Calcium and vitamin D--for whom and when

The basis of 'nutritional' interventions for the prevention of postmenopausal osteoporosis and osteoporotic fracture is a large topic with much genetic and biochemical evidence, as well as the results of randomized controlled trials, to guide the investigator and clinician. The efficacy of treatment with calcium and vitamin D was once controversial, but with the advent of controlled clinical trials using bone mineral density as an endpoint it has become clear that calcium with or without vitamin D therapy can lead to reductions in the rate of bone loss in postmenopausal women of all ages. Furthermore, with certain caveats, calcium with vitamin D therapy in the older postmenopausal woman can lead to useful reductions in fracture rates and falls, especially in populations with reduced exposure to sunlight, which is potentially the majority of postmenopausal women in both developed and developing countries. However, estrogen, selective estrogen receptor modulators (SERMs) and bisphosphonates (especially when given in combination with calcium and vitamin D) are more efficacious in preventing fracture, particularly in postmenopausal patients with impaired bone structure.     

Role of bisphosphonates in the management of postmenopausal osteoporosis: an update on recent safety anxieties

Following their introduction in the 1990s, bisphosphonates have become the mainstay of treatment in the management of postmenopausal osteoporosis, and their use continues to rise. Commonly noted adverse effects in clinical practice include gastrointestinal side-effects, acute phase reactions (predominately seen with intravenous preparations) cutaneous reactions and more rarely, ocular side-effects. However, recent reports of potentially serious adverse effects of bisphosphonate therapy, including atypical subtrochanteric and femoral shaft fractures, atrial fibrillation, oesophageal carcinoma and osteonecrosis of the jaw, have prompted concerns regarding the long-term safety of this class of drugs. This review summarizes the benefits and potential adverse effects of bisphosphonates used in the treatment of postmenopausal osteoporosis. Although evidence of a definitive casual relationship between bisphosphonate therapy and serious adverse effects is lacking, concern remains particularly in relation to atypical subtrochanteric and femoral shaft fractures. This has important consequences in terms of determining optimum duration of therapy and how best to target therapy at those most at risk. Recently, attention has focused on individual fracture risk assessment in order to optimize the risk-benefit ratio of treatment for individual patients. A review of the role of hormone replacement therapy in younger women with significant risk of osteoporotic fractures may be timely in these circumstances.     

Prevention of osteoporosis: one step forward, two steps back

For many years, hormone replacement therapy (HRT) was the mainstay for osteoporosis prevention in postmenopausal women until a large randomized clinical trial raised serious safety concerns. This resulted in a big drop in HRT use and its demotion by regulatory authorities to second-line treatment. Many clinicians now feel that HRT is not safe to use, and recommend various alternatives for the treatment of osteoporosis. But how effective are these alternative therapies, are they any safer than HRT, and how do their costs compare? This review questions the validity of the safety concerns about HRT, and highlights the safety concerns about alternative therapies. It concludes that HRT is as safe as the other treatment options, and its efficacy and low cost demand that it be restored as a first-line treatment for the prevention of postmenopausal osteoporosis. Other therapies are available for use in osteoporosis, and the bisphosphonates are particularly effective for the treatment of the established disease. However, they must be used selectively and with caution, and are best restricted to those patients who are elderly or have severe disease. New treatments are emerging, but again caution must be taken until any long-term adverse effects have been identified.     

The use of selective estrogen receptor modulators on bone health in men

Selective estrogen receptor modulators (SERMs) represent a class of drugs that act as agonist or antagonist for estrogen receptor in a tissue-specific manner. The SERMs drugs are initially used for the prevention and treatment of osteoporosis in postmenopausal women. Bone health in prostate cancer patients has become a significant concern, whereby patients undergo androgen deprivation therapy is often associated with deleterious effects on bone. Previous preclinical and epidemiological findings showed that estrogens play a dominant role in improving bone health as compared to testosterone in men. Therefore, this evidence-based review aims to assess the available evidence derived from animal and human studies on the effects of SERMs on the male skeletal system. The effects of SERMs on bone mineral density (BMD)/content (BMC), bone histomorphometry, bone turnover, bone strength and fracture risk have been summarized in this review.     

