Osteoporosis Cure Diet

The Osteoporosis Reversing Breakthrough

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

The Osteoporosis Reversing Breakthrough Summary


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Correlation between osteoporosis age and sex for hip fractures

Osteoporosis becomes an ever-increasing health problem world wide. It leads in older persons, starting in women already with the menopause, to an increased incidence of fractures. We are dealing with metabolic changes that involve all elements of bone tissue. Primarily we are facing a decrease of cancellous bone affecting its microarchitecture. Bone cannot resist even minor forces, to a point where fractures can occur spontaneously. Two main kinds must be distinguished the primary and the secondary (accompanying other diseases) osteoporosis. The primary kind predominates in hip fractures of elderly patients. It can be subdivided into two types type I is the post-menopausal osteoporosis and type II the senile osteoporosis (Riggs and Melton, 1992 Demster and Lindsay, 1993). Different risk factors play an eminent role in the development of osteoporosis. They may aggravate an existing osteoporosis or they themselves may induce bone loss as in alcoholics, after a prolonged immobilization...

Osteoporosis Is a Reduction in Bone Mass

Osteoporosis is a major health problem, particularly because older adults are more prone to this disorder and the average age of the population is increasing (see Clinical Fo cus Box 36.1). Osteoporosis involves a reduction in total bone mass with an equal loss of both bone mineral and organic matrix. Several factors are known to contribute directly to osteoporosis. Long-term dietary calcium deficiency can lead to osteoporosis because bone mineral is mobilized to maintain plasma calcium levels. Vitamin C deficiency also can result in a net loss of bone because vitamin C is required for normal collagen synthesis to occur. A defect in matrix production and the inability to produce new bone eventually result in a net loss of bones. For reasons that are not entirely understood, a reduction in the mechanical stress placed on bone can lead to bone loss. Immobilization or disuse of a limb, such as with a cast or paralysis, can result in localized osteoporosis of the affected limb. Space...

Calcium Intake and Bone Health

The major disease risk associated with inadequate bone health is osteoporosis, a skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with a consequent increase in bone fragility and susceptibility to fracture.3 Because of the increased risk of fragility fractures (particularly hip, wrist, and spine fractures), osteoporosis is a major health problem, especially in Europe and North America. From incidence rates of fragility fracture at one of these three sites in North America, Melton et al. have estimated that the lifetime risk among white women and men aged 50 years is 40 and 13 , respectively.13 Moreover, bone fractures are often associated with considerable morbidity and hip fractures may lead to an overall reduction in survival of around 15 . In a public health strategy to improve well-being and health and to reduce the risk of disease, the development of maximal bone mass during growth and reduction of loss of bone later in life are...


Osteoporosis is a common skeletal health problem characterised by low bone mass and bone microstructural deterioration leading to bone fragility and susceptibility to fracture. Peak bone mass depends on many factors, such as nutritional, hormonal, genetic and environmental factors. Vitamin D and calcium absorption, and the consequent parathormone levels, determine the degree of bone loss. Low bone mass can derive from a diminished bone formation resorption ratio and or increased remodeling process. Bone mass is evaluated and Criteria for assessing bone loss are expressed by two densitometric parameters, called T and Z scores, which are standard deviation scores expressed in relation to reference values for young healthy subjects (T score) and for gender- and age-matched healthy controls (Z score). A review of studies using DEXA demonstrated that osteopenia occurs in 40-50 and osteoporosis in 30 of patients with IBD. Osteoporosis and osteopenia are also reportedly more frequent in CD...

Bone Mineral Density

Androgens are required to achieve peak bone mass in adolescence and are responsible for the higher BMD in men compared to women. Hypogonadism is associated with a decrease in bone mass and is one cause of osteoporosis in men. With aging, progressive loss of BMD is associated with increased fracture rates. Interestingly, the BMD in older men is more significantly correlated with serum free estradiol than with serum free testosterone levels (44,45). The few case reports of estrogen-receptor mutations and aromatase deficiency in males were all associated with severe osteoporosis (46-48). Thus, the current hypothesis is that estrogens are required for maintaining peak BMD in men. The concentration of serum E2, or the level of estrogen activity in the target tissues, that is required to maintain BMD is not known. Although it is apparent that some estrogenic action is required for normal BMD, it is probable that testosterone also directly effects bone mass through androgen receptors.

Preface To The English Edition

Hip fractures constitute one of the most resource consuming diagnoses in health care. With an increasing amount of elderly in the population WHO has prognosticated an almost five fold increase from 1.7 million hip fractures in the year 1990 to 6.3 million in 2050. With age the osteoporosis becomes more abundant, and at the same times the tendency of the elderly to fall. Preventive measures against both osteoporosis and falls are necessary to stop the continuous increase of fragility fractures in the elderly. Hip fractures are the most resource consuming of all these fractures, all need surgery. With increasing number of hip fractures, and the frail constitution of the patients who often have other concomitant diseases, which impair mobilisation and rehabilitation, it is necessary to have surgical methods that are specifically suited for the fracture type. Too extensive surgery may impair the situation of the patient, whereas insufficient surgery endangers the early weight bearing and...

Systemic Mastocytosis and Malignancy

A feature especially found in some patients with the c-kit mutation (13,122, 123). Osteoporosis is often a feature of mastocytosis, and mast cells may contribute to bone resorption (124). Patients with mastocytosis may develop myelo-proliferative syndromes, myelodysplasia, and or lymphoreticular malignancy, the mechanisms of which are unknown (125). Interestingly, the marker, a-tryptase is elevated in the serum of patients and provides us with an excellent diagnostic clinical tool (126). By inducing angiogenesis, the secretion of VEGF and bFGF, and the elaboration of collagenases, mast cells can contribute to tumor pathology and invasiveness (127-129).

The Treatment of Acute Attacks

Prednisone, and others continue to be commonly used to shorten the attack. These potent anti-inflammatory drugs diminish the swelling within the brain and spinal cord that is seen as cells of the immune system invade and attack the nervous system. They do not appear to alter the long term course of the disease. They are clearly associated with osteoporosis, cataracts, psychological changes, skin acne, weight gain, and salt and water imbalance. Thus their effect on acute attacks must be weighed against potential problems from the treatment. People who have primary symptoms sometimes also suffer from problems that are only indirectly caused by the disease these are called secondary symptoms. For example, some people who are weak and stiff develop decreased movement at the joints, which are called contractures, and immobility can lead to osteoporosis or skin breakdown.

Anatomy and mechanism of injury

In most cases, axial loading with a varus or valgus force leads to a distal femoral fracture. In the young this is usually a high-energy injury, typically an RTA, with considerable comminution, displacement and soft tissue trauma. In the elderly with osteoporotic bone, a fall on a flexed knee is the most common mechanism of injury. A long spiral supracondylar fracture is the result, sometimes complicated by a femoral prosthesis above or below the fracture. Rarely, a fracture occurs without obvious trauma in the immobile, as a result of severe osteoporosis.

Phytoestrogens in the Human Diet

Genistein has been promoted as a possible preventive treatment or therapy for several diseases and conditions. There are claims that it reduces hot flashes associated with menopause, that it can prevent or delay the onset of osteoporosis in post-menopausal women, and that it can lower blood cholesterol levels. In each instance the potential effectiveness of genistein would be attributable to its acting as an estrogen replacement in older women, in whom the level of estradiol is naturally low. Genistein may also be effective in the treatment of certain breast cancers that require estrogen in order to grow. In this case it is theorized that the genistein, with weak estrogen activity, acts to reduce cancer growth by competing with the more potent estradiol for the estrogen receptor. Some of the evidence for the role of phytoes-trogens in women's health is circumstantial. It is based, in part, on observations that women who live in countries such as Japan and China, where soy products are...

Estimating the Range of BMI Associated with Minimal Mortality

Estimating the point of BMI associated with minimal mortality rate (i.e. the 'optimal' BMI) and the range around the point that still represents 'reasonable' BMIs for people is a challenging task involving empirical, statistical and conceptual issues. The empirical issue concerns the fact that the BMIs associated with minimal mortality seem to vary with subject characteristics such as age, sex, and race as described elsewhere in this chapter and may also vary as a function of other factors such as genotype. However, beyond the factors of age and sex, knowledge is very limited. Therefore, just as separate standards for BMI ranges associated with greater longevity are sometimes produced for men and women and people of different ages, perhaps the future will bring separate standards for people depending on other factors including ethnicity or genotype. Until greater information is available about genetic modifiers of the BMI-mortality relation, family history may be a useful proxy. For...

