Q&A Session at HealthTap.com

Does resveratrol affect male bone growth?

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Q&A Session at HealthTap.com

What do vitamin d and calcium do in the body?

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Q&A Session at HealthTap.com

My mum is suffering pubis rami fracture. She is having terrible pain on her g.maximus. Her feet r swollen. She cnt sleep at all. Is alprazolam ok?

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Mirror, Mirror, On the Wall . . . Part 4

Wouldn't it be great if we had a mirror on the wall which could tell us who's the fairest of all?  But then there'd be no need for television shows like America's Next Top Model.  Personally, I'd prefer the crystal ball that could tell me which stock to buy or sell, and more importantly, when!  Of course, neither of these prediction devices exists, at least not where I live.  But we continue to be enamored as a society about developing models (no, not those kinds) to predict the future.  Case in point was yesterday's look at diabetics' risk for developing dementia.

Well, one of the bigger risks for falling is living long enough, right?  If it's a simple slip & trip w/o injury, then no big deal.  But for our elderly, we worry about serious injuries especially conditions like hip fractures which portend tremendous disability.  But there are those who recover amazingly quick to their premorbid condition.  So of course, we want to know what sets them apart, right?

Well, in a prospective observational study published earlier this week in JAMA Internal Medicine, the authors concluded that post-fall recovery was linked to pre-fall function.  No fecal matter, Sherlock!  In other words, as if you couldn't already have guessed, the less disabled & therefore more functional you were prior to your fall, the better your chances of recovering quickly.  To arrive at their conclusions, the authors followed for 14yrs 754 community-dwelling participants avg 86yo, all of whom were not disabled in their activities of daily living at baseline, and of whom 130 sustained a serious fall.

But as one can imagine, there's a tremendous variation even among those who can perform their basic ADLs.  So the authors scored each participant according to 4 ADLs, 5 instrumental ADLs & 4 mobility tasks.  Those with least disability were most likely to recover quickly & totally.  Those with greatest disability were most likely not to recover.  Mortality also appears to be associated w/disability.

One other point: aside from those with gradual disability over the year preceding the fall, most elderly are relatively stable in their functional status.  But I would recommend that we should encourage them to exercise regularly, focusing not just on endurance (aerobics) but also strength, balance & flexibility.  Better to prevent the fall than have to recover afterwards.

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Q&A Session at HealthTap.com

What can I do to guard against osteoporosis ?

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78 year old female w/femur fracture. Diagnosed w/diabetes+emphysema. Has other heart/lung condition. How to best treat fracture or reduce pain?

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USPSTF Gives D Grade to Vitamin D

Clever title, huh?  Kinda made you want to read this post, right?  We're living in such a fast-paced world that we learn via sound bites and 140 characters at a time.  We want & need every morsel of information summarized neatly into easily digestible bits.  Unfortunately, truth & science aren't always so malleable to this way of learning.

Case in point is the United States Preventive Services Task Force's Clinical Guideline regarding vitamin D & calcium supplementation to prevent fractures in adults as published early online yesterday in the Annals of Internal Medicine.  Up until recently, we lumped everything & everyone together stating that calcium 500-1,000mg daily + vitamin D 400-800 units was good, regardless of age, gender, and risk factors.

Well, as the USPSTF attempted to explain in their guidelines, the evidence for primary fracture prevention in both men and premenopausal women is woefully scant.  Thus, they weren't able to analyze risks vs benefits.  And when it comes to noninstitionalized postmenopausal women, the data for benefit in primary fracture reduction using calcium doses greater than 1,000mg daily and vitamin D greater than 400 units daily, was inadequate to analyze risks vs benefits.

Before I get to the USPSTF's D grade, let's be clear as to how finely they're dividing the population & parsing their words, almost as if in legalese.  For instance, this Recommendation Statement only addresses primary fracture prevention, that is in those men & women who've never had an osteoporotic fracture before.  In this statement getting all the press, there's no attempt to address secondary prevention in those who've already sustained a hip or vertebral or wrist fracture.  Furthermore, there's no mention of institutionalized postmenopausal women, just noninstitutionalized postmenopausal women & premenopausal women (along w/men).  

