Osteoporosis: a concern for cancer survivors

PURPOSE/OBJECTIVES: To describe the risk factors, prevention, diagnosis, management, and impact of osteoporosis on the lives of women who have survived breast and endometrial cancer. DATA SOURCES: Journal articles, selected textbooks, prescribing information, and conference proceedings. DATA SYNTHESIS: Women who have not been able to have estrogen-replacement therapy (including women who have survived breast and endometrial cancer) are at higher risk for developing osteoporosis. Osteoporosis is associated with significant medical costs and can have a detrimental effect on long-term quality of life (QOL) as well as increased mortality. Recently, significant advances have been made in the ability to detect and manage osteoporosis. CONCLUSIONS: Thorough assessment, appropriate evaluation, and treatment of osteoporosis can reduce the complications of this condition and ultimately improve the QOL for women surviving cancer. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses should include assessment of risk for osteoporosis into their practice. Education about the prevention of osteoporosis should be included with other wellness education. Women at higher risk for the development of osteoporosis should be referred for a diagnostic evaluation. Oncology nurses can provide women with osteoporosis with education about treatment as well as psychosocial support.     

Treatment options for osteoporosis

The number of women affected by postmenopausal osteoporosis is likely to continue to increase substantially as the population ages. Furthermore, the therapeutic options for such patients are likely to increase. In this brief review, we outline the use of the currently available medications for the management of osteoporosis--namely, estrogen, calcitonin, calcium, and vitamin D. In addition, we discuss the next generation of drugs that are likely to become available in the future--the bisphosphonates and estrogen analogues. As these options become available, the prevention and treatment of osteoporosis will become similar to the management of other common disorders such as hypertension or hyperlipidemia, in which the most appropriate medication may differ for individual patients. Thus, the treatment of osteoporosis is likely to evolve from a decision of whether to initiate estrogen replacement therapy to a more complex decision of the best agent to use for an individual patient.     

Management of ventricular arrhythmias: detection, drugs, and devices

OBJECTIVE: To review evaluation and treatment of patients with ventricular arrhythmias, based on recent studies, with an emphasis on randomized controlled trials. DATA SOURCES: MEDLINE search of English-language publications of ventricular arrhythmias and their references from 1966 through April 27, 1998. References to articles were also scanned to broaden the search. STUDY SELECTION: Randomized controlled trials and all large nonrandomized trials of arrhythmias and arrhythmia therapy were reviewed. In addition, studies that led to changes in approach to patients with arrhythmias were reviewed. DATA EXTRACTION: We reviewed articles jointly for pertinent studies and information. DATA SYNTHESIS: The goals of treatment of the patient with ventricular arrhythmias are to suppress symptoms and prevent a fatal event. The steps in providing such therapy include defining the cardiac anatomy, assessing arrhythmia risk through noninvasive or invasive testing, and prescribing treatment based on these results. Patients may be separated into high- and low-risk groups to help identify appropriate treatment. While low-risk groups may benefit from reassurance or medications such as beta-blockers or verapamil, high-risk groups have been more difficult to treat. Recent randomized trials of implantable cardioverter defibrillators for ventricular arrhythmias suggest that they may provide better protection for high-risk patients than do antiarrhythmic medications. CONCLUSIONS: Treatment and understanding of risk from ventricular arrhythmias have advanced substantially in recent years. Classifying patients as being at high or low risk for fatal arrhythmias allows the physician to identify appropriate treatments for the high-risk patient without exposing the low-risk patient to unnecessary treatment-related risks.     

The human immunodeficiency virus (HIV)-type 1 coreceptor CXCR-4 (fusin) is preferentially expressed on the more immature CD34+ hematopoietic stem cells

Glucocorticoid-induced osteoporosis is a common clinical problem. This review briefly summarizes the pathogenesis of this disorder. All relevant studies on the prevention and treatment of glucocorticoid-induced osteoporosis are discussed more in detail. As the results of these studies are inconclusive, a proposal for a practical approach of the individual patient is formulated.     

Emergency medicine: beyond the basics

Medical emergencies can arise in the dental office. Preparedness for these emergencies is predicated on an ability to rapidly recognize a problem and to effectively institute prompt and proper management. In all emergency situations, management is based on implementation of basic life support, as needed. The author describes the appropriate management of two common emergency situations: allergy and chest pain.     

Food allergy: recent findings

Food allergy induces in infancy and childhood a large variety of symptoms which may be trivial in many children, chronic and severe in others and even fatal in rare cases. According to double-blind placebo controlled oral food challenges, cow's milk, egg, wheat and fish are the most common offending foods. Elimination of the offending food(s) is imperative for the management of children with food allergy. An appropriate formula without cow's milk proteins and allergenic epitopes should be given to infants with cow's milk allergy. Breast feeding and selected weaning after the sixth month of life are recommended for the prevention of food allergy in atopic prone babies.     