Assess Whether Expected Patterns of Disease are Present

For most diseases, epidemiologic understanding has advanced to the point that we can make predictions with some confidence about patterns of risk in relation to certain attributes and exposures. Many diseases rise with age, vary in predictable ways with gender or social class, or are known to be associated with tobacco or alcohol use. For example, if studying the influence of a drug that may prevent osteoporosis in middle-aged and elderly women, we would expect to observe decreased risk of osteoporosis among African-American women and among those who are most physically active as has been found in many previous stud For demographic and social predictors, the internal comparisons help to assess whether there has been some differential selection that has markedly distorted the patterns of disease. If we conducted a study of osteoporosis in which African-American women experienced comparable rates of osteoporosis or higher rates than white women, we would be motivated to ask whether...

Reinforcement of the third buttressing point lateral cortex

Stabilized fractures micromovements occur, these may increase in the presence of less stable fixation without a plate (errors in internal fixation, multi-fragmentary and comminuted fractures). Other factors such as osteoporosis, age, weight bearing and body weight will determine, whether the fracture will consolidate (possibly with a biologic plate ) or whether a loss of reduction will take place. To avoid the latter complication it is mandatory to reinforce the lateral cortex, particularly in the presence of osteoporosis in older patients. If the caudal screw finds support on Adam's arch and thus a two-arm leverage is operative, a 2 mm two-hole plate exerting a tension band effect is sufficient in the majority of patients. The use of a heavier and bigger plate is not warranted. - The patient is older than 80 years (osteoporosis) 64-year-old woman who underwent an aorto-bifemoral bypass surgery three months earlier. This intervention was followed by a revision surgery for an abscess...

Importance of the loss of reduction in rotation and possibilities to avoid it

Ment of small fragments or of a secondary displacement in rotation. During the assessment of lateral radiographs it is useful to look carefully at the usually less damaged anterior cortex. Kyle et al (1994) have shown that a primary displacement in rotation can be recognized by a deviation of the course of trabeculae. This requires a.-p. radiographs of excellent quality that are often difficult to obtain on account of senile osteoporosis (Fig. 157). The postoperative secondary loss of reduction in rotation can be prevented in the majority of cases with a standard double screw fixation complemented by a 2 mm two-hole plate attached to the caudal screw. In the presence of marked instability (severe osteoporosis, multifragmentary or comminuted fractures) the following modifications (possibly in combination) protect also against rotation when using the methods described earlier

Burst And Compression Fractures

Lumbar Comminuted With Retropulsion

Osteoporotic compression fractures are seen in patients with a diminished bone mass, commonly found in the elderly (primary osteoporosis). Other common causes of generalized osteoporosis (secondary osteoporosis) include alcoholism, smoking, poor nutrition, drugs, and hormonal and congenital disorders. Pathologic compression fractures are fractures secondary to weakened bone due to neoplastic infiltration with primary or secondary malignancies. Most of these fractures are the manifestation of metastatic disease. MRI has proven helpful in the differentiation between benign and pathologic compression fractures. Chronic benign osteoporotic compression deformities are characterized by isointense marrow signal relative to marrow of normal vertebrae on all pulse sequences. Acute, subacute, and pathologic compression deformities show similar signal characteristics on MRI, with decreased T1 signal and increased T2 signal relative to normal bone marrow. Nonspecific findings have been

Bartters Syndrome Kir11 Clinical features

In 1962, Bartter described two patients who had very low plasma K+ levels and metabolic acidosis, yet elevated plasma renin and aldosterone levels. Subsequently, it has become clear that the syndrome he described is both phenotypically and genetically heterogeneous, and at least three subtypes have been distinguished. The first of these is the classical Bartter's syndrome for which the underlying genetic defect remains unknown. The second, known as the Gitelman variant, is characterised by late age of onset and very low urinary Ca2+ and Mg2+ concentrations, and results from mutations in the gene encoding the NaCl cotransporter (NCCT). The third variant is known as antenatal Bartter's syndrome or hyper-prostaglandin E syndrome. It is a life-threatening disorder that presents in utero with a marked fetal polyuria and it can precipitate premature birth. Newborns show severe salt-wasting, moderate hypokalaemia and metabolic acidosis, and elevated urinary excretion of prostaglandins. In...

Laboratory studies and imaging

Imaging techniques are employed in defining the diagnosis, severity, progression, extent of disease, response to therapy, and presurgical state of RA patients. The most common plain radiographic findings are soft-tissue swelling, periarticular osteoporosis, marginal erosions, joint space narrowing, and joint deformities.

Clinical Applications

Despite the multitude of papers that have investigated the properties of IFN-y, the clinical use of IFN-y is still somewhat limited. In the USA, IFN-y has been approved for only two specific uses treatment of chronic granulomatous disorder (CGD), as these patients are more susceptible to fungal and bacterial infections, and severe osteoporosis. Current clinical trials are limited, with a major effort being made in the use of IFN-y for the treatment of idiopathic pulmonary fibrosis. In this condition, IFN-y administration resulted in a survival benefit in certain subgroups. Other trials involving IFN-y include analysis of the effects on lung immune function in Mycobacterium tuberculosis-infected patients tolerance and toxicity of IFN-y alone or in combination with tumor necrosis factor in AIDS-related complex patients the effects of IFN-y in hepatitis C patients that do not respond to IFN-a the use of adenovirus vectors expressing IFN-y in cancer patients and evaluation of antifibrotic...

Adverse Effects of Steroids

Three broad groups can be identified, although 50 of patients report no adverse event. Early effects are mainly due to high doses and include cosmetic effects (acne, moon face, oedema), sleep and mood disturbance, dyspepsia, or glucose intolerance. Effects associated with prolonged use (usually 12 weeks) include posterior subcapsular cataracts, osteoporosis, osteonecrosis of the femoral head, myopathy, and susceptibility to infections. Effects during withdrawal include acute adrenal insufficiency (from sudden cessation), a syndrome of myalgia, malaise, and arthralgia (similar to recrudescence of UC), or raised intracranial pressure. Complete steroid withdrawal is facilitated by early introduction of azathioprine, adjuvant nutritional therapy, or timely surgery.

Diagnosis Of Klinefelters Syndrome

KS in a prepubertal boy are verbal learning disabilities and taurodontism, the unusual enlargement of the pulp of the tooth seen roughly half of men and boys with KS (46). After puberty, individuals with KS will often exhibit tall stature (usually greater than 184 cm) with proportionally long legs and will frequently manifest an arm span that is greater than their height (51). In adults, the diagnosis of KS should be considered in men with gynecomastia, primary hypogonadism, infertility, or osteoporosis. Because serum testosterone levels may be normal, serum gonadotropins should also be measured. Peripheral blood karyotyping can be used to confirm the diagnosis, although this test can be negative in mosaic individuals, and tissue karyotype may be necessary (9).

Androgen Replacement Therapy

Testosterone therapy results in a more male phenotype, with increases in facial and pubic hair, muscle size and strength, libido, and bone mineral density, and improved mood (21,47,52,53). We recommend testosterone therapy beginning at the time of puberty to allow boys with KS to experience pubertal changes in tandem with their peers. In addition, this approach may allow for optimal enhancement of bone mineral density. Even if testosterone therapy is delayed until adulthood, it is still associated with beneficial improvements in mood, behavior, and sense of well-being (53). Testosterone therapy has no beneficial effect on infertility or gynecomastia, which is best treated with surgical resection if bothersome.

Regulating Other Functions

The thyroid also secretes a hormone called calcitonin, which works antagonistically with the hormone parathormone produced by the adjacent parathyroid glands. When blood calcium is high (as in a condition called hypercalcemia), the calcitonin gene in thyroid cells begins producing the protein hormone calcitonin, which stimulates bone cells called osteoblasts to build more bone, thereby removing calcium from the bloodstream. Once blood calcium levels are back to normal, calcitonin production halts. In hypercal-cemia, the parathormone gene in parathyroid cells begins producing parathormone (also a protein hormone) that stimulates bone cells called osteo-clasts to break down bone, thereby restoring blood calcium levels but possibly contributing to osteoporosis (bones that are brittle because of calcium deficiency) and other bone-related disorders. Parathormone production is stopped once blood calcium levels are back to normal.

