- Mastocytosis is a heterogeneous group of disorders involving infiltration of mast cells in tissues. The prevalence of indolent systemic mastocytosis is estimated to be at least 13.0 cases per 100,000 people aged 15 and older.
- A study of 221 patients with indolent systemic mastocytosis found that 41% reported lifetime fragility fractures, with many fractures occurring before mastocytosis diagnosis. Fracture risk assessment tools had poor accuracy in predicting fracture risk in these patients.
- A multivariate analysis identified male gender, elevated bone resorption, low hip bone mineral density, absence of urticaria pigmentosa rash, and alcohol use as independent risk factors associated with fragility fractures after mastocytosis diagnosis.
Vertebral Fracture Identification presented by Dr Andrew Pearson, Consultant Radiologist, Borders Hospital, Melrose at the fracture liaison service champions' summit 2016. #flschampions
Vertebral Fracture Identification presented by Dr Andrew Pearson, Consultant Radiologist, Borders Hospital, Melrose at the fracture liaison service champions' summit 2016. #flschampions
Dr Trevor Cole's presentation from Osteoporosis 2016: From family history to epigenetics of osteoporosis.
Find out more at: https://nos.org.uk/conference
Elizabeth Curtis's presentation from Osteoporosis 2016: Variation in UK fracture incidence by age, sex, geography, ethnicity, socioeconomic status, and time: results from the UK CPRD:
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
Dr Zoe Paskins's presentation from Osteoporosis 2016: Risk of fragility fracture over 10 years across eight inflammatory conditions: A UK population study.
Find out more at: https://nos.org.uk/conference
Rheumatological aspects in hemodialysis Samar Tharwat
Dr.Samar Tharwat ,Lecturer of Internal Medicine (Rheumatology & Immunology )represents a lecture on rheumatological manifestations in patients with chronic renal failure and on hemodialysis.
Multiple atraumatic osteoporotic vertebral fractures: Unusual cause of pain i...Apollo Hospitals
Secondary osteoporosis may not be detected early, and thus the condition remains clinically silent until the patient presents with multiple atraumatic compression fractures. It is devastating for a young patient to develop multiple vertebral fractures in view of the associated morbidity and mortality. To decrease the risk of additional fractures and preserve the quality of life in these patients, interventions should be initiated early. Hence, it is important to consider multiple osteoporotic vertebral fractures as a complication in any patient on prolonged steroid therapy.
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
Prof. Eugene McCloskey's presentation from Osteoporosis 2016: Assessment and intervention thresholds for FRAX probabilities in the UK- Impact on the need for BMD in older women with prior fracture
Find out more at: https://nos.org.uk/conference
Dr Trevor Cole's presentation from Osteoporosis 2016: From family history to epigenetics of osteoporosis.
Find out more at: https://nos.org.uk/conference
Elizabeth Curtis's presentation from Osteoporosis 2016: Variation in UK fracture incidence by age, sex, geography, ethnicity, socioeconomic status, and time: results from the UK CPRD:
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
Dr Zoe Paskins's presentation from Osteoporosis 2016: Risk of fragility fracture over 10 years across eight inflammatory conditions: A UK population study.
Find out more at: https://nos.org.uk/conference
Rheumatological aspects in hemodialysis Samar Tharwat
Dr.Samar Tharwat ,Lecturer of Internal Medicine (Rheumatology & Immunology )represents a lecture on rheumatological manifestations in patients with chronic renal failure and on hemodialysis.
Multiple atraumatic osteoporotic vertebral fractures: Unusual cause of pain i...Apollo Hospitals
Secondary osteoporosis may not be detected early, and thus the condition remains clinically silent until the patient presents with multiple atraumatic compression fractures. It is devastating for a young patient to develop multiple vertebral fractures in view of the associated morbidity and mortality. To decrease the risk of additional fractures and preserve the quality of life in these patients, interventions should be initiated early. Hence, it is important to consider multiple osteoporotic vertebral fractures as a complication in any patient on prolonged steroid therapy.