Systemic lupus erythematosus and hormone replacement therapy

The indications for hormone replacement therapy (HRT) in postmenopausal women is the treatment of climacteric symptoms and the prevention of osteoporosis. Women with systemic lupus erythematosus (SLE) are more likely to have a premature menopause, osteoporosis and cardiovascular disease. HRT can induce SLE flares and cardiovascular or venous thromboembolic events. Therefore it should not be used in women with active disease or those with antiphospholipid (aPL) antibodies. In general, it should be used only for patients without active disease, a history of thrombosis or aPL antibodies. Non-oral administration of estrogen is recommended because of its lesser effect on coagulation. With regard to the progestogen, progesterone or pregnane derivatives are preferred. Otherwise, non-estrogen-based strategies should be used.     

National Osteoporosis Society's Position statement on hormone replacement therapy in the prevention and treatment of osteoporosis

Hormone replacement therapy (HRT) has been shown to increase bone density, reduce the risk of fracture and can successfully relieve menopausal symptoms. From a time when HRT was the major therapeutic option for the management of osteoporosis, women and their clinicians now have a range of treatments available. Following the publication of the Women's Health Initiative (WHI) and the Million Women Study highlighting potential side-effects, such as breast cancer, heart disease and stroke, many doctors and women are now reluctant to use HRT. The National Osteoporosis Society felt that the role of HRT in the management of osteoporosis needed to be clarified. Using the Charity's expert clinical and scientific advisers, and through public consultation with members and key stakeholders, a Position Statement has been published. We conclude that HRT has a role to play in the management of osteoporosis in postmenopausal women below the age of 60 years. The key recommendations of the Position Statement are presented in this paper.     

Bazedoxifene: a new selective estrogen receptor modulator for postmenopausal osteoporosis

An ongoing need for safe and effective pharmacological therapies exists for postmenopausal osteoporosis, which imposes a significant burden on both women and the health-care system. Bazedoxifene is a novel selective estrogen receptor modulator with a unique tissue-selectivity profile. In phase 3 clinical trials of nearly 10,000 postmenopausal women, bazedoxifene was shown to significantly reduce the risk of new vertebral fracture versus placebo, with favourable effects on bone mineral density, bone turnover markers and the lipid profile. Moreover, in a subgroup of women at increased risk of fracture, bazedoxifene significantly decreased non-vertebral fracture risk versus both placebo and raloxifene. Bazedoxifene has been shown to be safe and well tolerated, with no evidence of endometrial or breast stimulation. These data suggest that bazedoxifene may offer significant clinical benefit for postmenopausal women with or at risk of developing osteoporosis, which may subsequently lessen the medical and economic burden of this disease.     

Oral health-related quality of life improves in employees with disabilities following a workplace dental intervention

This pilot study evaluated a dental intervention for employees with disabilities by measuring changes in self-rated oral health, dental behaviours and oral health-related quality of life (OHRQol). Consenting employees with disabilities (≥18 years) at two worksites in South Australia underwent dental examinations at baseline, three and six months. Referrals were arranged as needed to public dental clinics. At one and two months a dental hygienist provided group oral health education to the employees. Employees’ demographics, self-rated oral health, dental behaviours and OHRQol were collected via face-to-face interviews. Of the 39 referred employees, 28 (72%) of them completed the recommended treatment. Self-rated oral health improved and there were significant reductions in the prevalence of oral health impact on quality of life (percentage of employees reporting 1+ items fairly/very often) from 27% to 11% (McNemar’s test, p < 0.05); the extent of impact (mean number of items reported fairly/very often) from 1.3 to 0.6 and the severity of impact (mean of summed OHIP item scores) from 3.6 to 1.8 (paired t-tests, p < 0.01). As this pilot study indicates that enabling urgent referral for treatment and regular oral health education can improve OHRQol and self-rated oral health among employees with disabilities, a larger study with a control group should be undertaken.     

A Physician's Overview of Oral-Dental Problems at a Student Health Service

Abstract

This is a review of oral-dental problems for nurses and physicians in a student health service with the typical college-age population. The proper technique for an adequate physical examination of the oral cavity and surrounding structures is described.