Bone Mineral Mass and Density354

Bone mineral density (BMD) is considered a strong biomarker for fracture risk. It is not a true density measurement but rather a mathematical construct obtained by dividing the bone mineral content (BMC) by the area of the scanned bone envelope (BA), and it is expressed as g cm2 Absorptiometry can be used both in humans and in laboratory animals. In each case specific computer software is required. Especially whole-body bone mineral content (WBBMC) and whole-body bone area (WBBA) can be measured in anaesthetized rats using DXA to allow calculation of whole body bone mineral density (WBBMD). The coefficient of variation (CV sem) is 1.74 0.15, 96 and the

Integrated Assessment Of Potential Confounding

In order to evaluate the extent to which confounding may have biased the results of an epidemiologic study, the conceptual basis for confounding must first be examined. The question of exchangeability of exposed and unexposed needs to be posed for the specific research question under consideration Do nonsmokers have the risk of lung cancer that smokers would have had if they had not smoked Do women with low levels of calcium intake have the same risk of osteoporosis that women with high levels of calcium intake would have had if their intakes had been low This question, posed in the grammatically awkward but technically correct counterfactual manner serves to focus interest on the phenomenon of confounding rather than available covariates, which are at best, a means of addressing and mitigating the lack of comparability of the groups. The goal is not to achieve statistical control of covariates or to consider the longest possible list of potential confounders but rather to reduce or...

Long Term Management of Patients After Successful Pituitary Surgery for Cushings Disease

All patients with CD require life-long endocrine surveillance, and attention should be paid to body composition, psychologic health, blood pressure, carbohydrate tolerance, lipid status, and bone mineral density (BMD). At least yearly clinic attendances are required, with periodic assessment to exclude recurrence of disease. Established associated conditions should be aggressively treated, and BMD measured using dual-energy X-ray absorptiometry (DXA). BMD will increase in time with cure of CD however, if there is a severe persistent deficiency, bisphosphonates may be used however, the effects of the agents in human pregnancy are not yet established. Recent evidence indicates that reversible GH-deficiency (GHD) may persist for as long as 2 yr after successful treatment of CD. It has been recommended that definitive assessment of GH status in adults with cured CD be delayed for this period (20). In addition, the possibility of delayed hypopituitarism should be considered and measurement...

Methyleneblue Rib Targeting Technique

Using the rib marking technique, Little and associates reported success in 15 patients with known cancer to enable them to biopsy 13 ribs, one skull, and one scapula 11 . A pathological diagnosis was found in all patients, but only eight of 15 (53 ) had metastatic cancer. The other patients had a variety of benign diagnoses, including hypercellular marrow (2), old rib fractures (2), Pag-et's disease, granuloma, and osteoporosis. This methylene-blue targeting technique appears to work in experienced hands but requires careful coordination of the nuclear medicine department and surgical schedule. That is, a surgery room should be immediately available to accept the rib biopsy patient for surgery so that the blue dye does not have time to diffuse to other ribs. The surgeon performing only an occasional bone biopsy guided by this technique might find it difficult to duplicate the excellent results of Little and colleagues.

Growth Hormone Replacement

Not all subjects with GH deficiency have significant symptoms. In treated pituitary tumor patients, those with complaints relating to poor quality of life, altered body composition, with documented dyslipidemia or reduced bone mineral density, should undergo assessment for GH deficiency (Table 2). Severe GH deficiency has been defined as a peak GH response on provocative testing

Inulin Type Fructans and Phosphate Absorption

In gastrectomized rats (4-week-old male Sprague-Dawley) that were used to test for the preventing effect of oligofructose (10 w w in diet for 10 d) on osteopenia known to occur in gastrectomized patients, a significant increase in P absorption was reported when comparing the gastrectomized rats fed the oligofructose-contain-ing diet the control sham-operated rats (89 and 76.5 , respectively or a 16 increase). But in the two groups of gastrectomized rats the absorption of P was similar (89 and 92 ).131

Postoperative Management

A gravity drainage tube was removed from the dorsal surgical wound 5 days after surgery, and a long-arm thumb splint was reapplied until the sutures were removed 12 days after surgery. A nonremovable thumb spica splint was worn for 3 weeks. The patient's digital sensation had not improved. The patient returned in 1 week with increasing pain and swelling of the hand and fingers, further restricting finger movement. He was given two steroid dose packs and additional narcotic analgesics. One week later his pain increased despite no change in his exam. He was placed in a transcutaneous electrical nerve stimulation (TENS) unit, which improved his pain tolerance during the day. Just over 6 weeks after his surgery, the patient was taken to the operating room for removal of the pins. Two weeks later the swelling significantly decreased and the fingers were supple. The radiocarpal motion was noncrepitant, and the roentgenograms continued to be normal except for periartic-ular osteopenia. Pain...

Rheumatoid arthritis

Radiographs in patients with RA usually show erosions and juxtaarticular osteoporosis, although the findings are often normal in early RA. Osteophytes, subchondral bone cysts, and sclerosis suggest OA. However, Heberden's nodes and other degenerative abnormalities may coexist with RA.

Johannes D Veldhuis MD Ali Iranmanesh MD and Daniel Keenan PhD

The aging process is marked by a relatively subtle short-term decline in reproductive hormone outflow in men. However, the nominal 0.8-1.3 annual fall in systemic bioavailability of testosterone results in a reduction of 30-50 by the sixth through eighth decades of life. Low testosterone concentrations forecast relative sarcopenia, osteopenia, visceral fat accumulation, detectable cognitive impairment, and variable mood depression. Accordingly, the mechanisms driving progressive androgen deprivation are important to understand. To this end, age-associated alterations in three dominant sites of physiological control, namely the hypothalamus, pituitary gland, and testis, are highlighted. The cognate signals are gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), and testosterone, which jointly determine androgen availability via feedback and feedforward adaptations. According to this emergent notion, no single gland acts in isolation to maintain homeostasis. An integrative...

Femur fractures after internal fixation

Since the preparation of the lateral femoral cortex for screw fixation is considerably less traumatic than the chiseling necessary for the insertion of a Smith-Petersen nail, femur fractures usually occurring later are nowadays rarely observed. If they happened, they are the consequence of osteoporosis or metastases (see Fig. 148). In the past, when a fracture happened, we used to change the technique and employed an internal fixation with a DHS or a 95 blade-plate. However, it is often difficult to find an appropriate position for the stabilizing new implant in the head previously perforated by screws.

Robert E Booth and David G Nazarian

Many techniques of internal fixation are available, but all share significant technical difficulties as well as a surprisingly high incidence of nonunion and malunion. The medial mechanical axis of the lower limb, the concerted action of the posterior knee musculature, and the sagittal plane of motion of the joint itself all conspire to destabilize even the most rigid internal fixation. This is compounded by the effects of bony comminution, severe femoral osteopenia, and a stiff knee arthroplasty. It is not surprising, therefore, that many fractures develop nonunions or go on to a tardy malunion with the typical deformity of adduction, flexion, and internal rotation of the distal femoral fragment. Extensive grafting of the fracture may be required. At the very least, small bone fragments or paste will be helpful at the termination of the procedure to enhance healing in an area of extreme osteopenia. An intercalary graft, fashioned to surround the intramedullary rod but provide bulk...

Radiography and laboratory tests

Radiographs reveal osteopenia with various patterns of bone loss, including patchy, bandlike periarticular loss, irregular cortical outlines, cortical tunneling and striation, scalloping of inner cortical surfaces, surface erosions of subchondral and subarticular surfaces, and other subchondral changes. These may occur late and are nonspecific. Joint spaces are preserved until late in the course.

