Mineral Metabolism and Bone Disease after Bariatric Surgery and Ways to Optimize Bone Health

There is no consensus on how to protect the skeleton with adequate supplements in patients who have undergone bariatric operations. The main problem in mineral metabolism is usually related to secondary hyperparathyroidism (2 degrees HPT), often caused by a lack of dietary calcium, magnesium or vitamin D, together with changes in intestinal fermentation, transit time, and resorption surfaces left behind after bariatric operations. After primarily restrictive bariatric surgery, adequate mineral metabolism depends mainly on the active metabolite of vitamin D, whereas after primarily malabsorptive surgery, it depends largely on passive resorption by means of the calcium sensitizing receptor (CaSR). Notably, CaSR-activated calcium transport is coupled to the presence of sufficient magnesium. The current review discusses clinically relevant mechanisms of mineral metabolism and provides recommendations for adequate calcium, magnesium, and vitamin D supplementation. Nevertheless, formal supplementation guidelines are needed in the near future.     

Treatment of Post-Traumatic Epilepsy

OPINION STATEMENT: Post-traumatic epilepsy (PTE) due to traumatic brain injury is a diagnosis with multifactorial causes, diverse clinical presentations, and an evolving concept of management. Due to sports injuries, work-related injuries, vehicular accidents, and wartime combat, there is rising demand to understand the epidemiology, pathophysiology, diagnosis, prognosis, and treatment of PTE. PTE could occur at any time after injury and up to decades post-injury. The frontal and temporal lobes are the most commonly affected regions, and the resulting epilepsy syndrome is typically localization related. PTE should be actively considered as a diagnosis in any patient with a history of head trauma and episodic neurologic compromise regardless of how temporally remote the trauma occurred. The standard work-up includes a thorough history, neurological examination, neuroimaging, and electroencephalogram. Psychogenic nonepileptic seizures have a high comorbidity with seizures and need to be carefully excluded. PTE can spontaneously remit. For patients who do not go into remission, treatment for confirmed PTE includes antiepileptics, vagal nerve stimulator, and, when appropriate, surgical resection of an epileptogenic lesion. Lifestyle modification and counseling are critical for patients with PTE and should be routinely included in clinical management. The published evidence on the efficacy of various treatment modalities specific to PTE consists largely of retrospective studies and case reports. Despite a unique pathogenesis, the majority of current care parameters for PTE parallel those of standard care for localization-related epilepsy. The potential and need for rigorous clinical research in PTE continue to be in great demand.     

Response of Cortical Bone to Antiresorptive Treatment

A total of 113 postmenopausal women (69 controls, 33 using hormone replacement therapy (HRT), and 11 using bisphosphonate) were evaluated twice over 2 years with a new noninvasive, radiogrammetry-based technique called digital X-ray radiogrammetry (DXR) and conventional bone densitometry of the spine, hip, and forearm. Longitudinal changes in bone densitometry were compared with changes captured by DXR: BMD evaluated by DXR (BMDDXR), cortical thickness of the second metacarpal (CTMC2), and porosity of cortical bone. The expected annual postmenopausal reduction in BMD in the control group was detected by BMDspine (-0.8%, P < 0.01), BMDhip (-1.6%, P < 0.001), BMDforearm (-1.5%, P < 0.001), DXR-BMD (-0.8%, P < 0.001), and CTMC2 (-1.1%, P < 0.001). In the HRT group, smaller reductions were seen in BMDDXA, but only significant at the hip (-1.0%, P < 0.01) and distal forearm (-1.0%, P < 0.02). In the bisphosphonate group, cortical porosity was significantly reduced (P < 0.025). Comparing longitudinal changes in age-matched subsamples of controls and bisphosphonate treated, BMDDXR, CTMC2, and porosity of cortical bone all differed significantly (P < 0.01, P < 0.05, P < 0.05, respectively), whereas the BMDDXA measurements did not. In conclusion, DXR provides a densitometry equivalent measurement of the distal forearm and hand and seems to offer new information on the porosity of cortical bone. This may prove useful in the evaluation of bone loss and offer new insight into the effects of different antiresorptive treatment regimens used in the prevention of osteoporosis.     

