AFP Journal Review

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AFP Journal Review

• March 12, 2009

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Articles

• Diagnosis and Treatment of Osteoporosis
• Evaluation of Macrocytosis
• The Limping Child A Systematic Approach to
  Diagnosis

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Strength of Recommendation Grades

• A Consistent, good quality patient oriented
  evidence
• B Inconsistent or limited quality patient
  oriented evidence
• C Consensus, disease oriented evidence, usual
  practice, expert opinion, or case series for
  studies of diagnosis, treatment, prevention, or
  screening

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Diagnosis and Treatment of Osteoporosis

• U.S. Osteoporosis
• 8 million women
• 2 million men
• 34 million with osteopenia
• 1 in 2 women - osteoporotic Fx in lifetime
• Men w/ higher mortality and screened less
• 49 of women screened according to Recs

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Diagnosis and Treatment of Osteoporosis

• Hip Fx cause excess of 10 to 20 at 12 months
• 25 require long term nursing home care
• 2002 cost of a hip fx - 34k to 43k
• Annual total cost of all ostoporotic fxs
  18Billion

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Diagnosis and Treatment of Osteoporosis

• Osteoporosis
• Spinal or hip bone mineral density (BMD) of 2.5
  SD or more below the mean of healthy, young women
  as measured by dual energy x-ray absorptiometry
  (DEXA) scan.
• Osteopenia
• 1 to 2.5 SD

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Diagnosis and Treatment of Osteoporosis

• Primary Osteoporosis
• Result of bone loss related to decline in gonadal
  function associated with aging
• Secondary Osteoporosis
• Bone loss as related to chronic diseases,
  exposures, or nutritional deficiencies that
  adversely impact bone metabolism

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Recommendations
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Screening
Simple calculated osteoporosis risk estimation
(Score) tool - Determines if DEXA scan should
be done. - 91 Sensitive and 40 specificity
- http//osteoed.org/tools.php
Age range NNS to prevent 1 hip Fx over 5 years
55 to 59 gt 4000
60 to 64 1856
65 to 69 731
75 to 79 143

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Primary Osteoporosis
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Secondary Osteoporosis
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Secondary Osteoporosis
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Secondary Osteoporosis
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Secondary Osteoporosis
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Initial Eval in Secondary Osteoporosis
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Further Eval in Secondary Osteoporosis
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When to Treat

• National Osteoporosis Foundation (NOF) recommends
  treatment of
• Any postmenopausal women or men with h/o hip or
  vertebral fx
• T-score of 2.5 or below
• T-score of 1 to 2.5 with 10 year prob of hip fx
  of at least 3 or any major fx of at least 20

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WHO Fracture Risk Assessment (FRAXTM)

• Is the patient's race black? Yes No
• Does the patient have rheumatoid arthritis? Yes
  No
• Has the patient ever been on estrogen therapy?
  Yes No
• How many fractures of the hip, rib, or wrist has
  the patient had since age 45? 0 1 2 3 or
  more
• What is the patient's age?
• 40-49 50-59 60-69 70-79 80-89 90-99
  100
• What is the patient's weight in pounds?
• http//osteoed.org/tools.php

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Osteoporosis - Treatment

• Fall prevention
• Calcium
• Mixed study results but meta analysis with good
  results with 80 adherence rate
• 1200mg PO daily with food optimized in 500mg
  doses

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Osteoporosis - Treatment

• Vitamin D
• 800 to 1000 IU for both sexes 50 years and older
• Prevention of 1 hip fracture NNT (45 over 2 to 5
  years)
• If Vit D deficiency, then oral Vit D 50k IU
  weekly for 8 weeks. With 50k IU every 2 to 4 wks
  or 1k IU daily
• Goal 25-hydroxyvitamin D gt 30 ng/ml

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Osteoporosis - Treatment
22
Osteoporosis - Treatment
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Osteoporosis - Treatment
24
Follow UP

• Reasonable to reevaluate for response to
  treatment after 24 months from initiation of
  treatment

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• Which one of the following tests is most commonly
  used for the diagnosis and monitoring of
  osteoporosis?
• A. Quantitative computed tomography.
• B. Central dual energy x-ray absorptiometry
  (DEXA).
• C. Quantitative calcaneal ultrasonography.
• D. Peripheral DEXA.

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• Which one of the following tests is most commonly
  used for the diagnosis and monitoring of
  osteoporosis?
• A. Quantitative computed tomography.
• B. Central dual energy x-ray absorptiometry
  (DEXA).
• C. Quantitative calcaneal ultrasonography.
• D. Peripheral DEXA.

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• Which one of the following statements about
  screening for osteoporosis in women 55 to 59
  years of age is correct?
• A. Fewer than 50 women must be screened over five
  years to prevent one hip fracture.
• B. Approximately 200 women must be screened over
  five years to prevent one hip fracture.
• C. Approximately 1,000 women must be screened
  over five years to prevent one hip fracture.
• D. More than 4,000 women must be screened over
  five years to prevent one hip fracture.

