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Conditions: Osteoporosis


THREE TYPES: generalized, regional, and localized
--"a dz characterized by low bone mass and micoarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk" --WHO 1994
--ETIO FOR GENERALIZED: age related, post-menopause, steroid or heparin induced, dt multiple myeloma, mets, hyperparathyroidism, scurvy, osteomalacia, rickets, sickle cell anemia, osteogenesis imperfecta, colitis incl UC, Crohn's, etc.
--ETIO for regional: disuse, immobilization, RSD = reflex sympathetic dystrophy = sudex atrophy = complex regional pain syndrome = post traumatic osteoporosis
--ETIO for localized: infx, inflam arthritis, neoplasm

OSTEOPOROSIS FACTS
--10+ million in US have osteoporotic hips, count expected to rise to 15 million by 2015
--19 million more have low hip bone mass, rise to over 27 million by 2015
--hip fx numbers, total worldwide: 1990 1.66 million, predict 6.26 million for 2050
--in US: 1/2 of women, 1/8 of men age 50+ will experience O-related fracture
--1.3 million fractures annually, in order of occurrence: spine, hip, wrist
--up to 30% of elderly with hip fx die within 6 mos of injury
--presents in 5-6th decade of life
--average woman has acquired 98% of her skeletal mass by age 20
--blood findings not helpful in Dx
--worldwide 200 million women affected, 1/3 of women 60-70, 2/3 of women over 80
--20-25% of women over 50 have one or more vertebral fractures (US 25%, Scandinavia 26%, Denmark 21%, Australia 20%, W. Eur 19%)
--odds of more fractures after the first are high: 1/5 of women will suffer another fx within a year, women with vertebral fx have 5x increased risk of new vert fx and 2x risk of hip fx
--all types of vertebral fractures are associated with morbidity
--In my view this is justification enough to encourage a yoga practice that includes head stands, because bone deposition follows weight bearing. A regular practice of head stands may prevent or reduce osteoporotic fractures of the spine.
--currently in US over 25million Americans with ostoporsis, 80% female
--$10B/yr spent on tx
--#dxd will double by 2020
--nearly 1/3 of elderly US men will suffer hip fx and most will die within 1 year
--40% of all US women will suffer spontaneous fx by age 70

DDX
--post menopausal
--osteomalacia
--hyperparathyroid
--hyper cortisol (corticosteroids, Cushing's, thicker endplates, poor healing)
--renal insuff
--hyperthyroid
--chronic immobilization
--osteogenesis imperfecta
--hepatic insuff
--DM
--multiple myeloma (punchout lesions are late sign)
--mets
--drug induced

RADIOLOGICAL FEATURES
--radiolucency: bone quality is normal but deficient in amount
--dt resorption of cortical and medullary bone
--thinned cortex, "pencil thin" cortices & endplates
--in advanced cases: trabecular accentuation, esp vertical trabeculae, "pseudohemangiomatous appearance" because hemangiomas also display accentuated vertical trabeculae
--SPINE: pancake vertebrae aka plana (R/o mets & mult myel), wedged or trapezoidal vert bodies, biconcave end plates (fish, hourglass, codfish shaped vertebrae) at multiple contiguous levels, isolated endplate infraction (looks like schmorl's node, seen in oblique), schmorl's nodes mc in thorax and upper lumbar

CLINICAL
--kyphosis
--loss of height
--bulging abdomen
--acute and chronic pain
--breathing difficulties
--reflux and other GI Sx
--depression
--reduced quality of life...



PROXIMAL FEMORAL STRESS LINES
--principle compressive group (down in head w/ gravity)
--principle tensile group (arc from shaft to head)
--secondary compressive group (inward from greater trochanter)
--ward's triangle (between head and GT? or below GT? lecture conflicts with web)

AREAS WHERE BONE DENSITY IS MEASURED in the upper femoral metaphysis:
- The greater trochanter
- The intertrochanteric zone
- The femoral neck
- The Ward's triangle



SENILE/POST MENOPAUSAL OSTEOPOROSIS
--most common fractures after hip and spine: distal radius (colles fracture), humeral neck, and ankle maleoli
--also: sacrum (H/I/arc, H = inside SI and across), pubis, medial femoral necks, tib/fib, calcaneus, metatarsals

FDA APPROVED BONE DENSITY TESTS
--DXA o= DEXA = dual energy x-ray absorptiometry, the gold standard, low radiation exposure, moderate to low cost
--PDXA = PERIPHERAL DXA
--QCT = quantitative computed tomography (not as reproducible as DXA)
--pQCT = peripheral QCT
--Ultrasound