Numerous common lesions are described which will undoubtedly face the clinician at a university health service, and some current treatment regimens are given for each condition. The sequence used for the presentation will follow in accordance with anatomic location, e.g. lips, labial and buccal mucosa, hard and soft palate and oropharynx, tongue (dorsal, lateral, and ventral surfaces), floor of the mouth, and the teeth and the gums. Benign and malignant tumors of the oral cavity, and accidental injuries of the teeth are discussed. Preventive dental care including methods for good oral hygiene are reviewed. The effects of actinic radiation on the lips, and the effects of tobacco and alcohol on the oral cavity are discussed.

The physician and dentist both have an opportunity and responsibility to detect oral lesions. Until each student health service has a dental consultant on a regular basis, it is the responsibility of nurses and physicians to increase their proficiency in examining, diagnosing, and treating oral-dental lesions.     

How to help the aging male? Current approaches to hypogonadism in primary care

Hypogonadism is a common condition which occurs more frequently in older men. It is characterized by low testosterone (T) and is associated with symptoms which are often nonspecific. A key symptom is low libido, but it can also be associated with erectile dysfunction, reduced muscle mass and strength, increased body fat, reduced bone mineral density and osteoporosis, reduced vitality, and depressed mood. Hypogonadism is linked with a variety of comorbid conditions including erectile dysfunction, metabolic syndrome, diabetes, obesity, and osteoporosis. However, the condition is often underdiagnosed. T supplementation in hypogonadism is associated with a range of benefits including improved sexual function, increased lean body mass and/or reduced fat mass, and improved bone mineral density. A variety of T supplementation formulations are available. Although there is no evidence of increased risk of initiating prostate cancer with T supplementation, it is contraindicated in men with prostate cancer. It is important that primary care physicians are aware of both the signs and symptoms of hypogonadism, the monitoring and testing that is required and the merits and advantages of the various T preparations to ensure optimal management of the condition with a treatment approach that best suits patients’ needs.     

The microanatomy of trabecular bone in young normal and osteoporotic elderly males

Normally there is a gradual continual loss of cortical and trabecular bone in both men and women as they age. Osteopenia and osteoporosis are conditions in which the loss results in brittle bones that fracture easily. Males with low testosterone and hypogonadism are predisposed to osteoporosis and prevention tends to be overshadowed by the greater problem in postmenopausal women. The ability of the skeleton to resist external forces depends partly upon the amount of bone present and partly upon other factors including cancellous bone microarchitecture. This is examined in iliac crest bone biopsies from idiopathic osteoporotic men, mean age 60 ± 12 SD years [n = 16]. These were compared with a healthy control group (autopsy samples), mean age 30 ± 8.9 years [n = 28] with the aim of examining the pattern of cancellous atrophy in male idiopathic osteoporosis. Undecalcified specimens were embedded in methylmethacrylate and prepared for histomorphometry. Sections were analysed using an automated trabecular analysis system (TAS), whereby a binary image was created. Area measurements including the trabecular surface and distance measurements including the trabecular width were made. The binary image was thinned to its medial framework and the node and terminus number as indices of trabecular interconnection were recorded, together with the strut length. Results (median (range)) showed a lower percentage bone volume in the elderly osteoporotic male, 10.2% (5.4–23.1) compared to young normals 25.2% (14.6–43.9), p < 0.001. The trabeculae tended to be thinner, 95.7 µm (66.7–170.7) c.f. 120.8 µm (75.8–208.6) and considerably fewer in number, 11.1 (2.1–31.4) c.f. 48.3 (25.4–66.9), p < 0.001 per field and in particular the number of nodes, 2.1 (0.15–14) c.f. 40.6 (10.3–74.1) per field and the node: terminus ratio fell to 0.13 (0.01–1.19) c.f. controls 0.98 (0.24–6.69), p < 0.001. It was concluded that the pattern of cancellous atrophy in male idiopathic osteoporosis differs from normal aging and resembles that in postmenopausal women. Results using the automated TAS confirm previous observations made manually.     

Lead exposure is a risk for worsening bone mineral density in middle-aged male workers

Abstract

Objective: Lead exposure linked to osteoporosis in women. However, there is no direct evidence whether lead exposure has effects on bone metabolism in middle-aged male subjects. Therefore, the present study investigated the relationship between bone mineral densitometry measurements, bone markers, endocrine hormones and blood lead levels.