So it's for those non-institutionalized postmenopausal women who take less than 1,000mg daily of calcium and/or less than 400 units daily of vitamin D for whom the USPSTF was unable to find any benefit.  Worse there was some concern over an increase risk for kidney stones.  Thus they recommended against this dose in this group since they can't recommend something that offers no benefit while putting that person at risk, no matter how small.  Check out the editorial for more info.

If this appears to be an about-face from their December 2011 meta-analysis & June 2012 draft, both published in the Annals of Internal Medicine, read the conclusion carefully: Combined vitamin D and calcium supplementation can reduce fracture risk, but the effects may be smaller among community-dwelling older adults than among institutionalized elderly persons. Appropriate dose and dosing regimens, however, require further study (italics mine).

Bottom line: as much as I want to be able to make a blanket statement about vitamin D & calcium, the evidence doesn't allow for it.  So if you're a community-dwelling postmenopausal female, don't take small doses of calcium (less than 1,000mg daily) or vitamin D (less than 400 units daily).  But what about larger doses? What about men, institutionalized postmenopausal women, and premenopausal women?  What do they do?  Either wait for studies to be published (if they're more concerned about potential side effects) or "Go Big or Go Home".

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Q&A Session at HealthTap.com

I have reckets in my legs..how it can treated...by operation or by dose???

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Blood Pressure Lowering Drugs vs Hip Fracture

Unintended consequences.  As physicians, we always do our best to help our patients.  Certainly we strive to do no harm.  But sometimes, that's just not possible.  As I've noted previously, there's no free lunch so it often becomes a matter of choosing the lesser of two evils.  Until recently, just about everything that I'd read about high blood pressure was bad, which explains all our attempts to lower it.  But earlier this summer, a study was published in the Archives of Internal Medicine in which the authors concluded that robust old old benefited from antihypertensive therapy while the frail old old did not.

So I find it interesting that in a study published online earlier this week in the same Archives of Internal Medicine, the authors found that initiating use of blood pressure lowering medications increased the risk of hip fracture in community-dwelling elderly.  They followed 301,591 newly treated elderly, avg 81yo, and compared their risk for hip fracture for the 45 days immediately following the first prescription of an antihypertensive medication to the over 6 months before & after said initial prescription period.  

While use of any antihypertensive medication was statistically significantly linked to a 43% increase risk of hip fracture, this was mainly due to statistically significant increase risk from ACE inhibitors & beta blockers.  Thiaizide diuretics, ARBs and CCBs also increased risk of hip fracture but not in a statistically significant manner.

So how does this study impact our practice?  Do we stop prescribing medications?  Probably not.  Should our patients stop taking their medications?  Absolutely not!  How can  we safely get beyond the initial 45 days post-prescription?  It's unproven but I think we need to warn our patients to be very careful of position changes & orthostatic hypotension, especially if given ACE inhibitors and/or beta blockers.  Sure, the increased risk of a hip fracture is scary to ponder, but balance that against an increase risk of stroke & kidney failure if we don't treat high blood pressure.  Like I said, unintended consequences.  Risk, benefit & alternatives.  Communication is key.

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Q&A Session at HealthTap.com

what is a good vitamins for bones?

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Q&A Session at HealthTap.com

If buying a motion sensor, should we select? One with recordable message, alarm or silent pager to caregiver? Want to prevent falls if 92 yo arises.

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Q&A Session at HealthTap.com

Is there any medication that is proven to negatively affect bone growth or bone density?

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Q&A Session at Avvo.com

I am presently taking Citracal slow release and I want to know if it is safe.