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
Prof. Eugene McCloskey's presentation from Osteoporosis 2016: Assessment and intervention thresholds for FRAX probabilities in the UK- Impact on the need for BMD in older women with prior fracture
Find out more at: https://nos.org.uk/conference
Davenport Chiropractor, Dr. Clay, has prepared a short slide show presentation on some causes of carpal tunnel syndrome and the treatments for it. For more information, please visit http://familycarechiropracticdavenport.com
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
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.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
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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.
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263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
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!
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
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.
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
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
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
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
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
1. Dr.
E.
van
der
Veer
Zwolle,
28
november
2015
IWO
copyright
Dr. E. van der Veer
2.
• Wat
is
mastocytose
• PrevalenAe
mastocytose
• PrevalenAe
osteoporoAsche
fracturen
(laag
energeAsch
trauma)
• Fractuur
risico
inschaJng
voor
individuele
paAënt
copyright
Dr. E. van der Veer
3. • Heterogeneous group of disorders
• one or more organ systems are involved
WHO-classification:
– Indolent systemic mastocytosis
– Aggressive systemic mastocytosis
– Systemic mastocytosis with an associated clonal
haematological non-mast cell lineage disease
(SM-AHNMD)
– Mast cell leukaemia/sarcoma
URTICARIA PIGMENTOSA
copyright
Dr. E. van der Veer
4. Release of biochemical
mediators from mast cells
Pathologic infiltration of
mast cells in tissues
Abnormal growth and accumulation of
Clinical symptomsClinical symptoms
• Histamin
• Heparin
• Tryptase
• Prostaglandins
• Cytokines
• Interleukins
• etc
copyright
Dr. E. van der Veer
5. • In serum
tryptase > 10 ng/ml
• In 2de nuchtere urine histaminemetaboliet
methylimidazolazijnzuur (MIMA)
MIMA > 2,0 mmol/mol kreatinine
• Daarna volgt beenmergonderzoek met histologisch,
cytologisch en genetisch onderzoek en
immunofenotypering
copyright
Dr. E. van der Veer
6. diagnostic WHO-criteria
• Diagnosis in bone marrow biopsy:
– 1 major + 1 minor
– 3 minor
• Major criterion
– ≥ 2 multifocal mast cell infiltrates of ≥ 15 mast cells
• Minor criteria
– Atypical morphology of ≥ 25 % mast cells in bone marrow
– Atypical imunophenotype (co-expression of CD117 with CD2
and/or CD25)
– Increased serum tryptase (> 20 ng/ml)
– Detection of KIT point mutation at codon 816
copyright
Dr. E. van der Veer
7.
Heterogeen ziektebeeld
Klachten:
• Jeuk
• Flushing
• Diarree
• Invaliderende moeheid
• Recidiverende anafylaxie
• Osteoporose
• Fracturen
Gevolg van mestcelophoping
• Hepatosplenomegalie
• Vergrote lymfklieren
Sommige mastocytose patiënten hebben geheel geen klachten
Puntmutatie in de KIT-stamcelreceptor op de mestcellen (Asp-816-Val)
copyright
Dr. E. van der Veer
8. • Wat is mastocytose
• Prevalentie mastocytose
• Prevalentie osteoporotische fracturen
(laag energetisch trauma)
• Fractuur risico inschatting voor individuele
patiënt
copyright
Dr. E. van der Veer
9. UMCG & Martini Hospital:
42 Mastocytosis patients
age 55 yrs (19-75)
38% man
copyright
Dr. E. van der Veer
10. The prevalence of ISM was
at least
13.0 cases per 100.000
inhabitants aged ≥15 years.
ISM prevalence increased
with age.
JJ. van Doormaal et al
JACI 2013
copyright
Dr. E. van der Veer
11. • Wat is mastocytose
• Prevalentie mastocytose
• Prevalentie osteoporotische fracturen
(laag energetisch trauma)
• Fractuur risico inschatting voor individuele
patiënt
copyright
Dr. E. van der Veer
12. • Data on lifetime fractures and trauma circumstances were collected
– vertebral morphometry,
– patients’ records,
– questionnaires.
• Lifetime fractures were categorized
– a) high vs low energy trauma circumstances
– b) before and after ISM diagnosis.