Treatment Options in Juvenile Myoclonic Epilepsy

Juvenile myoclonic epilepsy (JME) is characterized by excellent response to treatment, if diagnosed correctly. Lifestyle advice is an integral part of the treatment of JME; it should include recommendations on avoidance of common triggers such as sleep deprivation and alcohol excess and emphasis on the importance of compliance with medication. The drug of first choice in the treatment of JME is sodium valproate, which has a response rate of up to 80%. Valproate should be avoided in women of childbearing age because of significantly increased risks of fetal malformations and neurodevelopmental delay. Levetiracetam or lamotrigine are alternative first-line options if valproate is contraindicated. With limited data from trials to support either of these drugs, the choice should take into account comorbidity factors and patient priorities. Because of its low side effect profile, excellent tolerability, and lack of interactions with other drugs, levetiracetam is our preferred alternative first-line agent. Lamotrigine is another first-line option but may exacerbate myoclonus. The failure of valproate or failure of two first-line antiepileptic drugs suggests that combination therapy is indicated. Drug interactions and the patient’s gender, age, and comorbidities need to be considered. Levetiracetam, lamotrigine, and valproate are suitable adjuncts, with a synergistic effect reported from the combination of valproate and lamotrigine. Clonazepam is a useful adjunct for myoclonus and can be used in combination with lamotrigine to avoid lamotrigine’s myoclonic effects. In women of childbearing potential, valproate should be considered if levetiracetam and lamotrigine have failed to control seizures at this stage. Topiramate is a cost-effective alternative monotherapy, but because of its poor tolerability, we recommend it as add-on treatment only. Zonisamide should remain a second-line adjunct in the treatment of JME, owing to the lack of supportive data. Phenobarbital is the most cost-effective drug and can be used to control the seizures of JME when antiepileptic drugs are limited or too costly. Carbamazepine, oxcarbazepine, and phenytoin can exacerbate absences and myoclonus and are therefore contraindicated, although they can improve control of tonic-clonic seizures when these are refractory to other medication. Gabapentin, pregabalin, tiagabine, and vigabatrin are contraindicated and can worsen seizures. (Tiagabine and vigabatrin have been reported to induce absence status epilepticus.) Surgical alternatives in refractory cases are rarely contemplated but may include vagus nerve stimulation and callosotomy. Deep brain stimulation is an experimental technique that may prove useful in managing refractory cases of JME.     

Treatment of Bone Tumors

In this article, the authors summarize the state of the art and future potential in the management of Osteosarcoma, Ewing's sarcoma, and Chondrosarcoma. They cover systemic therapy, surgical therapy, and radiotherapy, along with targeted therapies to inhibit signal transduction pathways. They discuss staging and the role of imaging evaluation to provide an overview of bone tumor treatment. Images presenting pathologic-radiologic correlations are included.     

Idiopathic Hypercalciuria and Bone Health

Calcium is an important participant in many physiologic processes including coagulation, cell membrane transfer, hormone release, neuromuscular activation, and myocardial contraction. The body cooperates in a sophisticated web of hormonally mediated interactions to maintain stable extracellular calcium levels. Calcium is vital for skeletal mineralization, and perturbations in extracellular calcium may be corrected at the expense of bone strength and integrity. The aim of this review is to delineate our current understanding of idiopathic hypercalciuria in the context of bone health, specifically its definition, etiology, epidemiology, laboratory evaluation, and potential therapeutic management.     

Vitamin K and Bone Health

Vitamin K has been purported to play an important role in bone health. It is required for the gamma-carboxylation of osteocalcin (the most abundant noncollagenous protein in bone), making osteocalcin functional. There are 2 main forms (vitamin K1 and vitamin K2), and they come from different sources and have different biological activities. Epidemiologic studies suggest a diet high in vitamin K is associated with a lower risk of hip fractures in aging men and women. However, randomized controlled trials of vitamin K1 or K2 supplementation in white populations did not increase bone mineral density at major skeletal sites. Supplementation with vitamin K1 and K2 may reduce the risk of fractures, but the trials that examined fractures as an outcome have methodological limitations. Large well-designed trials are needed to compare the efficacies of vitamin K1 and K2 on fractures. We conclude that currently there is not enough evidence to recommend the routine use of vitamin K supplements for the prevention of osteoporosis and fractures in postmenopausal women.     

