as fractures caused by low-impact falls from standing height or less. Fragility fractures are common in older adults and have severe consequences, including disability, reduced quality of life, and increased mortality. The document outlines best practices for assessing fragility fracture patients, including obtaining a detailed medical history, physical exam, lab tests, bone mineral density testing, and imaging to evaluate for additional fractures. The goal is to diagnose any underlying osteoporosis and implement secondary prevention strategies to reduce future fracture risk.
Operative treatment of osteoporotic spinal fracturesAlexander Bardis
Osteoporosis is a systemic disease, which results in :
progressive bone mineral loss
concurrent changes in bony architecture
leaving the spinal column vulnerable to compression fractures, usually after minimal or no trauma.
Operative treatment of osteoporotic spinal fracturesAlexander Bardis
Osteoporosis is a systemic disease, which results in :
progressive bone mineral loss
concurrent changes in bony architecture
leaving the spinal column vulnerable to compression fractures, usually after minimal or no trauma.
Chondral Injuries - Current Concepts in Management & Cartilage RegenerationVaibhav Bagaria
Chondral Injuries are one of the technically challenging cases for sports injury surgeons. There are various techniques described including lavage, abrasion chondroplasty, micro fracture, Mosaicplasty, ACI - various generations and newly developed Bioprinting
Surgical Approaches to Acetabulum and PelvisBijay Mehta
Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
femoral head fractures are very complex fractures that need immediate and prompt surgical intervention.conventional surgical appproaches to hip may lead to short and long term complications.dr mohamed ashraf ,dr rahul thampi et al are presenting their experience with gantz safe surgical dislocation approach to surgical management of femoral head fractures
Chondral Injuries - Current Concepts in Management & Cartilage RegenerationVaibhav Bagaria
Chondral Injuries are one of the technically challenging cases for sports injury surgeons. There are various techniques described including lavage, abrasion chondroplasty, micro fracture, Mosaicplasty, ACI - various generations and newly developed Bioprinting
Surgical Approaches to Acetabulum and PelvisBijay Mehta
Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
femoral head fractures are very complex fractures that need immediate and prompt surgical intervention.conventional surgical appproaches to hip may lead to short and long term complications.dr mohamed ashraf ,dr rahul thampi et al are presenting their experience with gantz safe surgical dislocation approach to surgical management of femoral head fractures
Everything you should know about Osteoporosis?
What is Osteoporosis?
Osteoporosis is a disorder of bones characterized by low bone density and a deterioration of bone micro- architecture that enhances bone fragility and increases the risk of fracture
Osteoporosis becomes a serious health threat for aging men & postmenopausal women by predisposing them to an increased risk of fracture
Do you know that?
Osteoporosis is responsible for >1.5 million vertebral and non-vertebral fractures per year
Spine, hip, and wrist fractures are most common.
Medical management of epilepsy,
Seizures,
Epileptogenesis,
Anti-seizure medications,
Anti epileptic drugs,
status epilepticus,
management of seizures,
Management of status epilepticus
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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.
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.
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
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.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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
2. 2
EVALUATION AND MEDICAL
MANAGEMENT OF FRAGILITY
FRACTURES
Thomas jeffersonian hospital and Rothman institute article in orthopedic
clinical of North America April 2014
Presented By: Harjot Singh Gurudatta
Moderator: DR. RAJAN SHARMA
3. 3
Definition of fragility fracture: (WHO)
Fracture during activity that would not normally injure
young healthy bone (i.e., fall from standing height or
less)
• Fragility fractures are a large and growing health issue
– 1 in 2 women and 1 in 4 men over 50 yrs of age will suffer a fracture in their remaining lifetime
• A prior fracture increases the risk of a new fracture 2- to 5-fold
• Yet few fracture patients receive evaluation and treatment of osteoporosis, the underlying
cause of most fragility fractures
– Calls for action to improve the evaluation and treatment of fracture patients have been published
around the World
4. 4
Fragility fractures are common
• 1 in 2 women and 1 in 5 men over age 50 will suffer a
fracture in their remaining life time
• 55% of persons over age 50 are at increased risk of
fracture due to low bone mass
• At age 50, a woman’s lifetime risk of fracture exceeds
combined risk of breast, ovarian & uterine cancer
• At age 50, a man’s lifetime risk of fracture exceeds risk of
prostate cancer
5. 5
Osteoporotic fractures:
Comparison with other diseases
1996 new cases,
annual estimate
women 30+
184 300 all ages
annual incidence
all ages
250 000
hip
250 000
forearm
250 000
other sites
750 000
vertebral
2000
1500
1000
500
0
Osteoporotic
fractures
annual estimate
women 29+
Heart
attack
Stroke Breast
cancer
Annual incidence x 1000
1 500 000
513 000
228 000
American Heart Association, 1996
American Cancer Society, 1996
Riggs & Melton, Bone, 1995; 17(5 suppl):505S-511S
6. 6
Consequences of hip fracture
Permanent
disability
Death within
one year
Cooper. Am J Med 1997; 103(2A):12s-19s.