• Clinical, lifestyle, and bone characteristics were measured at time of
diagnosis.
E. van der Veer et al
JACI 2014
Median follow-up 5.4 years (range 0.4-15.3)
start
symptoms
visit
life
Ame
fracture
diagnosis
Mastocytosis
data
collecAon
copyright
Dr. E. van der Veer
13. Median follow-up 5.4 years (range 0.4-15.3) 5.3 years; range 0.4-15.3
5-year fracture-free survival 77 ± 3% 78 ± 4%
10-year fracture-free survival 69 ± 4%, 71 ± 4%
E. van der Veer et l JCI
2014 online
Before ISM diagnosis:
139 FFx in 54 patients
Post-diagnosis:
125 FFx in 56 patients
Before ISM diagnosis:
40 FFx in 27 patients
Post-diagnosis:
88 FFx in 43 patients
Lifetime fragility fractures were
reported by 41% (90/221) of the
patients with indolent systemic
mastocytosis (ISM).
E. van der Veer et al
JACI 2014
copyright
Dr. E. van der Veer
14. • Wat is mastocytose
• Prevalentie mastocytose
• Prevalentie osteoporotische fracturen
(laag energetisch trauma)
• Fractuur risico inschatting voor individuele
patiënt
copyright
Dr. E. van der Veer
15. Aim:
• to determine the high/low risk of future fragility
fractures in patients presenting with indolent
systemic mastocytosis.
E. van der Veer et al
JACI 2014
copyright
Dr. E. van der Veer
16. • Data on lifetime fractures and trauma circumstances were collected
– vertebral morphometry,
– patients’ records,
– questionnaires.
• Lifetime fractures were categorized
– a) high vs low energy trauma circumstances
– b) before and after ISM diagnosis.
• Clinical, lifestyle, and bone characteristics were measured at time of
diagnosis.
- 28 patients receiving treatment for osteoporosis before ISM diagnosis
- 9 patients with missing bone data (BTM and BMD)
- 2 patients with a recent fracture or operation
- 1 patient had gender change
were excluded from FFx risk assessment.
E. van der Veer et al
JACI 2014
copyright
Dr. E. van der Veer
17. Median follow-up 5.4 years (range 0.4-15.3) 5.3 years; range 0.4-15.3
5-year fracture-free survival 77 ± 3% 78 ± 4%
10-year fracture-free survival 69 ± 4%, 71 ± 4%
E. van der Veer et l JCI
2014 online
Before ISM diagnosis:
139 FFx in 54 patients
Post-diagnosis:
125 FFx in 56 patients
Before ISM diagnosis:
40 FFx in 27 patients
Post-diagnosis:
88 FFx in 43 patients
E. van der Veer et al
JACI 2014
copyright
Dr. E. van der Veer
18. Low BMD T-score < -2.5 SD
High uCTX Above premenopausal
values (T-score > 2 SD)
Johnell et al Osteop.Int. 2002
of hip fracture
copyright
Dr. E. van der Veer
19. Fracture Risk Assessment Tools
10-year probability of hip fracture
10-year probability of a major osteoporotic fracture
(clinical spine, forearm, hip or shoulder fracture).
The model accepts:
• FRAX age 40 - 90 years.
• Garvan age 50 years or more
• Qfracture age 30 – 99 years
181 Indolent Systemic Mastocytosis patients,
aged 19-77 years,
mean 46 ± 13 years
copyright
Dr. E. van der Veer
20. Qfracture age 30 – 99 years
• The following factors are needed to calculate a QFracture score in men and women:
• Age
• Sex
• Ethnicity
• Smoking status (non smoker, ex smoker, light, moderate, heavy)
• Alcohol use
• Type 1 or Type 2 diabetes
• Parental history of hip fracture/osteoporosis
• Nursing or care home residence
• History of prior osteoporotic (wrist, spine, hip, or shoulder) fracture
• History of falls
• Dementia
• Cancer
• Asthma or COPD
• Cardiovascular disease
• Chronic liver disease
• Chronic kidney disease
• Parkinson's disease
• Rheumatoid arthritis or systemic lupus erythematosis (SLE)
• Gastrointestinal malabsorption (including Crohns disease, ulcerative colitis, celiac disease, steatorrhoea, blind loop
syndrome)
• Epilepsy or use of anticonvulsants
• Use of antidepressants (at least 2 scripts in last 6 months)
• Use of corticosteroids (at least 2 scripts in last 6 months)
• Body mass index
• Additional factors are used for women only: Use of oestrogen only Hormone Replacement Therapy
• Endocrine problems (thyrotoxicosis, primary or secondary hyperparathyroidism, Cushings syndrome)
copyright
Dr. E. van der Veer
21. The risk scores had poor accuracy,
AUC 0.60 (95% CI: 0.50-0.71) for major osteoporotic fractures,
AUC 0.66 (95% CI: 0.56-0.75) for hip fractures.
