Osteoporosis: an updated approach to prevention and management

Osteoporosis is a major public health problem whose impact will only continue to increase in the United States. Current evidence indicates that estrogen therapy will prevent bone loss and reduce the incidence of fractures. The major problem is identification of those most at risk of fracture. Currently, risk factor assessment and bone mass measurement used in combination offer the closest approximation to the ideal, although it is not yet completely clear how good identification is. Together these estimates of risk need only be used for those about whom there is a question concerning the use of estrogen, and need not be used for patients who have either already decided to initiate preventive treatment or have decided not to start such a program.     

Early rheumatoid arthritis: strategies for prevention and management

The treatment of rheumatoid arthritis (RA) has changed considerably in the past few years since new tools and new concepts have been developed and validated highlighting the need for guidelines focused on early RA. The treatment goal should now be to achieve clinical remission, in order to prevent structural damage and long-term disability. A very early use of effective disease-modifying anti-rheumatic drugs (DMARDs) is a key point in patients at risk of developing persistent and erosive arthritis. Intensive treatment such as combination DMARDs plus steroids or biological therapies can induce a high rate of remission, control of radiological progression and provide better outcome than DMARD monotherapy in early RA and should be considered in at risk patients. Regarding the risk:benefit ratio and the cost-effectiveness of these strategies, a reasonable course of action in early RA should be initial DMARD monotherapy such as methotrexate. However, a close monitoring of disease activity and radiographic progression is mandatory in order to change DMARD therapy and strategy if necessary. Systemic glucocorticoids are effective in the short-term relief of pain and swelling and should be considered, but mainly as a temporary therapy part of the DMARD strategy. Information and education for patients, as well as some non-pharmacological interventions, can be proposed as treatment adjuncts. Finally, the reduction or stopping of smoking, which could prevent the development and progression of early RA, is the only prevention tool currently available.     

Cardiotoxicity in childhood cancer survivors: strategies for prevention and management

Advances in cancer treatment have greatly improved survival rates of children with cancer. However, these same chemotherapeutic or radiologic treatments may result in long-term health consequences. Anthracyclines, chemotherapeutic drugs commonly used to treat children with cancer, are known to be cardiotoxic, but the mechanism by which they induce cardiac damage is still not fully understood. A higher cumulative anthracycline dose and a younger age of diagnosis are only a few of the many risk factors that identify the children at increased risk of developing cardiotoxicity. While cardiotoxicity can develop at anytime, starting from treatment initiation and well into adulthood, identifying the best cardioprotective measures to minimize the long-term damage caused by anthracyclines in children is imperative. Dexrazoxane is the only known agent to date, that is associated with less cardiac dysfunction, without reducing the oncologic efficacy of the anthracycline doxorubicin in children. Given the serious long-term health consequences of cancer treatments on survivors of childhood cancers, it is essential to investigate new approaches to improving the safety of cancer treatments.     

Lipid management in cardiovascular disease prevention guidelines: strategies and tactics for implementation

Despite the widespread dissemination of clinical practice guidelines on the prevention and treatment of cardiovascular disease (CVD), CVD causes one third of deaths worldwide and almost half of all deaths in the developed world. It is therefore likely that, although some aspects of CVD management have improved, there is still a significant shortfall between what is known about CVD prevention and what is put into action. Twenty-one experts in the field of CVD from around the world attended a focus panel meeting in Marlow-on-Thames, UK (see acknowledgements for a list of meeting participants). These experts were invited to discuss practical strategies and tactics for overcoming barriers to the implementation of guidelines on CVD prevention, and lipid management in particular. This article reviews and updates the key topics presented during the course of the meeting, captures the essence of the group discussions, and summarizes the meeting outcomes. The participants concluded that initial efforts to implement CVD prevention guidelines more effectively are best directed at high-risk patients who have already been identified. Once current patients achieve their targets, more attention can be paid to finding untreated patients at risk. Recommendations from the expert panel included: Harmonize guidelines; focus on common areas of consensus rather than state-of-the-art science. Remove the boundary between primary and secondary prevention and focus on level of overall risk. Help policy makers understand the different components of CVD. Include professional societies from different specialties in guideline development and implementation, to increase ownership and decrease fragmentation of guideline committees.     