Unable to carry out at
least one independent
activity of daily living
Unable to
walk
independently
40%
30%
20%
80%
One year after hip fracture
7. 7
Consequences of vertebral fractures
• Acute and chronic pain
– Narcotic use, decrease mobility
• Loss of height & deformity
– Reduced pulmonary function
– Kyphosis, protuberant abdomen
• Diminished quality of life:
– Loss of self-esteem, distorted body image, sleep disorders,
depression, loss of independence
• Increased fracture risk
• Increased mortality
8. 8
Consequences of distal radius fractures
• The most common fracture in women at
middle age
– Incidence increases just after menopause
• The most common fracture in men below
70 years
• Only 50% report good functional outcome
at 6 months
• Up to 30% of individuals suffer long-term
complications
O'Neill et al. Osteoporos Int. 2001; 12:555-558
9. 9
Fragility fractures are common and have
severe consequences
Fragility fractures lead to major morbidity, decreased quality of life
and increased mortality
– 10-25% excess mortality
– 50% unable to walk independently after hip fracture
– 50% show substantial decline from prior level of function (many lose
ability to live independently)
– Increased depression, chronic pain, disability
– Increased risk of subsequent fracture
10. 10
Definition of osteoporosis
“…a systemic skeletal disease
characterized by low bone mass and
micro-architectural deterioration of
bone tissue, leading to enhanced
bone fragility and a consequent
increase in fracture risk.”
World Health Organization (WHO), 1994
11. 11
Major risk factors for fractures
• Prior fragility fracture
• Increased age
• Low bone mineral density
• Low body weight
• Family history of osteoporotic fracture
• Glucocorticoid use
• Smoking
12. 12
Assessing bone density
• X-ray observation
– “Osteopaenic on x-ray” implies significant
bone loss already – decreased opacity,
thin cortices, wide canals, current fracture,
healing fractures
– A “late finding” in the course of the
disease, but may be the “first finding” for a
patient
13. 13
Assessment of bone mineral density by DXA
Current gold standard for diagnosis of osteoporosis
BMD (g/cm2) = Bone mineral content (g) / area (cm2)
Diagnosis based on comparing patient’s
BMD to that of young, healthy individuals of
same sex
14. 14
WHO criteria for diagnosis of osteoporosis
T-score: Difference expressed as standard deviation compared
to young (20’s) reference population
Kanis et al. J Bone Miner Res 1994; 9:1137-41
T-score
Normal - 1.0 and above
Osteopaenia - 1.0 to - 2.5
Osteoporosis - 2.5 and below
Severe (established)
osteoporosis
- 2.5 and below, plus one or
more osteoporotic
fracture(s)
15. 15 Bone strength is more than BMD
BMD is surrogate criteria for OP as BP for Stroke
young
elderly
Images from L. Mosekilde, Technology and
Health Care. 1998
Image courtesy of David Dempster
16. 16
Determinants of whole bone strength
• Geometry
– Gross morphology (size & shape)
– Microarchitecture
• Properties of bone material / bone matrix
– Mineralization
– Collagen characteristics
– Microdamage
Applied load
Bone strength
> 1 fracture
Factor of
risk
17. 17
Bone remodelling balance influences bone
strength
Bone strength
SIZE & SHAPE
macroarchitecture
microarchitecture
MATERIAL
tissue composition
matrix properties
BONE REMODELLING
formation / resorption
AGEING, DISEASE and THERAPIES
18. 18
High Bone Turnover
Resorption > Formation
Decreased Bone
Strength
Decreases Bone Mass
Disrupts Trabecular Architecture
Increases Cortical Porosity
Decreases Cortical Thickness
STOCHASTIC REMODELLING
Alters Bone Matrix Composition
L. Mosekilde
Tech and Health Care, 1998
19. 19
But bone quality is not the only factor…
Bone size (mass)
Bone shape
Architecture
Matrix properties
Fall
incidence
Fall characteristics
Energy absorption
External protection
Fall
impact
Bone
strength
Fracture risk
Neuromuscular function
Environmental risks
Age
20. 20
Optimal care of the fragility fracture patient
• Diagnosis of “fragility” fracture
– Identify “fragility” fracture & underlying disease, incorporate into
existing workup
– Influences treatment plan from the onset
• General fracture management