Linking the Gut Microbiota to Bone Health in Anorexia Nervosa

Purpose of Review

The purpose of this review is to examine the anorexia nervosa-microbiota-bone relationship, offering a compilation of the relevant human and animal studies that may contribute to a more comprehensive understanding of potential mechanisms involved.

Recent Findings

Recent studies have implicated fermentation by-products of the gut microbiota in bone metabolism.

Summary

Compromised bone health often accompanies anorexia nervosa due to energy deficiency and hypoestrogenism. The gut microbiome has been implicated as a link between these conditions and impaired bone growth phenotypes. Current research supports decrements in Firmicutes and short-chain fatty acids with increases in Methanobrevibacter smithii and Proteobacteria in anorexia nervosa. A potential mechanism for microbiome-regulated bone growth is through modulation of insulin-like growth factor-1. Future research should aim to examine short-chain fatty acids, probiotics, and prebiotics as alternative therapies to treat low bone density in anorexia nervosa.

     

How to Optimize Rosacea Treatment for Better Patient Outcomes: An Opinion Piece

Rosacea is a chronic disease requiring long-term management. However, it is often treated according to package label instructions, which reflect the conditions of a Phase III study rather than a chronic disease. Furthermore, due to a lack of clinical data or guidelines on long-term treatment, many clinicians choose to discontinue treatment once success has been reached, rather than continuing with maintenance therapy. As experienced practicing dermatologists and investigators in the field, in this article we address the current evidence gaps in rosacea management and provide practical advice to clinicians on how optimal outcomes can be achieved and maintained in patients with rosacea in real-world practice, based on our own experience and the available clinical data.     

开展家长健康教育提高癫癎患儿遵医行为研究

目的探讨患儿家长健康教育对癫患儿遵医行为及用药依从性的影响。方法随机将癫住院患儿家长分 为观察组和对照组各22人。采取多种健康教育方式对观察组进行针对性的健康教育;对照组只根据其所提问题, 做简单、必要的解释。用问卷调查对患儿家长入院后、出院时,出院3个月后进行癫知识问卷调查并评分,观察 两组患儿遵医依从性及疗效。结果入院时,两组癫知识知晓率比较,差异无显著性意义(P>0.05)。出院时和 出院后3个月,观察组知晓率高于对照组(均P<0.01);观察组患儿遵医依从性、疗效高于对照组(P<0.05,P< 0.01)。结论健康教育不但能提高癫患儿家长对相关知识的认知,亦能提高患儿治疗的依从性及临床疗效。     

National Bone Health Alliance: An Innovative Public-Private Partnership Improving America’s Bone Health

The U.S. National Bone Health Alliance (NBHA) is a public-private partnership launched in 2010 that brings together its 56 partners from the government, nonprofit, and for-profit sectors to collectively promote bone health and prevent disease; improve bone disease diagnosis and treatment; and enhance bone research, surveillance, and evaluation. NBHA is driven to achieve its 20/20 vision to reduce fractures 20 % by the year 2020 through projects including 2Million2Many, an osteoporosis awareness campaign; Fracture Prevention CENTRAL, an online resource center providing support to sites interested in launching a secondary fracture prevention program; bone turnover marker standardization project; and working groups in rare bone disease and the clinical diagnosis of osteoporosis. NBHA provides a platform to coordinate messaging among individuals and organizations on subjects important to bone health; pool funding and efforts around shared priorities; and work together towards the goals and recommendations of the National Action Plan on Bone Health.     

Editorial Commentary: Drill and Fill: Bone Marrow Stimulation Plus Allograft Matrix May Optimize the Treatment of Osteochondral Lesions of the Talus

Osteochondral lesions of the talus remain a challenging pathologic entity facing orthopaedic foot and ankle surgeons. Although multiple treatment options exist, there is limited evidence supporting one technique over another. The ultimate goal of surgical intervention is to achieve lesion infill with tissue properties that best mimic those of hyaline articular cartilage. Restoring the anatomic surface of the talus may provide long-term clinical success and improve function. Augmentation of bone marrow stimulation with extracellular matrix cartilage allograft aims to achieve this goal.