Multidisciplinary prevention and management strategies for colorectal cancer and cardiovascular disease

Colorectal cancer (CRC) and cardiovascular disease (CVD) are leading causes of morbidity and mortality worldwide. Their numerous shared and modifiable risk factors underscore the importance of effective prevention strategies for these largely preventable diseases. Conventionally regarded as separate disease entities, clear pathophysiological links and overlapping risk factors represent an opportunity for synergistic collaborative efforts of oncologists and cardiologists. In addition, current CRC treatment approaches can exert cardiotoxicity and thus increase CVD risk. Given the complex interplay of both diseases and increasing numbers of CRC survivors who are at increased risk for CVD, multidisciplinary cardio-oncological approaches are warranted for optimal patient care from primary prevention to acute disease treatment and long-term surveillance.     

Osteoporosis in elderly: prevention and treatment

Osteoporosis is a major clinical problem in older women and men. Almost any bone can fracture as a result of the increased bone fragility of osteoporosis. These fractures are associated with higher health care costs, physical disability, impaired quality of life, and increased mortality. Because the incidence of osteoporotic fracture increases with advancing age, measures to diagnose and prevent osteoporosis and its complications assume a major public health concern. BMD is a valuable tool to identify patients at risk for fracture, to make therapeutic decisions, and to monitor therapy. Several other modifiable and nonmodifiable risk factors for osteoporosis have also been identified. Treatment of potentially modifiable risk factors along with exercise and calcium and vitamin D supplementation forms an important adjunct to pharmacologic management of osteoporosis. Improved household safety can reduce the risk of falls. Hip protectors have been found to be effective in nursing home population. The pharmacologic options include bisphosphonates, HRT, SERMs and calcitonin. PTH had received FDA advisory committee approval. Alendronate has been approved for treatment of osteoporosis in men, and other treatments for men are under evaluation.     

机械通气相关肺炎发病机制及防治策略研究

机械通气相关肺炎(ventilator-associated pneumonia,VAP)是医院内获得性肺炎中最常见的类型之一,其发病率高.与无VAP患者相比,VAP患者住院时间长,医疗成本高,病死率高.宿主的呼吸道防御机制破坏和病原微生物定植及侵入呼吸道是VAP发病机制的关键,采取有针对性的防治措施可降低VAP的发生率.     

Osteoporosis: pathophysiology and non-pharmacological management

Osteoporosis is the disease of progressive bone loss that is most often associated with ageing and the post-menopausal state in women. All people, men and women, lose bone mass with advancing age, but in some the loss is so great that the skeleton is unable to maintain optimal structural integrity and the result is susceptibility to fractures, particularly of the hip and spine. The condition is increasing dramatically in prevalence as the numbers of elderly in the population increase.In this chapter, the epidemiology, clinical features and current modes of non-pharmacological management of osteoporosis are reviewed, with discussion of the potential of nutraceuticals and functional foods to influence the course of the disease.     

Diabetic nephropathy: strategies for prevention

A cumulative incidence of diabetic nephropathy of 30-35% has been documented after duration of diabetes of at lest 25 years in type 1 diabetes mellitus and 15-25% in type 2 diabetes mellitus. Diabetic Nephropathy has become the leading cause of chronic renal failure. Several strategies has been suggested to prevent renal disease in patients with diabetes mellitus. Two main treatment strategies for primary prevention of diabetic nephropathy are improved glycaemic control and lowering the blood pressure particularly with angiotensing-converting-enzyme inhibitors. Other therapeutics include, lipid-lowering therapy, dietary protein restriction, smoking cessation and aspirin therapy.     

NSAID-induced gastroduodenal damage: strategies for prevention

The improved knowledge of the mechanism by which NSAIDs work and damage the gastrointestinal (GI) mucosal suggested a series of measures for the prevention of NSAIDs-induced GI lesions, apart from the use of those proved to be less toxic. PPI have now been definitively shown to be more effective in the relief of symptoms and in the healing and prevention of ulcers/erosions than H2-antagonists and also better tolerated than misoprostol. Other more innovative approaches include selective and highly selective COX-2 inhibitors, NSAIDs containing NO or stimulating the gastric endogenous biosynthesis of NO, and chiral NSAIDs. Clinical usefulness of other compounds, including NSAIDs associated with zwitterionic phospholipids or fibroblast growth factor, is still under investigation.     