– Stabilize patient, pain relief, fracture care
• Rehabilitation
– Minimize dependence, maximize mobility
• Secondary prevention
– Treat and monitor underlying disease, prevent future fractures
21. 21
Optimal care of the fragility fracture patient
• Diagnosis of “fragility” fracture
– Identify “fragility” fracture & underlying disease, incorporate into
existing workup
– Influences treatment plan from the onset
22. 22
High risk for secondary osteoporosis
• Severe chronic liver or kidney diseases
• Steroid medication (>7.5mg for more than 6 months)
• Malabsorption (eg. Crohn´s disease)
• Rheumatoid arthritis
• Systemic inflammatory disorders
• Hyperthyroidism
• Primary hyperparathyroidism
• Antiepileptic medication
23. 23
Fragility fracture patient assessment
* In addition to routine pre-op or fracture evaluation
• Family history of OP
• Menarche / Menopause
• Nutrition
• Medications
– (past and present)
• Level of activity
• Fracture history
• Fall history & risk factors for falls
• Smoking, alcohol intake
• Risk factors for secondary OP
• Prior level of function
History
should include:
24. 24
Fragility fracture patient assessment
In addition to routine pre-op or fracture evaluation
• Height
• Weight
• Limb exam
– ROM, strength, deformity, pain,
neurovascular status
• Spine exam
– pain, deformity, mobility
• Functional status
Physical exam
should include:
25. 25
Laboratory tests*
• SR / CRP
• Blood count
• Calcium
• Phosphate
• Alkaline Phosphatase (AP)
• GGT
• Renal function studies
• Basal TSH
• Intact PTH
• Protein-immunoelectrophoresis
• Vit D (25 and 1.25)
NOTES:
- * These are in addition to
routine pre-op labs such as
coagulation studies
- These are screening labs,
more may be indicated based
on these results
26. 26
Bone mineral density and spine radiograph for
vertebral fracture assessment
• Bone mineral density assessment by DXA
– Establish severity of osteoporosis
– Baseline for monitoring treatment efficacy
• Consider spine radiographs (thoracic and lumbar, AP and
ML views) for patients with:
– Back pain
– Loss of height > 4 cm
– Progressive kyphosis
27. 27
DEXA– Flaws?
• DEXA overestimate the bone mineral density of
taller subjects and underestimate the bone mineral
density of smaller subjects.
• In DEXA, bone mineral content is divided by the
area of the site being scanned.
• DEXA calculates BMD using area (aBMD: areal
Bone Mineral Density), it is not an accurate
measurement of true bone mineral density, which
is mass divided by a volume.
28. 28
DEXA– Flaws?
• The confounding effect of differences in bone size
is due to the missing depth value in the calculation
of bone mineral density.
• The radiation dose is approximately 1/10th that of
a standard chest X-ray
• BMD testing with DXA is very susceptible to
operator error.
29. 29
DEXA– Flaws?
• A repeat BMD measurements should be done on the
same machine each time, or at least a machine from the
same manufacturer.
• Error between machines, or trying to convert
measurements from one manufacturer's standard to
another can introduce errors large enough to wipe out the
sensitivity of the measurements.
• DEXA results need to be adjusted if the patient is
taking strontium, and calcium supplements.
• Metallic artifacts in cloths or pockets cause errors.
• Osteomalacia, Osteoarthritis of spine, old Fractures of
spine and hip, aortic calcification affect BMD readings.
30. 30
Who should be screened?
• Problem of over-interpretation of results, & healthy
average people think they are at a much higher
risk.
• In 2000 an NIH consensus conference concluded:
"Until there is good evidence to support the cost-effectiveness
of routine screening, or the efficacy
of early initiation of preventive drugs, an
individualized approach is recommended.
31. 31
Who to screen
• Women > 65 years.
• Men > 70 years.
• Postmenopausal women /men >50 years with
clinical risk factors.
• H/o fracture at age > 50 years.
• Chronic steroid use.
• Risk factor for secondary OP
32. 32
Bone density at various sites for prediction of hip fractures
Cummings SR, Black DM, Nevitt MC, Browner W, Cauley J, Ensrud K, et
al. The Study of Osteoporotic Fractures Research Group. Lancet 1993; 34: 72-75.