Airway obstruction in pediatric patients. From croup to BOOP

Our knowledge of the pathophysiology of allergy continues to grow, and with that understanding better treatment methods are being developed. An understanding of the appropriate diagnosis and treatment of allergy is mandatory for the physician who is treating patients with nasal and sinus disorders. Provision for this aspect of patient care will materially benefit such patients, although ignoring it places the physician at risk for repeated treatment failures.     

Secondary osteoporosis

Secondary osteoporosis is diagnosed when there is a well-established disease-related risk factor for fracture or low bone mass. Secondary osteoporosis is associated with a substantial minority of osteoporotic fractures in women perhaps with a majority of osteoporotic related fractures in men. This chapter does not review all the possible causes of low bone mass and fractures but picks out some of the more important causes of, with an emphasis on the main iatrogenic cause, that is corticosteroid induced osteoporosis. It also highlights some of the possible causes which could be avoidable. Where appropriate the methods of prevention and treatment of secondary osteoporosis are reviewed.     

Corticosteroid-induced osteoporosis

Corticosteroid-induced osteoporosis is a serious disorder that results in significant morbidity. A summary of our understanding of the pathophysiology is provided and highlights some of the controversy the exists. Clinical trials for the prevention and treatment of corticosteroid-induced osteoporosis are reviewed.     

Food allergy. Most often conceals an inhalational allergy

Food allergy (hypersensitivity) is a form of adverse food reaction in which the reaction is caused by an immunological response to a food. Most immediate allergic reactions to food are IgE-mediated. The prevalence of food allergy in the general population without the oral allergy syndrome is about 1-2%. Although many foods have been described to cause an allergic reaction, only a few are responsible for the majority of hypersensitivity symptoms. Based on continuous studies by B. Wüthrich, Allergy Unit of the Dermatology Department, University Hospital, Zurich, celery (42%) followed by dairy products (16%), carrot (13%), hen's egg (12%) and fish (7%) is by far the major source of food allergy in Switzerland. In adults food hypersensitivity is mainly due to cross-reactivity between inhalative and food allergens. Pathophysiologically, IgE antibodies induced by aeroallergens recognize structurally similar components in certain foods even from taxonomically unrelated plants. Following an accurate allergological examination, oral provocation tests are considered the most conclusive procedures to establish diagnosis. The only proven form of management in food allergy is strict elimination of the offending food. Food-allergic patients must be provided with emergency medications. Identification of allergens and their characterization finally will improve our understanding for pathophysiologic mechanisms of food allergy.     

Osteoporosis: pathogenesis, diagnosis, and treatment in older adults

Prevention of osteoporosis is a major health concern. Bone loss occurs throughout life in both women and men due to calcium deficiency, hormonal deficiency, and changes in bone formation. The diagnosis of osteoporosis can now be made prior to fragility fracture, allowing for prevention as well as treatment. Criteria for diagnosis of osteoporosis are reviewed, and a plan for the evaluation of secondary causes of osteoporosis is discussed. Also reviewed are prevention and treatment options such as exercise, calcium supplementation, hormone replacement, and new and investigational drugs.     

Medically induced gingival hyperplasia

Gingival hyperplasia or gingival overgrowth is a common occurrence in patients taking phenytoin, cyclosporine, or calcium channel blockers. Speech, mastication, tooth eruption, and aesthetics may be altered. Controlling the inflammatory component through an appropriate oral hygiene program may benefit the patient by limiting the severity of the gingival overgrowth. In patients in whom gingival overgrowth is present or may be anticipated, recognition of this condition and referral to a general dentist or periodontist are appropriate steps to management. The physician's awareness of the potential for development of overgrowth and the dental practitioner's role in attempting to prevent or minimize this problem are important aspects. In this article, we discuss the medications associated with gingival hyperplasia and describe appropriate recommendations.     

Predisposing factors for individuals' Lyme disease prevention practices: Connecticut, Maine, and Montana

OBJECTIVES: This study examined factors that predispose individuals to protect against Lyme disease. METHODS: Knowledge, attitude, and practice questions concerning Lyme disease prevention were included in the Behavioral Risk Factor Surveillance surveys in Connecticut, Maine, and Montana. A total of 4246 persons were interviewed. RESULTS: Perceived risk of acquiring Lyme disease, knowing anyone with Lyme disease, knowledge about Lyme disease, and believing Lyme disease to be a common problem were significantly associated with prevention practices. CONCLUSIONS: Predisposing factors differ substantially between states and appear related to disease incidence. Personal risk, knowing someone with Lyme disease, and cognizance about Lyme disease and acting on this information are consistent with social learning theories.     