Score results of the analysis of reduction and internal fixation

We investigated the role of the technical execution of internal fixation and also the importance of biologic and biomechanical factors (osteoporosis, fracture type) with the goal to reduce the incidence of loss of reduction. The majority of scoring systems in orthopedics and traumatology compare the functional (at best also the social) state before and after surgery. They are supposed to allow a conclusion as to the efficacy of the method used and to permit a comparison with other methods (Parker and Maheshaer, 1997). Such a comparison raises doubts, in particular, when material has been collected from two or more hospitals or even from different countries. If the quality of execution is not taken into consideration and if errors have been excluded, one cannot

So What Is Hrt Good

It is recommended for women with bad menopausal symptoms, including flushing. It may slightly reduce the risk of thin bones (osteoporosis). Generally, in women who do not have symptoms, HRT does not make women less depressed, sleep better, be more sexually satisfied, interested, or active, or help their brain work better. There are always examples of women who are very pleased with their HRT and feel that it improves their hair and their skin. It is sensible for women to consult their doctor about these matters.

Clinical Focus Box 362

Cytokines, Estrogens, and Osteoporosis It is well established that a decline in circulating levels of 17p-estradiol is a major contributing factor in the development of osteoporosis in postmenopausal women. Until recently, specific mechanisms by which estradiol might influence bone metabolism were largely unknown. Recent studies suggest that estradiol influences the production and or modulates the activity of several cytokines involved in regulating bone remodeling. Current research efforts attempt to define more clearly the specific source(s) and roles of the cytokines involved. The elucidation of these factors might allow the development of diagnostic tools, such as the assessment of cytokine levels, to monitor osteoporosis. In addition, such knowledge should facilitate the development of drugs that might interfere with cytokine action and potentially be of value in the treatment of osteoporosis.

Suggested Reading

Male skeletal health and osteoporosis. Trends Endocrinol Metab Griffin JE, Ojeda SR, eds. Textbook of Endocrine Physiology. 4th Ed. Oxford Oxford University Press, 2000. Henry HL. The 25-hydroxyvitamin D 1a-hydroxylase. In Feldman D, Glorieux FH, Pike JW, eds. Vitamin D. San Diego Academic Press, 1997. National Osteoporosis Foundation Web site. Available at http www.nof.org Norman AW, Litwack G. Hormones. 2nd Ed. San Diego Academic Press, 1997.

Case Study for Chapter

Osteoporosis and, perhaps, glucocorticoid-induced osteoporosis. 2. Because the patient is young and has a relatively healthy lifestyle, the most probable cause of his osteoporosis is his 30-year history of treatment with glucocorticoids for asthma. Glucocorticoids increase bone loss by inhibiting osteoblasts, stimulating bone resorption, impairing intestinal calcium absorption, increasing urinary calcium loss, inhibiting secretion of sex hormones, and other effects.

Contraindications Precautions And Interactions

The glucocorticoids are administered with caution to patients with renal or hepatic disease, hypothyroidism, ulcerative colitis, diverticulitis, peptic ulcer disease, inflammatory bowel disease, hypertension, osteoporosis, convulsive disorders, or diabetes. The glucocorticoids

Side Effects of Steroid Therapy

Atrophy of the fatty tissue might occur, especially in the forehead region (Fig. 6.6). This can be corrected with a biodegradable filler (e.g., hyal-uronic acid if the source of the initial reaction is not hyaluronic acid but another filler). The continuous administration of highly potent steroids at short intervals should be accompanied by osteoporosis prophylaxis, especially in high-risk patients. One tablet of a combination of calcium carbonate 1.25 g and cholecalciferol (Vitamin D3) 10 g should be sufficient.

Assessment of the safety and effectiveness of intervertebral disc replacement

In addition to the need for better understanding of the overall long-term success of disc implant surgery, we need a better understanding of what population subgroups will likely benefit or fail. Evaluation of patient factors should include age, underlying conditions, prior back surgery, duration of back pain, occupation, activity level, smoking status, body mass index, and severity of disease. These all may have an effect on the survivability of the device and clinical patient outcome. Degenerative disease factors, such as trauma, osteoporosis, osteoarthritis, and cancer, will alter the success rates and rates of complications. It seems likely that the numbers of complications would increase with longer follow-up time, as was seen in total hip arthroplasty 60 . In addition, the type of surgical approach, e.g. percutaneous or open procedure, and number of levels of operated discs have also been shown to be important predictive factors in various spinal treatments. Several studies...

Etidronate Disodium Didronel

Osteoporosis prevention and treatment, Paget's disease of bone. For Paget's disease, 400 mg daily given as a single dose 2 hours before meals. Reassessment is indicated after 6 months of therapy. Dosages above 10 mg kg daily should be used cautiously and reserved for suppression of rapid bone turnover or for prompt reduction in elevated cardiac output. For treatment of postmenopausal osteoporosis, the dosage is 400 mg of etidronate daily (2 hours before or after a meal) for 14 days every 3 months.

Grade 3 Tibial Stress Fracture

Mri Tibula Stress Fracture

A recent study comparing MRI, CT, and bone scintigraphy described MRI as the single best technique to assess suspected tibial stress injuries 53 . The sensitivities of MRI, CT, and bone scintigraphy were 88 , 42 , and 74 respectively. The specificity, accuracy, and positive and negative predicted values were 100 , 90 , 100 , and 62 respectively for MRI and 100 , 52 , 100 , and 26 respectively for CT 53 . Using MRI, the transverse plane has been determined to be the best in the detection of tibial shaft stress injuries. Axial MR images may show endosteal marrow edema, subtle periosteal edema, and a thickened detached periosteum manifested as a thin line of signal void 53,55 . CT can show osteopenia in the tibial cortex, which is the earliest finding in cortical bone fatigue injury. CT may also show subperiosteal irregularity and cortical resorptive change 53 .

Parathyroid Hormone and Calcitonin

Calcitonin Osteoporosis

As mentioned in chapter 11, the thyroid gland secretes a hormone called calcitonin. Though its physiological significance in humans is questionable, its pharmacological action (as a drug) can be useful it inhibits the resorption of bone. People with stress fractures of vertebrae due to osteoporosis (discussed in the next Clinical box), may be helped by injections or nasal sprays of calcitonin. Another hormone needed for regulation of the skeletal system is estrogen. As may be recalled from chapter 11, estrogen is derived from androgen. For both men and women, estrogen produced within the epiphyseal discs (the cartilage growth plates in growing children) is needed for the discs to seal (become bone) this stops growth. Also, proper bone mineralization, and the prevention of osteoporosis, requires the production of estrogen within the bone. Men are less prone to osteoporosis than are The most common bone disorder in elderly people is osteoporosis. Osteoporosis is characterized by...

Temporally Relevant Exposure

In other etiologic pathways, the critical exposure window may be defined not in relation to the timing of disease but based on stage of development. Regardless of when congenital malformations come to attention, precisely timed developmental events indicate the days and weeks of gestation in which certain defects can be produced by external insults (Kline et al., 1989). Similarly, it has been hypothesized that physical activity among adolescent girls is influential on their long-term risk of osteoporosis (US DHHS, 1996). For illustrative purposes, assume that this window of adolescence is the only period in which physical activity is pertinent to osteoporosis. A study that measured lifetime physical activity or physical activity from ages 40 to 49 would suffer from misclassification and observe the expected inverse association only to the extent that physical activity at those measured ages corresponded to physical activity in adolescence.

Vertebroplasty and Kyphoplasty

Traditionally, these fractures have been treated nonsurgi-cally, except in cases of fractures associated with neurological compromise. Obviously, surgical reconstruction in the patient with osteoporosis is challenging. From a surgical point of view, orthopedic fracture care emphasizes the restoration of anatomy, correction of deformity, and subsequent preservation of function. These goals have not been met in the conservative care of patients with vertebral compression fractures. The ideal treatment should address both the fracture-related pain and the mechanical compromise related to kyphosis. Percutaneous vertebroplasty was described in 1987.76 In this procedure, whereby polymethylmethacrylate is injected into a compressed segment, immediate stability is obtained, but deformity is not corrected. Suggested indications included stabilization of painful osteoporotic fractures, painful fractures due to myeloma, and painful hemangiomata. Reports on clinical outcome for...

Complex Regional Pain Syndrome Type 1 Reflex Sympathetic Dystrophy

Fine detail radiography may help to suggest the presence of CRPS. Early radiologic changes seen with sympathetic hyperdysfunction include patchy demineralization of the epiphyses and short bones of the hands and feet. Periarticular osteoporosis in long bones and diffuse osteoporosis in small bones may be seen on plain radiographs. Sub-periosteal resorption, striation, and tunneling of the cortex may occur. Comparison with the unaffected limb is always required. Unfortunately, these findings may be seen whenever there is disuse of a limb. As CRPS advances, patchy osteopenia may be seen.