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How to Prevent Falls in Our Elderly

The Cochrane Library is a wonderful resource of evidence-based medicine.  They have the time to cull the existing data and perform an in-depth review & meta-analysis when possible.  Because they don't accept outside funding (near as I can tell), you can trust their recommendations to have the least bias, unlikely specialty organizations and industry trade groups who spin everything in such a fashion as to support their cause.  Cochrane also continuously updates their recommendations by reviewing more recent data.

For instance, Cochrane just updated last week their 2008 interventions to prevent falls in community dwelling elderly.  In order to perform their update, they reviewed 159 trials involving 79,193 participants.  Their conclusions?  Group & home exercises both reduced the rate of falls & risk of falling in a statistically significant fashion.  Tai Chi also made a dramatic difference when practiced regularly. Getting rid of psychotropic medications made some improvement in a small sampling of patients.

Bottom line: get active & stay active to minimize your risk for falling.

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Don't Just Sit There, Do Something! Part 10 Women's Bone Health

OK, let's just cut to the chase. Physical activity is important.  Physical activity is good for you.  Even if you're diabetic.  And especially if you're a premenopausal female worried about her bones in a study published early online in the Journal of Clinical Endocrinology & Metabolism in which the authors concluded that physical activity improved markers of bone health.

Granted, there was quite a bit of statistics to wade through in this study.  But my understanding is that the authors performed a cross-sectional analysis of 1,235 34yo premenopausal overweight (body mass index 27kg/m2) women divided into groups dependent upon physical activity.  Those who exercised >120min/week demonstrated better markers of bone health compared to their sedentary controls.  A subset of 120 women were then randomized to 8 weeks of physical activity at 120min/wk vs remaining sedentary.  Again, those who exercised to that degree demonstrated better bone health markers compared to their sedentary controls.

So, is this study the final word?  Absolutely not!  The cross-sectional study only demonstrates a correlation but is not proof of causation.  The randomized controlled trial is too small & too short for generalization.  In this day & age of inclusiveness, as much as I'd like to ignore the impact of ethnicity, I can't just assume that a study of Saudi women is generalizable to the rest of the global population.  Most importantly, this RCT only looked at markers of disease, rather than disease outcomes, or even more important, all-cause mortality.  

So, clearly, no, this study is not the final word.  But it supports the hypothesis that regular physical activity >120min/week  is a good thing.

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Better Vision = Lower Fracture Risk

As much as I try to ignore it, I'm getting older.  I put on old monovision prescription contact lenses yesterday morning while in a rush.  If ever I needed proof that I have presbyopia, I got it in spades.  My arms just weren't long enough for all the fine print & paperwork that I had to deal with.  Initially, I wasn't convinced a few months ago but I guess those bifocal contact lenses really do work!

I mention this because one of the risk factors for falls in the elderly is poor vision.  Well, in a retrospective study published in JAMA yesterday, the authors concluded that those elderly who underwent cataract surgery had a lower risk of hip fracture compared to those w/cataracts who did not have surgery.

The authors arrived at their conclusion by looking at a random sampling of 5% of Medicare beneficiaries and locating 1,113,640 w/cataracts.  They then compared those who'd undergone cataract surgery to those who hadn't, specifically with regards to hip fracture in the subsequent year.  Notably, they found a 16% reduction in risk in those who underwent cataract surgery compared to those w/cataract but elected against surgery.

Sure, this is only a retrospective observational study useful in developing hypotheses.  In this case, it's useful in supporting the basic premise that one needs to be able to see clearly in order to ambulate safely w/o injury.  It will be interesting to see if a prospective randomized double blind (pun intended) placebo controlled trial will support a causal relationship.  As for me, I'm searching desperately for my bifocal contact lenses!

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Q&A Session at HealthTap.com

Does boniva work better than miacalcin?

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Q&A Session at HealthTap.com

How safe is it to use miacalcin for osteoperosis treatment?

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Q&A Session at HealthTap.com

Is it safe to use Forteo now?

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