0
5
10
15
10 20 30 40 50 60 70 80
percentage
Age (years)
10-years fragility fracture risk
FFx post-diagnosis
E. van der Veer et al
JACI 2014
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Dr. E. van der Veer
22. E. van der Veer et alE. van der Veer et al
JACI 2014
Patient characteristic
Age (yrs) 46 ± 13 Age ≥ 50 yrs 77 42%
Male gender (n, %) 74 41%
Length (cm) 174 ± 10
Weight (kg) 79 ± 15 Weight < 60 kg 14 8%
BMI (kg/m2) 26.3 ± 4.4 BMI < 19.0 3 1.6%
BMI ≥ 30.0 34 19%
Smoking (n, %) 82 46% Current smoker 53 30%
Stopped within last 10 years 29 16%
Alcohol use (n, %) 135 75% Adverse reactions 38 21%
Mastocytosis characteristic
Disease duration (yrs) 7.5 (0.1 to 58)
Urticaria pigmentosa (n, %) 138 76%
Anaphylactic shock (n, %) 77 43%
Tryptase (µg/L) 27 (4.1 to 296) Tryptase > 20 122 67%
MH (µmol/mol creat) 257 (70 to 2554) MH > 167 141 78%
MIMA (mmol/mol creat) 3.2 (0.5 to 21.6) MIMA > 1.9 148 82%
MH = methylhistamin; MIMA = methylimidazole acetic acid; BMI = body mass index;
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Dr. E. van der Veer
23. Bone characteristics at diagnosis n %
Patients with FFx n % 27 15%
Number of FFx n 40
Osteosclerosis n % 10 6%
Osteocalcin µg/L 12.3 (3.6 to 37.2)
Osteocalcin Z-score SD -0.12 (-2.66 to 4.15) Osteocalcin Z-score > +2.0 10 6%
BALP U/L 21.5 (4.6 to 62.1)
BALP Z-score SD 1.22 (-2.09 to 8.55) BALP Z-score > +2.0 57 32%
PINP µg/L 39.9 (15.9 to 135)
PINP Z-score SD -0.04 (-2.10 to 6.62) PINP Z-score > +2.0 12 7%
sCTx pg/mL 195 (10 to 797)
sCTX Z-score SD -0.42 (-2.03 to 6.35) sCTX Z-score > +2.0 14 8%
LS BMD g/cm2 0.96 ± 0.15
LS BMD T-score SD -0.97 ± 1.39 Osteoporosis LS 25 14%
Hip BMD g/cm2 0.93 ± 0.13
Hip BMD T-score SD -0.35 ± 0.99 Osteoporosis hip 1 0.6%
FFx = Fragility fractures;
BALP = bone specific alkaline phosphatase; PINP = procollagen type 1 N-terminal peptide;
sCTX = serum type I collagen C-telopeptide; LS = lumbar spine; BMD = bone mineral density;
E. van der Veer et alE. van der Veer et al
JACI 2014
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Dr. E. van der Veer
24. • Multivariate Cox regression
HR
95% CI
P-value B
MastFx-
scoreLower Upper
Male gender 2,043 1,045 3,996 0,037 0,715 1
sCTX Z-score ≥ +1.0 2,632 1,278 5,424 0,009 0,968 1
Hip BMD T-score ≤ -1.0 2,187 1,128 4,240 0,021 0,782 1
UP absence 2,047 1,074 3,899 0,029 0,716 1
Alcohol use 3,445 1,016 11,688 0,047 1,237 1
HR: hazard ratio; CI: confidence interval; B: regression coefficient;
sCTX: serum type I collagen C-telopeptide;
BMD: bone mineral density; UP: urticaria pigmentosa
E. van der Veer et alE. van der Veer et al
JACI 2014
• Univariate Cox regression
Patients with fragility fractures post-ISM-diagnosis were:
older
more often male
more often anaphylactic reactions
less often UP
higher levels of MIMA, osteocalcin and sCTX
lower hip BMD scores
reported more often alcohol intake
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Dr. E. van der Veer
25. E. van der Veer et alE. van der Veer et al
JACI 2014
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Dr. E. van der Veer