Mobilization followup care

The internal fixation with two cannulated screws causes little stress and only slight wound pain in the majority of patients it allows weight bearing depending on fracture configuration and on bone stock. The patient can ambulate with two canes or a walker with weight bearing on the third day. In the presence of a multifragmentary or comminuted facture, a Pauwels-III fracture, severe osteoporosis or other bony changes (cyst, metastases) rendering the internal fixation less solid, the amount of weight bearing is determined individually. In general, we allow walking with forearm crutches or crutches reaching to the armpits and loading of the limb not exceeding the weight of the limb (10-15 kg as determined

Guidelines for the assessment of internal fixation

Faulty Internal Fixation

Already during the analysis of the first 1000 patients with femoral neck fractures seen at our institute between 1940 and 1955 our team paid special attention to the early and late complications arising from the position of the implant (Manninger et al, 1961b). During the subsequent half century osteoporosis has led to major changes in bone quality of the proximal femur. Due to the ever increasing mean age of the population osteoporosis has become a national concern. The trabecular bone stock of the femoral head and more so of the neck has decreased or even sometimes disappeared (Forgon, 1967). Even the cortex, foremost the lateral, is thinned. On one hand, important developments were imperative in respect to internal fixation use of three or more implants, identification of areas in the neck and head that contain a bone stock for adequate hold of the implant and reinforcement of the lateral cortex. On the other hand, a revision of our recommendations based on findings in much younger...

Femoral neck fractures in osteogenesis imperfecta

Osteogenesis Imperfecta

Osteopetrosis a congenital and a later appearing form are known. The congenital form can be recognized by intrauterine fractures and by bone deformities already apparent at birth. Typical for this disease is the absence of periosteal bone formation. Symptoms include a transparent blue sclera, deafness, deformation of the vertebral column and foremost the extreme fragility of bone. Later appearing forms can imitate a juvenile or postmenopausal osteoporosis (Fig. 234).

Exercise Plays a Role in Calcium Homeostasis

Bone Mineral Density Exercise Graph

Skeletal muscle contraction applies force to bone. Because the architecture of bone remodeling involves osteoblast and osteoclast activation in response to loading and unloading, physical activity is a major site-specific influence on bone mineral density and geometry. Repetitive physical activity can create excessive strain, leading to inefficiency in bone remodeling and stress fracture,- however, extreme inactivity allows osteoclast dominance and bone loss. The forces applied to bone during exercise are related both to the weight borne by the bone during activity and to the strength of the involved muscles. Consequently, bone strength and density appear to be closely related to applied gravitational forces and to muscle strength. This suggests that exercise programs to prevent or treat osteoporosis should emphasize weight-bearing activities and strength as well as endurance training. Adequate dietary calcium is essential for any exercise effect weight-bearing activity enhances...

Box 191 Names That Are Like Pictures

The opposite is genu varum, in which the knees are far apart and the bottom of the legs are close together, giving rise to the term bowleg. A dowager's hump appears dorsally between the shoulders as a result of osteoporosis and is most commonly seen in elderly women.

Granulomatous Reactions

If there is no improvement, 5-fluoruracil can be added to triamcinolon 10 mg or 40 mg. Again, injections should be performed at weekly intervals until an improvement can be seen Osteoporosis prophylaxis with a combination of calcium carbonate 1.25 g and cholecalciferol (Vitamin D3) 10 g is advisable for patients at risk of osteoporosis if the treatment should continue.

Patient Preparation

Images Compression Fracture

Fig. 1. (A-C) Elderly woman with chronic obstructive pulmonary disease and severe osteoporosis. PA (A) and lateral (B) chest plain films show multiple thoracic vertebral compression fractures from T4 to T12, of indeterminate age. The patient's pain was difficult to localize. Anterior and posterior bone scan (C) shows intense uptake of radionuclide in T9 and T10, with significant uptake in T11 and T12. Following vertebroplasty of these four levels, the patient described marked relief of her pain. Fig. 1. (A-C) Elderly woman with chronic obstructive pulmonary disease and severe osteoporosis. PA (A) and lateral (B) chest plain films show multiple thoracic vertebral compression fractures from T4 to T12, of indeterminate age. The patient's pain was difficult to localize. Anterior and posterior bone scan (C) shows intense uptake of radionuclide in T9 and T10, with significant uptake in T11 and T12. Following vertebroplasty of these four levels, the patient described marked relief of her...

Spermatogenesis Stimulation

Testosterone And Prenatal Development

To avoid androgen deficiency symptoms, such as loss of libido and potency, anemia, and osteoporosis on the one hand and side effects resulting from elevated testosterone levels, such as polycythemia on the other hand, serum testosterone levels should be checked at frequent intervals at the beginning of therapy until the correct treatment dose is identified. Subsequently, 6-12 mo for monitoring testosterone levels is usually sufficient. Serum estradiol levels should be checked at the same intervals, because elevated levels increase the risk of gynecomastia. Furthermore, hemoglobin and hematocrit should be monitored, because these parameters are dependent on testosterone levels.

Bone Deposition and Resorption

The protein component of the bone matrix is digested by enzymes, primarily one called cathepsin K, released by the os-teoclasts. The osteoclast can then move to another site and begin the resorption process again, or be eliminated. Interestingly, there is evidence that estrogen, often given to treat osteoporosis in postmenopausal women, works in part by stimulating the apoptosis (cell suicide) of osteoclasts. resorption in healthy people on earth. In the micro-II gravity (essentially, weightlessness) of space, however, astronauts have suffered from a slow, progressive loss of calcium from the weight-bearing bones of the legs and spine. For reasons that are not presently understood, about 100 mg of calcium are lost per day, which has reduced bone mineral density up to 20 in some astronauts who have been in space for several months. This loss cannot be countered simply by giving astronauts calcium, since hypercalcemia may cause kidney stones and other problems. The exercise machines...

Protocols and Methodologies

Has been discussed in detail.83,84 143 It is based on the assumption that the orally and intravenously administered isotopes (minimal quantities to avoid perturbation in mineral metabolism) are metabolized at the same rates once Ca pools have reached equilibrium.124 The main advantage over the metabolic balance methodology is that it measures true absorption by allowing a separate distinction between exogenously unabsorbed and endogenously secreted minerals. Because it is hypothesized that the effects of inulin-type fructans on mineral absorption take place in the large bowel where they are fermented, it is essential that urine is adequately collected to allow accurate measurement of all components of minerals absorption.84 Indeed, if, in normal circumstances, very little calcium absorption occurs in the colon,144 it is the case in the presence of nondigestible carbohydrates that shift part of the absorption process in the lower part of the intestine. Thus, it has been argued that a...

Inulin Origin Chemistry Biochemistry and Technological Properties

10.2.2 Calcium Intake and Bone Health 10.4 Methodologies for the Study of Mineral Absorption and Bone Health 10.4.2 Methodologies for the Study of Bone Health 10.5 Inulin-Type Fructans Mineral Absorption and Bone Health 10.5.3 Inulin-Type Fructans and Bone Health 10.7 Inulin-Type Fructans Mineral Absorption and Bone Health Discussion, Perspectives, and Conclusion

Diseases of the musculoskeletal system and connective tissue M00M99

M80.0 Postmenopausal osteoporosis with pathological fracture M80.1 Postoophorectomy osteoporosis with pathological fracture M80.2 Osteoporosis of disuse with pathological fracture M80.3 Postsurgical malabsorption osteoporosis with pathological fracture M80.4 Drug-induced osteoporosis with pathological fracture M80.5 Idiopathic osteoporosis with pathological fracture M80.8 Other osteoporosis with pathological fracture M80.9 Unspecified osteoporosis with pathological fracture M81.0 Postmenopausal osteoporosis M81.1 Postoophorectomy osteoporosis M81.2 Osteoporosis of disuse Excludes Sudeck's atrophy ( M89.0 ) M81.3 Postsurgical malabsorption osteoporosis M81.4 Drug-induced osteoporosis Use additional external cause code (Chapter XX), if desired, to identify drug. M81.5 Idiopathic osteoporosis Osteoporosis with pathological fracture Osteoporosis without pathological fracture See site code at the beginning of this chapter Excludes osteoporosis with pathological fracture ( M80.- ) M81.6...