Material and methods: The present study included lead exposure patients (n: 30) and control subjects (n: 32). We recorded information on patient demographics and risk factors of osteoporosis. Blood lead levels were evaluated using Varian AA 240Z atomic absorption spectrophotometry. Bone mineral density measurements were measured using dual-energy X-ray absorptiometry.

Results: Each lumbar T and Z scores in the lead exposure group were lower than the control group. There were no significant differences in femur neck and femur total T and Z scores between two groups. Blood lead levels were also negatively correlated with lumbar 2-4 T score, total lumbar T score, lumbar 2-4 Z score and total lumbar Z score. Urinary hydroxyproline and urinary deoxypyridinoline levels in the lead exposure group were significantly higher compared to controls. Blood lead levels were strong, positively correlated with urinary deoxypyridinoline. Endocrine hormone levels and 1,25-dihydroxy-vitamin D3 levels were comparable between lead exposure and control group.

Conclusion: Lead exposure in male workers is an important factor for deterioration in bone mineral density. We should be screening blood lead levels and history of lead exposure in male osteoporosis.     

Osteoporosis, falls and exercise

Osteoporosis, a manifestation of bone atrophy that leads to great susceptibility to fractures, is a very important public health problem today because of its great morbidity, mortality and important economic repercussions. It is a problem that will tend to become more serious with the increase in the number of elderly persons. Bone mass is gained during adolescence, reaches a plateau during the third decade and remains stable until approximately age 50, after which a progressively gradual loss is observed. There is no real cure for osteoporosis, but a series of strategies can be used to reduce bone loss and improve bone mass. Osteoporosis has been considered a disease that accompanies the process of ageing; however, this fatalistic attitude should be discarded, as it is possible to correct and decrease the risk factors. Intervention strategies are based on three pillars: nutrition, physical activity and pharmacological agents. Physical activities and exercise programmes are important because they not only can counter the loss of bone mass but also improve neuromuscular capacity, maintaining and increasing strength and muscle mass, which can help to avoid falls and reduce their impact and consequences. The general principles that apply to any exercise programme also apply to preventing bone mass loss. They also can be applied to persons with osteoporosis. However, to understand the peculiarities of these programmes, the propensity for suffering fractures of these former groups should be kept in mind. Special care should be taken to avoid falls and injuries. Weight-bearing exercise and resistance training are recommended for the prevention programmes. Other activities such as tai-chi, dancing, gymnastic or callisthenic exercises can help to improve balance, gait and muscle coordination and diminish the risk of falling. These programmes should be complemented with postural education and a series of safety precautions.     

Arsenic exposure associated with decreased bone mineralization in male

Abstract

Objective: Arsenic (As) exposure may cause several medical problems. There were a few studies investigated whether it has affected bone tissue in women. However, there was no study in men. The aim of this study was to evaluate associations between bone mineral density (BMD) and As exposure in men subjects.

Material and methods: We enrolled in this study 254 subjects who due to chronic As exposure suspected and 82 subjects as a control group. Hair As levels were detected by a hair analysis (Varian AA240Z Zeeman Atomic Absorption Spectrometer, USA). BMD measurements were obtained using dual-energy X-ray absorptiometry instrumentation. We investigated associations between the hair As levels and BMD measurements.

Results: The frequency of osteoporosis and osteopenia was found to be 0.8% and 54.5%, respectively, in the As exposure group. The frequency of osteoporosis was found to be 1% and osteopenia was 32.4% in control subjects. There was significant difference between two groups (p?<?0.001). Hair As level has a median 1.01 (min: 0.06 and max: 25.71). There were no significant correlation between hair As levels and BMD measurements.

Conclusion: According to our observations, As exposure was associated with bone metabolism. Possible cause of osteopenia may be exposure to As. Further investigations are needed to estimate the relationship between As and bone metabolism.     