26. • Multivariate Cox regression
HR
95% CI
P-value B
MastFx-
scoreLower Upper
Male gender 2,043 1,045 3,996 0,037 0,715 1
sCTX Z-score ≥ +1.0 2,632 1,278 5,424 0,009 0,968 1
Hip BMD T-score ≤ -1.0 2,187 1,128 4,240 0,021 0,782 1
UP absence 2,047 1,074 3,899 0,029 0,716 1
Alcohol use 3,445 1,016 11,688 0,047 1,237 1
HR: hazard ratio
CI: confidence interval;
B: regression coefficient
sCTX: serum type I collagen C-telopeptide
BMD: bone mineral density
UP: urticaria pigmentosa
Accuracy of the MastFx-model:
AUC = 0.80 (95% CI 0.73–0.88)
AUC = 0.80 (95% CI 0.72–0.87)
E. van der Veer et alE. van der Veer et al
JACI 2014
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Dr. E. van der Veer
27. Male gender 1
sCTX Z-score ≥ +1.0 1
Hip BMD T-score ≤ -1.0 1
UP absence 1
Alcohol use 1
E. van der Veer et alE. van der Veer et al
JACI 2014
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Dr. E. van der Veer
28. Prevalence Mastocytosis
• The prevalence of mastocytosis was at least
13.0 cases per 100.000 inhabitants aged ≥15 years.
• ISM prevalence increased with age.
Prevalence Mastocytosis
• Lifetime fragility fractures were reported by 41% (90/221) of the
patients with indolent systemic mastocytosis (ISM).
• Follow-up from ISM-diagnosis to Fx data collection:
– median 5.4 years (range 0.4-15.3)
– 5-year fracture-free survival 77 ± 3%
– 10-year fracture-free survival 69 ± 4%
E. van der Veer et alE. van der Veer et al
JACI 2014
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Dr. E. van der Veer
29. • Independent predictors for future fragility fractures
– Male gender
– high levels of bone resorption marker sCTX
– low hip BMD
– absence of urticaria pigmentosa
– alcohol intake
• The MastFx-score, a prediction model using five characteristics,
showed good accuracy to distinguishes ISM patients at high,
intermediate and low risk for new FFx.
– ISM patients with a MastFx-score of ≥2 have a high risk for fragility
fractures.
E. van der Veer et alE. van der Veer et al
JACI 2014
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Dr. E. van der Veer
30. • The calculation of the fragility fracture risk should be an
important component in the management of patients
presenting with ISM
• Efforts should be made by the caretakers to optimize bone
quality in all ISM patients
Lifestyle changes
– Do exercises
– Adequate vitamin D and calcium intake
– Alcohol cessation is highly recommended
(because drinking is a modifiable risk factor of FFx in ISM)
High-risk patients will probably benefit from an early start
of therapeutic intervention
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Dr. E. van der Veer
32. q University of Groningen
q University Medical Center Groningen
q Nederlands Mastocytose Centrum Groningen
• Eveline van der Veer
• Suzanne Arends
• Sjoukje van der Hoek
• Joris B Versluijs
• Jan GR de Monchy
• Joanne NG Oude Elberink
• Jasper J van Doormaal
Support your
bones
They support
you!
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Dr. E. van der Veer