• BMD poor predictor of fractures.
• When different scanners are used on the same
patients, the proportion of patients diagnosed with
osteoporosis varies from 6% up to 15%.
• Over 80% of low trauma fractures occur in people
who do not have osteoporosis (T score –
2.5).
33. 33
NOF recommendations
• National Osteoporosis Foundation US and the
American Association of Clinical
Endocrinologists recommend routine monitoring
of bone mineral density within two years of
starting treatment.
NHS no recommendation
• The UK National Osteoporosis Guidelines Group,
US National Institutes of Health, and the
Osteoporosis Society of Canada do not make a
recommendation either way on monitoring.
34. 34
FRAX
Do you know what is your T – Score?
Take one minute test!
Do you know what are your chances of
getting fractures in next 10 years?
Go online FRAX site!
For Treatment consult your physician
or your “Osteoporosis Society”
36. 36
Dr. Judith Brenner New York University
power of the FRAX tool
• Add daily consumption of two or more alcoholic
drinks, and the risk becomes 9 percent.
• Instead of 60, say the woman is 80 years old,
slender and with no family or personal history of
fractures, smoking or steroid use. Dr. Brenner
calculated her risk of fracturing a hip in 10 years
as 10 percent and of having any major
osteoporotic fracture at 35 percent.
37. 37
Rehabilitation in the fragility fracture patient
Goal is to improve strength,
balance, position sense,
reactions to:
– Improve level of function /
independence
– Decrease risk of falls
– Decrease risk of fractures
Balance (position sense, reaction)
Mechanical vibration plate
Limb and core strength
Mobility in activities of daily living
Safety in gait and transfers
Sensory and visual limitations
Home safety evaluation and adaptation
38. 38
Interventions to reduce future fracture risk
• Basics
– Nutrition, exercise, fall prevention strategies
– Modify risk factors as able (smoking, excess alcohol)
– Treat co-morbidities (i.e., endocrine disorder?)
• Pharmacological agents
39. 39
Interventions: General recommendations
• Regular physical activity
– Maintaining safe ambulatory status, indep ADLs
– Daily limb and core home exercise routine
• Sufficient intake of calcium and vitamin D
– daily 1000-1500 mg calcium, 400-800 IU vitamin D
– by foods or foods and supplements combined
• Adequate nutrition
• Avoid cigarettes, excess alcohol
40. 40
Who to treat ?
Postmenopausal women
/men > 50 yrs
with
Prior h/o hip/vertebral #
or
T Score < -2.5
or
T Score -1 to -2.5 &
10 yr risk (FRAX) :
HIP # > 3 % or
major osteoporotic # > 20 %
41. 41
Pharmacological agents for treatment of
osteoporosis
Effective therapies are widely available and
can reduce vertebral, hip and other fractures
by 30% to 65%,
even in patients who have already suffered a
fracture
43. 43
Bone marrow precursors
Osteoblasts
Osteoclast
Lining cells
Stimulators of
Bone Formation
Fluoride
PTH analogs
Sr Ranelate (?)
Inhibitors of
Bone
Resorption
Estrogen, SERMs
Bisphosphonates
Calcitonin
Inhibitors of
RANKL
Cathepsin K
Therapeutic strategies
44. 44
Mainstay of treatment :
Bisphosphonates
Approval in US for osteoporosis
• Alendronate week : 1995
• Risedronate : 2000
• Ibandronate mnth: 2005
• Zoledronate yearly.iv : 2007.
45. 45
Treatments & Efficacy
Vertebral Fx Non-vertebral Fx
Other Fx Hip Fx
Oral
HRT Yes Yes Yes
Etidronate* Yes
Alendronate* Yes Yes Yes
Risedronate* Yes Yes Yes
Ibandronate* Yes [Yes]
Raloxifene* Yes
Calcitriol* Yes
Strontium Ranelate* Yes Yes [Yes]
46. 46
Vertebral Fx Non-vertebral Fx
Other Fx Hip Fx
Subcutaneous
Teriparatide* Yes Yes
1-84 PTH* Yes
Denosumab* Yes Yes Yes
Intravenous
Pamidronate
Ibandronate*
Zoledronate* Yes Yes Yes
Intranasal or Subcutaneous
Calcitonin* Yes
47. 47
Appropriate use of appropriate treatments can
halve the incidence of fractures
Vertebral Fx Nonvertebral Fx
Other Fx Hip Fx
Alendronate* Yes Yes Yes
Risedronate* Yes Yes Yes
Zoledronic acid* Yes Yes Yes
PTH* Yes Yes ???