Clinical effects of growth hormone on bone: a review

Growth hormone (GH) stimulates bone turnover. Deficiency of GH due to hypopituitarism is related to low bone mineral density and increased fracture risk. GH substitution increases and thus normalizes bone mineral density in these patients, which is one of a number of arguments for GH substitution in hypopituitarism. In contrast, a possible therapeutic use of GH in idiopathic osteoporosis and glucocorticoid-induced osteoporosis is speculative and not established. Reduction of osteoporosis risk is an argument brought up for a use of GH in healthy elderly persons (anti-aging medicine). However, since only very limited data are available yet, this cannot be based on scientific evidence, and there are important concerns about the safety of use of GH in healthy elderly persons.     

Sexually transmitted infections in the older woman

Dependent upon sexual behaviour peri- and postmenopausal women are increasingly at risk of sexually transmitted infections, although the overall rates remain low when compared with younger people. Symptoms are often non-specific or absent and may be misinterpreted as being due to the menopause. In addition, both the women and their clinicians may not be aware of their infection risk, thus leading to a delayed or missed diagnosis. Risk assessment and referral for screening of infections should be carried out wherever appropriate.     

Risk management issues in postmenopausal health care

As in other areas of clinical activity, unintended harm to patients may occur in the course of postmenopausal health care, and measures to ensure patient safety should be actively promoted. This paper discusses the application of some basic principles of risk management to postmenopausal health care. To facilitate communication and reduce errors in diagnosis and treatment, risk management should be incorporated in the development of a dedicated menopause service.     

Dehydroepiandrosterone (DHEA) and the menopause: an update

Since we last reviewed this topic in 2001, considerably more information about dehydroepiandrosterone (DHEA) has accrued, but this has not necessarily left us any wiser about the use of this steroid in postmenopausal women. There is no further evidence that DHEA supplementation is likely to be useful in the prevention of cardiovascular disease or cognitive impairment, or in the promotion of wellbeing. Evidence has, however, accumulated for beneficial effects of DHEA on osteoporosis, both in postmenopausal women and in patients receiving long-term glucocorticoid therapy. What is also emerging is a link between low DHEA levels and cardiovascular risk, and between high DHEA levels and breast cancer risk. In fact, the benefits and adverse effects of DHEA administration in postmenopausal women increasingly resemble those of conventional hormone replacement therapy. Overall, we conclude that DHEA is not currently to be recommended for therapeutic use in the majority of postmenopausal women. However, DHEA supplementation may be of benefit in two specific groups of women: those with the lowest circulating levels of DHEA; and those for whom osteoporosis is a particular problem.     

Thyroid dysfunction in perimenopausal and postmenopausal women

Thyroid dysfunction is common, especially among women over the age of 50. In caring for peri- and post-menopausal women, it is important to recognize the changing clinical manifestations of thyroid disease with age. Postmenopausal women are at increased risk of both osteoporosis and cardiovascular disease, and untreated thyroid disease may exacerbate these risks. Screening for thyroid dysfunction in asymptomatic individuals is controversial, but aggressive case-finding should be pursued, especially in older women. Women with overt thyroid dysfunction should be treated. Therapy for women with subclinical thyroid dysfunction is more controversial, although women with levels of thyroid stimulating hormone (TSH) > or =10 mU/L should be treated, and treatment may be considered in symptomatic women with subclinical hypothyroidism and TSH values <10 mU/L, and in women with subclinical hyperthyroidism who have TSH values consistently <0.1 mU/L. In women who are treated with thyroxine, careful dose titration and monitoring are required in order to prevent the adverse consequences of iatrogenic subclinical hyperthyroidism or hypothyroidism. Finally, caution is required in diagnosing and treating thyroid dysfunction in women who are taking oral estrogens or selective estrogen receptor modulators.     

Osteoporosis: implications for risk reduction in the college setting.

Osteoporosis is often considered a chronic disease of older adulthood. As with many chronic diseases, lifestyle behaviors adopted during young adulthood are important risk factors for future development of osteoporosis. The college student population represents the age group in which optimal bone development is likely to occur and certain lifestyle behaviors are reinforced. Therefore, risk factors for osteoporosis, including nutritional insufficiency of calcium and vitamin D, smoking, alcohol abuse, excessive exercise, use of steroids, and high-protein diets, have special relevance for this target population. The authors examine risk factors for osteoporosis that are especially relevant to the college health setting and offer intervention strategies for college health professionals.