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• Which one of the following statements about
  screening for osteoporosis in women 55 to 59
  years of age is correct?
• A. Fewer than 50 women must be screened over five
  years to prevent one hip fracture.
• B. Approximately 200 women must be screened over
  five years to prevent one hip fracture.
• C. Approximately 1,000 women must be screened
  over five years to prevent one hip fracture.
• D. More than 4,000 women must be screened over
  five years to prevent one hip fracture.

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• Which of the following agents has/have been shown
  to reduce the risk of nonvertebral fracture in
  patients with osteoporosis?
• A. Alendronate (Fosamax).
• B. Ibandronate (Boniva).
• C. Calcitonin (Miacalcin).
• D. Risedronate (Actonel).

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• Which of the following agents has/have been shown
  to reduce the risk of nonvertebral fracture in
  patients with osteoporosis?
• A. Alendronate (Fosamax).
• B. Ibandronate (Boniva).
• C. Calcitonin (Miacalcin).
• D. Risedronate (Actonel).

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Evaluation of Macrocytosis

• Macrocytosis MCV gt 100
• 3 of the population

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Evaluation of Macrocytosis
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Evaluation of Macrocytosis

• Megaloblastic vs Non
• Peripheral smear with macro-ovalocytes and
  hypersegmented neutrophils

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Differential Diagnosis of Macrocytosis
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Evaluation of Macrocytosis
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Evaluation of Macrocytosis
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Evaluation of Macrocytosis
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Evaluation of Macrocytosis
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• Which one of the following conditions will
  typically be associated with an increased
  reticulocyte count at the time of initial
  evaluation of macrocytosis?
• A. Vitamin B12 deficiency.
• B. Hemolysis.
• C. Folate deficiency.
• D. Hypothyroidism.

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• Which one of the following conditions will
  typically be associated with an increased
  reticulocyte count at the time of initial
  evaluation of macrocytosis?
• A. Vitamin B12 deficiency.
• B. Hemolysis.
• C. Folate deficiency.
• D. Hypothyroidism.

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• Which of the following conditions can create a
  spurious macrocytosis?
• A. Cold agglutinations.
• B. Primary bone marrow disorders.
• C. Hypoglycemia.
• D. Marked leukocytosis.

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• Which of the following conditions can create a
  spurious macrocytosis?
• A. Cold agglutinations.
• B. Primary bone marrow disorders.
• C. Hypoglycemia.
• D. Marked leukocytosis.

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The Limping Child A Systematic Approach to
Diagnosis

• You may start off rough, but.

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The Limping Child A Systematic Approach to
Diagnosis

• Affects 1.8 per 1000 children under 14y/o
• Thorough history
• presence of pain, trauma history, and associated
  systemic Sx.
• presence of fever, night sweats, weight loss, and
  anorexia
• suggests the possibility of infection,
  inflammation, or malignancy

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The Limping Child A Systematic Approach to
Diagnosis

• Antalgic gait
• Shortening of the stance phase to reduce pain
• Non-antalgic gait (less urgent)
• Trendelenburg gait
• Steppage gait
• Equinus gait
• Circumduction gait

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The Limping Child A Systematic Approach to
Diagnosis
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• Which one of the following findings is most
  characteristic of an antalgic gait?
• A. Walking on the toes.
• B. Shortening of the stance phase.
• C. Shortening of the swing phase.
• D. Downward tilt of the pelvis during the swing
  phase.

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• Which one of the following findings is most
  characteristic of an antalgic gait?
• A. Walking on the toes.
• B. Shortening of the stance phase.
• C. Shortening of the swing phase.
• D. Downward tilt of the pelvis during the swing
  phase.

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• Which of the following tests is/are useful in
  distinguishing septic arthritis from transient
  synovitis?
• A. Erythrocyte sedimentation rate greater than 40
  mm per hour.
• B. Peripheral white blood cell count of more than
  12,000 cells per mm3 (12.0 109 cells per L).
• C. C-reactive protein level greater than 2.0 mg
  per dL (20.0 mg per L).
• D. The Patrick (FABER) test.

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• Which of the following tests is/are useful in
  distinguishing septic arthritis from transient
  synovitis?
• A. Erythrocyte sedimentation rate greater than 40
  mm per hour.
• B. Peripheral white blood cell count of more than
  12,000 cells per mm3 (12.0 109 cells per L).
• C. C-reactive protein level greater than 2.0 mg
  per dL (20.0 mg per L).
• D. The Patrick (FABER) test.

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Resources

• Sweet M, Sweet J , Jeremiah M, Galazaka S.
  Diagnosis and Treatment of Osteoporosis. American
  Family Physician. Feb 1, 2009.
• Kaferle J, Strzoda C. Evaluation of Macrocytosis.
  American Family Physician. Feb 1, 2009.
• Sawyer J. Kapoor M. The Limping Child A
  Systematic Approach to Diagnosis. American Family
  Physician. Feb 1, 2009.