Strontium ranelate* Yes Yes ???
Denosumab* Yes Yes Yes
plus calcium + vitaminD
51. 51
Vitamin D levels
• 25-OHD Vit D status Manifestation Management
• <25 nmol/l Deficient Rickets/ Osteomalacia High-dose
calciferol
• 25-50 nmol/l Disease risk Vit D supps
• 50-75 nmol/l Adequate Healthy Lifestyle advice
• >75 nmol/l Optimal Healthy None
– Divide by 2.5 for ug/L
52. 52
Patients who did not need treatment in the first place
Discontinue Treatment
Lower risk patients, if DXA is stable/increasing
Consider a drug holiday after 3-5 years of treatment
Higher risk patients (fractures, corticosteroid Rx, very low BMD)
Consider a drug holiday after 10 years of therapy
May use teriparatide or raloxifene (but not another potent
antiresorptive agent – ie. denosumab) during the holiday from
bisphosphonates
53. 53
Treatment of vitamin D deficiency
Deficiency (25-OHD <25 nmol/l)
10 000 IU calciferol daily or 60 000 IU
calciferol weekly for 8-12 weeks*
or
Calciferol 300 000 or 600 000 IU orally
or by intramuscular injection once or
twice
54. 54
Treatment of vitamin D insufficiency
Insufficiency (25-OHD 25-50 nmol/l) or
maintenance therapy following deficiency
1000-2000 IU calciferol daily
or
10 000 IU calciferol weekly
–
56. 56
HRT: A CONSENSUS
• Prime role of HRT is relief of menopausal Sx
• Risks/benefits need to be explained to each
woman (breast Ca extra 2-6 cases per 1000
women treated with HRT for 5 years)
• Use lowest effective estrogen dose, assess CV
risk
• Review need annually (esp aged>60)
57. 57
HRT: A CONSENSUS
• Can give up to age 50 if prem
menopause
• Do not use as primary or secondary
prev. of CAD/CVA, or Alzheimers
• Transdermal estrogen has lower DVT
risk
58. 58
RALOXIFENE
• SERM licensed for OP
• Reduces vertebral (not non-vertebral) fracture risk,
just as does calictonin
• Reduces development of new breast Ca.
• No increased risk of CVD (reduces CV events!)
• Increased risk of thromboembolism
• May worsen flushes
• Well tolerated, easy dosing
59. 59
NICE 2005:
(secondary prevention)
• Teriparatide – use in women >65
years unresponsive to / intolerance
of bisphosphonates, and:
–with extremely low BMD (<-4)
–with very low BMD (<-3), multiple
fractures PLUS an additional risk
factor
National Institute for Clinical Excellence, Technology Appraisal 87, Jan 2005
60. 60
Emerging Rx’s in osteoporosis
Prof Compston
2010
• Denosumab
– Monoclonal Ab to RANKL which drives osteoclasts
– Subcut every 6m/12m! 60mg
– Dramatic and quick effect
– Fracture reduction similar to Zoledronate
– Cost similar to risedronate (in 2010)!
– NICE appraised
61. 61
Denosumab Binds RANK Ligand and Inhibits
Osteoclast Formation, Function, and Survival
RANKL
RANK
OPG
Denosumab
Osteoclast Formation, Function,
and Survival Inhibited
Bone Formation Bone Resorption
Inhibited
CFU-GM Prefusion
Osteoclast
Osteoblasts
Hormones
Growth Factors
Cytokines
Adapted from: Boyle WJ, et al. Nature. 2003;423:337-342.
62. 62 Few Simple ways
You need not know about your T-score
• If you are or consider your self Obese,
• If you are exposed to Sun during your shopping
in open markets at least twice a week,
• If you take Milk and you are a vegetarian,
• If you are taking regular Morning walk,
• If you are regular about exercises (YOGA).
• Your Relatives’ Death is not due to Fractures but
due to age and co morbidity.
63. 63 Summary
There is an acute need for reconsidering
– Globalization of Diagnosis of Osteoporosis &
Osteopenia,
– BMD screening,
– Redefining Risk factors & role of fall and BMD in
fractures,
– Cost effectiveness of drug treatment,
– Hype about Hip fractures,
– Role of Big Pharma in propaganda of diagnosis,
management, corruption in scientific literature, misuse
political system and creation a state of
“Fear psychosis & Hope selling”.