Reinforcement of the first point of buttressing improvement of the purchase in the femoral head

Thick Subchondral Bone

The inadequacy of the first point of buttressing may have two causes (1) faulty placement of the implant (2) advanced osteoporosis In a publication dealing with our results of the first 1000 femoral neck fractures between 1940 and 1955 we analyzed the importance of the nail position in the femoral neck (Manninger et al, 1961a). We noted that the placement of the implant in the cranial part in the head is wrong. We determined the limits of nail placement in a.-p. and lateral films (as a rule the outer third of the head). Placing the nails beyond this limit is questionable as the stability is insufficient. We also analyzed the importance of the distance between the tip of the screw and head contour. We found that a distance exceeding 15 mm leads to a marked increase in the incidence of complications. Distances ranging between 1 and 15 mm did not influence the incidence of complications regardless of the length of the distance. In the aforementioned study we did not investigate the...

Table E3 Commonly used topical preparations

Periodic determinations of blood sugar, complete blood cell counts, stool guaiac tests, and blood pressure measurements should be obtained. Diabetes mellitus, hypertension, pregnancy, and psychosis are relative contraindications. In patients receiving long-term steroids, the hypothalamic-pituitary-adrenal axis is suppressed, and they require glucocorticoid supplementation when undergoing surgical procedures or other physiologic stress. Repeated administration of intraarticular injections of corticosteroid may lead to disruption of cartilage and supporting soft-tissue structures. Soft-tissue injections may cause similar effects. Long-term steroid use demands appropriate immunizations and measures to ensure protection against osteoporosis.

Metabolic Bone Diseases

Radiology Signs Bone Disease

Osteoporosis is a loss of bone mass that results in weakening of the bones (Fig. 19-8). A decrease in estrogens after menopause makes women over age 50 most susceptible to the effects of this disorder. Efforts to prevent osteoporosis include adequate intake of calcium and engaging in weight-bearing exercise. Because of safety concerns, hormone replacement therapy (HRT) is currently being re-evaluated for use in prevention of osteoporosis. Some drugs are available for reducing bone resorption and increasing bone density. Osteoporosis can be diagnosed and monitored using a DEXA (dual-energy x-ray absorptiometry) scan, an imaging technique that measures bone mineral density (BMD). Other conditions that can lead to osteoporosis include nutritional deficiencies disuse, as in paralysis or immobilization in a cast and excess steroids from the adrenal cortex. Overactivity of the parathyroid glands also leads to osteoporosis because parathyroid hormone releases calcium from bones to raise...

Aroma Compound In Food

Protein Test Food Ppt

It was only in 1975 that it was discovered that bone tissue contains a y-carboxyglutamyl protein, osteocalcin, which accounts for up to 15 of non-collagenous proteins in bone. Fully carboxylated osteocalcin is able to form a strong complex with hydroxyapatite, the calcium phosphate mineral component of bone. Much circumstantial evidence suggests a key role for vitamin K in bone health. For example, treatment of pregnant mothers with vitamin K anticoagulants, such as warfarin, can lead to bone defects in their infants. Measurement of 'undercarboxylated' species of osteocalcin has been explored as an index of vitamin K deficiency. Yet in practice, there is no direct evidence that vitamin K deficiency has long-term adverse effects on bone health. This apparent paradox is probably due to insufficient detailed information and this area promises to be an important growth point in bone research.

History And Physical Examination

History and physical examination are key components in the evaluation of patients being considered for percutaneous vertebroplasty. A focused history and examination concentrating on the patient's back pain, mobility level, and medication use (including analgesics, steroids, and osteoporosis antagonists) is recommended. Presenting symptoms, pertinent medical, surgical and allergy histories, a list of current medications, and evidence of failed medical therapy are documented. Use of visual analog scales for determining pain levels, dermatome drawings for pain localization, and standardized questionnaires are helpful for collecting data pre- and post-procedure.

Miscellaneous drug classes

Centration of 25-hydroxyvitamin D (25-OH-D(2) -D(3)) in human plasma. A deuterated standard is used and the tandem spectrometer is in the multiple-reaction-monitoring mode. Intra- and interassay variations 2-6 recoveries 104-99 . Potential applications are the evaluation of the vitamin D status in postmenopausal women and elderly subjects, the diagnosis of vitamin D insufficiency deficiency, as well as for the treatment and prevention of osteoporosis. tration of vitamin K and related compounds (phylloquinone (PK), menaquinone-4 (MK-4), and menaquinone-7 (MK-7)) in human plasma. The internal standard is an isotope-labeled compound (O18) detection is by MS-MS using multiple reaction monitoring. Intra and interassay variations

Open reduction of a displaced neck fracture

Femur Neck Fracture Open Reduction

If two or three careful attempts at a closed reduction are unsuccessful, an open reduction is preferable as further manipulations may endanger the circulation in the femoral head. Fortunately this is rarely necessary in elderly patients who constitute the majority of our patients. Due to their osteoporosis in

Disorders of the Spine

Sealy Mattress For Cervical Spondylitis

Ankylosing spondylitis. Bone bridges fuse one vertebra to the next across the intervertebral discs and fuse the posterior portions of the vertebrae. There is osteoporosis from disuse. (Reprinted with permission from Rubin E, Farber JL. Pathology. 3rd Ed. Philadelphia Lippincott Williams & Wilkins, 1999.)

Coherence of Cases and Controls

As we move away from clear, enumerated sampling frames, the problems of control selection become more severe. Even in studies conducted within a defined geographic area, there is the challenge of identifying all cases of disease that occur in the area. Doing so is easier for some conditions than for others. Several diseases are fully enumerated by registries in defined geographic areas, most notably cancer and birth defects. Vital records provide a complete roster of births, and thus certain associated birth outcomes, and deaths, including cause of death. For most conditions of interest, however, there is not a geographically based register in place. Chronic diseases such as diabetes, myocardial infarction, or osteoporosis require essentially developing one's own register to fully ascertain cases in a geographically defined population, tabulating information from all medical care providers, developing a systematic approach to defining cases, etc. Beyond the potential difficulties in...

And Hormone Mechanisms

Braverman, 2003 Developmental Endocrinology From Research to Clinical Practice, edited by Erica A. Eugster and Ora Hirsch Pescovitz, 2002 Osteoporosis Pathophysiology and Clinical Management, edited by Eric S. Orwoll and Michael Bliziotes, 2002 Challenging Cases in Endocrinology, edited by

Morbidity Of Hypoglycaemia And Need For Emergency Treatment

Many people with type 1 diabetes regard severe hypoglycaemia with the same degree of trepidation as that reserved for the advanced complications of diabetes such as loss of sight or renal failure (Pramming et al., 1991). Hypoglycaemia is not simply extremely unpleasant for the individual concerned it has the potential risk of severe morbidity and may precipitate major vascular events such as stroke, myocardial infarction, acute cardiac failure and ventricular arrhythmias (Landstedt-Hallin et al., 1999 McAulay and Frier, 2001 Desouza et al., 2003) (see Chapter 12). Healthcare professionals may not always recognise the causative role of hypoglycaemia when treating these secondary events, especially if they are unfamiliar with some of the age-related neurological manifestations of hypoglycaemia. The elderly are particularly at risk of hypoglycaemia-related physical injury and bone fractures as a result of their general frailty and the presence of co-morbidities, such as osteoporosis...

Training And Education

Adult infectious disease fellowship training programs should seriously consider incorporating into their curriculum information that is relevant to the care of the elderly with infection, i.e., biology of aging (especially gerontoimmunology) geriatric pharmacology and the epidemiology, clinical manifestations, diagnostic approach, treatment, prognosis, and prevention of the most common and important infections afflicting older people. In addition, an understanding of geriatric syndromes (e.g., urinary incontinence, dementia, falls, osteoporosis) and issues of long-term care is essential for the infectious disease specialists who may care for older patients.