Exercise and gall bladder function

Epidemiological research has demonstrated protective effects of varying strength from physical activity against the risk for several chronic diseases such as coronary heart disease, hypertension, non-insulin-dependent diabetes mellitus and osteoporosis. Epidemiological studies have been supported by experimental research showing that exercise training improves coronary heart disease risk factors and other health-related factors. In contrast, the association between physical activity, exercise and gall stone disease has not yet been firmly established. This paper presents the theoretical role of aerobic exercise: (i) in the primary prevention of gall stone disease; and (ii) as a potential prokinetic agent in high risk gall stone disease groups. Primary risk factors in the pathogenesis of gall stone formation include cholesterol supersaturation in the solutes that precipitate from bile, hypernucleation (measured as "crystal appearance time') and finally hypomotility of the gall bladder which allows bile stasis and crystal formation. While the results of epidemiological studies suggest that physical activity may be inversely associated with gall stone disease, the mechanisms by which exercise may influence gall stone disease pathogeneses are poorly understood. In this paper the association between physical activity and exercise to gall bladder function and gall stone disease will be examined. Recommendations for future research and the implications for the primary prevention of gall stone disease will also be discussed.     

Detecting osteoporosis. Beyond the history and physical examination

A number of developments are contributing to clinicians' understanding of osteoporosis as a clinical continuum characterized by low bone mass and increased risk of fractures rather than as a disease characterized by fragility fractures. With improved capability for accurate measurement of bone mass, the prevalence of this disease has increased to include at least 25 million Americans. The responsibility of primary care physicians to detect and treat osteoporosis has increased accordingly. Parents should be counseled regarding their children's diet and lifestyle to optimize peak adult bone mass and ensure adequate dietary calcium intake. Adults should be counseled to minimize behaviors that result in accelerated bone loss (e.g., smoking, alcohol use, anorexia, bulimia). Physicians need to be aware of the serious potential complications of osteoporosis and offer counseling to menopausal women about the disease and the benefits and risks of hormone replacement and estrogen replacement therapy. Physicians should be familiar with technologies available in their community for measuring bone mass and recognize the need to consider prescribing pharmacologic and nonpharmacologic therapies for patients with low bone mass or osteoporosis. Physicians also can educate caregivers about prevention of falls and fractures in elderly patients who are unsteady on their feet. Improved technologies for bone mass measurement and fracture risk assessment, as well as expanded options for treatment and prevention of osteoporosis, are likely to become available within the next 5 to 10 years, thereby increasing the wisdom of early detection and treatment of osteoporosis.     

Physicians' prevention-related practice behaviors in treating adult patients with asthma: results of a national survey

To improve the health outcome of adults with asthma, it is important to understand the current practice behaviors of physicians related to the prevention and treatment of asthma. A national survey was conducted to ascertain the practice behaviors of physicians in five specialty areas: internal medicine, pulmonary, allergy/immunology, occupational health, and family health. Similarities and differences in practice among the specialty areas are indicated. The data provide a basis for recommendations to improve the management of asthma by standardizing history taking, increasing the use of pulmonary function testing, and using effective counseling and patient education strategies.     

Osteoporosis prevention in premenopausal women: Using a stage model approach to examine the predictors of behavior.

The precaution adoption process model was used to examine the predictors of 2 behaviors recommended to reduce the risk of developing osteoporosis: calcium consumption and weightbearing exercise. A total of 452 premenopausal women completed a mailed questionnaire assessing stage in the precaution adoption process and 12 knowledge and attitudinal variables. Participants were also given an opportunity to request information about osteoporosis. In all, 11 of the 12 knowledge and attitudinal variables were associated with calcium stage; 8 were associated with exercise stage. lnformation requests were associated with both calcium and exercise stage. Findings provide substantial support for the precaution adoption process model and suggest that the model can be usefully applied in this area to increase understanding of why many women do not practice behaviors that could reduce their risk of developing osteoporosis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Association between plasma vitamin E concentration and the risk of equine motor neuron disease

Venous ulceration is a common problem in western countries and results in large costs to healthcare systems. A number of hypotheses of the mechanisms of development of venous ulceration have been advanced, but this question has not been fully resolved. In recent years research effort has focused on the microcirculation of the skin and many methods of investigation have been employed to study this. Some of the principal findings described in published work are reviewed in this article. It seems unlikely from the available evidence that venous ulceration is attributable solely to failure of diffusion of oxygen and other small nutritional molecules to the tissues of the skin. The microvascular changes in the skin are characterised by activated endothelium and perivascular inflammatory cells. It is much more likely that leucocytes attach themselves to the cutaneous microcirculation, become activated and produce endothelial injury. Repeated over many months or years, this chronic inflammatory process leads to be tissues changes of lipodermatosclerosis. Although there is evidence of leucocyte involvement in the pathogenesis of venous ulceration, the exact mechanisms remain to be resolved. Improved treatment for patients may be devised once a better understanding of the basic causes of this condition has been reached.