Wardround 16xii05

16xii05

This week’s theme for the two minute tutorials was osteoporosis:

Pathophysiology MJM
Epidemiology AA
Dexa AS
Non-pharmacological treatments GAJ
Bisphosphonates HG
Other drugs CT

This week’s prize to Dr Anand (for effort and perceived excitement). The SIGN guidelines are a good source for basic information and links to other sources. Newer agents such as Parathyroid hormone and strontium ranelate are not covered in the SIGN document. If you want a ‘ten second tutorial’ on these have a look at the SMC statements.

http://www.scottishmedicines.org.uk/updocs/Teriparatide%20(Forsteo).pdf
http://www.scottishmedicines.org.uk/updocs/strontium%20ranelate%20(Protelos)%20(178-05).pdf

I would see these as aperitifs...they whet your appetite but are not really enough to satisfy your hunger for knowledge.

How can I sum up these tutorials? Osteoporosis is common, it manifests as fractures, deformity, respiratory compromise, increased mortality, pain and disability and is very common. The costs of untreated and unprevented (oh! english teacher, forgive me for that word) osteoporosis are substantial.

Peak bone mass is reached in the fourth decade and genetic factors are the most important in the absence of malnutrition. It all starts going pear shaped with middle age as the bone remodelling units (osteoblasts and osteoclasts) break down more bone than is produced. Oestrogenic suppression of osteoblast produced iL-6 fails at the menopause leading to increased osteoclast activity and even greater bone loss.

Post menopausal osteoporosis particularly increases fragility fractures in bones dependent on trabecular bone (vertebrae, distal radius), senile osteoporosis increases fractures in these and long bones ( neck of femur, humerus). Steroid osteoporosis has a ‘trabecular pattern’.

Falls, age and bone density are the important triad of risk factors for osteoporotic fractures.Treatment should be aimed at reducing falls and minimising bone loss by ensuring adequate calcium and vitamin D intake, addressing other reversible risks (controlling active systemic inflammatory disease), inhibiting bone resorbtion and stimulating bone formation (less easy).

The indications for DEXA are in the SIGN document.

We did not have time to discuss the In a Stew paper due to the staff Christmas dinner. Another time perhaps.

Interesting topics this week:

Marfan’s...how do you diagnose a ‘sporadic’ case. This paper lists and discusses the diagnostic criteria.

Thalidomide for Behçet’s ulceration

Clinical experience with thalidomide in the management of severe oral and genital ulceration in conditions such as Behcet's disease: use of neurophysiological studies to detect thalidomide neuropathy. JM Gardner-Medwin, NJ Smith and RJ Powell. Annals of the Rheumatic Diseases, 1994, Vol 53, 828-832. It's not available on-line but I have a copy in my office if you would like to read it.

Sjogren’s syndrome


Next week is a special tutorial theme...you are invited to regale us with two minutes about your favourite film or book. Medical textbooks are not allowed as choices!

The reading for next week is Polythenia gravis: the downside of evidence based medicine
Down End Research Group. BMJ 1995;311:1666-1668.


Merry Christmas

MJM