Constitutional Delay of Puberty

Finkelstein and colleagues reported decreased radial (51), spinal (51,52), and femoral (52) bone mineral density (BMD) in otherwise healthy adult men with history of delayed puberty, in comparison with controls (who had a normal onset of puberty). However, another study recently showed that young men with a history of delayed puberty have normal volumetric BMD, and the authors proposed that the reduced

Compression Fractures

Thoracic Vertebral Compression Fracture

Post-menopausal woman aged 60 or older (23). Osteoporosis is a disease characterized by low bone mass and microarchitectural deterioration of bone tissue that leads to pronounced bone fragility and increased fracture risk. The compression fracture of the osteoporotic patient can reduce vertebral height and can also cause lateral displacement of the bone. The fracture may extend into the lateral masses and posterior arch. The compression fractures of the spine often produce wedging of the vertebral body, which may also be associated with retropulsion of bone fragments and posttraumatic disc herniation. Other fracture types include burst or vertical shear fractures. Anterior to posterior dislocations may result from disruption of the anterior or posterior longitudinal ligaments. Changes in the matrix of bone lead to osteoporosis and increased fracture risk, which can be detected by bone mineral densitometry. The bone mineral density is a noninvasive measurement of the bone mineral...

Diagnosis And Management

Controversies regarding anticoagulation in pregnant women arise mainly from concerns about safety to the mother vs potential damage to the fetus. Coumarin derivatives cross the placenta and can cause an embryopathy, which consists of nasal hypoplasia and or stippled epiphyses after exposure during the first trimester, and CNS abnormalities after exposure during any trimester (80). Heparin does not cross the placenta and is safe to the fetus, but prolonged heparin use causes osteoporosis a reduction in bone density is reported in up to one-third of women who receive heparin (81). Low mol-wt heparins (LMWH) also do not cross the placenta and have benefits over unfractionated heparin, such as longer half-life, more predictable dose-response, and a decreased risk of heparin-induced thrombocytopenia (82,83). A recent study showed LMWH to be safe and effective when used in 61 pregnant women at risk of embolic events, although concerns about bone density were raised in this study (83).

Clinical Presentation

Hypercalciuria with subsequent renal calculi, glucocorticoid-induced osteopenia osteoporosis, menstrual irregularities (e.g., amenorrhea), loss of libido in both genders (hypogonadism secondary to hypercortisolism), and muscle weakness in association with proximal muscle atrophy are common features of CD CS. Avascular necrosis of the hip can be the presenting manifestation of an ACTH-secreting pituitary adenoma and requires immediate attention to save the femoral head and avoid subsequent disability (15). Cataracts (classically posterior subcapsular) and glaucoma frequently occur in patients with exogenous CS but not in those with endogenous hypercortisolism (16). Psychiatric manifestations in CD include cognitive deficits with memory loss and poor concentration, anxiety with insomnia, irritability, atypical depression, acute psychosis, and mania (17-19).

The Role of 5a Reduction of Testosterone in the Muscle

Sattler et al. (92) reported that serum DHT levels are lower and the ratio of testosterone to DHT levels is higher in HIV-infected men than in healthy men. From these data, the investigators proposed that an abnormality in the conversion of testosterone to DHT may contribute to wasting in a subset of HIV-infected men. If this hypothesis were true, then it would be rational to treat HIV-AIDS patients with DHT rather than with testosterone. A DHT gel is currently under clinical investigation. However, unlike testosterone, DHT is not aromatized to estradiol. Therefore, there is concern that suppression of endogenous testosterone and estradiol production by DHT may produce osteoporosis and other undesirable adverse effects.

Preface To The German Edition

In spite of these marked technical progresses the femoral neck fracture remains a problem giving rise to many controversies. The search for solutions extents from epidemiology, osteoporosis research and prevention to the improvement of existing implants and design of new ones. While focusing on solutions one should always keep in mind their impact on the limited resources of our health care systems.

Integrated Assessment Of Potential For Selection Bias In Casecontrol Studies

Cancer Causes Control 1994 5 73-82. Melhus H, Michaelsson K, Kindmark A, Bergstrom R, Holmberg L, Mallmin H, Wolk A, Ljunghall S. Excessive dietary intake of Vitamin A is associated with reduced bone mineral density and increased risk for hip fracture. Ann Intern Med 1998 129 770-778. Miettinen OS, The case-control study valid selection of subjects. J Chron Dis 1985 38 543-548.

New Paradigm For Medicine

The genetic revolution that has already begun will usher in the beginning of a new paradigm in the diagnosis and treatment of cardiac disorders. Physicians traditionally have been taught to diagnose and treat disease. Cardiology in the past 50 years has advanced more than perhaps in the previous 2000 years.37 Nevertheless, despite our ability to diagnose, we seldom know the precise molecular defect or pathogenesis of a particular phenotype. In the near future, a single blood sample will make available to the physician 100,000 etiologies with their multiple mutations. This represents a new era in which specific etiologies will be looking for their respective diseases. This will further challenge the physician to attempt to associate genes with physiological functions and mutations with disease. The physician will be well positioned to advance functional genomics through translational research at the bedside. In fact, until recently, physicians who saw individuals without complaints...

Pathological Fractures

Pathological fractures occur in diseased, weakened bone following minimal trauma or, occasionally, spontaneously. Pre-existing disease includes metabolic bone disease, metastatic malignant disease, primary benign or malignant bone tumours and infection. Osteoporosis is the most common cause. Primary malignant bone tumours require specialist management and are beyond the scope of this chapter. The term 'insufficiency fracture' is used for fractures through bone weakened by a process other than neoplasia. Repeated loading may cause a 'stress fracture', most commonly in the athlete or military recruit's foot or tibia (this term is a misnomer and a stress fracture is not really a pathological fracture).

P Michael Conn Series Editor

Braverman, 2003 Developmental Endocrinology From Research to Clinical Practice, edited by Erica A. Eugster and Ora Hirsch Pescovitz, 2002 Osteoporosis Pathophysiology and Clinical Management, edited by Eric S. Orwoll and Michael Bliziotes, 2002 Challenging Cases in Endocrinology, edited by

Common Effects of Aging

Physical function or capacity tends to decline with age. This is largely due to the atrophy of muscles, which is more common as the body gets older. The joints tend to become stiffer and less mobile. Range of motion may be restricted. Changes in bone density may lead to loss of teeth, osteoporosis, and subsequent fractures. Tooth loss and osteoporosis have been documented in monkeys over the age of twenty years. Pictures of such older monkeys reveal a stooped posture, with shoulders hunched forward, similar to the kyphosis observed in many older human women.

The Clinical Effect of Leydig Cell Dysfunction

Howell et al. (22) investigated a cohort of men treated with MVPP, ChlVPP EVA hybrid, or high-dose chemotherapy for several malignancies. They identified a cohort of 35 men with biochemical evidence of mild Leydig cell insufficiency, as defined by a raised LH level and a testosterone level in the lower half of the normal range or, frankly, subnormal. They demonstrated significantly reduced bone mineral density at the hip in these men compared with a similarly treated cohort with normal hormone levels and found some evidence of altered body composition, reduced sexual activity, and mood alterations (42,43). The men were then enrolled into a 12-mo randomized, single-blind placebo-controlled testosterone replacement trial (44). However, during the 12-mo study period, there were no significant improvements in bone density, body

Special management considerations

The effects of estrogen replacement therapy on SLE disease activity remain unclear. Although it may prove useful as a means to reduce the risk for osteoporosis and atherosclerosis in women with SLE, estrogen replacement therapy in SLE patients is controversial and is the subject of a national collaborative study. It is clearly contraindicated in those with a history of thrombosis or anti-phospholipid antibodies.

Effects of Inulin Type Fructans on Absorption of Minerals

Help rats overcome symptoms of anemia and osteopenia In their first study on mineral absorption, van den Heuvel et al. found no effect of 15 g d inulin-type fructans on calcium absorption in young men, using a dualisotope tracer method.66 One criticism of this study was that urine was only collected for 24 h, potentially missing the late colonic phase of absorption.124 Indeed, a subsequent study by the same group, using a 36 h urine collection, showed that 15 g d oligofructose significantly increased calcium absorption.67 Further data have shown a significant increase in calcium absorption in adolescent girls in response to the consumption of 8 g d of oligofructose-enriched inulin Synergy 1 but no beneficial effect to the same dose of oligofructose.126,127 This suggests that this mixture may be a more potent promoter of calcium absorption than oligofructose, thus confirming the experimental data reported by Coudray et al.145 The studies by Griffin et al. differed from previous studies...