Dyslipidemia management in primary prevention of cardiovascular disease:Current guidelines and strategies

Cardiovascular disease is the leading cause of death in the United States. In 2010, the Centers for Disease Control and Prevention estimated that $444 billion was spent on cardiovascular diseases alone, about $1 of every $6 spent on health care. As life expectancy continues to increase, this annual cost will also increase, making costeffective primary prevention of cardiovascular disease highly desirable. Because of its role in development of atherosclerosis and clinical events, dyslipidemia management is a high priority in cardiovascular prevention. Multiple major dyslipidemia guidelines have been published around the world recently, four of them by independent organizations in the United States alone. They share the goal of providing clinical guidance on optimal dyslipidemia management, but guidelines differ in their emphasis on pharmacotherapy, stratification of groups, emphasis on lifestyle modification, and use of a fixed target or percentage reduction in low density lipoprotein cholesterol. This review summarizes eight major guidelines for dyslipidemia management and considers the basis for their recommendations. Our primary aim is to enhance understanding of dyslipidemia management guidelines in patient care for primary prevention of future cardiovascular risk.     

Osteoporosis in childhood rheumatic diseases: prevention and therapy

Bone mass is primarily genetically determined, but exogenous factors also play a major role. The prevention of osteoporosis can start from childhood, and optimal achievement of peak bone mass during childhood and adolescence is important in order to minimize the future risk of fracture. Chronic inflammatory diseases can have a detrimental effect on bone mass by means of several mechanisms. Different diagnostic methods for detection and monitoring of osteoporosis are in use or under investigation. The role of calcium and vitamin D supplementation for the prevention and treatment of osteoporosis associated with paediatric rheumatic diseases remains to be established. New treatments such as bisphosphonates and calcitonin are now available, although their use for paediatric patients has been limited.     

Osteoporosis in systemic lupus erythematosus: prevention and treatment

The patient with systemic lupus erythematosus (SLE) is at risk of osteoporosis through several factors: the inflammatory disease itself, disease-related co-morbidity, and its treatment. Bone loss is apparent early in the disease and this may be confounded primarily by treatment with corticosteroids. Patients should be assessed for additional risk factors for osteoporosis and general lifestyle measures adopted. Bone mineral density measurement should be considered in SLE patients at high risk of osteoporosis, particularly those starting corticosteroids and in postmenopausal women. Calcium and vitamin D supplementation provide general prophylaxis and are a suitable first-line option. Hormone replacement should be used in hypogondal subjects unless contra-indicated. In subjects at high fracture risk, particularly in postmenopausal women, bisphosphonate therapy should be considered as these agents have been shown to significantly reduce vertebral fracture risk. These measures should reduce the burden of osteoporosis and fracture in patients with lupus.     

Osteoporosis in men: diagnosis, pathophysiology, and prevention

Osteoporosis in men is a significant problem in clinical medicine and in society in general. Systematic consideration of the differential diagnosis of osteopenia and osteoporosis in men is appropriate in every affected patient. Dynamic bone histomorphometry has diagnostic usefulness in some patients and has provided important pathogenetic implications by study of bone remodeling and turnover. Review of the multifactorial pathophysiology of age-related bone loss in men suggests that routine maintenance of adequate calcium and vitamin D intake, exercise, early recognition and treatment of testosterone deficiency, and modification of other osteoporotic risk factors may have prophylactic value. Future basic research on the cellular biology of bone in health and disease and clinical trials assessing the effects of long-term prophylactic and treatment regimens on bone mass and fracture occurrence will expand the understanding of osteoporosis in men.     

Osteoporosis screening and risk management

Osteoporosis is common among older adults and results in costly osteoporotic fractures. Screening for this metabolic bone disorder is warranted in most older adults and clinicians must be diligent in identifying persons at risk. The evaluation should include an assessment of risk factors for falls, a bone density test, and consideration of possible secondary causes of osteoporosis. Several medications are available to improve bone density and decrease fractures. Adequate calcium and vitamin D intake (and treatment of vitamin D deficiency) are paramount in the management of osteoporosis.