INDICATIONS FOR DXA
--women considering HRT
--fractures suggesting osteopenia
--corticosteroid or anticonvulsant therapy
--SSRI's (incr ser-->decr osteoblast)
--other risk factors: age, female, postmenopausal
--monitor treatment response (1-2 year followups)

MORE ON DXA
--you get an image of the part being scanned that plots bone mineral density vs age
--usu parts scanned: radius, femoral head, lumbar
--gives BMD as a % of young adult pop, as a % of age-matched pop
--T scores comparing to young adult (diagnostic)
--Z scores comparing to same age, gender, ethnicity
--BMD should increase from L1 to L3
--L3 to L4 BMD should be constant or decrease slightly
--BMD categories: normal, low, osteoporosis, severe osteoporosis
--T scores for those: normal less than -1, -penia -1.0 to -2.5,
porosis under -2.5, severe is -2.5 plus fragility fractures
--each standard deviation change in BMD increases fracture rish by ~ 2x
--Z score compares with age-matched peers, also ethnicity, gender, is much different from peers then search for secondary cause, use for monitoring of treatment
--DDX: if Z score under -2.0 consider lab evals to r/o other dz: HPTH (serum Ca+ and phosphate), liver dz, osteomalacia, Paget's (alk phos), renal dz (BUN, creatinine, electrolytes), hyperthyroid (TSH, free T3, T4?), multiple myeloma (protein electrophoresis)
--order 2-5 year followups unless rapid bone turnover situation (high dose corticosteroids)

WEB
www.nof.org
www.surgeongeneral.gov/library/bonehealth/
www.ama-cmeonline.com/osteo_mgmt/module02/pdf/osteo_mgmt_02.pdf
www.iscd.org/
www.osteofound.org/
http://courses.washington.edu/bonephys/

REGIONAL OSTEOPOROSIS
--due to disuse and immobilization, trauma, paralysis, inflam of bones/jts
--changes on x-ray after 7-10 DAYS!!!, becoming more extreme by 2-3 months
--reflex sympathetic dystrophy syndrome = complex regional pain syndrome: post-traumatic bone disorder characterized by acute PAINFUL osteoporosis, pt over 50, trauma mb trivial, pain is progressive, w/ swelling & atrophy distal to trauma site, dt neurovascular imbalance-->osseous hyperemia. Xray looks patchy, mottled, metaphyseal location, no joint dz

LOCALIZED OSTEOPOROSIS
--inflammatory arthritis (rheumatoid)
--infection
--neoplasm

OSTEOMALACIA
--characterized by lack of osteoid mineralization leading to generalized bone softening
--S/Sx: muscle weakness, bone pain, deformities
--LABS: high PTH, ALP, and urinary hydroxyproline
--X-ray: decreased bone density, coarse trabecular pattern, loss of cortical definition, pseudofx (biilat and perpendicular to cortex), deformities (in wt bearing bones)
--medial femoral neck, scapula
--in kids


RICKETS
--systemic skel disorder
--3 forms, most common: vit D deficiency
--less common forms: renal osteodystrophy, renal tubular defect (not resorb phosophate)
--in kids: 6 mo to 1 year
--S/Sx: growth plate swellings (lumpy knee), irritable, deformities (bowed leg), tetany, delayed maturity, weakness, elevated alk phos

RADIOLOGICAL FEATURES:
--generalized osteopenia, coase trabeculae
--growth plates are widened, differentiate from scurvy
--rachitic rosary, anterior rib hypertrophy @ costal jct with cartilage
--absent zone of provisional calcification
--cupped metaphyses, "paintbrush" frayed look




SCURVY
see "vit C" tag

***************************************
notes added from Marz lecture:

obese pts have decr bone loss dt incr wt bearing and incr est
bones need tensile strength to not break, just density is not enough
average daily Calcium turnover: 500mg/day
calcium RDA: 800mg
1200-1500mg/day often prescribed by physicians for osteoporosis
this is beating a dead horse: more than you can use