Localized amyloidosis

Radiography may show soft-tissue swelling and generalized osteoporosis with or without lytic lesions joint space narrowing is not seen, and erosions are rare. The diagnosis can be confirmed by an examination of the synovial fluid and, when necessary, by synovial biopsy. The synovial fluid is noninflammatory and yellow or xanthochromic, and it may contain fibrils that have the tinctorial and ultrastructural features of amyloid. Clinicians must keep in mind the importance of the differential diagnosis with rheumatoid arthritis a biopsy of the involved tissue may be needed. Careful evaluation for the presence of primary plasma cell dyscrasia and systemic organ involvement must also be carried out. B. Diagnosis. The erythrocyte sedimentation rate is normal and rheumatoid factor is absent. The synovial fluid shows good viscosity, with leukocyte counts below 1,000 mm3. During acute episodes of pseudogout, synovial fluid leukocytosis and calcium pyrophosphate crystals may be...

Clinical Focus Box 361

Bone Weight Strength Charts

The Toll of Osteoporosis Osteoporosis is often called the silent disease because bone loss initially occurs without symptoms. People may not know that they have significant bone loss until their bones become so weak that a sudden strain, bump, or fall causes a fracture. Osteoporosis is a major public health threat in the United States because it affects some 28 million Americans. Some 10 million individuals have been diagnosed with the disease and another 18 million have low bone mass, placing them at increased risk for osteoporosis. Approximately 80 of those affected by osteoporosis are women. While osteoporosis is often thought of as an older person's disease, it can strike at any age. The seeds of osteoporosis are sown in childhood, and it takes a lifetime of effort to prevent the disease. A frightening number of children do not get sufficient exercise, vitamin D, and calcium to ensure protection from developing the disease later in life. Osteoporosis is responsible for more than...

Related titles

As the proportion of the elderly increases in many developed countries, there is an increasing emphasis on preventing some of the chronic diseases particularly associated with ageing. This important collection reviews the role of functional foods in preventing a number of degenerative conditions from osteoporosis and cancer to immune function and gut health.

Intrinsic factors

Bone is more ductile in the young, leading to the characteristic greenstick and plastic deformation types of failure. With increasing age, as well as osteoporosis, bone becomes more brittle. The modulus of elasticity reduces by 1.5 per annum. In the elderly, bone may be osteoporotic cortical bone is resorbed endosteally, widening the intramedullary canal. The bony trabeculae of cancellous bone become thinner. The resultant reduction in bone density weakens the bone and the ultimate strength reduces by 5-7 per decade.

Oncea Week Drugs

Soon many drugs will be available for once-a-week, or even twice-a-month, administration. The doses are designed to replace daily doses of drugs. One of the first is alendronate (Fosamax), a drug used to treat osteoporosis (see Chapter 21). In 2001, the FDA approved two new strengths for this drug to be given once a week 70-mg and 35-mg tablets. The 70-mg tablet is used to treat postmenopausal osteoporosis, and the 35-mg tablet for prevention of osteoporosis in postmenopausal osteoporosis. In clinical trials the once-a-week dosing showed no greater adverse reactions than the once-daily regimen. Once-a-week dosing may prove beneficial for those experiencing mild adverse reactions in that the reactions would be experienced once a week, rather than every day.


Mortality rates than more 'mid-BMI' people (e.g. 24 BMI 28). There are several non-exclusive possible explanations for this. The most commonly mentioned is that this is due to confounding by smoking or pre-existing disease. A second is that this has to do with using BMI as a proxy for adiposity. These two possibilities were discussed elsewhere in this chapter. A possibility that seems to receive less consideration is that being in the mid-BMI range may cause one to be at lower risk of death from certain causes. Consider a few examples that range from well-supported to plausible-but-highly-speculative. It is clear that relative to thinness, being in the mid-BMI range is protective against osteoporosis (72,73). There is a clear biological mechanism because thinness is a clear risk factor for hip fracture (74) which is in turn a risk for mortality (72,75). Thus, it is plausible that thinness (at least among the elderly) causes increased mortality rate through an osteoporosis fracture...

General Assessment

Can be associated with a protuberant abdomen. The accentuated thoracic kyphosis can be associated with compression fractures of the spine. Collapsed vertebrae can cause a protuberant spinous process such as that found in a gibbus deformity. Collapsed vertebrae have also been associated with osteoporosis and infections (such as tuberculosis, metastatic diseases, and multiple myeloma).

Nursing Alert

Alendronate is administered orally each day or as a once-a-week dose. The nurse should check the physician's order to be certain of the dosage and the times of administration. When administering the drug for treatment of osteoporosis in postmenopausal women, the dosage is 70 mg once weekly or 10 mg daily. When administering the drug for prevention of osteoporosis, 5 mg of the drug is given daily or 35 mg once a week.

Among women only

Menopausal estrogen use and osteoporosis, there might be no causal relation between screening history and that outcome. If there were an association between screening and use of estrogens, however, which is plausible, then the distortion due to random digit dialing would require adjustment in the analysis. The control sampling mechanism would have generated an association with disease status because of the overrepresentation of women who tend to have more health screening (and may well have a higher prevalence of estrogen use as well).


Initial therapy for PMR is usually 10 to 15 mg of prednisone daily. A prompt and dramatic clinical response is considered by some to be an absolute criterion for the diagnosis. Most symptoms resolve in 48 to 72 hours, and the ESR should normalize after 7 to 10 days. Unusually, a patient who fails to respond to prednisone may respond to another corticosteroid, such as methylprednisolone or dexamethasone. If a dramatic response does not occur after several days, steroids should be discontinued. Following control of symptoms, the dose of corticosteroids should be reduced to the lowest level required to suppress symptoms, as the morbidity associated with therapy often exceeds that of the underlying disease. The dose of prednisone should be increased only for a recurrence of symptoms, not for an elevation of the ESR alone. Consideration should be given to ensure an adequate calcium intake in these elderly patients on corticosteroids who are at risk for corticosteroid induced...


Acrylic cements have been used for the augmentation of weakened or partially destroyed bones for decades (63). The term vertebroplasty originally described an open surgical procedure that introduces bone graft or acrylic cement to mechanically augment weakened vertebral bodies. Polymethyl methacrylate (PMMA) is the acrylic most commonly used as a bone filler. The first image-guided percutaneous vertebral augmentation or percutaneous vertebroplasty (PVP) was performed in France in 1984, when Deramond and Galibert injected PMMA into a C2 vertebra that had been partially destroyed by an aggressive hemangioma (64). The procedure relieved the patient's chronic pain. Shortly thereafter, PVP was used to treat vertebral compression fractures caused by osteoporosis (65). The interest in PVP has continued to grow since its introduction in Europe and its subsequent introduction in the United States (66). In 1993, the first vertebroplasty procedure in the United States was performed at the...


Menopause is the cessation of monthly menstrual cycles. This generally occurs between the ages of 45 and 55 years. Levels of reproductive hormones decline, and egg cells in the ovaries gradually degenerate. Some women experience unpleasant symptoms, such as hot flashes, headaches, insomnia, mood swings, and urinary problems. There is also some atrophy of the reproductive tract with vaginal dryness. Most importantly, decline in estrogen is associated with weakening of the bones (osteoporosis).

Serum studies

Soft-tissue swelling and osteopenia may occur as nonspecific early changes on radiographs. As the disease progresses, soft-tissue tophi may be seen as well as punched-out, sharply marginated areas of bony destruction. Pure urate stones are radiolucent, and imaging studies must take this into account.

Metabolic disease

Pathological fractures occur in bone affected by metabolic bone disease such as osteoporosis or osteomalacia, and in other systemic disease states such as osteogenesis imperfecta, Paget's disease, polyostotic fibrous dysplasia and osteopetrosis. The most common sites of osteoporotic fractures are the distal radius and femoral neck. Femoral neck fractures may occur without trauma and some patients report an acute event around their hip before their fall. Treatment of fractures in metabolically diseased bone is by conservative or operative means, aiming for early mobilization. The underlying disease should be investigated and treated as appropriate. Future preventative measures are essential to reduce the ever rising number of fractures, in particular femoral neck fractures, related to osteoporosis. Increasing awareness of HRT, which to be effective should be started within 6 years of the menopause, may be an essential preventative measure.