RISK FACTORS RELATED TO OSTEOPOROSIS
hx of gum dz, tooth decay
renal disease, DM, HTN (kidneys do last hydroxylation 25->1,25 to activate vit D)
meds: corticosteroids incl inhaled, antiepileptic
meds: chol lowering (malabsorb of fat sol nutrients), est blocking
meds: methotrexate (blocks folate pathway, elevates homocysteine-->osteop)
elevated levels of homocysteine leads to osteoporosis, not well known conventionally
liver dz
thyroid dz (hyper or hypo)
Dr Marz says vit K will be the next rage in nutrition
vit K RDA: 100mcg (70-140)
malabsorption: UC, Crohn's, celiac
hemochromatosis
hyperhomocysteinuria
coffee and any other diuretics increases excretion of minerals
elevated blood sugar (even just spiking, use glycomark test)
alcohol: incr Ca+ excretion, decr nutrition
smoking
acidosis
elders with low 1,25 dihydroxy vitamin D may not be able to hydroxylate 25

SX
periodontal disease
compression fx, backaches, decreased height
nocturnal leg cramps
tap side of lip and get spasm
poor nail growth

LABS
DEXA scan
Heidelberg (HCl eval)
urinary pH (should be more alkaline to decr Ca+ excretion)
24 hour urine calcium, hyroxyproline, type I collagen, pyridinoline, deoxypyridinoline
vit K levels (Meridian Valley labs)
Hair analysis (elevated lead-->osteoporosis and caries)

for tissue electrolytes, nutrition
exatest Intracellular Diagnostics, Inc
now in Medford Oregon
650-349-5233
1-800-874-4804

TX
take calcium at bedtime
check bone density before there's a problem
time of year affects bone density: higher in summer dt vit D

FOSAMAX?
bisphosphonates
causes weird fractures
femoral head pops off dt brittle bones
SE: osteonecrosis

HRT??
estrogen promotes bone deposition

MAGNESIUM
imp for bone tensile strength
many who have fx have low tissue levels
RDA for magnesium for males: 425, 350 for females, we really need much more
our intakes have been decreasing for 100 years
take too much Mg and your Ca levels suffer, and opposite
regulates PTH secretion and tissue sensitivity to PTH

CALCIUM
400-800mg citrate or malate plus Ca rich foods for total of 800-1200mg intake
citrate only if stone former
calcium balance depends on protein intake
eat more prot, lose more calcium
is this due to the acid generated or something else?
need 1200-1400mg ca to balance American protein intakes
how much normally absorb ca from GI? 10-25% less with low HCl levels
citrate is better for pts with low HCl
want Ca:Phos ratio of 2:1 or 1:1 (table p338 in Marz book)

VITAMIN K2
VIT K
phytondione or phylloquinone
1-10mg/day
also consider MK4 menoquinone 4 and MK 7
involved in syn of osteocalcin, prot containing gamma carboxyglutamic acid
which binds calcium
glutamic acid is part of protein in bone
it is activated by vitamin K and protein carboxylase to bind calcium
osteocalcin-->mineralization of bone (forms hydroxyapatite crystals)
def high in pts with GI issues
LABS: test via prothrombin anti-antigen or serum vit K assay
FOODS rich in K from more to less: kale, chard, parsley, turnip greens, brocc, cabbage, liver, grn tea, lettuce, spinach, asparagus, oats, chs, watercress, peach

VIT D METABOLISM
sunlight-->7 dehydrocholesterol in skin
plus dietary sources of cholecalciferol
-->liver becomes 25-hydroxycholecalciferol
if blood calcium is low or high goes different way in kidneys
low blood calcium hydroxylates in 1,25 position (calcitriol = D3)
high blood calcium hydroxylates in 24,25 position
1,25-->incr intestinal absorption of ca, incr bone resorption of ca
-->incr serum calcium
24,25-->less active than 1,25
if supplement 1,25 form monitor calcium levels, can be dangerously elevated

VIT D3
400-10,000iu/day taken with fat
want levels in 50-70ng/ml range
want levels near 90 if they have cancer
takes 4-6 mo to change levels

VIT A
20,000 IU/day
not with vit d
involved in bone matrix formation

ALKALINIZE BODY PH
decr meats and grains in diet
decr coffee, soda

BORON
3-6mg/day if you have arthritis, 2-3mg otherwise
-->incr hydroxylation and excretion of 17-est

SILICA
1mg/day
in bone matrix

MANGANESE
20mg/day up to 60-80mg/day
stims production of mucopolysaccharides (bone's organic matrix)
also for inflam conditions like bursitis, tendonitis

ZINC
20-40mg

COPPER

STRONTIUM
Dr Peabody uses

BOOK Marz keeps in office for pts:
Osteoporosis Solution
by Carl Germano

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